Psychotherapy – Page 7 – Mental Health Matters

What is the Management of Depression?

Published on 05/07/2021 by Andrew MarshallLeave a comment

Introduction

Depression is a symptom of some physical diseases; a side effect of some drugs and medical treatments; and a symptom of some mood disorders such as major depressive disorder or dysthymia. Physical causes are ruled out with a clinical assessment of depression that measures vitamins, minerals, electrolytes, and hormones. Management of depression may involve a number of different therapies: medications, behaviour therapy, psychotherapy, and medical devices.

Though psychiatric medication is the most frequently prescribed therapy for major depression, psychotherapy may be effective, either alone or in combination with medication. Combining psychotherapy and antidepressants may provide a “slight advantage”, but antidepressants alone or psychotherapy alone are not significantly different from other treatments, or “active intervention controls”. Given an accurate diagnosis of major depressive disorder, in general the type of treatment (psychotherapy and/or antidepressants, alternate or other treatments, or active intervention) is “less important than getting depressed patients involved in an active therapeutic program.”

Psychotherapy is the treatment of choice in those under the age of 18, with medication offered only in conjunction with the former and generally not as a first line agent. The possibility of depression, substance misuse or other mental health problems in the parents should be considered and, if present and if it may help the child, the parent should be treated in parallel with the child.

Psychotherapy and Behaviour Therapy

There are a number of different psychotherapies for depression which are provided to individuals or groups by psychotherapists, psychiatrists, psychologists, clinical social workers, counsellors or psychiatric nurses. With more chronic forms of depression, the most effective treatment is often considered to be a combination of medication and psychotherapy. Psychotherapy is the treatment of choice in people under 18. A meta-analysis examined the effectiveness of psychotherapy for depression across ages from younger than 13 years to older than 75 years. It summarizes results from 366 trials included 36,702 patients. It found that the best results were for young adults, with an average effect size of g=.98 (95% CI, 0.79-1.16). The effects were smallest for young children (<13 years), g = .35 (95% CI, 0.15-0.55), and second largest in the oldest group, g = .97 (95% CI, 0.42-1.52). The study was not able to compare the different types of therapy to each other. Most of the studies with children used therapies originally developed with adults, which may have reduced the effectiveness. The greater benefits with young adults might be due to a large number of studies including college students, who might have an easier time learning therapy skills and techniques. Most of the studies in children were done in the USA, whereas in older age groups, more balanced numbers of studies came from Europe and other parts of the world as well.

As the most studied form of psychotherapy for depression, cognitive behavioural therapy (CBT) is thought to work by teaching clients to learn a set of cognitive and behavioural skills, which they can employ on their own. Earlier research suggested that cognitive behavioural therapy was not as effective as antidepressant medication in the treatment of depression; however, more recent research suggests that it can perform as well as antidepressants in treating patients with moderate to severe depression. Beck’s treatment manual, Cognitive therapy of depression, has undergone the most research and accumulated the most evidence for its use. However, a number of other CBT manuals also have evidence to support their effectiveness with depression.

The effect of psychotherapy on patient and clinician rated improvement as well as on revision rates have declined steadily from the 1970s.

A systematic review of data comparing low-intensity CBT (such as guided self-help by means of written materials and limited professional support, and website-based interventions) with usual care found that patients who initially had more severe depression benefited from low-intensity interventions at least as much as less-depressed patients.

For the treatment of adolescent depression, one published study found that CBT without medication performed no better than a placebo, and significantly worse than the antidepressant fluoxetine. However, the same article reported that CBT and fluoxetine outperformed treatment with only fluoxetine. Combining fluoxetine with CBT appeared to bring no additional benefit in two different studies or, at the most, only marginal benefit, in a fourth study.

Behaviour therapy for depression is sometimes referred to as behavioural activation. Studies exist showing behavioural activation to be superior to CBT. In addition, behavioural activation appears to take less time and lead to longer lasting change. Two well-researched treatment manuals include Social skills training for depression and Behavioural activation treatment for depression.

Emotionally focused therapy, founded by Sue Johnson and Les Greenberg in 1985, treats depression by identifying and processing underlying emotions. The treatment manual, Facilitating emotional change, outlines treatment techniques.

Acceptance and commitment therapy (ACT), a mindfulness form of CBT, which has its roots in behaviour analysis, also demonstrates that it is effective in treating depression, and can be more helpful than traditional CBT, especially where depression is accompanied by anxiety and where it is resistant to traditional CBT.

A review of four studies on the effectiveness of mindfulness-based cognitive therapy (MBCT), a recently developed class-based program designed to prevent relapse, suggests that MBCT may have an additive effect when provided with the usual care in patients who have had three or more depressive episodes, although the usual care did not include antidepressant treatment or any psychotherapy, and the improvement observed may have reflected non-specific or placebo effects. Of note, although Mindfulness-based cognitive therapy for depression prevented relapse of future depressive episodes, there is no research on whether it can cause the remission of a current depressive episode.

Interpersonal psychotherapy (IPT) focuses on the social and interpersonal triggers that may cause depression. There is evidence that it is an effective treatment for depression. Here, the therapy takes a fairly structured course (often 12 sessions, as in the original research versions) as in the case with CBT; however, the focus is on relationships with others. Unlike family therapy, IPT is an individual format, so it is possible to work on interpersonal themes even if other family members do not come to the session. Therapy can be used to help a person develop or improve interpersonal skills in order to allow him or her to communicate more effectively and reduce stress. In a meta-analysis of 16 studies and 4,356 patients, the average improvement in depressive symptoms was an effect size of d = 0.63 (95% CI, 0.36 to 0.90). IPT combined with pharmacotherapy was more effective in preventing relapse than pharmacotherapy alone, number needed to treat = 7.63.

Psychoanalysis, a school of thought founded by Sigmund Freud that emphasizes the resolution of unconscious mental conflicts, is used by its practitioners to treat clients presenting with major depression. A more widely practiced technique, called psychodynamic psychotherapy, is loosely based on psychoanalysis and has an additional social and interpersonal focus. In a meta-analysis of three controlled trials, psychodynamic psychotherapy was found to be as effective as medication for mild to moderate depression.

Shared Care

Shared decision making is an approach whereby patients and clinicians freely share important evidence when tasked with decision making and where patients are guided to consider the best available options to make an informed decision. The principles are well documented, but there is a gap in that it’s hard to apply them in routine clinical practice. The steps have been simplified into five steps. The first step is seeking patient participation in that the health practitioner is tasked with communicating existing choices and therefore inviting them to the decision making process. The next step involves assisting the patient to explore and compare the treatment options by a critical analysis of the risks and benefits. The third step involves the assessment of the patient’s values and what they prefer taking to account what is of paramount urgency to the patient. Step 4 involves decision making where the patient and the practitioner make a conclusive decision on the best option and arrange for subsequent follow up meetings. Finally, the fifth step involves the analysis of the patient’s decision’. Five steps for you and your patients to work together to make the best possible health care decisions. The step involves monitoring of the degree of implementation, overcoming of barriers of decision implantation consequently the decisions need to be revisited and optimised thus ensuring the decision has a positive impact on health outcomes its success relies on the ability of the health practitioner to create a good interpersonal relationship with the patient.

Depression still remains a major problem in the US whereby statistics have it that 16 million people were affected in the year 2017. The depression is multifactorial and has been on the increase due to societal pressure, genetic association and increase in use of drugs. incorporation of nursing in management of depression may seem important in that nursing holds a pivotal role in health care delivery where they are the health practitioners that have been trained to be versatile from clinical to psychological care. Their incorporation in shared decision making in treating depression may be important as nurses are known to have the best interpersonal relationship with the patients thus a better collaborative model can be achieved due to this fact. With this in mind, the nurses may serve to administer drugs in management, prepare and maintain the patient’s records, interaction with other care staff to achieve optimum care, and organising therapy sessions. In a study another study concerning shared decision-making interventions for people with mental health conditions there were no overt benefits that were discovered and the called for further research in this area. Another study found that it is important to begin the dissemination and implementation of SDM as they proved that it has benefits in healthcare especially in mental health care and has received social and government support and however transitioning to SDM has proven to be an uphill task. It has been suggested that SDM is of importance in demonstrating patient preferences in decision making when there is no clear approach to treatment. In addition, numerous tools can be used to make the decision making the process easier these include the Controlled Preferences Scale that informs clinicians on how to actively involve patients

Commentators suggest that providers need to embrace shared decision making by making sure that patients participate actively in their management thus enabling the success of the model.

Medication

To find the most effective pharmaceutical drug treatment, the dosages of medications must often be adjusted, different combinations of antidepressants tried, or antidepressants changed. Norepinephrine reuptake inhibitor (NRIs) can be used as antidepressants. Selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft, Lustral), escitalopram (Lexapro, Cipralex), fluoxetine (Prozac), paroxetine (Seroxat), and citalopram, are the primary medications considered, due to their relatively mild side effects and broad effect on the symptoms of depression and anxiety, as well as reduced risk in overdose, compared to their older tricyclic alternatives. Those who do not respond to the first SSRI tried can be switched to another. If sexual dysfunction is present prior to the onset of depression, SSRIs should be avoided. Another popular option is to switch to the atypical antidepressant bupropion (Wellbutrin) or to add bupropion to the existing therapy; this strategy is possibly more effective. It is not uncommon for SSRIs to cause or worsen insomnia; the sedating noradrenergic and specific serotonergic antidepressant (NaSSA) antidepressant mirtazapine (Zispin, Remeron) can be used in such cases. CBT for Insomnia can also help to alleviate the insomnia without additional medication. Venlafaxine (Effexor) from the SNRI class may be moderately more effective than SSRIs; however, it is not recommended as a first-line treatment because of the higher rate of side effects, and its use is specifically discouraged in children and adolescents. Fluoxetine is the only antidepressant recommended for people under the age of 18, though, if a child or adolescent patient is intolerant to fluoxetine, another SSRI may be considered. Evidence of effectiveness of SSRIs in those with depression complicated by dementia is lacking.

Tricyclic antidepressants (TCAs) have more side effects than SSRIs (but less sexual dysfunctions) and are usually reserved for the treatment of inpatients, for whom the tricyclic antidepressant amitriptyline, in particular, appears to be more effective. A different class of antidepressants, the monoamine oxidase inhibitors, have historically been plagued by questionable efficacy (although early studies used dosages now considered too low) and life-threatening adverse effects. They are still used only rarely, although newer agents of this class (RIMA), with a better side effect profile, have been developed.

In older patients TCAs and SSRIs are of the same efficacy. However, there are differences between TCA related antidepressants and classical TCAs in terms of side effect profiles and withdrawal when compared to SSRIs.

There is evidence a prominent side-effect of antidepressants, emotional blunting, is confused with a symptom of depression itself. The cited study, according to Professor Linda Gask was: ‘funded by a pharmaceutical company (Servier) and two of its authors are employees of that company’, which may bias the results. The study authors’ note: “emotional blunting is reported by nearly half of depressed patients on antidepressants and that it appears to be common to all monoaminergic antidepressants not only SSRIs”. Additionally, they note: “The OQuESA scores are highly correlated with the HAD depression score; emotional blunting cannot be described simply as a side-effect of antidepressant, but also as a symptom of depression…More emotional blunting is associated with a poorer quality of remission…”

Acetyl-l-Carnitine

Acetylcarnitine levels were lower in depressed patients than controls and in rats it causes rapid antidepressant effects through epigenetic mechanisms. A systematic review and meta-analysis of 12 randomised controlled trials found “supplementation significantly decreases depressive symptoms compared with placebo/no intervention, while offering a comparable effect with that of established antidepressant agents with fewer adverse effects.”

Zinc

A 2012 cross-sectional study found an association between zinc deficiency and depressive symptoms among women, but not men, and a 2013 meta-analysis of 17 observational studies found that blood zinc concentrations were lower in depressed subjects than in control subjects. A 2012 meta-analysis found that zinc supplementation as an adjunct to antidepressant drug treatment significantly lowered depressive symptom scores of depressed patients. The potential mechanisms underlying the association between low serum zinc and depression remain unclear, but may involve the regulation of neurotransmitter, endocrine and neurogenesis pathways. Zinc supplementation has been reported to improve symptoms of ADHD and depression. A 2013 review found that zinc supplementation may be an effective treatment in major depression.

Magnesium

Many studies have found an association between magnesium intake and depression. Magnesium was lower in serum of depressed patients than controls. One trial found magnesium chloride to be effective for depression in seniors with type 2 diabetes while another trial found magnesium citrate decreased depression in patients with fibromyalgia. One negative trial used magnesium oxide, which is poorly absorbed. A randomised, open-label study found that consumption of magnesium chloride for 6 weeks resulted in a clinically significant net improvement in depression, and that effects were observed within 2 weeks.

Augmentation

Physicians often add a medication with a different mode of action to bolster the effect of an antidepressant in cases of treatment resistance; a 2002 large community study of 244,859 depressed Veterans Administration patients found that 22% had received a second agent, most commonly a second antidepressant. Lithium has been used to augment antidepressant therapy in those who have failed to respond to antidepressants alone. Furthermore, lithium dramatically decreases the suicide risk in recurrent depression. Addition of atypical antipsychotics when the patient has not responded to an antidepressant is also known to increase the effectiveness of antidepressant drugs, albeit at the cost of more frequent and potentially serious side effects. There is some evidence for the addition of a thyroid hormone, triiodothyronine, in patients with normal thyroid function. Stephen M. Stahl, renowned academician in psychopharmacology, has stated resorting to a dynamic psychostimulant, in particular, d-amphetamine is the “classical augmentation strategy for treatment-refractory depression”. However, the use of stimulants in cases of treatment-resistant depression is relatively controversial.

Efficacy of Medication and Psychotherapy

Antidepressants are statistically superior to placebo but their overall effect is low-to-moderate. In that respect they often did not exceed the National Institute for Health and Clinical Excellence (NICE) criteria for a “clinically significant” effect. In particular, the effect size was very small for moderate depression but increased with severity, reaching “clinical significance” for very severe depression. These results were consistent with the earlier clinical studies in which only patients with severe depression benefited from either psychotherapy or treatment with an antidepressant, imipramine, more than from the placebo treatment. Despite obtaining similar results, the authors argued about their interpretation. One author concluded that there “seems little evidence to support the prescription of antidepressant medication to any but the most severely depressed patients, unless alternative treatments have failed to provide benefit.” The other author agreed that “antidepressant ‘glass’ is far from full” but disagreed “that it is completely empty”. He pointed out that the first-line alternative to medication is psychotherapy, which does not have superior efficacy.

Antidepressants in general are as effective as psychotherapy for major depression, and this conclusion holds true for both severe and mild forms of MDD. In contrast, medication gives better results for dysthymia. The subgroup of SSRIs may be slightly more efficacious than psychotherapy. On the other hand, significantly more patients drop off from the antidepressant treatment than from psychotherapy, likely because of the side effects of antidepressants. Successful psychotherapy appears to prevent the recurrence of depression even after it has been terminated or replaced by occasional “booster” sessions. The same degree of prevention can be achieved by continuing antidepressant treatment.

Two studies suggest that the combination of psychotherapy and medication is the most effective way to treat depression in adolescents. Both TADS (Treatment of Adolescents with Depression Study) and TORDIA (Treatment of Resistant Depression in Adolescents) showed very similar results. TADS resulted in 71% of their teen subjects having “much” or “very much” improvement in mood over the 61% with medication alone and 43% with CBT alone. Similarly, TORDIA showed a 55% improvement with CBT and drugs versus a 41% with drug therapy alone. However, a more recent meta-analysis of 34 trials of 14 drugs used with children and adolescents found that only fluoxetine produced significant benefit compared to placebo, with a medium sized effect (standardize mean difference = .5).

Treatment Resistance

The risk factors for treatment resistant depression are: the duration of the episode of depression, severity of the episode, if bipolar, lack of improvement in symptoms within the first couple of treatment weeks, anxious or avoidant and borderline comorbidity and old age. Treatment resistant depression is best handled with a combination of conventional antidepressant together with atypical antipsychotics. Another approach is to try different antidepressants. It is inconclusive which approach is superior. Treatment resistant depression can be misdiagnosed if subtherapeutic doses of antidepressants is the case, patient nonadherence, intolerable adverse effects or their thyroid disease or other conditions is misdiagnosed as depression.

Experimental Treatments

Chromium

Clinical and experimental studies have reported antidepressant activity of chromium particularly in atypical depression, characterised by increased appetite and carbohydrate craving.

Essential Fatty Acids

A 2015 Cochrane Collaboration review found insufficient evidence with which to determine if omega-3 fatty acid has any effect on depression. A 2016 review found that if trials with formulations containing mostly eicosapentaenoic acid (EPA) are separated from trials using formulations containing docosahexaenoic acid (DHA), it appeared that EPA may have an effect while DHA may not, but there was insufficient evidence to be sure.

Creatine

The amino acid creatine, commonly used as a supplement to improve the performance of bodybuilders, has been studied for its potential antidepressant properties. A double-blinded, placebo-controlled trial focusing on women with major depressive disorder found that daily creatine supplementation adjunctive to escitalopram was more effective than escitalopram alone. Studies on mice have found that the antidepressant effects of creatine can be blocked by drugs that act against dopamine receptors, suggesting that the drug acts on dopamine pathways.

Dopamine Receptor Agonist

Some research suggests dopamine receptor agonist may be effective in treating depression, however studies are few and results are preliminary.

Inositol

Inositol, an alcohol sugar found in fruits, beans grains and nuts may have antidepressant effects in high doses. Inositol may exert its effects by altering intracellular signalling.

Ketamine

Research on the antidepressant effects of ketamine infusions at subanaesthetic doses has consistently shown rapid (4 to 72 hours) responses from single doses, with substantial improvement in mood in the majority of patients and remission in some. However, these effects are often short-lived, and attempts to prolong the antidepressant effect with repeated doses and extended (“maintenance”) treatment have resulted in only modest success.

N-Acetylcysteine

A systematic review and meta-analysis of 5 studies found that N-Acetylcysteine reduces depressive symptoms more than placebo and has good tolerability. N-Acetylecysteine may exert benefits as a precursor to the antioxidant glutathione, thus modulating glutamatergic, neurotropic, and inflammatory pathways.

St John’s Wort

A 2008 Cochrane Collaboration meta-analysis concluded that:

“The available evidence suggests that the hypericum extracts tested in the included trials a) are superior to placebo in patients with major depression; b) are similarly effective as standard antidepressants; c) and have fewer side effects than standard antidepressants. The association of country of origin and precision with effects sizes complicates the interpretation.”

The United States National Centre for Complementary and Integrative Health advice is that “St. John’s wort may help some types of depression, similar to treatment with standard prescription antidepressants, but the evidence is not definitive.” and warns that “Combining St. John’s wort with certain antidepressants can lead to a potentially life-threatening increase of serotonin, a brain chemical targeted by antidepressants. St. John’s wort can also limit the effectiveness of many prescription medicines.”

Rhodiola Rosea

A 2011 review reported Rhodiola rosea “is an adaptogen plant that can be especially helpful in treating asthenic or lethargic depression, and may be combined with conventional antidepressants to alleviate some of their common side effects.” A 6 week double-blind, placebo-controlled, randomised study with 89 patients with mild to moderate depression found that R. rosea statistically significantly reduced depression symptoms, and no side effects were reported.

Saffron

A 2013 meta-analysis found that saffron supplementation significantly reduced depression symptoms compared to placebo, and both saffron supplementation and the antidepressant groups were similarly effective in reducing depression symptoms. A 2015 meta-analysis supported the “efficacy of saffron as compared to placebo in improving the following conditions: depressive symptoms (compared to anti-depressants and placebo), premenstrual symptoms, and sexual dysfunction. In addition, saffron use was also effective in reducing excessive snacking behavior.” The antidepressant effect of saffron stigma extracts may be mediated via its components safranal and crocin: “crocin may act via the uptake inhibition of dopamine and norepinephrine, and safranal via serotonin.” Therapeutic doses of saffron exhibits no significant toxicity in both clinical and experimental investigations.

SAMe

S-Adenosyl methionine (SAMe) is available as a prescription antidepressant in Europe and an over-the-counter dietary supplement in the US. Evidence from 16 clinical trials with a small number of subjects, reviewed in 1994 and 1996 suggested it to be more effective than placebo and as effective as standard antidepressant medication for the treatment of major depression.

Tryptophan and 5-HTP

The amino acid tryptophan is converted into 5-hydroxytryptophan (5-HTP) which is subsequently converted into the neurotransmitter serotonin. Since serotonin deficiency has been recognized as a possible cause of depression, it has been suggested that consumption of tryptophan or 5-HTP may therefore improve depression symptoms by increasing the level of serotonin in the brain. 5-HTP and tryptophan are sold over the counter in North America, but requires a prescription in Europe. The use of 5-HTP instead of tryptophan bypasses the conversion of tryptophan into 5-HTP by the enzyme tryptophan hydroxylase, which is the rate-limiting step in the synthesis of serotonin, and 5-HTP easily crosses the blood–brain barrier unlike tryptophan, which requires a transporter.

Small studies have been performed using 5-HTP and tryptophan as adjunctive therapy in addition to standard treatment for depression. While some studies had positive results, they were criticised for having methodological flaws, and a more recent study did not find sustained benefit from their use. The safety of these medications has not been well studied. Due to the lack of high quality studies, preliminary nature of studies showing effectiveness, the lack of adequate study on their safety, and reports of Eosinophilia-myalgia syndrome from contaminated tryptophan in 1989 and 1990, the use of tryptophan and 5-HTP is not highly recommended or thought to be clinically useful.

Medical Devices

A variety of medical devices are in use or under consideration for treatment of depression including devices that offer electroconvulsive therapy, vagus nerve stimulation, repetitive transcranial magnetic stimulation, and cranial electrotherapy stimulation. The use of such devices in the United States requires approval by the US Food and Drug Administration (FDA) after field trials. In 2010 an FDA advisory panel considered the question of how such field trials should be managed. Factors considered were whether drugs had been effective, how many different drugs had been tried, and what tolerance for suicides should be in field trials.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is a standard psychiatric treatment in which seizures are electrically induced in patients to provide relief from psychiatric illnesses. ECT is used with informed consent as a last line of intervention for major depressive disorder. Among the elderly, who often experience depression, the efficacy of ECT is difficult to determine due to the lack of trials comparing ECT to other treatments.

A round of ECT is effective for about 50% of people with treatment-resistant major depressive disorder, whether it is unipolar or bipolar. Follow-up treatment is still poorly studied, but about half of people who respond, relapse with twelve months.

Aside from effects in the brain, the general physical risks of ECT are similar to those of brief general anaesthesia. Immediately following treatment, the most common adverse effects are confusion and memory loss. ECT is considered one of the least harmful treatment options available for severely depressed pregnant women.

A usual course of ECT involves multiple administrations, typically given two or three times per week until the patient is no longer suffering symptoms ECT is administered under anaesthetic with a muscle relaxant. Electroconvulsive therapy can differ in its application in three ways: electrode placement, frequency of treatments, and the electrical waveform of the stimulus. These three forms of application have significant differences in both adverse side effects and symptom remission. After treatment, drug therapy is usually continued, and some patients receive maintenance ECT.

ECT appears to work in the short term via an anticonvulsant effect mostly in the frontal lobes, and longer term via neurotrophic effects primarily in the medial temporal lobe.

Deep Brain Stimulation

The support for the use of deep brain stimulation in treatment-resistant depression comes from a handful of case studies, and this treatment is still in a very early investigational stage. In this technique electrodes are implanted in a specific region of the brain, which is then continuously stimulated. A March 2010 systematic review found that “about half the patients did show dramatic improvement” and that adverse events were “generally trivial” given the younger psychiatric patient population than with movements disorders. Deep brain stimulation is available on an experimental basis only in the United States; no systems are approved by the FDA for this use. It is available in Australia.

Repetitive Transcranial Magnetic Stimulation

Transcranial magnetic stimulation (TMS) or deep transcranial magnetic stimulation is a non-invasive method used to stimulate small regions of the brain. During a TMS procedure, a magnetic field generator, or “coil” is placed near the head of the person receiving the treatment. The coil produces small electric currents in the region of the brain just under the coil via electromagnetic induction. The coil is connected to a pulse generator, or stimulator, that delivers electric current to the coil.

TMS was approved by the FDA for treatment-resistant major depressive disorder in 2008 and as of 2014 clinical evidence supports this use. The American Psychiatric Association, the Canadian Network for Mood and Anxiety Disorders, and the Royal Australia and New Zealand College of Psychiatrists have endorsed rTMS for trMDD.

Vagus Nerve Stimulation

Vagus nerve stimulation (VNS) uses an implanted electrode and generator to deliver electrical pulses to the vagus nerve, one of the primary nerves emanating from the brain. It is an approved therapy for treatment-resistant depression in the EU and US and is sometimes used as an adjunct to existing antidepressant treatment. The support for this method comes mainly from open-label trials, which indicate that several months may be required to see a benefit. The only large double-blind trial conducted lasted only 10 weeks and yielded inconclusive results; VNS failed to show superiority over a sham treatment on the primary efficacy outcome, but the results were more favourable for one of the secondary outcomes. The authors concluded “This study did not yield definitive evidence of short-term efficacy for adjunctive VNS in treatment-resistant depression.”

Cranial Electrotherapy Stimulation

A 2014 Cochrane review found insufficient evidence to determine whether or not Cranial electrotherapy stimulation with alternating current is safe and effective for treating depression.

Transcranial Direct Current Stimulation

A 2016 meta-analysis of transcranial direct current stimulation (tDCS) reported some efficacy of tDCS in the treatment of acute depressive disorder with moderate effect size, and low efficacy in treatment-resistant depression, and that use of 2 mA current strength over 20 minutes per day over a short time span can be considered safe.

Other Treatments

Bright Light Therapy

A meta-analysis of bright light therapy commissioned by the American Psychiatric Association found a significant reduction in depression symptom severity associated with bright light treatment. Benefit was found for both seasonal affective disorder and for non-seasonal depression, with effect sizes similar to those for conventional antidepressants. For non-seasonal depression, adding light therapy to the standard antidepressant treatment was not effective. A meta-analysis of light therapy for non-seasonal depression conducted by Cochrane Collaboration, studied a different set of trials, where light was used mostly in combination with antidepressants or wake therapy. A moderate statistically significant effect of light therapy was found, with response significantly better than control treatment in high-quality studies, in studies that applied morning light treatment, and with patients who respond to total or partial sleep deprivation. Both analyses noted poor quality of most studies and their small size, and urged caution in the interpretation of their results. The short 1-2 weeks duration of most trials makes it unclear whether the effect of light therapy could be sustained in the longer term.

Exercise

The 2013 Cochrane Collaboration review on physical exercise for depression noted that, based upon limited evidence, it is moderately more effective than a control intervention and comparable to psychological or antidepressant drug therapies. Smaller effects were seen in more methodologically rigorous studies. Three subsequent 2014 systematic reviews that included the Cochrane review in their analysis concluded with similar findings: one indicated that physical exercise is effective as an adjunct treatment with antidepressant medication; the other two indicated that physical exercise has marked antidepressant effects and recommended the inclusion of physical activity as an adjunct treatment for mild-moderate depression and mental illness in general. These studies also found smaller effect sizes in more methodologically rigorous studies. All four systematic reviews called for more research in order to determine the efficacy or optimal exercise intensity, duration, and modality. The evidence for brain-derived neurotrophic factor (BDNF) in mediating some of the neurobiological effects of physical exercise was noted in one review which hypothesized that increased BDNF signalling is responsible for the antidepressant effect.

Meditation

Mindfulness meditation programs may help improve symptoms of depression, but they are no better than active treatments such as medication, exercise, and other behavioural therapies.

Music Therapy

A 2009 review found that 3 to 10 sessions of music therapy resulted in a noticeable improvement in depressive symptoms, with still greater improvement after 16 to 51 sessions.

Sleep

Depression is sometimes associated with insomnia – (difficulty in falling asleep, early waking, or waking in the middle of the night). The combination of these two results, depression and insomnia, will only worsen the situation. Hence, good sleep hygiene is important to help break this vicious circle. It would include measures such as regular sleep routines, avoidance of stimulants such as caffeine and management of sleeping disorders such as sleep apnoea.

Smoking Cessation

Quitting smoking cigarettes is associated with reduced depression and anxiety, with the effect “equal or larger than” those of antidepressant treatments.

Total/Partial Sleep Deprivation

Sleep deprivation (skipping a night’s sleep) has been found to improve symptoms of depression in 40-60% of patients. Partial sleep deprivation in the second half of the night may be as effective as an all night sleep deprivation session. Improvement may last for weeks, though the majority (50-80%) relapse after recovery sleep. Shifting or reduction of sleep time, light therapy, antidepressant drugs, and lithium have been found to potentially stabilise sleep deprivation treatment effects.

Shared Care

Shared care, when primary and specialty physicians have joint management of an individual’s health care, has been shown to alleviate depression outcomes.

On This Day … 09 April

Published on 04/09/202104/04/2021 by Andrew MarshallLeave a comment

People (Births)

1930 – Nathaniel Branden, Canadian-American psychotherapist and author (d. 2014).

Nathaniel Branden

Nathaniel Branden (born Nathan Blumenthal; 09 April 1930 to 03 December 2014) was a Canadian-American psychotherapist and writer known for his work in the psychology of self-esteem. A former associate and romantic partner of Ayn Rand, Branden also played a prominent role in the 1960s in promoting Rand’s philosophy, Objectivism. Rand and Branden split acrimoniously in 1968, after which Branden focused on developing his own psychological theories and modes of therapy.

Early Life and Education

Nathaniel Branden was born Nathan Blumenthal in Brampton, Ontario, and grew up alongside three sisters, two older and one younger. A gifted student, he became impatient with his studies during his first year of high school and skipped school often in favour of the library. After getting failing grades as a result, he convinced his mother to send him to a special accelerated high school for adults, and subsequently did well in that environment.

After graduating from high school, Branden went on to earn his BA in psychology from the University of California Los Angeles, an MA from New York University, and in 1973, a Ph.D. in psychology from the California Graduate Institute (CGI), then an unaccredited, state-approved school whose graduates may be licensed by the state to practice psychology (Graduates of unaccredited state-approved schools such as CGI are limited to associate membership in the American Psychological Association).

Objectivist Movement

In 1950, after he had read The Fountainhead and exchanged letters and phone calls with Ayn Rand, Branden and his then-girlfriend Barbara Weidman visited Rand and her husband Frank O’Connor at their Los Angeles home. The four became close friends, with Branden and Rand in particular sharing a vivid interest in philosophical exploration and development. After the publication of Rand’s novel Atlas Shrugged, Branden sensed an interest on the part of Rand’s readers in further philosophic education. In 1958 he created the Nathaniel Branden Lectures, later renamed the Nathaniel Branden Institute (NBI). The organization disseminated Rand’s philosophy of Objectivism by offering live and taped lecture courses by a variety of Objectivist intellectuals, including Rand, Branden, and Alan Greenspan, whom Branden had brought into Rand’s fold. During this time, Branden also contributed articles to Rand’s newsletters on subjects ranging from economics to politics to psychology. Branden’s work at NBI included translating the principles expressed by Rand in her fiction and non-fiction writing into a systematised construct that became known as Objectivism.

NBI expanded considerably over the course of its existence, ultimately offering courses in 80 cities and establishing an office in the Empire State Building. In 1968, Rand publicly broke with Branden and published an article denouncing him and accusing him of a variety of offenses, such as philosophic irrationality and unresolved psychological problems. In response, Branden sent out a letter to the NBI mailing list denying Rand’s accusations and suggesting that the actual cause of Rand’s denunciation of him was his unwillingness to engage in a romantic relationship with her (Branden later explained in his memoir that he and Rand had in fact been romantically intimate for a period of time in the late 1950s; see personal life).

After the break, Branden went on to publish The Psychology of Self-Esteem (many chapters of which he had published originally in Rand’s newsletter), and then to develop his theory and mode of therapy more independently of Rand’s influence. Though he remained supportive of the broad essentials of Rand’s philosophy, he eventually offered criticisms of aspects of her work, naming as problems a tendency to encourage emotional repression and moralizing, a failure to understand psychology beyond its cognitive aspects, and a failure to appreciate adequately the importance of kindness in human relationships. He also apologised in an interview to “every student of Objectivism” for “perpetuating the Ayn Rand mystique” and for “contributing to that dreadful atmosphere of intellectual repressiveness that pervades the Objectivist movement.”

Psychology of Self-Esteem

Branden argued that self-esteem is a human psychological need and that to the extent this need remains unmet, pathology (defensiveness, anxiety, depression, difficulty in relationships, etc.) tends to result. He defined self-esteem formally as “the disposition to experience oneself as competent to cope with the basic challenges of life and as worthy of happiness”, and proposed that, while others (parents, teachers, friends) can nurture and support self-esteem in an individual, self-esteem also relies upon various internally generated practices. These consisted, in Branden’s framework, of six “pillars” of self-esteem:

Living consciously: the practice of being aware of what one is doing while one is doing it, i.e. the practice of mindfulness.
Self-acceptance: the practice of owning truths regarding one’s thoughts, emotions, and behaviours; of being kind toward oneself with respect to them; and of being “for” oneself in a basic sense.
Self-responsibility: the practice of owning one’s authorship of one’s actions and of owning one’s capacity to be the cause of the effects one desires.
Self-assertiveness: the practice of treating one’s needs and interests with respect and of expressing them in appropriate ways.
Living purposefully: the practice of formulating goals and of formulating and implementing action plans to achieve them.
Personal integrity: the practice of maintaining alignment between one’s behaviours and convictions.

In his book Taking Responsibility Branden defended voluntarism as a moral concept and libertarianism as a political one; likewise, individualism and personal autonomy are seen as essential to human freedom.

Branden distinguished his approach to self-esteem from that of many others by his inclusion of both confidence and worth in his definition of self-esteem, and by his emphasis on the importance of internally generated practices for the improvement and maintenance of self-esteem. For this reason, he at times expressed lack of enthusiasm about the teachings of the “self-esteem movement”, which he is sometimes credited with having spawned (he was sometimes referred to as “the father of the self-esteem movement”).

Mode of Therapy

While Branden began his practice of therapy as, primarily, a cognitivist, starting in the 1970s he rapidly shifted toward a decidedly technically eclectic stance, utilising techniques from gestalt therapy, psychodrama, neo-Reichian breathwork, Ericksonian hypnosis, as well as original techniques such as his sentence completion method, which he favoured. In a piece from 1973, he characterised his mode of therapy as consisting of four aspects: education, emotional unblocking, stimulation of insight, and encouragement of behaviour change. In contrast to the exclusively experiential or exclusively cognitive (insight-oriented) methods of the day, Branden saw his mode of therapy as distinguished in part by “the integration of the emotional and the cognitive, the practice of constantly moving back and forth between the experiential and the conceptual.”

Sentence completion, a method that figured prominently in Branden’s mode of therapy, is an example of this dual focus. In its most common variation, it consists of a therapist giving a client an incomplete sentence – a sentence stem – and having the client repeat the sentence stem over and over, each time adding a new ending, going quickly, without thinking or censoring, and inventing endings when stuck. In this way, a therapist can facilitate the generation of awareness and insight (for example, with a stem such as, “If my fear could speak, it might say—”), and shifts in cognitive-motivational structure (for example, with a stem such as, “If I were to be kinder to myself when I’m afraid—”). By improvising a succession of such stems, many based on endings generated by a previous stem, a therapist can, according to Branden, lead a client on a sometimes dramatically emotional journey of self exploration and self-discovery.

Eventually, Branden integrated techniques from the field of energy psychology, such as Thought Field Therapy and Seemorg Matrix work, into his practice, viewing psychological trauma (which such techniques target) as a significant barrier to growth and development. He has described human problems as occurring both “above the line” – that is, in the realm of cognition and volitional behaviour – and “below the line” – that is, in the realm of unconscious trauma stored in the body.

What is Family Therapy?

Published on 04/05/2021 by Andrew Marshall3 Comments

Introduction

Family therapy, also referred to as couple and family therapy, marriage and family therapy, family systems therapy, and family counselling, is a branch of psychotherapy that works with families and couples in intimate relationships to nurture change and development. It tends to view change in terms of the systems of interaction between family members.

The different schools of family therapy have in common a belief that, regardless of the origin of the problem, and regardless of whether the clients consider it an “individual” or “family” issue, involving families in solutions often benefits clients. This involvement of families is commonly accomplished by their direct participation in the therapy session. The skills of the family therapist thus include the ability to influence conversations in a way that catalyses the strengths, wisdom, and support of the wider system.

In the field’s early years, many clinicians defined the family in a narrow, traditional manner usually including parents and children. As the field has evolved, the concept of the family is more commonly defined in terms of strongly supportive, long-term roles and relationships between people who may or may not be related by blood or marriage.

The conceptual frameworks developed by family therapists, especially those of family systems theorists, have been applied to a wide range of human behaviour, including organisational dynamics and the study of greatness.

Brief History and Theoretical Frameworks

Formal interventions with families to help individuals and families experiencing various kinds of problems have been a part of many cultures, probably throughout history. These interventions have sometimes involved formal procedures or rituals, and often included the extended family as well as non-kin members of the community (see for example Ho’oponopono). Following the emergence of specialisation in various societies, these interventions were often conducted by particular members of a community – for example, a chief, priest, physician, and so on – usually as an ancillary function.

Family therapy as a distinct professional practice within Western cultures can be argued to have had its origins in the social work movements of the 19th century in the United Kingdom and the United States. As a branch of psychotherapy, its roots can be traced somewhat later to the early 20th century with the emergence of the child guidance movement and marriage counselling. The formal development of family therapy dates from the 1940s and early 1950s with the founding in 1942 of the American Association of Marriage Counsellors (the precursor of the AAMFT), and through the work of various independent clinicians and groups – in the United Kingdom (John Bowlby at the Tavistock Clinic), the United States (Donald deAvila Jackson, John Elderkin Bell, Nathan Ackerman, Christian Midelfort, Theodore Lidz, Lyman Wynne, Murray Bowen, Carl Whitaker, Virginia Satir, Ivan Boszormenyi-Nagy), and in Hungary, D.L.P. Liebermann – who began seeing family members together for observation or therapy sessions. There was initially a strong influence from psychoanalysis (most of the early founders of the field had psychoanalytic backgrounds) and social psychiatry, and later from learning theory and behaviour therapy – and significantly, these clinicians began to articulate various theories about the nature and functioning of the family as an entity that was more than a mere aggregation of individuals.

The movement received an important boost starting in the early 1950s through the work of anthropologist Gregory Bateson and colleagues – Jay Haley, Donald D. Jackson, John Weakland, William Fry, and later, Virginia Satir, Ivan Boszormenyi-Nagy, Paul Watzlawick and others – at Palo Alto in the United States, who introduced ideas from cybernetics and general systems theory into social psychology and psychotherapy, focusing in particular on the role of communication (refer to Bateson Project). This approach eschewed the traditional focus on individual psychology and historical factors – that involve so-called linear causation and content – and emphasized instead feedback and homeostatic mechanisms and “rules” in here-and-now interactions – so-called circular causation and process – that were thought to maintain or exacerbate problems, whatever the original cause(s). This group was also influenced significantly by the work of US psychiatrist, hypnotherapist, and brief therapist, Milton H. Erickson – especially his innovative use of strategies for change, such as paradoxical directives. The members of the Bateson Project (like the founders of a number of other schools of family therapy, including Carl Whitaker, Murray Bowen, and Ivan Boszormenyi-Nagy) had a particular interest in the possible psychosocial causes and treatment of schizophrenia, especially in terms of the putative “meaning” and “function” of signs and symptoms within the family system. The research of psychiatrists and psychoanalysts Lyman Wynne and Theodore Lidz on communication deviance and roles (e.g. pseudo-mutuality, pseudo-hostility, schism and skew) in families of people with schizophrenia also became influential with systems-communications-oriented theorists and therapists. A related theme, applying to dysfunction and psychopathology more generally, was that of the “identified patient” or “presenting problem” as a manifestation of or surrogate for the family’s, or even society’s, problems (refer to Double Bind).

By the mid-1960s, a number of distinct schools of family therapy had emerged. From those groups that were most strongly influenced by cybernetics and systems theory, there came MRI Brief Therapy, and slightly later, strategic therapy, Salvador Minuchin’s Structural Family Therapy and the Milan systems model. Partly in reaction to some aspects of these systemic models, came the experiential approaches of Virginia Satir and Carl Whitaker, which downplayed theoretical constructs, and emphasized subjective experience and unexpressed feelings (including the subconscious), authentic communication, spontaneity, creativity, total therapist engagement, and often included the extended family. Concurrently and somewhat independently, there emerged the various intergenerational therapies of Murray Bowen, Ivan Boszormenyi-Nagy, James Framo, and Norman Paul, which present different theories about the intergenerational transmission of health and dysfunction, but which all deal usually with at least three generations of a family (in person or conceptually), either directly in therapy sessions, or via “homework”, “journeys home”, etc. Psychodynamic family therapy – which, more than any other school of family therapy, deals directly with individual psychology and the unconscious in the context of current relationships – continued to develop through a number of groups that were influenced by the ideas and methods of Nathan Ackerman, and also by the British School of Object Relations and John Bowlby’s work on attachment. Multiple-family group therapy, a precursor of psychoeducational family intervention, emerged, in part, as a pragmatic alternative form of intervention – especially as an adjunct to the treatment of serious mental disorders with a significant biological basis, such as schizophrenia – and represented something of a conceptual challenge to some of the “systemic” (and thus potentially “family-blaming”) paradigms of pathogenesis that were implicit in many of the dominant models of family therapy. The late-1960s and early-1970s saw the development of network therapy (which bears some resemblance to traditional practices such as Ho’oponopono) by Ross Speck and Carolyn Attneave, and the emergence of behavioural marital therapy (renamed behavioural couples therapy in the 1990s; see also relationship counselling) and behavioural family therapy as models in their own right.

By the late-1970s, the weight of clinical experience – especially in relation to the treatment of serious mental disorders – had led to some revision of a number of the original models and a moderation of some of the earlier stridency and theoretical purism. There were the beginnings of a general softening of the strict demarcations between schools, with moves toward rapprochement, integration, and eclecticism – although there was, nevertheless, some hardening of positions within some schools. These trends were reflected in and influenced by lively debates within the field and critiques from various sources, including feminism and post-modernism, that reflected in part the cultural and political tenor of the times, and which foreshadowed the emergence (in the 1980s and 1990s) of the various “post-systems” constructivist and social constructionist approaches. While there was still debate within the field about whether, or to what degree, the systemic-constructivist and medical-biological paradigms were necessarily antithetical to each other (refer to Anti-psychiatry; Biopsychosocial model), there was a growing willingness and tendency on the part of family therapists to work in multi-modal clinical partnerships with other members of the helping and medical professions.

From the mid-1980s to the present, the field has been marked by a diversity of approaches that partly reflect the original schools, but which also draw on other theories and methods from individual psychotherapy and elsewhere – these approaches and sources include: brief therapy, structural therapy, constructivist approaches (e.g. Milan systems, post-Milan/collaborative/conversational, reflective), Bring forthism approach (e.g. Dr. Karl Tomm’s IPscope model and Interventive interviewing), solution-focused therapy, narrative therapy, a range of cognitive and behavioural approaches, psychodynamic and object relations approaches, attachment and emotionally focused therapy, intergenerational approaches, network therapy, and multi-systemic therapy (MST). Multicultural, intercultural, and integrative approaches are being developed, with Vincenzo Di Nicola weaving a synthesis of family therapy and transcultural psychiatry in his model of cultural family therapy, A Stranger in the Family: Culture, Families, and Therapy. Many practitioners claim to be “eclectic”, using techniques from several areas, depending upon their own inclinations and/or the needs of the client(s), and there is a growing movement toward a single “generic” family therapy that seeks to incorporate the best of the accumulated knowledge in the field and which can be adapted to many different contexts; however, there are still a significant number of therapists who adhere more or less strictly to a particular, or limited number of, approach(es).

The Liberation Based Healing framework for family therapy offers a complete paradigm shift for working with families while addressing the intersections of race, class, gender identity, sexual orientation and other socio-political identity markers. This theoretical approach and praxis is informed by Critical Pedagogy, Feminism, Critical Race Theory, and Decolonising Theory. This framework necessitates an understanding of the ways Colonisation, Cis-Heteronormativity, Patriarchy, White Supremacy and other systems of domination impact individuals, families and communities and centres the need to disrupt the status quo in how power operates. Traditional Western models of family therapy have historically ignored these dimensions and when white, male privilege has been critiqued, largely by feminist theory practitioners, it has often been to the benefit of middle class, white women’s experiences. While an understanding of intersectionality is of particular significance in working with families with violence, a liberatory framework examines how power, privilege and oppression operate within and across all relationships. Liberatory practices are based on the principles of Critical-Consciousness, Accountability and Empowerment. These principles guide not only the content of the therapeutic work with clients but also the supervisory and training process of therapists. Dr. Rhea Almeida, developed the Cultural Context Model as a way to operationalize these concepts into practice through the integration of culture circles, sponsors, and a socio-educational process within the therapeutic work.

Ideas and methods from family therapy have been influential in psychotherapy generally: a survey of over 2,500 US therapists in 2006 revealed that of the 10 most influential therapists of the previous quarter-century, three were prominent family therapists and that the marital and family systems model was the second most utilised model after cognitive behavioural therapy.

Techniques

Family therapy uses a range of counselling and other techniques including:

Structural therapy – identifies and re-orders the organisation of the family system.
Strategic therapy – looks at patterns of interactions between family members.
Systemic/Milan therapy – focuses on belief systems.
Narrative therapy – restoring of dominant problem-saturated narrative, emphasis on context, separation of the problem from the person.
Transgenerational therapy – transgenerational transmission of unhelpful patterns of belief and behaviour.
IPscope model and Interventive Interviewing.
Communication theory.
Psychoeducation.
Psychotherapy.
Relationship counselling.
Relationship education.
Systemic coaching.
Systems theory.
Reality therapy.
The genogram.

The number of sessions depends on the situation, but the average is 5-20 sessions. A family therapist usually meets several members of the family at the same time. This has the advantage of making differences between the ways family members perceive mutual relations as well as interaction patterns in the session apparent both for the therapist and the family. These patterns frequently mirror habitual interaction patterns at home, even though the therapist is now incorporated into the family system. Therapy interventions usually focus on relationship patterns rather than on analysing impulses of the unconscious mind or early childhood trauma of individuals as a Freudian therapist would do – although some schools of family therapy, for example psychodynamic and intergenerational, do consider such individual and historical factors (thus embracing both linear and circular causation) and they may use instruments such as the genogram to help to elucidate the patterns of relationship across generations.

The distinctive feature of family therapy is its perspective and analytical framework rather than the number of people present at a therapy session. Specifically, family therapists are relational therapists: They are generally more interested in what goes on between individuals rather than within one or more individuals, although some family therapists – in particular those who identify as psychodynamic, object relations, intergenerational, or experiential family therapists (EFTs) – tend to be as interested in individuals as in the systems those individuals and their relationships constitute. Depending on the conflicts at issue and the progress of therapy to date, a therapist may focus on analysing specific previous instances of conflict, as by reviewing a past incident and suggesting alternative ways family members might have responded to one another during it, or instead proceed directly to addressing the sources of conflict at a more abstract level, as by pointing out patterns of interaction that the family might have not noticed.

Family therapists tend to be more interested in the maintenance and/or solving of problems rather than in trying to identify a single cause. Some families may perceive cause-effect analyses as attempts to allocate blame to one or more individuals, with the effect that for many families a focus on causation is of little or no clinical utility. It is important to note that a circular way of problem evaluation is used as opposed to a linear route. Using this method, families can be helped by finding patterns of behaviour, what the causes are, and what can be done to better their situation.

Summary of Theories and Techniques

Theoretical Model	Theorists	Summary	Techniques
Adlerian family therapy	Alfred Adler	Also known as “individual psychology”. Sees the person as a whole. Ideas include compensation for feelings of inferiority leading to striving for significance toward a fictional final goal with a private logic. Birth order and mistaken goals are explored to examine mistaken motivations of children and adults in the family constellation.	Psychoanalysis, typical day, reorienting, re-educating
Attachment theory	John Bowlby, Mary Ainsworth, Douglas Haldane	Individuals are shaped by their experiences with caregivers in the first three years of life. Used as a foundation for Object Relations Theory. The Strange Situation experiment with infants involves a systematic process of leaving a child alone in a room in order to assess the quality of their parental bond.	Psychoanalysis, play therapy
Bowenian family systems therapy	Murray Bowen, Betty Carter, Philip Guerin, Michael Kerr, Thomas Fogarty, Monica McGoldrick, Edwin Friedman, Daniel Papero	Also known as “intergenerational family therapy” (although there are also other schools of intergenerational family therapy). Family members are driven to achieve a balance of internal and external differentiation, causing anxiety, triangulation, and emotional cutoff. Families are affected by nuclear family emotional processes, sibling positions and multigenerational transmission patterns resulting in an undifferentiated family ego mass.	Detriangulation, non-anxious presence, genograms, coaching
Cognitive behavioural family therapy	John Gottman, Albert Ellis, Albert Bandura	Problems are the result of operant conditioning that reinforces negative behaviours within the family’s interpersonal social exchanges that extinguish desired behaviour and promote incentives toward unwanted behaviours. This can lead to irrational beliefs and a faulty family schema.	Therapeutic contracts, modelling, systematic desensitisation, shaping, charting, examining irrational beliefs
Collaborative language systems therapy	Harry Goolishian, Harlene Anderson, Tom Andersen, Lynn Hoffman, Peggy Penn	Individuals form meanings about their experiences within the context of social relationship on a personal and organisational level. Collaborative therapists help families reorganise and dis-solve their perceived problems through a transparent dialogue about inner thoughts with a “not-knowing” stance intended to illicit new meaning through conversation. Collaborative therapy is an approach that avoids a particular theoretical perspective in favour of a client-centred philosophical process.	Dialogical conversation, not knowing, curiosity, being public, reflecting teams
Communications approaches	Virginia Satir, John Banmen, Jane Gerber, Maria Gomori	All people are born into a primary survival triad between themselves and their parents where they adopt survival stances to protect their self-worth from threats communicated by words and behaviours of their family members. Experiential therapists are interested in altering the overt and covert messages between family members that affect their body, mind and feelings in order to promote congruence and to validate each person’s inherent self-worth.	Equality, modelling communication, family life chronology, family sculpting, metaphors, family reconstruction
Contextual therapy	Ivan Boszormenyi-Nagy	Families are built upon an unconscious network of implicit loyalties between parents and children that can be damaged when these “relational ethics” of fairness, trust, entitlement, mutuality and merit are breached.	Rebalancing, family negotiations, validation, filial debt repayment
Cultural family therapy	Vincenzo Di Nicola Key influences: Celia Falicov, Antonio Ferreira, James Framo, Edwin Friedman, Mara Selvini Palazzoli, Carlos Sluzki, Victor Turner, Michael White	A synthesis of systemic family therapy with cultural psychiatry to create cultural family therapy (CFT). CFT is an interweaving of stories (family predicaments expressed in narratives of family life) and tools (clinical methods for working with and making sense of these stories in cultural context). Integrates and synthesizes systemic therapy and cultural and medical anthropology with narrative therapy.	Conceptual tools for working across cultures – spirals, masks, roles, codes, cultural strategies, bridges, stories, multiple codes (metaphor and somatics), therapy as “story repair”
Emotion-focused therapy	Sue Johnson, Les Greenberg	Couples and families can develop rigid patterns of interaction based on powerful emotional experiences that hinder emotional engagement and trust. Treatment aims to enhance empathic capabilities of family members by exploring deep-seated habits and modifying emotional cues.	Reflecting, validation, heightening, reframing, restructuring
Experiential family therapy	Carl Whitaker, David Keith, Laura Roberto, Walter Kempler, John Warkentin, Thomas Malone, August Napier	Stemming from Gestalt foundations, change and growth occurs through an existential encounter with a therapist who is intentionally “real” and authentic with clients without pretence, often in a playful and sometimes absurd way as a means to foster flexibility in the family and promote individuation.	Battling, constructive anxiety, redefining symptoms, affective confrontation, co-therapy, humour
Family mode deactivation therapy (FMDT)	Jack A. Apsche	Target population adolescents with conduct and behavioural problems. Based on schema theory. Integrate mindfulness to focus family on the present. Validate core beliefs based on past experiences. Offer viable alternative responses. Treatment is based on case conceptualisation process; validate and clarify core beliefs, fears, triggers, and behaviours. Redirect behaviour by anticipating triggers and realigning beliefs and fears.	Cognitive behavioural therapy, mindfulness, acceptance and commitment therapy, dialectical behaviour therapy, defusion, validate-clarify-redirect
Family-of-origin therapy	James Framo	He developed an object relations approach to intergenerational and family-of-origin therapy.	Working with several generations of the family, family-of-origin approach with families in therapy and with trainees
Feminist family therapy	Sandra Bem Marianne Walters	Complications from social and political disparity between genders are identified as underlying causes of conflict within a family system. Therapists are encouraged to be aware of these influences in order to avoid perpetuating hidden oppression, biases and cultural stereotypes and to model an egalitarian perspective of healthy family relationships.	Demystifying, modelling, equality, personal accountability
Milan systemic family therapy	Luigi Boscolo, Gianfranco Cecchin, Mara Selvini Palazzoli, Giuliana Prata	A practical attempt by the “Milan Group” to establish therapeutic techniques based on Gregory Bateson’s cybernetics that disrupts unseen systemic patterns of control and games between family members by challenging erroneous family beliefs and reworking the family’s linguistic assumptions.	Hypothesizing, circular questioning, neutrality, counter-paradox
MRI brief therapy	Gregory Bateson, Milton Erickson, Heinz von Foerster	Established by the Mental Research Institute (MRI) as a synthesis of ideas from multiple theorists in order to interrupt misguided attempts by families to create first and second order change by persisting with “more of the same”, mixed signals from unclear metacommunication and paradoxical double-bind messages.	Reframing, prescribing the symptom, relabelling, restraining (going slow), Bellac Ploy
Narrative therapy	Michael White, David Epston	People use stories to make sense of their experience and to establish their identity as a social and political constructs based on local knowledge. Narrative therapists avoid marginalising their clients by positioning themselves as a co-editor of their reality with the idea that “the person is not the problem, but the problem is the problem.”	Deconstruction, externalising problems, mapping, asking permission
Object relations therapy	Hazan & Shaver, David Scharff & Jill Scharff, James Framo	Individuals choose relationships that attempt to heal insecure attachments from childhood. Negative patterns established by their parents (object) are projected onto their partners.	Detriangulation, co-therapy, psychoanalysis, holding environment
Psychoanalytic family therapy	Nathan Ackerman	By applying the strategies of Freudian psychoanalysis to the family system therapists can gain insight into the interlocking psychopathologies of the family members and seek to improve complementarity.	Psychoanalysis, authenticity, joining, confrontation
Solution focused therapy	Kim Insoo Berg, Steve de Shazer, William O’Hanlon, Michelle Weiner-Davis, Paul Watzlawick	The inevitable onset of constant change leads to negative interpretations of the past and language that shapes the meaning of an individual’s situation, diminishing their hope and causing them to overlook their own strengths and resources.	Future focus, beginner’s mind, miracle question, goal setting, scaling
Strategic therapy	Jay Haley, Cloe Madanes	Symptoms of dysfunction are purposeful in maintaining homeostasis in the family hierarchy as it transitions through various stages in the family life cycle.	Directives, paradoxical injunctions, positioning, metaphoric tasks, restraining (going slow)
Structural family therapy	Salvador Minuchin, Harry Aponte, Charles Fishman, Braulio Montalvo	Family problems arise from maladaptive boundaries and subsystems that are created within the overall family system of rules and rituals that governs their interactions.	Joining, family mapping, hypothesizing, re-enactments, reframing, unbalancing

Evidence Base

Family therapy has an evolving evidence base. A summary of current evidence is available via the UK’s Association of Family Therapy. Evaluation and outcome studies can also be found on the Family Therapy and Systemic Research Centre website. The website also includes quantitative and qualitative research studies of many aspects of family therapy.

According to a 2004 French government study conducted by French Institute of Health and Medical Research, family and couples therapy was the second most effective therapy after Cognitive behavioural therapy. The study used meta-analysis of over a hundred secondary studies to find some level of effectiveness that was either “proven” or “presumed” to exist. Of the treatments studied, family therapy was presumed or proven effective at treating schizophrenia, bipolar disorder, anorexia and alcohol dependency.

Concerns and Criticism

In a 1999 address to the Coalition of Marriage, Family and Couples Education conference in Washington, D.C., University of Minnesota Professor William Doherty said:

“I take no joy in being a whistle blower, but it’s time. I am a committed marriage and family therapist, having practiced this form of therapy since 1977. I train marriage and family therapists. I believe that marriage therapy can be very helpful in the hands of therapists who are committed to the profession and the practice. But there are a lot of problems out there with the practice of therapy – a lot of problems.”

Doherty suggested questions prospective clients should ask a therapist before beginning treatment:

“Can you describe your background and training in marital therapy?”
“What is your attitude toward salvaging a troubled marriage versus helping couples break up?”
“What is your approach when one partner is seriously considering ending the marriage and the other wants to save it?”
“What percentage of your practice is marital therapy?”
“Of the couples you treat, what percentage would you say work out enough of their problems to stay married with a reasonable amount of satisfaction with the relationship.” “What percentage break up while they are seeing you?” “What percentage do not improve?” “What do you think makes the differences in these results?”

Licensing and Degrees

Family therapy practitioners come from a range of professional backgrounds, and some are specifically qualified or licensed/registered in family therapy (licensing is not required in some jurisdictions and requirements vary from place to place). In the United Kingdom, family therapists will have a prior relevant professional training in one of the helping professions usually psychologists, psychotherapists, or counsellors who have done further training in family therapy, either a diploma or an M.Sc. In the United States there is a specific degree and license as a marriage and family therapist; however, psychologists, nurses, psychotherapists, social workers, or counsellors, and other licensed mental health professionals may practice family therapy. In the UK, family therapists who have completed a four-year qualifying programme of study (MSc) are eligible to register with the professional body the Association of Family Therapy (AFT), and with the UK Council for Psychotherapy (UKCP).

A master’s degree is required to work as a Marriage and Family Therapist (MFT) in some American states. Most commonly, MFTs will first earn a M.S. or M.A. degree in marriage and family therapy, counselling, psychology, family studies, or social work. After graduation, prospective MFTs work as interns under the supervision of a licensed professional and are referred to as an MFTi.

Prior to 1999 in California, counsellors who specialised in this area were called Marriage, Family and Child Counsellors. Today, they are known as Marriage and Family Therapists (MFT), and work variously in private practice, in clinical settings such as hospitals, institutions, or counselling organisations.

Marriage and family therapists in the United States and Canada often seek degrees from accredited Masters or Doctoral programmes recognised by the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE), a division of the American Association of Marriage and Family Therapy.

Requirements vary, but in most states about 3,000 hours of supervised work as an intern are needed to sit for a licensing exam. MFTs must be licensed by the state to practice. Only after completing their education and internship and passing the state licensing exam can a person call themselves a Marital and Family Therapist and work unsupervised.

License restrictions can vary considerably from state to state. Contact information about licensing boards in the United States are provided by the Association of Marital and Family Regulatory Boards.

There have been concerns raised within the profession about the fact that specialist training in couples therapy – as distinct from family therapy in general – is not required to gain a license as an MFT or membership of the main professional body, the AAMFT.

Values and Ethics

Since issues of interpersonal conflict, power, control, values, and ethics are often more pronounced in relationship therapy than in individual therapy, there has been debate within the profession about the different values that are implicit in the various theoretical models of therapy and the role of the therapist’s own values in the therapeutic process, and how prospective clients should best go about finding a therapist whose values and objectives are most consistent with their own. An early paper on ethics in family therapy written by Vincenzo Di Nicola in consultation with a bioethicist asked basic questions about whether strategic interventions “mean what they say” and if it is ethical to invent opinions offered to families about the treatment process, such as statements saying that half of the treatment team believes one thing and half believes another. Specific issues that have emerged have included an increasing questioning of the longstanding notion of therapeutic neutrality, a concern with questions of justice and self-determination, connectedness and independence, “functioning” versus “authenticity”, and questions about the degree of the therapist’s “pro-marriage/family” versus “pro-individual” commitment.

The American Association for Marriage and Family Therapy requires members to adhere to a “Code of Ethics”, including a commitment to “continue therapeutic relationships only so long as it is reasonably clear that clients are benefiting from the relationship.”

Founders and Key Influences

Some key developers of family therapy are:

Alfred Adler (individual psychology).
Nathan Ackerman (psychoanalytic).
Tom Andersen (reflecting practices and dialogues about dialogues).
Harlene Anderson (postmodern collaborative therapy and Collaborative Language Systems).
Maurizio Andolfi (interactional, integrative, multigenerational, and relational family therapy).
Harry J Aponte (Person-of-the-Therapist).
Jack A. Apsche (family mode deactivation therapy, FMDT).
Gregory Bateson (1904–1980) (cybernetics, systems theory).
Ivan Boszormenyi-Nagy (contextual therapy, intergenerational, relational ethics).
Murray Bowen (systems theory, intergenerational).
Steve de Shazer (solution focused therapy).
Vincenzo Di Nicola (cultural family therapy).
Milton H. Erickson (hypnotherapy, strategic therapy, brief therapy).
Richard Fisch (brief therapy, strategic therapy).
James Framo (object relations theory, intergenerational, family-of-origin therapy).
Edwin Friedman (family process in religious congregations).
Harry Goolishian (postmodern collaborative therapy and collaborative language systems).
John Gottman (marriage).
Robert-Jay Green (LGBT, cross-cultural issues).
Douglas Haldane (Attachment-based couple therapist).
Jay Haley (strategic therapy, communications).
Lynn Hoffman (strategic, post-systems, collaborative).
Don D. Jackson (systems theory).
Sue Johnson (emotionally focused therapy, attachment theory).
Walter Kempler (Gestalt psychology).
Cloe Madanes (strategic therapy).
Salvador Minuchin (structural family therapy).
Braulio Montalvo (structural family therapy).
Virginia Satir (communications, experiential, conjoint and co-therapy).
Mara Selvini Palazzoli (Milan family systems therapy).
Karl Tomm (IPscope model and interventive interviewing, Bringforthism).
Robin Skynner (group analysis).
Paul Watzlawick (brief therapy, systems theory).
John Weakland (brief therapy, strategic therapy, systems theory).
Carl Whitaker (family systems, experiential, co-therapy).
Michael White (narrative therapy).
Lyman Wynne (schizophrenia, pseudomutuality).

What was the Bateson Project?

Published on 04/05/202104/05/2021 by Andrew Marshall2 Comments

Introduction

The Bateson Project (1953-1963) was the name given to a ground-breaking collaboration organised by Gregory Bateson which was responsible for some of the most important papers and innovations in communication and psychotherapy in the 1950s and early 1960s. Its other members were Donald deAvila Jackson, Jay Haley, John Weakland, and Bill Fry.

Background

Perhaps their most famous and influential publication was Towards a Theory of Schizophrenia (1956), which introduced the concept of the Double Bind, and helped found Family Therapy.

One of the project’s first locations was the Menlo Park VA Hospital, which was chosen because of Bateson’s previous work there as an ethnologist. The initial research, which was funded by a Rockefeller grant, focused on “strange communication” and nonsensical language among the patients of the institution who were suffering from schizophrenia. The group studied this within the context of double bind communication in family dynamics.

Refer to Double Bind and Family Therapy.

What is Behaviour Therapy?

Published on 03/30/202103/30/2021 by Andrew Marshall8 Comments

Introduction

Behaviour therapy or behavioural psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviourism and/or cognitive psychology.

It looks at specific, learned behaviours and how the environment, or other people’s mental states, influences those behaviours, and consists of techniques based on learning theory, such as respondent or operant conditioning. Behaviourists who practice these techniques are either behaviour analysts or cognitive-behavioural therapists. They tend to look for treatment outcomes that are objectively measurable. Behaviour therapy does not involve one specific method but it has a wide range of techniques that can be used to treat a person’s psychological problems.

Behavioural psychotherapy is sometimes juxtaposed with cognitive psychotherapy, while cognitive behavioural therapy integrates aspects of both approaches, such as cognitive restructuring, positive reinforcement, habituation (or desensitisation), counterconditioning, and modelling.

Applied behaviour analysis (ABA) is the application of behaviour analysis that focuses on functionally assessing how behaviour is influenced by the observable learning environment and how to change such behaviour through contingency management or exposure therapies, which are used throughout clinical behaviour analysis therapies or other interventions based on the same learning principles.

Cognitive-behavioural therapy views cognition and emotions as preceding overt behaviour and implements treatment plans in psychotherapy to lessen the issue by managing competing thoughts and emotions, often in conjunction with behavioural learning principles.

A 2013 Cochrane review comparing behaviour therapies to psychological therapies found them to be equally effective, although at the time the evidence base that evaluates the benefits and harms of behaviour therapies was felt to be weak.

Brief History

Precursors of certain fundamental aspects of behaviour therapy have been identified in various ancient philosophical traditions, particularly Stoicism. For example, Wolpe and Lazarus wrote,

While the modern behavior therapist deliberately applies principles of learning to this therapeutic operations, empirical behavior therapy is probably as old as civilization – if we consider civilization as having started when man first did things to further the well-being of other men. From the time that this became a feature of human life there must have been occasions when a man complained of his ills to another who advised or persuaded him of a course of action. In a broad sense, this could be called behavior therapy whenever the behavior itself was conceived as the therapeutic agent. Ancient writings contain innumerable behavioral prescriptions that accord with this broad conception of behavior therapy.

The first use of the term behaviour modification appears to have been by Edward Thorndike in 1911. His article Provisional Laws of Acquired Behaviour or Learning makes frequent use of the term “modifying behaviour”. Through early research in the 1940s and the 1950s the term was used by Joseph Wolpe’s research group. The experimental tradition in clinical psychology used it to refer to psycho-therapeutic techniques derived from empirical research. It has since come to refer mainly to techniques for increasing adaptive behaviour through reinforcement and decreasing maladaptive behaviour through extinction or punishment (with emphasis on the former). Two related terms are behaviour therapy and applied behaviour analysis. Since techniques derived from behavioural psychology tend to be the most effective in altering behaviour, most practitioners consider behaviour modification along with behaviour therapy and applied behaviour analysis to be founded in behaviourism. While behaviour modification and applied behaviour analysis typically uses interventions based on the same behavioural principles, many behaviour modifiers who are not applied behaviour analysts tend to use packages of interventions and do not conduct functional assessments before intervening.

Possibly the first occurrence of the term “behaviour therapy” was in a 1953 research project by B.F. Skinner, Ogden Lindsley, Nathan Azrin and Harry C. Solomon. The paper talked about operant conditioning and how it could be used to help improve the functioning of people who were diagnosed with chronic schizophrenia. Early pioneers in behaviour therapy include Joseph Wolpe and Hans Eysenck.

In general, behaviour therapy is seen as having three distinct points of origin: South Africa (Wolpe’s group), The United States (Skinner), and the United Kingdom (Rachman and Eysenck). Each had its own distinct approach to viewing behaviour problems. Eysenck in particular viewed behaviour problems as an interplay between personality characteristics, environment, and behaviour. Skinner’s group in the United States took more of an operant conditioning focus. The operant focus created a functional approach to assessment and interventions focused on contingency management such as the token economy and behavioural activation. Skinner’s student Ogden Lindsley is credited with forming a movement called precision teaching, which developed a particular type of graphing programme called the standard celeration chart to monitor the progress of clients. Skinner became interested in the individualising of programs for improved learning in those with or without disabilities and worked with Fred S. Keller to develop programmed instruction. Programmed instruction had some clinical success in aphasia rehabilitation. Gerald Patterson used programme instruction to develop his parenting text for children with conduct problems. With age, respondent conditioning appears to slow but operant conditioning remains relatively stable. While the concept had its share of advocates and critics in the west, its introduction in the Asian setting, particularly in India in the early 1970s and its grand success were testament to the famous Indian psychologist H. Narayan Murthy’s enduring commitment to the principles of behavioural therapy and biofeedback.

While many behaviour therapists remain staunchly committed to the basic operant and respondent paradigm, in the second half of the 20th century, many therapists coupled behaviour therapy with the cognitive therapy, of Aaron Beck, Albert Ellis, and Donald Meichenbaum to form cognitive behaviour therapy (CBT). In some areas the cognitive component had an additive effect (for example, evidence suggests that cognitive interventions improve the result of social phobia treatment) but in other areas it did not enhance the treatment, which led to the pursuit of third generation behaviour therapies. Third generation behaviour therapy uses basic principles of operant and respondent psychology but couples them with functional analysis and a clinical formulation/case conceptualisation of verbal behaviour more inline with view of the behaviour analysts. Some research supports these therapies as being more effective in some cases than cognitive therapy, but overall the question is still in need of answers.

Theoretical Basis

The behavioural approach to therapy assumes that behaviour that is associated with psychological problems develops through the same processes of learning that affects the development of other behaviours. Therefore, behaviourists see personality problems in the way that personality was developed. They do not look at behaviour disorders as something a person has, but consider that it reflects how learning has influenced certain people to behave in a certain way in certain situations.

Behaviour therapy is based upon the principles of classical conditioning developed by Ivan Pavlov and operant conditioning developed by B.F. Skinner. Classical conditioning happens when a neutral stimulus comes right before another stimulus that triggers a reflexive response. The idea is that if the neutral stimulus and whatever other stimulus that triggers a response is paired together often enough that the neutral stimulus will produce the reflexive response. Operant conditioning has to do with rewards and punishments and how they can either strengthen or weaken certain behaviours.

Contingency management programmes are a direct product of research from operant conditioning.

Current Forms

Behavioural therapy based on operant and respondent principles has considerable evidence base to support its usage. This approach remains a vital area of clinical psychology and is often termed clinical behaviour analysis. Behavioural psychotherapy has become increasingly contextual in recent years. Behavioural psychotherapy has developed greater interest in recent years in personality disorders as well as a greater focus on acceptance and complex case conceptualisations.

Functional Analytic Psychotherapy

One current form of behavioural psychotherapy is functional analytic psychotherapy. Functional analytic psychotherapy is a longer duration behaviour therapy. Functional analytic therapy focuses on in-session use of reinforcement and is primarily a relationally-based therapy. As with most of the behavioural psychotherapies, functional analytic psychotherapy is contextual in its origins and nature. and draws heavily on radical behaviourism and functional contextualism.

Functional analytic psychotherapy holds to a process model of research, which makes it unique compared to traditional behaviour therapy and cognitive behavioural therapy.

Functional analytic psychotherapy has a strong research support. Recent functional analytic psychotherapy research efforts are focusing on management of aggressive inpatients.

Assessment

Behaviour therapists complete a functional analysis or a functional assessment that looks at four important areas: stimulus, organism, response and consequences. The stimulus is the condition or environmental trigger that causes behaviour. An organism involves the internal responses of a person, like physiological responses, emotions and cognition. A response is the behaviour that a person exhibits and the consequences are the result of the behaviour. These four things are incorporated into an assessment done by the behaviour therapist.

Most behaviour therapists use objective assessment methods like structured interviews, objective psychological tests or different behavioural rating forms. These types of assessments are used so that the behaviour therapist can determine exactly what a client’s problem may be and establish a baseline for any maladaptive responses that the client may have. By having this baseline, as therapy continues this same measure can be used to check a client’s progress, which can help determine if the therapy is working. Behaviour therapists do not typically ask the why questions but tend to be more focused on the how, when, where and what questions. Tests such as the Rorschach inkblot test or personality tests like the MMPI (Minnesota Multiphasic Personality Inventory) are not commonly used for behavioural assessment because they are based on personality trait theory assuming that a person’s answer to these methods can predict behaviour. Behaviour assessment is more focused on the observations of a persons behaviour in their natural environment.

Behavioural assessment specifically attempts to find out what the environmental and self-imposed variables are. These variables are the things that are allowing a person to maintain their maladaptive feelings, thoughts and behaviours. In a behavioural assessment “person variables” are also considered. These “person variables” come from a person’s social learning history and they affect the way in which the environment affects that person’s behaviour. An example of a person variable would be behavioural competence. Behavioural competence looks at whether a person has the appropriate skills and behaviours that are necessary when performing a specific response to a certain situation or stimuli.

When making a behavioural assessment the behaviour therapist wants to answer two questions:

What are the different factors (environmental or psychological) that are maintaining the maladaptive behaviour; and
What type of behaviour therapy or technique that can help the individual improve most effectively.

The first question involves looking at all aspects of a person, which can be summed up by the acronym BASIC ID. This acronym stands for behaviour, affective responses, sensory reactions, imagery, cognitive processes, interpersonal relationships and drug use.

Clinical Applications

Behaviour therapy based its core interventions on functional analysis. Just a few of the many problems that behaviour therapy have functionally analysed include intimacy in couples relationships, forgiveness in couples, chronic pain, stress-related behaviour problems of being an adult child of a person with an alcohol use disorder, anorexia, chronic distress, substance abuse, depression, anxiety, insomnia and obesity.

Functional analysis has even been applied to problems that therapists commonly encounter like client resistance, partially engaged clients and involuntary clients. Applications to these problems have left clinicians with considerable tools for enhancing therapeutic effectiveness. One way to enhance therapeutic effectiveness is to use positive reinforcement or operant conditioning. Although behaviour therapy is based on the general learning model, it can be applied in a lot of different treatment packages that can be specifically developed to deal with problematic behaviours. Some of the more well known types of treatments are: Relaxation training, systematic desensitisation, virtual reality exposure, exposure and response prevention techniques, social skills training, modelling, behavioural rehearsal and homework, and aversion therapy and punishment.

Relaxation training involves clients learning to lower arousal to reduce their stress by tensing and releasing certain muscle groups throughout their body. Systematic desensitisation is a treatment in which the client slowly substitutes a new learned response for a maladaptive response by moving up a hierarchy of situations involving fear. Systematic desensitisation is based in part on counter conditioning. Counter conditioning is learning new ways to change one response for another and in the case of desensitisation it is substituting that maladaptive behaviour for a more relaxing behaviour. Exposure and response prevention techniques (also known as flooding and response prevention) is the general technique in which a therapist exposes an individual to anxiety-provoking stimuli while keeping them from having any avoidance responses.

Virtual reality therapy provides realistic, computer-based simulations of troublesome situations. The modelling process involves a person being subjected to watching other individuals who demonstrate behaviour that is considered adaptive and that should be adopted by the client. This exposure involves not only the cues of the “model person” as well as the situations of a certain behaviour that way the relationship can be seen between the appropriateness of a certain behaviour and situation in which that behaviour occurs is demonstrated. With the behavioural rehearsal and homework treatment a client gets a desired behaviour during a therapy session and then they practice and record that behaviour between their sessions. Aversion therapy and punishment is a technique in which an aversive (painful or unpleasant) stimulus is used to decrease unwanted behaviours from occurring. It is concerned with two procedures:

The procedures are used to decrease the likelihood of the frequency of a certain behaviour; and
Procedures that will reduce the attractiveness of certain behaviours and the stimuli that elicit them.

The punishment side of aversion therapy is when an aversive stimulus is presented at the same time that a negative stimulus and then they are stopped at the same time when a positive stimulus or response is presented. Examples of the type of negative stimulus or punishment that can be used is shock therapy treatments, aversive drug treatments as well as response cost contingent punishment which involves taking away a reward.

Applied behaviour analysis is using behavioural methods to modify certain behaviours that are seen as being important socially or personally. There are four main characteristics of applied behaviour analysis:

First behaviour analysis is focused mainly on overt behaviours in an applied setting.
- Treatments are developed as a way to alter the relationship between those overt behaviours and their consequences.
Another characteristic of applied behaviour analysis is how it (behaviour analysis) goes about evaluating treatment effects.
- The individual subject is where the focus of study is on, the investigation is centred on the one individual being treated.
A third characteristic is that it focuses on what the environment does to cause significant behaviour changes.
Finally the last characteristic of applied behaviour analysis is the use of those techniques that stem from operant and classical conditioning such as providing reinforcement, punishment, stimulus control and any other learning principles that may apply.

Social skills training teaches clients skills to access reinforcers and lessen life punishment. Operant conditioning procedures in meta-analysis had the largest effect size for training social skills, followed by modelling, coaching, and social cognitive techniques in that order. Social skills training has some empirical support particularly for schizophrenia. However, with schizophrenia, behavioural programmes have generally lost favour.

Some other techniques that have been used in behaviour therapy are contingency contracting, response costs, token economies, biofeedback, and using shaping and grading task assignments.

Shaping and graded task assignments are used when behaviour that needs to be learned is complex. The complex behaviours that need to be learned are broken down into simpler steps where the person can achieve small things gradually building up to the more complex behaviour. Each step approximates the eventual goal and helps the person to expand their activities in a gradual way. This behaviour is used when a person feels that something in their lives can not be changed and life’s tasks appear to be overwhelming.

Another technique of behaviour therapy involves holding a client or patient accountable of their behaviours in an effort to change them. This is called a contingency contract, which is a formal written contract between two or more people that defines the specific expected behaviours that you wish to change and the rewards and punishments that go along with that behaviour. In order for a contingency contract to be official it needs to have five elements. First it must state what each person will get if they successfully complete the desired behaviour. Secondly those people involved have to monitor the behaviours. Third, if the desired behaviour is not being performed in the way that was agreed upon in the contract the punishments that were defined in the contract must be done. Fourth if the persons involved are complying with the contract they must receive bonuses. The last element involves documenting the compliance and noncompliance while using this treatment in order to give the persons involved consistent feedback about the target behaviour and the provision of reinforcers.

Token economies is a behaviour therapy technique where clients are reinforced with tokens that are considered a type of currency that can be used to purchase desired rewards, like being able to watch television or getting a snack that they want when they perform designated behaviours. Token economies are mainly used in institutional and therapeutic settings. In order for a token economy to be effective there must be consistency in administering the program by the entire staff. Procedures must be clearly defined so that there is no confusion among the clients. Instead of looking for ways to punish the patients or to deny them of rewards, the staff has to reinforce the positive behaviours so that the clients will increase the occurrence of the desired behaviour. Over time the tokens need to be replaced with less tangible rewards such as compliments so that the client will be prepared when they leave the institution and won’t expect to get something every time they perform a desired behaviour.

Closely related to token economies is a technique called response costs. This technique can either be used with or without token economies. Response costs is the punishment side of token economies where there is a loss of a reward or privilege after someone performs an undesirable behaviour. Like token economies this technique is used mainly in institutional and therapeutic settings.

Considerable policy implications have been inspired by behavioural views of various forms of psychopathology. One form of behaviour therapy, habit reversal training, has been found to be highly effective for treating tics.

In Rehabilitation

Currently, there is a greater call for behavioural psychologists to be involved in rehabilitation efforts.

Treatment of Mental Disorders

Two large studies done by the Faculty of Health Sciences at Simon Fraser University indicates that both behaviour therapy and cognitive-behavioural therapy (CBT) are equally effective for OCD. CBT has been shown to perform slightly better at treating co-occurring depression.

Considerable policy implications have been inspired by behavioural views of various forms of psychopathology. One form of behaviour therapy (habit reversal training) has been found to be highly effective for treating tics.

There has been a development towards combining techniques to treat psychiatric disorders. Cognitive interventions are used to enhance the effects of more established behavioural interventions based on operant and classical conditioning. An increased effort has also been placed to address the interpersonal context of behaviour.

Behaviour therapy can be applied to a number of mental disorders and in many cases is more effective for specific disorders as compared to others. Behaviour therapy techniques can be used to deal with any phobias that a person may have. Desensitisation has also been applied to other issues such as dealing with anger, if a person has trouble sleeping and certain speech disorders. Desensitisation does not occur over night, there is a process of treatment. Desensitisation is done on a hierarchy and happens over a number of sessions. The hierarchy goes from situations that make a person less anxious or nervous up to things that are considered to be extreme for the patient.

Modelling has been used in dealing with fears and phobias. Modelling has been used in the treatment of fear of snakes as well as a fear of water.

Aversive therapy techniques have been used to treat sexual deviations as well as alcohol use disorder.

Exposure and prevention procedure techniques can be used to treat people who have anxiety problems as well as any fears or phobias. These procedures have also been used to help people dealing with any anger issues as well as pathological grievers (people who have distressing thoughts about a deceased person).

Virtual reality therapy deals with fear of heights, fear of flying, and a variety of other anxiety disorders. VRT has also been applied to help people with substance abuse problems reduce their responsiveness to certain cues that trigger their need to use drugs.

Shaping and graded task assignments has been used in dealing with suicide and depressed or inhibited individuals. This is used when a patient feel hopeless and they have no way of changing their lives. This hopelessness involves how the person reacts and responds to someone else and certain situations and their perceived powerlessness to change that situation that adds to the hopelessness. For a person with suicidal ideation, it is important to start with small steps. Because that person may perceive everything as being a big step, the smaller you start the easier it will be for the person to master each step. This technique has also been applied to people dealing with agoraphobia, or fear of being in public places or doing something embarrassing.

Contingency contracting has been used to deal with behaviour problems in delinquents and when dealing with on task behaviours in students.

Token economies are used in controlled environments and are found mostly in psychiatric hospitals. They can be used to help patients with different mental illnesses but it doesn’t focus on the treatment of the mental illness but instead on the behavioural aspects of a patient. The response cost technique has been used to address a variety of behaviours such as smoking, overeating, stuttering, and psychotic talk.

Treatment Outcomes

Systematic desensitisation has been shown to successfully treat phobias about heights, driving, insects as well as any anxiety that a person may have. Anxiety can include social anxiety, anxiety about public speaking as well as test anxiety. It has been shown that the use of systematic desensitisation is an effective technique that can be applied to a number of problems that a person may have.

When using modelling procedures this technique is often compared to another behavioural therapy technique. When compared to desensitisation, the modelling technique does appear to be less effective. However it is clear that the greater the interaction between the patient and the subject he is modelling the greater the effectiveness of the treatment.

While undergoing exposure therapy, a person typically needs five sessions to assess the treatment’s effectiveness. After five sessions, exposure treatment has been shown to provide benefit to the patient. However, it is still recommended treatment continue beyond the initial five sessions.

Virtual reality therapy (VRT) has shown to be effective for a fear of heights. It has also been shown to help with the treatment of a variety of anxiety disorders. Due to the costs associated with VRT, therapists are still awaiting results of controlled trials investigating VRT, to assess which applications demonstrate the best results.

For those with suicidal ideation, treatment depends on how severe the person’s depression and sense of hopelessness is. If these things are severe, the person’s response to completing small steps will not be of importance to them, because they don’t consider the success an accomplishment. Generally, in those not suffering from severe depression or fear, this technique has been successful, as completion of simpler activities builds their confidences and allows them to progress to more complex situations.

Contingency contracts have been seen to be effective in changing any undesired behaviours of individuals. It has been seen to be effective in treating behaviour problems in delinquents regardless of the specific characteristics of the contract.

Token economies have been shown to be effective when treating patients in psychiatric wards who had chronic schizophrenia. The results showed that the contingent tokens were controlling the behaviour of the patients.

Response costs has been shown to work in suppressing a variety of behaviours such as smoking, overeating or stuttering with a diverse group of clinical populations ranging from sociopaths to school children. These behaviours that have been suppressed using this technique often do not recover when the punishment contingency is withdrawn. Also undesirable side effects that are usually seen with punishment are not typically found when using the response cost technique.

Third Generation

The third-generation behaviour therapy movement has been called clinical behaviour analysis because it represents a movement away from cognitivism and back toward radical behaviourism and other forms of behaviourism, in particular functional analysis and behavioural models of verbal behaviour. This area includes acceptance and commitment therapy (ACT), cognitive behavioural analysis system of psychotherapy (CBASP), behavioural activation (BA), dialectical behavioural therapy, functional analytic psychotherapy (FAP), integrative behavioural couples therapy, metacognitive therapy and metacognitive training. These approaches are squarely within the applied behaviour analysis tradition of behaviour therapy.

ACT may be the most well-researched of all the third-generation behaviour therapy models. It is based on relational frame theory. Other authors object to the term “third generation” or “third wave” and incorporate many of the “third wave” therapeutic techniques under the general umbrella term of modern cognitive behavioural therapies.

Functional analytic psychotherapy is based on a functional analysis of the therapeutic relationship. It places a greater emphasis on the therapeutic context and returns to the use of in-session reinforcement. In general, 40 years of research supports the idea that in-session reinforcement of behaviour can lead to behavioural change.

Behavioural activation emerged from a component analysis of cognitive behaviour therapy. This research found no additive effect for the cognitive component. Behavioural activation is based on a matching model of reinforcement. A recent review of the research, supports the notion that the use of behavioural activation is clinically important for the treatment of depression.

Integrative behavioural couples therapy developed from dissatisfaction with traditional behavioural couples therapy. Integrative behavioural couples therapy looks to Skinner (1969) for the difference between contingency-shaped and rule-governed behaviour. It couples this analysis with a thorough functional assessment of the couple’s relationship. Recent efforts have used radical behavioural concepts to interpret a number of clinical phenomena including forgiveness.

Organisations

Many organisations exist for behaviour therapists around the world. In the United States, the American Psychological Association’s Division 25 is the division for behaviour analysis. The Association for Contextual Behaviour Therapy is another professional organisation. ACBS is home to many clinicians with specific interest in third generation behaviour therapy. Doctoral-level behaviour analysts who are psychologists belong to American Psychological Association’s division 25 – Behaviour analysis. APA offers a diploma in behavioural psychology.

The Association for Behavioural and Cognitive Therapies (formerly the Association for the Advancement of Behaviour Therapy) is for those with a more cognitive orientation. The ABCT also has an interest group in behaviour analysis, which focuses on clinical behaviour analysis. In addition, the Association for Behavioural an Cognitive Therapies has a special interest group on addictions.

Characteristics

By nature, behavioural therapies are empirical (data-driven), contextual (focused on the environment and context), functional (interested in the effect or consequence a behaviour ultimately has), probabilistic (viewing behaviour as statistically predictable), monistic (rejecting mind–body dualism and treating the person as a unit), and relational (analysing bidirectional interactions).

Behavioural therapy develops, adds and provides behavioural intervention strategies and programs for clients, and training to people who care to facilitate successful lives in the communities.

Training

Recent efforts in behavioural psychotherapy have focused on the supervision process. A key point of behavioural models of supervision is that the supervisory process parallels the behavioural psychotherapy.

Methods

Behaviour management.
Behaviour modification.
Clinical behaviour analysis.
Contingency management.
Covert conditioning.
Decoupling.
Exposure and response prevention.
Flooding.
Habit reversal training.
Matching law.
Modelling.
Observational learning.
Operant conditioning.
Professional practice of behaviour analysis.
Respondent conditioning.
Stimulus control.
Systematic desensitisation.

Reference

Skinner, B.F. (1969). Contingencies of Reinforcement: A Theoretical Analysis. New York: Meredith Corporation.

On This Day … 24 March

Published on 03/24/202103/21/2021 by Andrew MarshallLeave a comment

People (Births)

1897 – Wilhelm Reich, Austrian-American psychotherapist and academic (d. 1957).

Wilhelm Reich

Wilhelm Reich (24 March 1897 to 03 November 1957) was an Austrian doctor of medicine and psychoanalyst, a member of the second generation of analysts after Sigmund Freud. The author of several influential books, most notably Character Analysis (1933), The Mass Psychology of Fascism (1933), and The Sexual Revolution (1936), Reich became known as one of the most radical figures in the history of psychiatry.

Reich’s work on character contributed to the development of Anna Freud’s The Ego and the Mechanisms of Defence (1936), and his idea of muscular armour – the expression of the personality in the way the body moves – shaped innovations such as body psychotherapy, Gestalt therapy, bioenergetic analysis and primal therapy. His writing influenced generations of intellectuals; he coined the phrase “the sexual revolution” and according to one historian acted as its midwife. During the 1968 student uprisings in Paris and Berlin, students scrawled his name on walls and threw copies of The Mass Psychology of Fascism at police.

After graduating in medicine from the University of Vienna in 1922, Reich became deputy director of Freud’s outpatient clinic, the Vienna Ambulatorium. Described by Elizabeth Danto as a large man with a cantankerous style who managed to look scruffy and elegant at the same time, he tried to reconcile psychoanalysis with Marxism, arguing that neurosis is rooted in sexual and socio-economic conditions, and in particular in a lack of what he called “orgastic potency”. He visited patients in their homes to see how they lived, and took to the streets in a mobile clinic, promoting adolescent sexuality and the availability of contraceptives, abortion and divorce, a provocative message in Catholic Austria. He said he wanted to “attack the neurosis by its prevention rather than treatment”.

From the 1930s he became an increasingly controversial figure, and from 1932 until his death in 1957 all his work was self-published. His message of sexual liberation disturbed the psychoanalytic community and his political associates, and his vegetotherapy, in which he massaged his disrobed patients to dissolve their “muscular armour”, violated the key taboos of psychoanalysis. He moved to New York in 1939, in part to escape the Nazis, and shortly after arriving coined the term “orgone”—from “orgasm” and “organism”—for a biological energy he said he had discovered, which he said others called God. In 1940 he started building orgone accumulators, devices that his patients sat inside to harness the reputed health benefits, leading to newspaper stories about sex boxes that cured cancer.

Following two critical articles about him in The New Republic and Harper’s in 1947, the US Food and Drug Administration obtained an injunction against the interstate shipment of orgone accumulators and associated literature, believing they were dealing with a “fraud of the first magnitude”. Charged with contempt in 1956 for having violated the injunction, Reich was sentenced to two years imprisonment, and that summer over six tons of his publications were burned by order of the court. He died in prison of heart failure just over a year later, days before he was due to apply for parole.

What is Medical Psychology?

Published on 03/18/2021 by Andrew MarshallLeave a comment

Introduction

Medical psychology, or Medicopsychology, is the application of psychological principles to the practice of medicine, primarily drug-oriented, for both physical and mental disorders.

The American Society for the Advancement of Pharmacotherapy defines medical psychology as “that branch of psychology integrating somatic and psychotherapeutic modalities into the management of mental illness and emotional, cognitive, behavioral and substance use disorders”.

A medical psychologist who holds prescriptive authority for specific psychiatric medications and other pharmaceutical drugs must first obtain specific qualifications in Psychopharmacology. A trained medical psychologist, or psychopharmacologist who has prescriptive authority is equated with a mid-level provider who has the authority to prescribe psychotropic medication such as antidepressants for neurotic disorders. However, a medical psychologist does not automatically equate with a psychologist who has the authority to prescribe medication. In fact, most medical psychologists do not prescribe medication and do not have the authority to do so.

Medical psychologists apply psychological theories, scientific psychological findings, and techniques of psychotherapy, behaviour modification, cognitive, interpersonal, family, and life-style therapy to improve the psychological and physical health of the patient. Psychologists with post doctoral specialty training as medical psychologists are the practitioners with refined skills in clinical psychology, health psychology, behavioural medicine, psychopharmacology, and medical science. Highly qualified and post graduate specialised doctors are trained for service in primary care centres, hospitals, residential care centres, and long-term care facilities and in multidisciplinary collaboration and team treatment.

Medical Psychology Specialty

The field of medical psychology may include pre-doctoral training in the disciplines of health psychology, rehabilitation psychology, pediatric psychology, neuropsychology, and clinical psychopharmacology, as well as sub-specialties in pain management, primary care psychology, and hospital-based (or medical school-based) psychology as the foundation psychological training to qualify for proceeding to required post-doctoral specialty training to qualify to become a Diplomate/Specialist in Medical Psychology. To be a Specialist in Medical Psychology a psychologist must hold Board Certification from the American Board of Medical Psychology which requires a doctorate degree in psychology, a license to practice psychology, a post doctorate graduate degree or acceptable post doctoral didactic training, a residency in medical psychology, submission of a work product for examination, a written and oral examination by the American Board of Medical Psychology. The American Board of Medical Psychology maintains a distinction between specialists and psychopharmacological psychologists or those interested in practicing one of the related psychological disciplines in primary care centres. The term Medical Psychologists is not an umbrella term, and many other specialties in psychology such as healthcare psychology, embracing the biopsychosocial paradigm of mental/physical health and extending that paradigm to clinical practice through research and the application of evidenced-based diagnostic and treatment procedures are akin to the specialty and are prepared to practice in Integrated and Primary Care Settings.

Adopting the biopsychosocial paradigm, the field of medical psychology has recognised the Cartesian assumption that the body and mind are separate entities is inadequate, representing as it does an arbitrary dichotomy that works to the detriment of healthcare. The biopsychosocial approach reflects the concept that the psychology of an individual cannot be understood without reference to that individual’s social environment. For the medical psychologist, the medical model of disease cannot in itself explain complex health concerns any more than a strict psychosocial explanation of mental and physical health can in itself be comprehensive.

Duties

Medical psychologists and some psychopharmacologists are trained and equipped to modify physical disease states and the actual cytoarchitecture and functioning of the central nervous and related systems using psychological and pharmacological techniques (when allowed by statute), and to provide prevention for the progression of disease having to do with poor personal and life-style choices and conceptualisation, behavioural patterns, and chronic exposure to the effects of negative thinking, choosing, attitudes, and negative contexts. The specialty of medical psychology includes training in psychopharmacology and in states providing statutory authority may prescribe psychoactive substances as one technique in a larger treatment plan which includes psychological interventions. The medical psychologists and psychopharmacologists who serve in states that have not yet modernised their psychology prescribing laws may evaluate patients and recommend appropriate psychopharmacological techniques in collaboration with a state authorised prescriber. Medical psychologists and psychopharmacologists who are not Board Certified strive to integrate the major components of an individual’s psychological, biological, and social functioning and are designed to contribute to that person’s well-being in a way that respects the natural interface among these components. The whole is greater than the sum of its parts when it comes to providing comprehensive and sensible behavioural healthcare and the medical psychologist is uniquely qualified to collaborate with physicians that are treating the patients physical illnesses.

Certifications

The Academy of Medical Psychology defines medical psychology as a specialty trained at the post doctoral level and designed to deliver advanced diagnostic and clinical interventions in Medical and Healthcare Facilities utilising the knowledge and skills of clinical psychology, health psychology, behavioural medicine, psychopharmacology and basic medical science. The Academy of Medical Psychology makes a distinction between the Psychopharmacologist who is a psychologist with advanced training in psychopharmacology and may prescribe medicine or consult with physician or nurse practitioner prescribers to diagnose mental illness and select and recommend appropriate psychoactive medicines, and the Medical Psychologists who are prepared to do the psychopharmacology consulting or prescribing, but also must have training which prepares them for functioning with Behavioural and Lifestyle components of physical disease and functioning in or in consultation with multidisciplinary healthcare teams in Primary Care Centres or Community Hospitals in addition to traditional roles in the treatment of mental illness and substance abuse disorders. The specialty of Medical Psychology and this distinction from Psychopharmacologist is recognised by the National Alliance of Professional Psychology Providers (the psychology national practitioner association; see http://www.nappp.org).

A specialty of medical psychology has established a specialty board certification, American Board of Medical Psychology and an Academy of Medical Psychology (www.amphome.org) requiring a doctorate degree in psychology and extensive post doctoral training in the specialty and the passage of an oral or written examination.

Although the Academy of Medical Psychology defines medical psychology as a “specialty” and has established a “specialty board certification,” and is recognised by the national psychology practitioner association (www.nappp.org) there is a split in national psychology associations between NAPPP and APA and the American Psychological Association and the National Alliance of Professional Psychology Providers do not currently recognise the same specialties with the APA being a group that represents scientists, academics, and practitioners (as a minority) and NAPPP being an organization that represents only practitioners. However, Louisiana, having a unique to that state definition of medical psychology does recognise the national distinction between Medical Psychology as a Specialty and a psychopharmacology proficiency (See APA proficiency in psychopharmacology) and restricts the term and practice of medical psychology by statute (the Medical Psychology Practice Act) as a “profession of the health sciences” with prescriptive authority. It is equally important to note than the American Psychological Association does not recognise that the term medical psychology has, as a prerequisite, nor should the term be equated with having, prescriptive authority and has established psychology post doctoral prescribing medicines as “a proficiency in psychopharmacology”.

In 2006, the American Psychological Association (APA) recommended that the education and training of psychologists, who are specifically pursuing one of several prerequisites for prescribing medication, integrate instruction in the biological sciences, clinical medicine and pharmacology into a formalised programme of postdoctoral education. In 2009, the National Alliance of Professional Providers in Psychology recognised the education and training specified by the American Board of Medical Psychology (www.amphome.org; ABMP) and the Academy of Medical Psychology as the approved standards for post graduate training and examination and qualifications in the nationally recognised specialty in Medical Psychology. Since then numerous hospitals, primary care centres, and other health facilities have recognised the ABMP standards and qualifications for privileges in healthcare facilities and verification of specialty status.

The following Clinical Competencies are identified as essential in the education and training of psychologists, wishing to pursue prescriptive authority. These recommended prerequisites are not required or specifically recommended by APA for the training and education of medical psychologists not pursuing prerequisites for prescribing medication:

Basic Science: anatomy, & physiology, biochemistry.
Neurosciences: neuroanatomy, neurophysiology, neurochemistry.
Physical Assessment and Laboratory Exams: physical assessment, laboratory and radiological assessment, medical terminology.
Clinical Medicine and Pathophysiology: pathophysiology with emphasis on the principal physiological systems, clinical medicine, differential diagnosis, clinical correlation and case studies, chemical dependency, chronic pain management.
Clinical and Research Pharmacology and Psychopharmacology: pharmacology, clinical pharmacology, pharmacogenetics, psychopharmacology, developmental psychopharmacology.
Clinical Pharmacotherapeutics: professional, ethical and legal issues, combined therapies and their interactions, computer-based aids to practice, pharmacoepidemiology.
Research: methodology and design of psychopharmacology research, interpretation and evaluation, FDA drug development and other regulatory processes.

The 2006 APA recommendations also include supervised clinical experience intended to integrate the above seven knowledge domains and assess competencies in skills and applied knowledge.

The national psychology practitioner association (NAPPP; http://www.nappp.org) and top national certifying body (Academy of Medical Psychology; http://www.amphome.org) have established the national training, examination, and specialty practice criterion and guidelines in the specialty of Medical Psychology and have established a national journal in the specialty. Such certifying bodies, view psychopharmacology training (either to prescribe or consult) as one component of the training of a specialist in Medical Psychology, but recognise that training and specialised skills in other aspects of the treatment of behavioural aspects of medical illness, and mental illness affecting physical illness is essential to practice at the specialty level in Medical Psychology. The Louisiana Academy of Medical Psychology (LAMP), currently the largest organisation of psychologists with prescriptive authority in the world and the only organization representing practitioners of medical psychology in Louisiana as defined by Louisiana statute within any jurisdiction in the United States, no longer recognises the Academy of Medical Psychology as an adequate certifying body for its practitioners, and its members have resigned from the Academy of Medical Psychology en masse. Similarly, virtually all members of LAMP have also resigned from the Louisiana Psychological Association (LPA) after many LPA members uncovered that the LAMP’s prescriptive authority movement covertly came to an agreement with Louisiana’s medical board to transfer the entire practice of psychology for psychologists with prescriptive authority to the medical board. Louisiana is the only state in which the practice of psychology, including psychological testing, psychotherapy, diagnosis, and treatment for some psychologists (i.e. medical psychologists) is regulated by a medical board.

What is Person-Centred Therapy?

Published on 03/16/2021 by Andrew Marshall3 Comments

Introduction

Person-centred therapy, also known as person-centred psychotherapy, person-centred counselling, client-centred therapy and Rogerian psychotherapy, is a form of psychotherapy developed by psychologist Carl Rogers beginning in the 1940s and extending into the 1980s. Person-centred therapy seeks to facilitate a client’s self-actualising tendency, “an inbuilt proclivity toward growth and fulfilment”, via acceptance (unconditional positive regard), therapist congruence (genuineness), and empathic understanding.

It is one of the most influential and fundamental modalities of treatment in modern psychological practice, and is applied almost universally in modern psychotherapy. However, it is rarely used on its own; typically it is combined with other forms of therapy.

Background

Person-centred therapy, now considered a founding work in the humanistic school of psychotherapies, began with Carl Rogers, and is recognised as one of the major psychotherapy “schools” (theoretical orientations),[clarification needed] along with psychodynamic psychotherapy, psychoanalysis, classical Adlerian psychology, cognitive behavioural therapy, existential therapy, and others.

Rogers affirmed individual personal experience as the basis and standard for living and therapeutic effect. This emphasis contrasts with the dispassionate position which may be intended in other therapies, particularly the behavioural therapies. Living in the present rather than the past or future, with organismic trust, naturalistic faith in one’s own thoughts and the accuracy in one’s feelings, and a responsible acknowledgment of one’s freedom, with a view toward participating fully in our world, contributing to other peoples’ lives, are hallmarks of Rogers’ person-centred therapy. Rogers also claimed that the therapeutic process is essentially the accomplishments made by the client. The client having already progressed further along in their growth and maturation development, only progresses further with the aid of a psychologically favoured environment.

Although client-centred therapy has been criticised by behaviourists for lacking structure and by psychoanalysts for actually providing a conditional relationship, it has been shown to be an effective treatment.

What is Required for Therapeutic Change?

Rogers (1957; 1959) stated that there are six necessary and sufficient conditions required for therapeutic change:

Therapist-client psychological contact: a relationship between client and therapist must exist, and it must be a relationship in which each person’s perception of the other is important.
Client incongruence: that in-congruence exists between the client’s experience and awareness.
Therapist congruence, or genuineness: the therapist is congruent within the therapeutic relationship. The therapist is deeply involved – they are not ‘acting’ – and they can draw on their own experiences (self-disclosure) to facilitate the relationship.
Therapist unconditional positive regard: the therapist accepts the client unconditionally, without judgment, disapproval or approval. This facilitates increased self-regard in the client, as they can begin to become aware of experiences in which their view of self-worth was distorted or denied.
Therapist empathic understanding: the therapist experiences an empathic understanding of the client’s internal frame of reference. Accurate empathy on the part of the therapist helps the client believe the therapist’s unconditional regard for them.
Client perception: that the client perceives, to at least a minimal degree, the therapist’s unconditional positive regard and empathic understanding.

Core Conditions

It is believed that the most important factor in successful therapy is the relational climate created by the therapist’s attitude to their client. The therapist’s attitude is defined by the three conditions focused on the therapist, which are often called the core conditions (3, 4, and 5 of the above six conditions):

Congruence: the willingness to transparently relate to clients without hiding behind a professional or personal façade.
Unconditional positive regard: the therapist offers an acceptance and prizing for their client for who he or she is without conveying disapproving feelings, actions or characteristics and demonstrating a willingness to attentively listen without interruption, judgement or giving advice.
Empathy: the therapist communicates their desire to understand and appreciate their client’s perspective.

Processes

Rogers believed that a therapist who embodies the three critical and reflexive attitudes (the three core conditions) will help liberate their client to more confidently express their true feelings without fear of judgement. To achieve this, the client-centred therapist carefully avoids directly challenging their client’s way of communicating themselves in the session in order to enable a deeper exploration of the issues most intimate to them and free from external referencing. Rogers was not prescriptive in telling his clients what to do, but believed that the answers to the clients’ questions were within the client and not the therapist. Accordingly, the therapists’ role was to create a facilitative, empathic environment wherein the client could discover the answers for him or herself.

What is Functional Analytic Psychotherapy?

Published on 03/10/2021 by Andrew Marshall4 Comments

Introduction

Functional analytic psychotherapy (FAP) is a psychotherapeutic approach based on clinical behaviour analysis (CBA) that focuses on the therapeutic relationship as a means to maximise client change. Specifically, FAP suggests that in-session contingent responding to client target behaviours leads to significant therapeutic improvements.

FAP was first conceptualised in the 1980s by psychologists Robert Kohlenberg and Mavis Tsai who, after noticing a clinically significant association between client outcomes and the quality of the therapeutic relationship, set out to develop a theoretical and psychodynamic model of behavioural psychotherapy based on these concepts. Behavioural principles (e.g. reinforcement, generalisation) form the basis of FAP (See The five rules below).

FAP is an idiographic (as opposed to nomothetic) approach to psychotherapy. This means that FAP therapists focus on the function of a client’s behaviour instead of the form. The aim is to change a broad class of behaviours that might look different on the surface but all serve the same function. It is idiographic in that the client and therapist work together to form a unique clinical formulation of the client’s therapeutic goals, rather than one therapeutic target for every client who enters therapy.

The Basics

FAP posits that client behaviours that occur in their out-of-session interpersonal relationships (i.e. in the “real world”) will, if clients are given a therapeutic relationship of sufficiently high quality, occur in the therapy session as well. Based on these in-session behaviours, FAP therapists, in collaboration with their client, develop a case formulation that includes classes of behaviours (based on their function not their form) that the client wishes to increase and decrease.

In-session occurrence of a client’s problematic behaviour is called clinically relevant behaviour 1 (CRB1). In-session occurrence of improvements is called clinically relevant behaviour 2 (CRB2). The goal of FAP therapy is to decrease the frequency of CRB1s and increase the frequency of CRB2s.

The FAP therapist evokes (i.e. sets the context for) CRB1s and in response gradually shapes CRB2s.

The five Rules

“The five rules” operationalise the FAP therapist’s behaviour with respect to this goal. It is important to note that the five rules are not rules in the traditional sense of the word, but instead a set of guidelines for the FAP therapist.

Rule 1 – Watch for CRBs:
- Therapists focus their attention on the occurrence of CRBs that are in-session problems (CRB1s) and improvements (CRB2s).
Rule 2 – Evoke CRBs:
- Therapists set a context which evoke the client’s CRBs.
Rule 3 – Reinforce CRB2s naturally:
- Therapists reinforce the occurrence of CRB2s (in-session improvements), increasing the probability that these behaviours will occur more frequently.
Rule 4 – Observe therapist impact in relation to client CRBs:
- Therapists assess the degree to which they actually reinforced behavioural improvements by noting the client’s behaviour subsequent behaviour after Rule 3.
- This is similar to the behaviour analytic concept of performing a functional analysis.
Rule 5 – Provide functional interpretations and generalise:
- Therapists work with the client to generalise in-session behavioural improvements to the client’s out-of-session relationships.
- This can include, but is not limited to, providing homework assignments.

The ACL Model

Researchers at the Centre for the Science of Social Connection at the University of Washington are developing a model of social connection that they believe is relevant to FAP. This model – called the ACL model – delineates behaviours relevant to social connection based on decades of scientific research.

Awareness (A):
- Behaviours include paying attention to your own and the other’s needs and values within an interpersonal relationship.
Courage (C):
- Behaviours include experiencing emotion in the presence of another person, asking for what you need, and sharing deep, vulnerable experiences with another person in the service of improving the relationship.
Love (L):
- Behaviours involve responding to another’s courage behaviours with attunement to what that person needs in the moment. These include providing safety and acceptance in response to a client’s vulnerability.

FAP has the potential to target awareness, courage, and love behaviours as they occur in session as described by the five rules above. More research is needed to confirm the utility of the ACL model.

Research Support

Radical behaviourism and the field of clinical behaviour analysis have strong scientific support. Additionally, researchers have conducted a number of case studies, component process analyses, a study with non-randomised design on FAP-enhanced cognitive therapy for depression, and a randomised controlled trial on FAP-enhanced acceptance and commitment therapy for smoking cessation.

Third Generation behaviour Therapy

FAP belongs to a group of therapies referred to as third-generation behaviour therapies (or third-wave behaviour therapies) that includes dialectical behaviour therapy (DBT), acceptance and commitment therapy (ACT), behavioural activation (BA), and integrative behavioural couples therapy (IBCT).

Criticism

FAP has been criticised for “being ahead of the data”, i.e. having not enough empirical support to justify its widespread use. Challenges encountered by FAP researchers are widely discussed There is also criticism of using the ACL model as it detracts from the idiographic nature of FAP.

What is Acceptance and Commitment Therapy?

Published on 03/08/2021 by Andrew Marshall9 Comments

Introduction

Acceptance and commitment therapy (ACT, typically pronounced as the word “act”) is a form of psychotherapy and a branch of clinical behaviour analysis.

It is an empirically-based psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and behaviour-change strategies, to increase psychological flexibility. The approach was originally called comprehensive distancing. Steven C. Hayes developed acceptance and commitment therapy in 1982 in order to create a mixed approach which integrates both covert conditioning and behaviour therapy. There are a variety of protocols for ACT, depending on the target behaviour or setting. For example, in behavioural health areas a brief version of ACT is called focused acceptance and commitment therapy (FACT).

The objective of ACT is not elimination of difficult feelings; rather, it is to be present with what life brings us and to “move toward valued behaviour”. Acceptance and commitment therapy invites people to open up to unpleasant feelings, and learn not to overreact to them, and not avoid situations where they are invoked. Its therapeutic effect is a positive spiral where feeling better leads to a better understanding of the truth. In ACT, ‘truth’ is measured through the concept of ‘workability’, or what works to take another step toward what matters (e.g. values, meaning).

Technique

Basics

ACT is developed within a pragmatic philosophy called functional contextualism. ACT is based on relational frame theory (RFT), a comprehensive theory of language and cognition that is an offshoot of behaviour analysis. Both ACT and RFT are based on B.F. Skinner’s philosophy of Radical Behaviourism.

ACT differs from some other kinds of cognitive behavioural therapy (CBT) in that rather than trying to teach people to better control their thoughts, feelings, sensations, memories and other private events, ACT teaches them to “just notice,” accept, and embrace their private events, especially previously unwanted ones. ACT helps the individual get in contact with a transcendent sense of self known as self-as-context – the you who is always there observing and experiencing and yet distinct from one’s thoughts, feelings, sensations, and memories. ACT aims to help the individual clarify their personal values and to take action on them, bringing more vitality and meaning to their life in the process, increasing their psychological flexibility.

While Western psychology has typically operated under the “healthy normality” assumption which states that by their nature, humans are psychologically healthy, ACT assumes, rather, that psychological processes of a normal human mind are often destructive. The core conception of ACT is that psychological suffering is usually caused by experiential avoidance, cognitive entanglement, and resulting psychological rigidity that leads to a failure to take needed behavioural steps in accord with core values. As a simple way to summarise the model, ACT views the core of many problems to be due to the concepts represented in the acronym, FEAR:

Fusion with your thoughts.
Evaluation of experience.
Avoidance of your experience.
Reason-giving for your behaviour.

And the healthy alternative is to ACT:

Accept your reactions and be present.
Choose a valued direction.
Take action.

Core Principles

ACT commonly employs six core principles to help clients develop psychological flexibility:[9]

Cognitive defusion: Learning methods to reduce the tendency to reify thoughts, images, emotions, and memories.
Acceptance: Allowing unwanted private experiences (thoughts, feelings and urges) to come and go without struggling with them.
Contact with the present moment: Awareness of the here and now, experienced with openness, interest, and receptiveness. (e.g., mindfulness)
The observing self: Accessing a transcendent sense of self, a continuity of consciousness which is unchanging.
Values: Discovering what is most important to oneself.
Committed action: Setting goals according to values and carrying them out responsibly, in the service of a meaningful life.

Correlational evidence has found that absence of psychological flexibility predicts many forms of psychopathology. A 2005 meta-analysis showed that the six ACT principles, on average, account for 16-29% of the variance in psychopathology (general mental health, depression, anxiety) at baseline, depending on the measure, using correlational methods. A 2012 meta-analysis of 68 laboratory-based studies on ACT components has also provided support for the link between psychological flexibility concepts and specific components.

Research

A 2008 meta-analysis concluded that the evidence was still too limited for ACT to be considered a supported treatment, and raised methodological concerns about the research base. A 2009 meta-analysis found that ACT was more effective than placebo and “treatment as usual” for most problems (with the exception of anxiety and depression), but not more effective than CBT and other traditional therapies. A 2012 meta-analysis was more positive and reported that ACT outperformed CBT, except for treating depression and anxiety.

A 2015 review found that ACT was better than placebo and typical treatment for anxiety disorders, depression, and addiction. Its effectiveness was similar to traditional treatments like cognitive behavioural therapy (CBT). The authors suggested that the CBT comparison of the previous 2012 meta-analysis may have been compromised by the inclusion of nonrandomised trials with small sample sizes. They also noted that research methodologies had improved since the studies described in the 2008 meta-analysis.

The number of randomised clinical trials (RCT) and controlled time series evaluating ACT for a variety of problems is growing. In 2006, only about 30 such studies were known, but in 2011 the number had approximately doubled. The website of the Association for Contextual Behavioural Science states that there were 171 RCTs of ACT published as of December 2016, and over 20 meta-analyses and 45 mediational studies of the ACT literature as of Spring 2016. Most studies of ACT so far have been conducted on adults and therefore the knowledge of its effectiveness when applied to children and adolescents is limited.

Professional Organisations

The Association for Contextual Behavioural Science is committed to research and development in the area of ACT, RFT, and contextual behavioural science more generally. As of 2017 it had over 7,600 members worldwide, about half outside of the United States. It holds annual “world conference” meetings: The 16th will be held in Montreal, in July 2018.

The Association for Behaviour Analysis International (ABAI) has a special interest group for practitioner issues, behavioural counselling, and clinical behaviour analysis ABA:I. ABAI has larger special interest groups for autism and behavioural medicine. ABAI serves as the core intellectual home for behaviour analysts. ABAI sponsors three conferences/year – one multi-track in the US, one specific to Autism and one international.

The Association for Behavioural and Cognitive Therapies (ABCT) also has an interest group in behaviour analysis, which focuses on clinical behaviour analysis. ACT work is commonly presented at ABCT and other mainstream CBT organisations.

The British Association for Behavioural and Cognitive Psychotherapies (BABCP) has a large special interest group in ACT, with over 1,200 members.

Doctoral-level behaviour analysts who are psychologists belong to the American Psychological Association’s (APA) Division 25 – Behaviour analysis. ACT has been called a “commonly used treatment with empirical support” within the APA-recognized specialty of behavioural and cognitive psychology.

Similarities

ACT, dialectical behaviour therapy (DBT), functional analytic psychotherapy (FAP), mindfulness-based cognitive therapy (MBCT) and other acceptance- and mindfulness-based approaches are commonly grouped under the name “the third wave of cognitive behaviour therapy”. The first wave, behaviour therapy, commenced in the 1920s based on Pavlov’s classical (respondent) conditioning and operant conditioning that was correlated to reinforcing consequences. The second wave emerged in the 1970s and included cognition in the form of irrational beliefs, dysfunctional attitudes or depressogenic attributions. In the late 1980s empirical limitations and philosophical misgivings of the second wave gave rise to Steven Hayes’ ACT theory which modified the focus of abnormal behaviour away from the content or form towards the context in which it occurs. ACT research has suggested that many of the emotional defences individuals use with conviction to try to solve their problems actually entangle humans into greater suffering. Rigid ideas about themselves, lack of focus on what is important in their life and struggling to change sensations, feelings or thoughts that are troublesome only serve to create greater distress.

Steven C. Hayes described this group in his ABCT President Address as follows:

Grounded in an empirical, principle-focused approach, the third wave of behavioral and cognitive therapy is particularly sensitive to the context and functions of psychological phenomena, not just their form, and thus tends to emphasize contextual and experiential change strategies in addition to more direct and didactic ones. These treatments tend to seek the construction of broad, flexible and effective repertoires over an eliminative approach to narrowly defined problems, and to emphasize the relevance of the issues they examine for clinicians as well as clients. The third wave reformulates and synthesizes previous generations of behavioral and cognitive therapy and carries them forward into questions, issues, and domains previously addressed primarily by other traditions, in hopes of improving both understanding and outcomes.

ACT has also been adapted to create a non-therapy version of the same processes called Acceptance and Commitment Training. This training process, oriented towards the development of mindfulness, acceptance, and valued skills in non-clinical settings such as businesses or schools, has also been investigated in a handful of research studies with good preliminary results. This is somewhat similar to the awareness-management movement in business training programmes, where mindfulness and cognitive-shifting techniques are employed.

The emphasis of ACT on ongoing present moment awareness, valued directions and committed action is similar to other psycho-therapeutic approaches that, unlike ACT, are not as focused on outcome research or consciously linked to a basic behavioural science programme, including approaches such as Gestalt therapy, Morita therapy and Voice Dialogue, IFS and others.

Wilson, Hayes & Byrd explore at length the compatibilities between ACT and the 12-step treatment of addictions and argue that, unlike most other psychotherapies, both approaches can be implicitly or explicitly integrated due to their broad commonalities. Both approaches endorse acceptance as an alternative to unproductive control. ACT emphasizes the hopelessness of relying on ineffectual strategies to control private experience, similarly the 12-step approach emphasizes the acceptance of powerlessness over addiction. Both approaches encourage a broad life-reorientation, rather than a narrow focus on the elimination of substance use, and both place great value on the long-term project of building of a meaningful life aligned with the clients’ values. ACT and 12-step both encourage the pragmatic utility of cultivating a transcendent sense of self (higher power) within an unconventional, individualised spirituality. Finally they both openly accept the paradox that acceptance is a necessary condition for change and both encourage a playful awareness of the limitations of human thinking.

Criticisms

Some published empirical studies in clinical psychology have argued that ACT is not different from other interventions. Stefan Hofmann argued that ACT is similar to the much older Morita therapy.

A meta-analysis by Öst in 2008 concluded that ACT did not yet qualify as an “empirically supported treatment”, that the research methodology for ACT was less stringent than cognitive behavioural therapy, and that the mean effect size was moderate. Supporters of ACT have challenged those conclusions by showing that the quality difference in Öst’s review was accounted for by the larger number of funded trials in the CBT comparison group.

Several concerns, both theoretical and empirical, have arisen in response to the ascendancy of ACT. One major theoretical concern was that the primary authors of ACT and of the corresponding theories of human behaviour, relational frame theory (RFT) and functional contextualism (FC), recommended their approach as the proverbial holy grail of psychological therapies. Later, in the preface to the second edition of Acceptance and Commitment Therapy, the authors clarified that “ACT has not been created to undercut the traditions from which it came, nor does it claim to be a panacea.” Psychologist James C. Coyne, in a discussion of “disappointments and embarrassments in the branding of psychotherapies as evidence supported”, said: “Whether or not ACT is more efficacious than other therapies, as its proponents sometimes claim, or whether it is efficacious for psychosis, is debatable”. The textbook Systems of Psychotherapy: A Transtheoretical Analysis provides criticisms of third-wave behaviour therapies including ACT from the perspectives of other systems of psychotherapy.

Psychologist Jonathan W. Kanter said that Hayes and colleagues “argue that empirical clinical psychology is hampered in its efforts to alleviate human suffering and present contextual behavioural science (CBS) to address the basic philosophical, theoretical and methodological shortcomings of the field. CBS represents a host of good ideas but at times the promise of CBS is obscured by excessive promotion of ACT and Relational Frame Theory (RFT) and demotion of earlier cognitive and behaviour change techniques in the absence of clear logic and empirical support.” Nevertheless, Kanter concluded that “the ideas of CBS, RFT, and ACT deserve serious consideration by the mainstream community and have great potential to shape a truly progressive clinical science to guide clinical practice.”

ACT currently appears to be about as effective as standard CBT, with some meta-analyses showing small differences in favour of ACT and others not. For example, a meta-analysis published by Francisco Ruiz in 2012 looked at 16 studies comparing ACT to standard CBT. ACT failed to separate from CBT on effect sizes for anxiety, however modest benefits were found with ACT compare to CBT for anxiety and quality of life. The author did find separation between ACT and CBT on the “primary outcome” – a heterogeneous class of 14 separate outcome measures that were aggregated into the effect size analysis. This analysis however is limited by the highly heterogeneous nature of the outcome variables used in the analysis, which has the tendency to increase the number needed to treat (NNT) to replicate the effect size reported. More limited measures, such as depression, anxiety and quality of life decrease the NNT, making the analysis more clinically relevant, and on these measures ACT did not outperform CBT.

A 2013 paper comparing ACT to cognitive therapy (CT) concluded that “like CT, ACT cannot yet make strong claims that its unique and theory-driven intervention components are active ingredients in its effects.” The authors of the paper suggested that many of the assumptions of ACT and CT “are pre-analytical, and cannot be directly pitted against one another in experimental tests.”