Psychopathology AKA Understanding people The Developmental Process.

PsychopathologyAKA Understanding people

The Developmental Process

Why these two books? What I have learned is that if you can understand people from a

variety of formats, you can integrate these formats with many clients. These two books provide you with many of the skills you will need to

conceptualize and diagnose a variety of disorders. Many of the skills you will learn will transfer fully or in part to other

diagnoses you will treat. Thus we will address Supportive, Expressive and Uncovering

therapies; as well as CBT, Psychodynamic, and Interpersonal Interventions. Pharmacology, Diversity, and Systems will be included. Finally, you will read about Object Relations, Self and Freudian Theories (analytic).

In your program you have specific classes that will more fully cover substance abuse, and work with children, adolescents and families.

Finally, your Reader book provides several worksheets and handouts to use with clients. In addition, I have collated some handouts from workbooks to provide you with further resources which are referenced. Thus, if they fit your style, you can buy the book.

Make sure your development as a Psychologist has a firm foundation. If you put yourself into the class Complete all the reading with a curious mind Participate actively in class discussions Complete the assignments with the purpose of

expanding both your personal and profession growth, as well as your fellow student’s…

You will leave here with a strong base from which to develop the rest of your skills in this program

If you are not already knowledgeable about all the disorders in the DSM-TR-IV

Review your Master’s diagnostic class and ensure competency in this area

Utilize my power points to help guide you at www.santa-barbara-therapist.com under Antioch, then Psychopathology

Read Essential Psychopathology and it’s treatment by Maxmen and Ward. (It is excellent and very readable)

The 5 Axis Diagnosis

The Mood Disorders

Unipolar Major Depression Dysthymia Depressive Disorder

NOS

Bipolar Cyclothymia Bipolar I Bipolar II Bipolar disorder NOS

Substance induced mood disorder Mood disorder due to a medical condition Mood Disorder NOS

Etiology

Genetics- Short Alleles on genes Biology-Neurotransmitters, Diet… Environment-Trauma, Abuse, Sun…. Substances Medical Issues Characterological Issues

To send for a med eval or not?

Ethical & Legal Issues What you believe and what the professional

research supports are too different things. NIMH Statement

Depression

Cognitive Approaches

Cognitive Therapy Research Considerations Completed prior to newer medications and don’t

include combination medication treatments Only based on Mild to Moderate Depressions Studies with “severe” are meta analysis, and lacking

in any real “proof” Some Controversy in the research findings,

methodology, etc. What about client’s who can’t participate in therapy

due to cognitive effects of Depression Often conducted with people with one “pure”

diagnosis. This is not reality. Studies completed in the 90’s

Most Important

“Through more sophisticated research studies, we hope that it will be possible to assess which types of depressed patients will benefit most from which type of treatment, or combination of treatments, and in what sequence”

Cognitions

Triad of Depression- Negative view of self, environment and future

Learned Helplessness- “their own efforts will be insufficient to change the unsatisfying course of their lives”

Latent Schema’s activated by depression Interpretation, memory, predications, focus

Early Maladaptive Schemas

The “Blame the Parent” problem Comparing “Early Maladaptive Schemas” to

Psychoanalytic Diagnosis (Beck was an Analyst)

Early Maladaptive Schemas vs. Effects of long term depression and recent Schemas

CBT- A guided discovery process

CBT basically takes each thought or “schema” and turns it into a hypothesis

This hypothesis is then tested and evidence is gathered that supports or refutes the hypothesis

Past, present and future are utilized to logically analyze the evidence

Experiments are devised to test the validity of particular cognitions

You do not “persuade” the client, they will “discover” this themselves

The Structure of a Session Establish an Agenda for the session

Short synopsis of last weeks experiences, including review of homework

Compose short list of problems to work on in this session Prioritize problems and choose one or two

Socratic Questioning Questions to determine early maladaptive schemas, misinterpretations

of events, unrealistic expectations, was appropriate behavior used, were all possible solutions considered

Chose intervention and explain rational Pick one or two significant thoughts, schemas, images, or behaviors

and use to chose intervention. Client Summarizes major conclusions and gives reactions to session

Often summarizes in written form. Therapist gives Homework to apply skills and concepts to the problem

during the week

Phase 1 of 2 in treatment

Phase one: focus is on symptom reduction, overcoming helplessness, identifying problems, setting priorities, socializing client to therapy, establishing collaborative relationship, demonstrating the relationship between thoughts and emotions, labeling errors in thinking, and making rapid progress on target problems

It is symptom focused

Phase 2 of 2 in treatment

Once less depressed, the shift is towards core schemas about self and life. These include rules or formulas used to make sense of the world. By changing core schemas , client may be less vulnerable to future episodes. Client takes on more responsibility for coming up with solutions and therapist becomes more of a consultant.

Schema focused and relapse prevention

The Process: Session One

Some symptom relief by defining a set of problems and demonstrating some strategies to deal with them.

Demonstrate the close relationship of cognitions and emotion (client’s mood shifts, ask about thoughts right before the shift. Label negative thoughts and the relationship to the change in mood)

Socialize client to Cognitive Therapy (Be structured and problem-solving. This may require interrupting clients who tend to speculate about the source of the problem and look for interpretations)

Communicate the importance of Self-help homework assignments (Stress it is more important than therapy itself. Explain that client’s who complete it improve more quickly)

Techniques: Which would work better, questions or exhortations?

Eliciting automatic thoughts Ask what thoughts went thru clients mind in response to an

event (this encourages introspection) Use detailed imagery to help client connect with actual event Role play interpersonal events Noted mood changes in session and ask about preceding

thoughts Daily Thought Record (DTR)

First record automatic thoughts and emotions in reaction to events

Later learn to develop more rational responses to dysfunctional automatic thoughts and record them

When automatic thoughts can not be identified by client, help client look at meaning assigned to the event to gain insight into thoughts

Techniques

Testing Automatic Thoughts Key automatic thoughts are identified thru DTRs One of these key thoughts become hypotheses and the

scientific method is used (here the client learns firsthand that one’s view of reality can be quite different from what actually takes place)

Design experiments to analyze automatic thoughts thus teaching clients the process of rational thinking which leads to modification of thoughts

Client lists evidence from their experience for and against their hypothesis

If previous experience is not sufficient or appropriate to test the hypothesis and experiment is designed for that purpose.

The client predicts an outcome and then gathers data If data contradicts thought, then it can be rejected If data supports thought, thought may not be distorted

Techniques

Some automatic thoughts do not lend to being tested Therapist provides information from client’s

report or uses questioning to gain evidence that contradicts thought

“I can not survive this depression” “last year you had an episode and did survive, what

makes you think you can not do it now”

Techniques Redefining Language

Global labels: operationally define them Reattribution (of self-blame for example)

Examine all relevant events to make a more realistic assessment of responsibility (do not take all responsibility away from client, but help spread it out in a more realistic way)

Demonstrate clients uses stricter criteria for own behavior than in evaluating the behavior of others

Show that thinking and behavior are symptoms of depression and not physical deficiencies or physical decay (loss of concentration)

Reattribution can be used for many issues If patient is accurate in problem or skill deficit

Generate alternative solutions

Behavioral Techniques

Scheduling activities to increase mastery and pleasure Weekly Activity Schedule Rated 0-1 for M&P

Cognitive Rehearsal (imagery of completing tasks) Self-reliance training Role playing (Automatic thought ID, practicing attending to

thoughts during high emotional arousal, and rehearsing new behaviors)

Role Reversal (for a more accurate view of how others view them and to increase compassion for self)

Diversion techniques (reduce ruminations, reduce painful affects, reduce emotional reactivity)

Interpersonal Therapy for Depression

(Barlow, 2001; Klerman, Weissman, Rounsaville, and Chevron, 1984)

Interpersonal therapy says:

There is an interpersonal issue in one of 4 domains that has triggered the depressive episode Grief Interpersonal Disputes Role Transitions Interpersonal Deficits

Interpersonal Therapy Process

Sessions 1 thru Session 4 Establish a Working Alliance

Engender hope by telling client IPT is a highly effective treatment for depression

Give client the sick role (Depression is an illness) Educate client on depression prevalence to reduce

loneliness, stigma, and isolation. Conduct a Symptom Review

Helps to educate the client on the symptoms of depression and his/her own symptom pattern.

Provides a Baseline Do an Interpersonal Inventory (see next slide) Identify the Interpersonal Focus

Look at the past 6 months when choosing a focus

Interpersonal Inventory

Goal: To have a clear sense of the important people in the patient’s life both past and present. (Quality & Quantity) Genograms Listen for omissions Listen for Disruptions (conflict, new job,

losses) Look for interconnectedness of networks Is there a negative network Any relationships that can be regenerated

The Middle Phase of TreatmentSessions 4 thru 12 Therapy tasks: Provision of support and

reassurance, clarification of cognitive-affective markers that precede and often ignite interpersonal difficulties, active problem solving of interpersonal problems.

Patient problems are reviewed each week and tied to the focus area.

Let’s look at each area briefly…

Grief

Reactivate the mourning process and work thru grief process

When “complete”, shift to helping the client establish interests and relationships that may substitute the lost relationship.

Role Disputes

Clarify the stage of the dispute and help resolve Renegotiation-work with communication styles Impasse- Go back to renegotiation Dissolution- Grieve

Transitions (anyone feeling this one!?!)

Goal: Help patient mourn the loss of the old role and accept the new role.

Common occurrence: Loss of self-esteem due to diminished sense of competency

Examine positive and negatives of both new and old roles to help the patient experience all their feelings about both roles.

Develop mastery in the new role Develop new relationships Learn from those who have experience in this role

Interpersonal Deficits (maybe PD)

Goal: Increase quality and quantity of interpersonal relationships.

Examine the therapeutic relationship dynamics and how these parallel other relationships.

Be sure to examine positive and negative skills

Have modest expectations in brief therapy

Final Phase of Therapy

Discuss termination from day 1, acknowledge it is a loss and work with grief

Remind patient of strengths and skills Teach patient to know early warning signs of

depression and when and where to get help (Plan)

Review the interpersonal inventory, discuss the importance of increasing social attachments when symptoms flare up, review past learning to concrete it.