Download Identify the Interpersonal Focus

Psychopathology
AKA Understanding people
The Developmental Process
Why these two books?
 What I have learned is that if you can understand people from a variety
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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.
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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
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Major Depression
Dysthymia
Depressive Disorder
NOS
 Bipolar
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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
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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
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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
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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
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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
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Pick one or two significant thoughts, schemas, images, or behaviors
and use to chose intervention.
 Client Summarizes major conclusions and gives reactions to session
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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
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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)
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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
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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
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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
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Therapist provides information from client’s
report or uses questioning to gain evidence
that contradicts thought
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“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
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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)
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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
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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)
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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 Treatment
Sessions 4 thru 12
 Therapy tasks: Provision of support and
reassurance, clarification of cognitiveaffective 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
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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
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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.