Shaping Used to produce a complex behavior which is not in the organism \200\231s initial r epertoire. Initially, component parts of the desired behavior are rewarded, then reward is limited to behavior which approximates the 20_Semple_Chap20.indd 845 12/7/2012 4:32:55 PM CHAPTER 20 Psychotherapy 846 desired result. As appropriate behavior appears it is only rewarded if it is \200\230in th e right direction \200\231 and further reward is contingent upon continued advancement unti l the organism is only rewarded once the entire behavior is performed. Extinction Occurs over time when the response is no longer followed by the reinforcer. Tech niques based on operant conditioning concepts (b p. 848) \200 \200 Behavior modi \201 cation. Aversion therapy. 20_Semple_Chap20.indd 846 12/7/2012 4:32:56 PM This page intentionally left blank CHAPTER 20 Psychotherapy 848 Behavior therapy Techniques based on learning theory are used in order to extinguish mal- a daptive behaviors and substitute more adaptive ones. Systematic desensitization Holds as a central tenet the principle of reciprocal inhibition (i.e. anxi- ety and relaxation cannot coexist). Systematic graded exposure to the source of anxiety is coupled with the use of relaxation techniques (the \200\230desensitization \200\231 component). Effective for simple phobias, but less so for other phobic/anxiety dis orders (e.g. agoraphobia). Process in a typical case is as follows: \200 \200 Patient identi \201 es the speci \201 c fear (e.g. cats). Patient and therapist develop a hierarchy of situations listing the most anxiety-provoking situation at the top (e.g. stro king a cat on one \200\231s knee > touching a cat > having a cat in the room > looking at p ictures of cats > thinking about cats). Patient is instructed in relaxation technique. Pati ent experiences the lowest item on the hierarchy while practicing the relaxation technique and remains exposed to the item until the anxiety has diminished. The process is repeated u ntil the item no longer produces anxiety. The next item in the hierarchy is tackled in simi lar fashion. \200 \200 Flooding/implosive therapy High levels of anxiety cannot be maintained for long periods, an d a pro- cess of \200\230exhaustion \200\231 occurs. By exposing the patient to the phobic object and preventing the usual escape or avoidance, there is extinction of the usual (mal adaptive) anxiety response. This may be done in vivo ( \202 ooding) or in imagination (imp losion). Behavior modi \201 cation Based on operant conditioning. Behavior may be shaped towards th e desired \201 nal modi \201 cation through the rewarding of small, achievable inter- me diate steps. This can be utilized in behavioral disturbance in children and patients with l earning disability. Other forms of behavioral modi- \201 cation include the more explicit use of secondary reinforcement, such as \200\230token economy \200\231, in which socially desirable/acceptable behaviors are rewarded with tokens that can be exchanged for other ma terial items or privileges, or \200\230star charts \200\231 where children \200\231s good behavior is rewarded when a certain level is achieved. May also be used for less voluntary actions such as childhood nocturnal enuresis. Aversion therapy and covert sensitization The use of negative reinforcement (the unpleasant consequence of a par- ticular behavior) to inhibit the usual maladaptive behavioral respon se (extinction). True \200\230aversion \200\231 therapy (e.g. previously used to treat sex ual deviancy) is not used today; however, covert techniques (e.g. the use of antabuse in al cohol dependency) can be (at least partially) effective. 20_Semple_Chap20.indd 848 12/7/2012 4:32:56 PM This page intentionally left blank CHAPTER 20 Psychotherapy 850 Cognitive behavioral therapy 1 The theory and method of cognitive behavior therapy (CBT) we re developed by Aaron Beck and outlined in a series of papers published in the 1960s.1 CBT development was prompted by the observation that patients referred for psychotherapy often held ingrained, negatively skewed assumptions of themselves, their future, and their enviro nment. Treatment is based on the idea that disorder is caused not by life events, but by th e view the patient takes of events. It is a short-term, collaborative therapy, focused on c urrent problems, whose goals are symptom relief and the development of new skills to sustai n recovery. Rationale A person \200\231s emotions, thoughts, behaviors, physiological sensations and th eir external environment all exist together in equilibrium. Altering any component of this system will bring about change in the others. While pathological emotions may not be direct ly amenable to change, the unhelpful cognitions and behaviors associated with these emotion s may be examined and modi \201 ed, leading to change in the underlying emotion. CBT aims to \200\230change how you feel by changing the way you think \200\231.2 The cognitive mode l is a guide for therapy, not a comprehensive model of illness causation, and precludes nei ther neurochemical or other factors as important in symptom development, nor the use of pha rmacological treatments. How illness is viewed In some personality types and in mental illness there are errors in t he evaluation and processing of information (i.e. cognitive distortions). These distortions relate to the self, the world, and the future (Beck \200\231s cognitive triad) and origina te from the child \200\231s early learning and experience of the world around him. Cognitiv e errors are associated with unpleasant emo- tions and maladaptive behavior. An example of this vicious circle is: an event (friend doesn \200\231t call when she said s he would) l negative automatic thought ( \200\230friend doesn \200\231t like me because she thinks I \200\231m a loser \200\231) l emotional response (sadness) l mal- adaptive behavi or l (avoiding friend l self-isolation l worsening of low mood) = pathology (depression). I n CBT with this patient, the therapist would facilitate their recognition of the faulty cog nitive appraisal (cognitive error) and then teach skills to address it \200\224see Box 20.2 and Box 20.3. Modes of delivery CBT can be delivered on an individual basis, in groups, or as self-help v ia books or computer programs (including online). As such it is a cost- effective treatment with evidence of good ef \201 cacy. It is worth stressing that CBT is at its most effecti ve when delivered \200\230by the book \200\231, following established protocols. Sessions by trainees are therefore often taped to ensure adherence to a standard regimen. 20_Semple_Chap20.indd 850 12/7/2012 4:32:56 PM COGNITIVE behavioral THERAPY 1 851 Box 20.2 Cognitions Cognitions are appraisals of events. They may be elicited by asking the patient about thoug hts, ideas, or images in their head. CBT describes three types of thoughts or beliefs: \200 Automatic thoughts are involuntary and appear plausible, but may be distorted, e.g. \200 \230my friend phoned to cancel meeting me tomorrow \200\224she must not like me any more. \200\231 Underlying assumptions fundamental beliefs and shaped by experience, e.g. \200 \230I can \200\231t enjoy myself unless I \200\231m with other people. \200\231 Schemas or core beliefs about themselves and the world around them, e.g. a neglected child believing \200\230I am unlovable. \200\231 are the most super \201 cial and accessible. They are a person \200\231s \200\230rules \200\231 for behaving, based on are a person \200\231s most fundamental beliefs Box 20.3 Common types of cognitive error \200 Selective abstraction \200\224drawing a conclusion based only on part of the information, e .g. \200\230My whole dinner party was a failure because my dessert didn \200\231t turn out as I \200\231d hoped. \200\231 Arbitrary inference \200\224drawing an unjusti \201 ed con clusion, e.g. \200\230My partner appears stressed, s/he must be about to leave me. \200 \231 All or nothing thinking \200\224seeing things only as extremes of black or white with no shades of gray, e.g. \200\230I must win or else I \200\231m a failure. \200\231 Magni \201 cation/minimization \200\224emphasizing negatives and playing down positives, e.g. \200\230My career hasn \200\231t been successful, even my few achievements weren \200\231t all that impressive. \200\231 Disqualifying the positive \200\224e.g. \200\230I only came \201 rst by chance. \200\231 Personalization \200\224assuming responsibility for all nega tive events, e.g. \200\230My sister is in a bad mood, she must be angry with me. \200\231 Catastrophic thinking \200\224e.g. \200\230I embarrassed myself in front of my colleagues \200\224I \200\231ll never be able to face them again. \200\231 Over-generalization \200 \224viewing a single negative event as the norm, e.g. \200\230I made a mistake, therefore I \200\231m incompetent to do my job. \200\231 Emotional reasoning \200\224using emotions a s evidence, e.g. \200\230I feel very anxious, therefore that spider must be really dangero us. \200\231 Jumping to conclusions \200\224mindreading or fortune-telling, e.g. \200\230I know the exam will ask about topics I haven \200\231t had time to study. \200 1 Wright JH (2006) Cognitive behavior therapy: basic principles and recent advances. Focus 4(2): 173 \200\2238. 2 Padesky CA and Greenberger D (1995) Mind over mood. New York: Guilfo rd. 20_Semple_Chap20.indd 851 12/7/2012 4:32:56 PM CHAPTER 20 Psychotherapy 852 Cognitive behavioral therapy 2 Techniques The CBT therapist works together with the patient in a spirit of scienti \201 c inquiry to explore the problem and possible solutions. Thro ugh a process of psychoeducation and guided discovery, the therapist assists the patient in monitoring cognitions and their associated emotions and behaviors; identifying and challen ging cognitive distortions; and exploring alternative strategies for approaching distressin g situations. Progress is measured against objective rating scales (e.g. the Beck Depressio n Inventory1), as well as the patient \200\231s own goals for therapy. Phases of treatment Initial assessment is usually followed by 6 \200\22320 hour-long sessio ns. There may be a review after 6 sessions to share a formulation, take stock of progress s o far and refocus goals if therapy is to continue. Attention is primarily focused on events in the \200\230here and now \200\231. Each session gener- ally proceeds as follows: deal with emergencies; jointly set agenda; review homework task; focus on speci \201 c items gu ided by current problems; sug- gestion of cognitive or behavioral techniques (see Box 20.4) ; jointly agree on homework task. Indications and contraindications CBT is an active treatment requiring patient understandin g and collabora- tion (see Box 20.4). Patients should be motivated and be able to recognize , articulate, and link their thoughts and emotions (i.e. be psychologically minded). The ge neral contraindications to psychotherapy (b p. 822) apply. It is indicated for: \200 \200 \200 \200 \200 \200 Mild to moderate depressive illness. Eating disorders. Anxiety disorders. Bipolar disorder (reduce risk of relapse). Substance abuse disorders. Schizophrenia and other chronic psycho tic disorders as an adjunct to pharmacotherapy, for both positive and negative symptoms. Ch ronic medical conditions such as \201 bromyalgia, chronic fatigue, or chronic pain, where there may be a psychological component and misinterpretation of physiological phenomena. Ef \201 cacy There is good evidence for effectiveness in depressive illness, eating disor- ders and anxiety disorders. CBT is at least as effective as pharmacotherapy in mild to mod erate depression and may be more effective in long-term follow-up (e.g. in preventing relap se). 20_Semple_Chap20.indd 852 12/7/2012 4:32:56 PM COGNITIVE behavioral THERAPY 2 853 Box 20.4 CBT techniques for depression and anxiety Depression \200 Psychoeducation, including straightforward reading material about depression and introducin g the cognitive model \200\224a useful \201 rst homework assignment. Activity diary: over a week, ask the patient to record what they did in the morning, afternoon and evening of e ach day. The patient may rate the sense of pleasure associated on a scale of 0 \200\22310, and assign a score of 0 \200\22310 for their mood each day. Activity and pleasant event sch eduling: make plans for the week in advance to increase general physical activity and enjoy able events, both of which are often reduced and contribute to the vicious cycle of depress ion. Goals should be small and achievable. Thoughts diary: ask the patient to make a record at the times when they feel particularly distressed, noting the trigger situation, their m ood rating, and the thoughts which they experience. Teach the patient to identify cognitive errors in their automatic thoughts. Socratic questioning to elicit further thoughts ( \200 \230If that were true, what would it mean? and what would that mean? etc. \200 \231). Examine the evidence for and against the patient \200\231s faulty beliefs and genera te rational alternatives. Behavioral experiments: designed collaboratively to test the hypo thesis that the patient \200\231s beliefs are true, e.g. inviting a friend to meet for coff ee to test the thought \200\230my friends don \200\231t want to know me any more \200\231 \200 Anxiety \200 \200 Psychoeducation, introducing the cognitive model of anxiety. Diary keeping: to record and m onitor episodes of anxiety, their triggers, the intensity of anxiety on a scale of 0 \200 \22310, and the associated thoughts and physical symptoms. Relaxation techniques: e.g. thro ugh breathing or progressive muscular relaxation. Distraction to divert the cognitive focus elsewhere. Challenge negative thoughts by examining the evidence for and against them, gen erating rational alternatives, and identifying cognitive errors. Construct a hierarchy of t he patient \200\231s most anxiety-provoking situations, consisting of many small steps. Gra ded exposure: starting with the least threatening step of the hierarchy, coupled with relax ation techniques. Role play/rehearsal or attempting an activity together with the therapist (e.g. going into a shop) may be helpful. Behavioral experiments: e.g. recording anxiety re peatedly during exposure to a stressful situation, to challenge patient \200\231s assumptio n that, unless they escape, their anxiety will continue to rise. \200 1 Beck AT, Ward C, and Mendelson M (1961). The Beck Depression Inventory (BDI). Arch Gen Ps ychiat 4: 561 \200\22371. 20_Semple_Chap20.indd 853 12/7/2012 4:32:56 PM CHAPTER 20 Psychotherapy 854 Interpersonal psychotherapy Interpersonal psychotherapy (IPT) was developed in the 1970s by Klerman and Weissman as a treatment for depressive illness and later developed for use in other disorders. Its development followed the observation that depression is frequently ass ociated with impaired interpersonal function- ing. IPT aims, by improving interpersonal fun ctioning, to improve emo- tional symptoms. It is a practical, short-term psychotherapy whic h may be offered in conjunction with medication and is suitable for delivery by a variety o f health care professionals. It is described in a manual for practi- tioners1 and a guide f or patients.2 Rationale Emotional disturbance (e.g. depression) tends to be associated with \200\230here and now \200\231 de \201 cits in interpersonal functioning. Emotional problems are best u nderstood by studying the interpersonal context in which they arise. Life events related to illness development include: grief, interpersonal dis- putes, change of role, and interper sonal de \201 cits. These events are not viewed as directly causing the episode of illness , but helping the patient to understand their role in the evolution of illness and resolvin g the interper- sonal problem is seen as a route to recovery. How illness is viewed Illnesses are viewed as medical disorders and are diagnosed according to standard criteria (e.g. ICD-10) and rated in severity by rating scales (e.g. BDI). IPT makes no attempt to differentiate whether the cause of depression is biological or psychoso cial. In fact, psychoeducation about both is key, and the use of antidepressant medication is encouraged when indicated. Depressive symptoms, regardless of etiology, are viewed as mo di \201 able through the application of IPT techniques. Techniques After a thorough assessment, patient and therapist contract to meet weekly for 1 2 \200\22316 hour-long individual sessions. A key feature of IPT involves \200\230giving t he sick role \200\231 to the patient: this entails educating them about the depressive illn ess, ascribing their symptoms to the current epi- sode of depression, offering appropriate treatment, and giving the patient responsibility for change. Depending on the focus, speci \201 c techniques are applied as outlined in the IPT manual. The relationship between symp - toms, interpersonal functioning, and personality factors are common to all four foci. Dep ressive symptom reduction is reviewed weekly and linked to changes in attitude or behavior in the interpersonal arena. A focus in one of the following four areas is mutually agreed upon: Role transitions (dif \201 culty with life changes, e.g. graduating from school, marriage, job change, childbeari ng or retirement). Interpersonal disputes (differing opinions and expectations about relati onship roles between the patient and another person, e.g. a partner, family member or in th e workplace). Grief (abnormal reactions to bereavement). Interpersonal de \201 cits (long- standing dif \201 culties with impoverished social environment and unful \201 lling relat ionships). \200 20_Semple_Chap20.indd 854 12/7/2012 4:32:56 PM INTERPERSONAL PSYCHOTHERAPY 855 The IPT therapist is an active advocate and facilitator to encourage the patient to see the ir problems from different perspectives, to make attempts at change, and to return to discu ss their successes or failures at subsequent weekly sessions. Transference interpretations are avoided in order to keep the patient focused on how to negotiate better with people in their current life outside of therapy. Phases of treatment \200 Phase I communication of diagnosis to patient; assessment of need for psychotropic medicati on; establishment of the \200\230sick role \200\231; completion of interpersonal inventory (description of current relationships); setting of the patient \200\231s depression within their interpersonal context; identi \201 cation of focus for therapy; explanation of rati onale for treatment and its aims and processes; agreement of therapeutic contract. Phase II techniques outlined in the IPT manual. These include: facilitation of the grieving process ; mourning the loss of the old role and learning to embrace the challenges of the new role in the role transition focus; teaching of speci \201 c communication, problem-solving or c on \202 ict resolution skills; and role play. Review progress in depressive symptom reduct ion weekly. Review overall progress at the \200\230halfway point \200\231 which encourages sustained effort before \200\230time runs out \200\231. Phase III the outset in the contr act with encouragement to continue to apply what the patient has learned from therapy in th eir real-life interpersonal sphere. The IPT therapist points out that progress toward bette r coping (leading to reduced depressive symptoms) has been \200\230earned \200\231 by the patient who did the work of changing. The therapist also reminds the patient that the thera pist \200\231s own role was merely to facilitate that which the patient now knows they can do for themselves. (sessions 1 \200\2232): Standard psychiatric history; risk assessment; (sessions 3 \200\22312): Commence work on the focus utilizing speci \201 c ( \201 nal 3 \200\2234 sessions): Anticipate termination as scheduled from Indications Non-psychotic depressive disorders. Adaptations of IPT have been applied to var ious subgroups such as adolescents, geriatric patients, primary care clinic patients, and p atients with HIV, bulimia, panic disorder, bipolar dis- order, dysthymic disorder, bereavem ent, post-partum depression, social phobia, and insomnia. Modi \201 cations of IPT for gro ups, couples therapy, maintenance therapy, and via telephone have been developed. IPT is no t indicated for treating substance abuse or personality disorders. Ef \201 cacy Several randomized controlled trials in adults, adolescents, elders, and pri- mary care patients have demonstrated ef \201 cacy for IPT either alone or in combination with antidepressant medication. 1 Klerman GL, Weissman MM, Rounsaville BJ, et al. (1984) Interpersonal psychotherapy of dep ression. New York: Basic Books Inc. 2 Weissman MM (1995) Mastering depression: a patient gu ide to interpersonal psychotherapy. Albany: Graywind Publications. 20_Semple_Chap20.indd 855 12/7/2012 4:32:56 PM CHAPTER 20 Psychotherapy 856 Dialectical behavior therapy Dialectical1 behavior therapy (DBT) was introduced in 1991 by Linehan2,3 and colleagues as a treatment for borderline personality disorder (BPD). Patient s with BPD are supported in understanding their own emotional experiences and are taught ne w skills for dealing with their distress through a combination of group and individual ther apy sessions. By learning more adaptive responses to distress and more effective problem-so lving tech- niques, patients \200\231 quality of life and functioning may be improved, and their morbidity and mortality reduced. Rationale Patients with borderline personality disorder suffer from signi \201 cant psy- c hiatric morbidity and mortality related to completed suicide. They are a dif \201 cult gro up of patients to treat as their characteristic patterns of behavior tend to challenge ther apeutic progress and exhaust therapist resources ( \200\230burnout \200\231). Such individu als can however learn more adaptive responses later in life, with subsequent improvement in functioning and quality of life and reduction in morbidity and mortality. How illness is viewed BPD occurs as a product of emotional vulnerability (which may have a bio- logical basis) and a childhood experience of an \200\230invalidating environment \200 \231. Here, the child \200\231s experiences and emotions are repeatedly disquali \201 ed o r invalidated by others, and their dif \201 culties with self-control or problem- solving are not acknowledged. As a consequence, the child grows up with dif \201 culty in recogniz ing, understanding and trusting their emotions, and in order to have feelings acknowledged and needs for care met, may dis- play extremes of emotion and behavior. As certain skills ( e.g. tolerating emotional distress, problem-solving) have not been taught, the individual t ends to set unrealistic goals and then respond with shame and self-loath- ing when they can not be met. These patterns are reinforced as the child grows and develops, with self-harmin g behavior frequently emerging as a way to cope with the intense extremes of emotion experi enced. Techniques DBT is a complex treatment which combines cognitive \200\223behavioral inter- ve ntions with Eastern meditative practice, notably mindfulness (in which a person intentional ly becomes aware of their thoughts and actions in the \200\230here-and-now \200\231). \200 Individual therapy responses (recognizing their distress and behaviors as legitimate and un derstandable but ultimately harmful), reinforces adaptive behaviors, and facilitates analys is of maladaptive behaviors and their triggers. Group skills training context: \200 \200 , where the therapist validates the patient \200\231s where the following modules are taught in a group Mindfulness skills. Interpersonal effectiveness skills (e.g. problem-solving, assertiveness training, communication skills). Emotion modulation skills (to change distressing emotiona l states). Distress tolerance skills (e.g. distraction, self-soothing strategies). \200 20_Semple_Chap20.indd 856 12/7/2012 4:32:56 PM DIALECTICAL behavior THERAPY 857 according to the contract agreed between patient Telephone contact and therapist, to suppor t the patient in applying DBT skills in real life situations between sessions and \201 nd alternatives to self-harming. Therapist consultation groups according to the DBT model, to prevent \200\230burnout \200\231. where therapists support each other, Phases of treatment Each stage of treatment has speci \201 c targets, arranged hierarchica lly by importance. Within each session, targets should also be attended to in this order, e .g. addressing episodes of self-harm \201 rst. Each stage of therapy must be completed, w ith the targeted behaviors for that stage modi \201 ed, before progressing to the next sta ge. DBT takes a hierarchical view of treatment aspirations, with the focus \201 rst on re ducing behaviors which cause self-harm, then on reducing those behaviors which interfere wi th therapy and \201 nally aiming to reduce behaviors which diminish quality of life and p ersonal relationships. \200 Pre-treatment: therapeutic contract. Focuses on reducing life-threatening behavior (episode s Stage 1: of deliberate self-harm with or without suicidal intent), behavior which may int erfere with the progress of therapy (e.g. inappropriate use of telephone contact, unreliabl e attendance for therapy), and behavior which interferes with quality of life (e.g. substan ce misuse, interpersonal con \202 icts). In individual therapy sessions, exploration of in ternal and external antecedents to these behaviors, and generation of possible solutions. W eekly DBT skills group introduces basic skills. Stage 2: experiences, to target post-trauma tic stress-related symptoms such as \202 ashbacks. Examines underlying historical causes of dysfunction, including exposure to memories of abuse or trauma, in combination with dist ress tolerance techniques. Stage 3: individual targets negotiated with the patient. Assessment, orientation to therapy, commitment to Focuses on emotional processing of previous traumatic Aims to develop self-esteem and establish future goals \200\224 Indications and contraindications DBT methods are described speci \201 cally for patients with borderline per- sonality disorder. Ef \201 cacy The original DBT group produced RCT evidence of reduced rates of deliberate s elf-harm and admission to hospital, and improved retention in therapy compared with \200 \230treatment as usual \200\231. Subsequent RCTs have sup- ported the ef \201 cacy of DBT, including studies in other patient populations (e.g. substance abusers) for whom it has be en adapted. 1 Dialectic refers to a means of arriving at the truth by examination of the argument (the \200\230thesis \200\231 and the contradictory argument the \200\230antithesis \200\231) i n order to resolve them into a coherent \200\230synthesis \200\231. 2 Linehan MM (1993) Co gnitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. 3 Linehan MM (1993) Skills training manual for treating borderline personality disorder. Ne w York: Guilford Press. 20_Semple_Chap20.indd 857 12/7/2012 4:32:57 PM CHAPTER 20 Psychotherapy 858 Cognitive analytic therapy Cognitive analytic therapy (CAT) is a therapy method introduced by Anthony Ryle in 1990. It aims to bring together ideas from dynamic cog- nitive and behav ioral therapies by attempting to explain psychoanalytic ideas in cognitive terms. Rationale Problems such as depression, anxiety disorders, and interpersonal dif \201 cul- ties cause emotional suffering and also hinder the ability of the individual to make positi ve change. These problems can often be understood in the context of an individual \200\231s history and early experiences and can be prolonged by habitual coping mechanisms. Through collaborative therapy these mechanisms can be identi \201 ed, understood, and changed. How illness is viewed Traumatic childhood and adolescent experiences can give rise to cop- ing mechanisms to protect the individual from conscious distress. These maladaptive mechani sms can be inappropriately maintained into adult life when they give rise to emotional symp toms such as anxiety and depres- sion and destructive behaviors such as self-harm. Although harmful these behaviors are maintained by \200\230neurotic repetition \200\231. Neurotic repetition has three essential patterns: \200 \200\230Traps \200\231 consequences, which in turn reinforce assumptions. \200\230Dilemma s \200\231 : a person acts as if available actions or possible roles are limited and polari zed (called \200\230false dichotomy \200\231) and so resists change. \200\230Snags \200 \231 others would oppose them or they are thought to be \200\230forbidden \200\231 or \200\230dangerous \200\231 in light of personal beliefs. : negative assumptions generate acts that produce : appropriate goals or roles are abandoned either because Techniques The \200\230three Rs \200\231 of CAT are recognition of maladaptive behavior an d beliefs, reformulation of these (the main \200\230work \200\231 of therapy), and revisio n. The reformulation is agreed between therapist and patient and documented in a \200\230p sychotherapy \201 le \200\231. This reformulation is expressed in narrative and diagramma tic form and considers both past history and current problems. It is used throughout therap y to guide the active focus, to set homework, and to enable recognition of transference/cou ntertransference. Phases of treatment Therapy involves active participation from both parties. \200 Assessment number and timing of sessions (8 \200\22324 sessions, normally 12). Early sessio ns (1 \200\2233) exploring common traps, dilemmas, and snags. Diary keeping to monitor mood s and behaviors. Recapitulation of early experiences and narrative of current relationships . Agreement on reformulation of problems with Middle sessions (4 \200\2238) written and dia grammatic description of \200\230target problem procedures \200\231. Explanation of rationale of method of therapy. Planning of Patient asked to begin \200\230psychotherapy \201 le \200\231 20_Semple_Chap20.indd 858 12/7/2012 4:32:57 PM COGNITIVE ANALYTIC THERAPY 859 Exploration of methods of change, (called \200\230exits \200\231) via work in sessions and in homework. Ending sessions (9 \200\22312) which emerged during therapy. Both therapist a nd patient write \200\230goodbye \200\231 letters summarizing progress and formally closin g the relationship. There may be a planned 3-mth review appointment. Identi \201 cation and recapitulation of key themes Indications and contraindications As for other cognitive therapies. Ef \201 cacy Ongoing RCTs examining effectiveness in personality disorders and com- paring CAT with other methods. 20_Semple_Chap20.indd 859 12/7/2012 4:32:57 PM CHAPTER 20 Psychotherapy 860 Solution-focused therapy This therapy, developed by de Shazer,1 aims to empower patients to rec- ognize and make use of their own strengths. It is a brief intervention which may be d elivered in a single session. Rationale The patient is more than the sum of their problems and already has a range of ski lls for coping with adversity. The best way for the patient to achieve their goals is for t hem to discover and harness those capabilities and resources which are already helpful and to make even better use of them. The solution-focused therapist facilitates this process. How illness is viewed Solution focused therapy avoids viewing problems or symptoms as goals for therapy. Rather, it prompts the patient to visualize a future without the problem and to plan the stages necessary to achieve this. In-depth consideration of the development of current dif \201 culties is avoided, as this may imply that the problems are inevitable an d unchangeable. Techniques (Box 20.5) \200 Problem-free talk helps the therapist to understand the \200\230patient behind the problem s \200\231 and may elicit areas of strength or competence. If the patient discusses their p roblems, the therapist listens actively, re \202 ects on the coping strategies described b y the patient, and highlights the possibility of change. Preferred future from the current complaints. Exception \201 nding future seemed more attainable. Rather than seeing them a s \200\230the exception which proves the rule \200\231, these situations are examined to d etermine which skills the patient used to help bring about a favorable outcome. Scales Rati ng their preferred future as 10, the patient rates their current position numerically betwe en 0 and 10. They are invited to discuss the difference between 0 and where they are now, t he resources responsible for this, and to identify the steps or signs of progress between p oints on the scale. Discussion of other areas of the patient \200\231s life \200\224this The patient identi \201 es future goals, shifting focus away The patient identi \201 es situations when the preferred Phases of treatment First session Establishes the patient \200\231s goals or best hopes fro m therapy, recognizes what the patient already does or has done which helps them to cope or moves them towards this preferred future, and identi \201 es what the next signs of progr ess may be. Subsequent sessions Explore what the patient has done since the previous session which has been helpful, place this in the context of the patient \200\231s goals for therapy, and ide ntify what may be further evidence of progress. Indications Depression, substance misuse, interpersonal relationship dif \201 - culties, p resentation in crisis or after self-harm. May be used with children and adolescents and peo ple with learning disability. 20_Semple_Chap20.indd 860 12/7/2012 4:32:57 PM SOLUTION-FOCUSED THERAPY 861 Ef \201 cacy Few controlled trials but some evidence of effectiveness for adults with depr ession and for children and adolescents with emotional and behavioral problems. Box 20.5 Solution-focused questions2 Problem-free talk How do you spend your time? What do you enjoy? What are you good at? How would your friends describe you? Preferred future (the miracle question) Imagine that tonight, while you are asleep, a mirac le happens and your hopes from coming here are realized (or the problems that bring you her e are resolved), but because you are asleep you don \200\231t realize this miracle has happ ened. What are you going to notice different about your life when you wake up that begins t o tell you that this miracle has happened? Exceptions When doesn \200\231t the problem happen? When doesn \200\231t it last as long? W hen does it feel less intense? When do you feel less upset by it? When do you manage to res ist the urge to \200 ? What are the signs that the miracle has already started to happen? Scales On a scale of 0 \200\22310, where 0 is the worst things have ever been and 10 repres ents your best hopes, where are you today? Where on that scale would be good enough, the po int that you would settle for? What are you doing that means you are at 2 and not at 0? If you are at 2 now, what will you be doing that will tell us that you have reached 3? Locating resources It sounds as if things are very stressful; how do you cope? What helps y ou to keep going? How did you manage to get here? What have you been doing that has stopped things from getting even worse? When you \200\231ve faced this sort of problem before, how did you resolve it? 1 De Shazer S (1985) Keys to solution in brief therapy. New York: Norton. 2 BRIEF (2007) BR IEFER: A solution-focused manual. London: BRIEF. 20_Semple_Chap20.indd 861 12/7/2012 4:32:57 PM CHAPTER 20 Psychotherapy 862 Counseling methods Counseling may be thought of as a method of relieving distress under- ta ken by means of a dialog between two people. The aim is to help the client or patient \201 nd their own solutions to problems, while being supported to do so and being guided by appropriate advice. In Western countries over the last \201 fty years, counseling has em erged as a profession in its own right and individual forms of speci \201 c counseling hav e been developed. In its more general sense \200\224helping others by the provision of advi ce, non-judgemental re \202 ection, and emotional support \200\224counseling takes place a ll over the world in the guise of family members, priests, tutors, teachers, etc. Counseling skills are integral to the practice of medicine, particularly in primary care an d psychiatry, where counseling techniques are useful in history-taking, assessing and ensur ing compliance, etc. Counseling should not be thought of as \200\230cut-down \200\231 or \200\230half-price \200\231 psychotherapy. There is clearly overlap in the methods and skil ls of a psychotherapist and a coun- sellor. However, the decision to use counseling as a sp eci \201 c treatment (e.g. for postnatal depression) should be made after considering both the disorder and the patient. There are a variety of counseling services in the voluntary and private sectors, some directed towards speci \201 c problems and some more general. Rationale Behavior and emotional life are shaped by previous expe- rience, current environm ent, and the relationships the individual has. Many life problems can be viewed as arising from resolvable dif \201 culties in one of these three areas, rather than as an \200\230i llness \200\231. People have a ten- dency towards positive change and ful \201 lment which can be retarded by \200\230life problems \200\231. A collaborative relationship with a co unselor (however de \201 ned) is one method of addressing these issues. This relationship will proceed according to agreed rules, towards a goal, and will be based on developing the client \200\231s strengths. Techniques \200 Information giving Key to all psychiatric treatment and psychotherapeutic work. Information should be provided in a form the patient can understand and information giving should not be a \200\230one-off \200\231 but should continue throughout counseling. Client-focused di scussion particularly beyond the early information gathering sessions. Time constraints may hinder this. Problem solving from cognitive behavioral therapy, are employed here. The bas ic goal is to use the session time to explore current and potential future problems and to help the client consider the optimum solution. The client should \200\230lead \200\231 the sessions, A variety of techniques, particularly those borrowed Different types of counseling \200 Information sharing/discussion psychoeducation. Aim is to properly inform a client prior to them making their own decision. Techniques of guided learning, providing verbal and written information, collaborative enquiry (cf. CBT). In some contexts is also called 20_Semple_Chap20.indd 862 12/7/2012 4:32:57 PM counseling METHODS 863