Current Psychological Approaches In The

Management of Mental Health

ProblemsToyin Idowu

Cognitive Behaviour TherapistRN; RMN; BA (Hons) MSc

Overview• Understanding Mental Health

Problems• Psychopathology of Mental Health

Problems• Psychological Perspectives• Evidence-base psychological

treatments

Mental Health Problems

• Daily worries we all experience• To serious long-term conditions • Recovery depend on intervention• Diagnosis Vs Stigma• Quality of life

Mental Health Problems

• Diagnosis symptoms• Differences across cultures• In definition and classification• Standard Criteria Guidelines

Mental Health Problems

One third of people at some point in their life reported symptoms which meet criteria for diagnosis of one or more of the common types of mental disorder

WHO (2004)

Classification

• Key Issue for researchers and service providers

• Determines diagnosis of symptoms• By disorders• Normal vs Abnormal Behaviours• Continuum vs Spectrum Approach• Scientific Vs Subjective Value

Judgement

The function of classification

• Inform effective treatment selection• Administrative functions e.g. Medical

aids, legal system.• Provides vocabulary for professionals

to communicate. Clinical shorthand.• Provides information on prognosis.

Traditional Classifications

• Organic/Functional• Neurosis/Psychosis• Minor/Major• Severe Mental Illness• Modern Classifications

DSM-IV-TR & ICD-10

• DSM-IV-TR• Larger no. of

discrete categories.• Uses a multi-axial

system.• Uses term

psychotic.

• ICD-10• More general

categories.• Generally single

axis. But uses broad aetiology.Uses term neurotic.

Psychopathology

• Commonly used in Psychiatry• Behaviours or experiences indicative

of mental illness • Disease Process• Abnormality in responses of

cognition, emotion, physiology and behaviour

• Subsequent effect on functioning

Classifying Psychopathology

DSM – IV – TR Axis I: Clinical Syndromes• This is what we typically think of as the diagnosis

(e.g., depression, schizophrenia, social phobia)Axis II: Developmental Disorders and

Personality Disorders• Developmental disorders include autism and

mental retardation, disorders which are typically first evident in childhood 

• Personality disorders are clinical syndromes which have a more long lasting symptoms and encompass the individual's way of interacting with the world.  They include Paranoid, Antisocial, and Borderline Personality Disorders.

Axis III: Physical Conditions which play a role in the development, continuance, or exacerbation of Axis I and II Disorders

Physical conditions such as brain injury or HIV/AIDS that can result in symptoms of mental illness are included here. 

Axis IV: Severity of Psychosocial Stressors Events in a persons life, such as death of a loved

one, starting a new job, college, unemployment, and even marriage can impact the disorders listed in Axis I and II.  These events are both listed and rated for this axis.

Axis V: Highest Level of FunctioningOn the final axis, the clinician rates the person's level of functioning both at the present time and the highest level within the previous year.  This helps the clinician understand how the above four axes are affecting the person and what type of changes could be expected.

Example of Diagnosis:

• Patient: John Doe

– Axis I: Major depressive Disorder– Axis II: Narcissistic Personality

Disorder – some features only

– Axis III: Poor liver functioning, frequent migraines.

– Axis IV: Recently retrenched– Axis V: 65

Psychological Perspectives

Before Psychology there were Philosophers - asked questions about the mind:

• Plato (427-347 BC): Does perception accurately reflect reality?

• Aristotle (384-322 BC): Logic forms the laws of thought

• Descartes (1596-1650): “I think therefore I am”

The Beginning of PsychologyWilhelm Wundt (1832-1920)

•Focuses on the scientific study of the mind.

•First Experimental Psychological Lab in 1879

•Scientific Method: Predict what will happenSystematically observe eventsDo events support predictions

•Philosopher and Psychologist•Focus on understanding mental Processes•Theory of Emotion•Interpretation of stimulus

William James (1842-1910)

•Classical Conditioning

•Stimulus Response Psychology

• "Pavlov's dog" -Someone who merely reacts to a situation rather than using critical thinking

Ivan Pavlov (1849 – 1936)

John Watson (1878-1958)

•Theory of Behaviourism

•Understanding animal behaviour

•Little Albert Experiment (Unconditioned Stimulus)

•The idea of the The idea of the UNCONSCIOUSUNCONSCIOUS

•Thoughts, memories & desires exist below conscious awareness and exert an influence on our behavior

•Psychoanalytic Theory attempts to explain personality, mental disorders & motivation in terms of unconscious determinants of behavior

Sigmund Freud (1856-1939)

Contemporary Psychological Perspectives

• Several theories within an approach• Share common assumption.• No right or wrong approach• Each perspective has its strengths

and weaknesses• 5 Perspectives

Behaviourist Perspectives

• People are controlled by their environment

• How environmental factors (stimuli) affect observable behaviour (response)

• Classical conditioning - Learning by association

• Operant conditioning - Learning from the consequences of behaviour (B.R Skinner)

Psychodynamic Perspective

•  Events in our childhood can have a significant impact on our behaviour as adults (Frued)

• People have little free will to make choices in life.

• Behaviour is determined by the unconscious mind and childhood experiences.

• Id ego and super ego principle

Humanistic Perspective

• Look at human behaviour from the eyes of the person doing the behaviour

• The study of the WHOLE person• individual's behaviour connected to

inner feelings and self-image. • Uniqueness of the individual• Individual has free will to change at

any time.

Cognitive Perspective

• Cognition - the mental act or process by which knowledge is acquired.

• Mental Processing/Function – memory, perception and attention etc

• Human brains as computers• Memory stages (encoding, memory

and retrieval)• Basis for cognitive therapy

Biological Perspectives

• Genetics and evolution play a role in human behaviour – Charles Darwin (1859)

• Most behaviours are inherited (Adaptive function)

• Brain physiology and behaviour• Abnormal Behaviour• Dopamine and schizophrenia

Evidence Base Treatments

• Based on Empirical outcome• Science on its own• Eliminates risky practice• Favour better outcomes• Decision Making• Professional practice• Influence outcome• Recovery

Types of Evidences (Muir-Gray, 1997)

• Type 1Strong evidence from at least one systemic review of multiple well designed randomized control trials.

• Type 2Strong evidence from at least one properly designed randomized controlled trials of appropriate size

• Type 3Evidence from well designed trials without randomization, single group pre-post, cohort, time series or matched case-control studies.

Types of Evidences (Muir-Gray, 1997)

• Type 4Evidence from well designed non-experimental studies from more than one centre or research group.

• Type 5Opinions of well respected authorities, based upon clinical evidence, descriptive studies or reports of expert committees.

Evidence Base Psychological Approaches

• Practitioners to follow approaches based on the best available research evidence (Sackett et al 2000)

• A psychological therapy is efficacious and specific - evidence from at least two settings that it is superior to a pill or psychological placebo or another bona fide treatment (Chambless and Hollon, 1998)

Evidence Base Psychological Approaches

• EBT not followed rigorously • Not all mental health practitioners

trained• Patients are often unaware that

evidence-based practices exist. • Consequently, patients do not always

receive the most effective, safe, and cost effective treatments available.

Berke et al, 2011

NICE Guidelines (UK)• CBT – Strongest Evidence across mental health

problems

• Dialectical Behaviour Therapy

• IPT – Depression

• Behaviour Couples Therapy - depression

• Counselling - Depression

• Brief Dynamic Therapy - Depression

Psychodynamic Psychotherapy

• Focus on revealing the unconscious content of a client's psyche in an effort to alleviate psychic tension

• Internal conflicts and their relation to development

• Patients develop defences to avoid unpleasant consequences of conflict

• Psychopathology develops especially from early childhood experiences

• Causing inter-relational difficulties

Psychodynamic Psychotherapy

• Emerges in Transference and Counter-Transference in therapy

• No structure in therapy• Interpreting the dynamics in

therapy to work through the presenting symptoms

• Ability to trust own insight is critical to successful outcome

Counselling

• Person Cantered opportunity to vent feelings and emotions

• Evaluate own situations and behaviours

• Work in a problem solving approach manner

Behaviour Couples Therapy

• Joint Relationship Treatment• Changing views (Blame-Game)• Modifies Dysfunctional Behaviours• Decrease Emotional Avoidance• Improve Communication

Interpersonal Psychotherapy (IPT)

• Focuses on the interpersonal context• Building interpersonal skills• Interpersonal factors contribute to

psychological problems• Interpersonal not Intra-psychic• Change in behaviour through

adaptation to current roles and situations

What is CBT ? Mental health problem

involves on-going interactions amongst

• Biological factors genes; biological state• Psychological factors

cognitions; affects; overt behaviours

• Social factorsimmediate social environment & culture

Biological

SocialPsychological

Mental HealthMental Health

What is CBT ?

• CBT addresses Psychological aspect of mental health issues

• Based on idea that thoughts create moods, influence behaviour &alter physiological state

Feelings & behaviour depend

on interpretation of events

Feelings & behaviour depend

on interpretation of events

What is CBT ?• In CBT we help clients

learn that we all have inherent tendencies to certain cognitive styles that can evoke mood and behaviour disturbance

• We can learn to spot unhelpful cognitions as they come up; then challenge and re- think them

Cognitive Behaviour Therapy

(CBT)• Cognitive Therapy is combined with

behaviour ‘experiments’ • These help clients act on their new ideas.

Disconfirm original idea and confirm alternative beliefs e.g. asserting self usually does not end in hostility but engenders respect

• Reduce behavioral excesses (e.g. avoidance) & deficits (e.g. problem-solving)

• When combined, termed Cognitive Behaviour Therapy

First Generation CBT

Skinner

Pavlov

Watson

BEHAVIOUR THERAPY

Second Generation CBT

•Beck

•Ellis

•Social psychology and developing cognitive Sciences•Cognitive therapies

Depression

Aaron BeckChristopher Martell

Generalised Anxiety Disorder

Tom BorkovecMichel Dugas

Obsessive Compulsive Disorder

Steketee/Kozac/Foa Protocol

Panic Disorder

•Clark•Barlow

PTSD

•Ehlers•Foa and Rothbaum

Psychosis

•Garety et al 2001•Morisson 2001

New Wave CBT• Acceptance and Committed Therapy (ACT) –

Steven HayesChronic Pain; Depression

• Dialectical Behaviour Therapy

• Mindfulness Based Cognitive Therapy (MBCT) Mark Williams et al

Recurrent Depression

• Compassion Focussed Therapy (CFT) – Paul Gilbert

Shame and Self attack in PTSD

Mastery

Deal with Life Challenges

Change our approach to problems

What is IAPT

I – Improving A – Access to P – Psychological T – Therapies A commissioner led, outcome focused

programme to deliver and improve access to

psychological therapies for people suffering anxiety and depression

Depressed/Anxious????

• “Would you rather have medication now or Psychological Therapy in 18 months time?”

Four Year Plan (DOH, 2011)

• Children and young people, • Physical health long-term conditions

(LTCs) and mental health. • Medically Unexplained Symptoms (MUS)• Severe mental illness (SMI) • Complete roll out to adults• Equitable access for under-represented

(older adults, BMEs etc)• 100% sustainability

Workforce Integration

BME Orgs

GPs

CAMHS

CMHTE

Specialist Acute Trust

Clinics

University Adult CMHT

IAPT

CBT for BMEs

• Main Critics in current model

• Main focus of researchers in the last 5 years

• Ongoing Community Integrated CBT Model – Southampton Model

Implications for Africa

• Huge • Gargantuan• Brain Gain• Individual Professional Contributions• Focus in Future of Recovery Model• Drive for the Third World• IAPN N and other Orgs.

Thank You

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• Email – idowuT@aol.com

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