C LINICAL PSYCHOLOGY: L 10: Psy 1123 Summary Lecture

1. CLINICAL PSYCHOLOGY:L 10: Psy 1123 Summary Lecture HUW WILLIAMS

2. Exam…need to know • Models for understanding causes of mental health issues • Psychological treatment approaches for common mental health problems • How, Why & whether are MHP are not “disease entities” but may be on a continuum of experience that most people generally feel

3. Overview of course • Historical background • Socio-cultural context of mental health issues • Mental Health Disorders • Mood disorders • depression • anxiety states • Psychosis • Specialist services, e.g. • Cardiac • eating disorders • drug & alcohol • Social Issues: equality • Psychological theories & therapies

4. Pre-Greek (& in Medieval) Animism & scapegoating “evil spirits” Greco-Roman Somatogenesis brain/body pathology (H) Psychogenesis Reactive mind set (MA) Medieval Legal classifications systems for organising people “mad are kept safe” Renaissance & Elizabethan period •  events cause emotional distress,–    Macbeth, Hamlet But in society…witchcraft etc. Enlightenment: MHP: reasoning affected by severe personal and social problems Late 19c and early 20c Struggle between Eugenic movement and humanitarianism Biological Approach Kraeplin (1856-1926) “chemical imbalance” Psychogenesis in psychoanalysis intermittent paralysis triggered by discussion of early trauma Behavioural approaches Phobias can be learnt and unlearnt Socio-historical context of mental health problems [MHP]

5. Overview of Mental Health Disorders • Modern era: • Bio-psycho-social approach • Biological • Genetic risk/ injury/ toxic exposure • Psychological • Attachment/sibling relationship/trauma event… • Sociocultural • Opportunities denied/oppression/… • Nb. Insight a key isssue

6. Deal with disorders in which there are a mix of emotional, cognitive and behavioural issues Aims to provide an understanding of: Causes of MHP the features and symptoms of MHP The prevalence of specific MHP Treatment options Assessment & Diagnosis Must understand what the condition is to treat properly BUT Must be able to “see the person” not the diagnostic label Treatment needs to be: Evidence based monitored for effectiveness Role of Clinical Psychology in Mental Health Services

7. Depression • Major or Unipolar • General feeling of sadness/ “down” • Negative view of self, world and future • Lethargy/anhedonia/poor sleep/loss appetite • Bipolar • Occasional feelings of elation, grandiosity mixed with periods of extreme “down” • Genetic risk for bipolar • Depression leads to depressed biological state, e.g. less neurotransmitter (serotonin) available • leading to further…nausea/poor sleep/change of appetite etc.

8. Anxiety • unpleasant emotional state -- fearfulness, unwanted and distressing physical symptoms, & intrusive thoughts • Phobias, Panic , Generalized , OCD, PTSD • evolutionary mechanism involving primitive brain areas and decision making (fight or flight) • genetic risk, possibly linked to OCD/Agoraphobia • Those with close (1st degree) relative with agoraphobia have greater risk of agoraphobia & other phobias • Some people with more or less “autonomic lability” • Role models for fears? • Traumatic event(s)

9. Evolutionary preparedness?

10. Psychosis & Schizophrenia • Psychosis: loss of “abilities for reality testing” • Psychosis may be due to: drug use/neurological injury etc., but also a common feature in… • Schizophrenia • Disorganised, catatonic, paranoid diagnoses • “Positive” or “Negative” pattern of symptoms • (P) delusional beliefs • misinterpretation of reality • (P) hallucinations • hearing voices that others don’t hear (commenting/arguing/directing) • (N) withdrawal states • avolition - loss of energy &absence of interest in routine activities

11. Schizophrenia • Genetic risk, probably normally distributed • risk from viral infection, e.g. in-utero • risk from << to brain development • risk from social disadvantage • risk from being in particular family environment • particular social stresses - history of stress related to << • not a disease entity but a bio-psycho-social condition, with one or more of each factor being influential

12. Drugs …alcohol • Biological factors: • Reward centre? • Social • Peer/culture • Stress/lack opportunities • Cognitive-Behavioural • Short term positive • Long term, negative reinforcement • Self medicatruing for negative self-beliefs/NAT’s • Psychodynamic • Poor attachment> dependency issues • Treatments: eg • CBT: behavioural self-control • Tends to be most effective for misuse problems • Need to be in combination with detox for dependence • Key components: • Education on alcohol • Have contract • Identify triggers and coping strategies • Develop Goals: e.g.

13. Anorexia & Bulimia • AN • Refusal to maintain body weight (self-starvation)/ Restricting and/or binge & purging • At least 15% below normal weight • Intense fear of weight gain • Disturbance of body image • BN • Loss of control over eating • Bingeing/purging cycles • Other signs? • Over-exercising

14. Eating disorders • … primarily as an adolescent disorder (but not only) • Extreme end of a continuum of weight control • Issues re: media/personal control/… • Interventions • Psychotropic medication • Nutritional counselling • Family therapy (Clin Psy) • Psychotherapy (Clin Psy) • E.g. CBT for cognitive style/errors & beliefs about food/control Self-help/group work

15. CARDIAC DISEASE – What is it? - Who does it affect? - Extent of problem? RISK FACTORS - Fixed - Psychosocial/behavioural PREVENTION The Experience: - patient/person - healthcare system - medical model CARDIAC REHABILITATION - current status - components - effectiveness

16. Risk factors • AGE • FAMILY HISTORY • MALE Smoking, alochol, low activity level, isolation, depression, anxiety…personality?

17. Theories of MHP: Psychodynamic- humanistic • Roots of MHP is in unresolved childhood conflicts • involve emotions that are latent/unconscious • Unable to feel as if needs were met e.g. actual or emotional absence by parents • hostility over having felt abandoned which cannot be expressed, therefore “stuck” (projected grief/repressed anger) • Development of unrealistic belief systems (overcompensating) • “It is a dire necessity that I be universally loved and approved of” (see A. Ellis, RET 1950’s) • Fear of future loss/ rejection/ being abandoned & anger being internalised • MK: referred for depression & anger and had poor relationships – kept ending them when felt getting “close” • “parents were just so cold, I could never get any feeling from them of whether I was doing ok or not, never felt safe. They’re getting on... When I start to talk about how I felt as a child, they just move on to something else…can’t change them now”

18. Psychodynamic Psychotherapy • If roots are in childhood, then need to unlock the latent emotion and gain insight into the “dynamic” • “work” centred on childhood • Treatments vary, classically the use of techniques to get through defence mechanisms, e.g. denial/projection • E.g. developing an attachment in which to develop forms of “projection” during therapy • Can take ++ time • May be seen more as an artistic form of expression • Some evidence of treatment effectiveness • Short treatments (Sheffield group) focussed on factors e.g. “developing an alliance” “getting a narrative” • Interesting work on attachment theory (Fonaghy at UCL)

19. Cognitive behavioural approach • Cognitive Theory • People who are depressed/anxious/ or have schizophrenia have good reasons to feel that way • Forces • Family life • Adolescence • Peers • Losses and stresses • have shaped their thinking patterns • shaped their behaviour • Thought and behaviour patterns can be re-shaped • Need empathic, but guiding support (via Socratic dialogue)

20. Cognitive Behaviour Model of MHP • Negative core beliefs and automatic/intrusive negative thoughts • Vicious spirals: • do less> avoid situations> less to feel good about > more to feel bad about> withdrawal, etc…no evidence against negative thoughts • Treatment: • Behaviour experiments • Tracking NAT’s • Challenging NAT’s, and by checking them, • Challenging core beliefs • By reviewing evidence

21. Cognitive behaviour therapy • Depression: • Negative view of self, the world and the future • General belief: “I’m not good enough” • Specific thoughts “I can’t do this, I’ll never do..I deserve to fail” • E.g. minimising positive aspects, maximising negative aspects • Anxiety states • unlearning the fear response (avoidance loop) • learn a coping response • breathing/relax • managing Negative Intrusive Thoughts (NITS) & developing coping thoughts • over progressive stages, from least worrisome to most • Psychosis • Investigate content of beliefs and sources of voices, e.g. in paranoia • modifying strength of belief in the “beliefs” • checking evidence for them • Managing/answering voices

22. “ Social Inequality exists when an ascribed characteristic such as sex, race, ethnicity, class, and disability, determines access to socially valued resources. These resources include access to money, status and power, especially the power to define societal rules, rights and privileges.” Acheson (1998) Independent Inquiry Report: health inequalities in the UK have widened since 1980 60% of the population live on less than the average wage numbers of people living on less than half the average wage increased since 1961 from 10% to 20% in 1991 1 in 3 children were living in poverty in the mid-1990s Gender inequalities, major…(see notes) Social Inequalities

23. Psychological Interventions (changing coping styles, engaging with rehab, managing mood) can produce 46% reduction non-fatal cardiac events 41% reduction in mortality 2 years follow up (Ref: Linden et al 1996) Exercise based interventions may have Positive effect of patients – physical ability to exercise Improve some physiological measures of cardiac disease but do not impact on Blood lipids Morbidity Overall mortality Insufficient evidence re psychological and social outcomes

24. Socio-cultural general environmental factors/historical issues will contain causes for distress can empower people at other levels e.g. involved in support/pressure groups Therapies “delivered” in different forms Individual level families specialised groups... bereavement Alcohol Eating disorder Hearing voices Delivering services…

25. Becoming a Clinical Psychlogist • “good”degree in psych • 2-3-5… years of work as an assistant • and/or a post graduate qualification • e.g. clinically related PhD, or Msc • useful experience • voluntray work • Mind/Samaritans/Headway… • Useful background • work across cultures/groups • maturity of thinking/empathy • ability to be boundaried & supportive • ability to maintain a life outside work

26. …as a psychologist..an easy job if you have a pipe and a couch…NOT

27. BPS web site information • To get into Clinical psychology you will need to study for a degree in psychology first. This should be an accredited degree giving you eligibility for Graduate Basis for Registration with the British Psychological Society. The list of accredited degrees courses is available on our web site at the following URL:www.bps.org.uk/careers/search.cfm • After that you will have to do a 3 years doctorate in Clinical psychology. Again lists of accredited courses are available on our web site. You will also find there the careers information related to becoming a psychologist. You can go to the general careers page to start looking at; www.bps.org.uk/careers/careers.cfm Finally, you might find it useful to look up the Clearing House for courses in Clinical Psychology web site: www.leeds.ac.uk/chpccp/index.htm • Work experience is not an entry requirement for the Clinical training courses. However, the competition to get onto courses is fierce because of limited places. Therefore it is a fact that experience is highly desirable to be successful in gaining a place. Voluntary work in the caring profession might help in gaining an Assistant post. • When you apply for a place on a clinical training course you apply for funded training. … you receive a trainee salary. For more information on funding of Clinical psychology courses please contact: Clearing House for Post Graduate Courses in Clinical Psychology (CHPCCP) University of Leeds 15 Hyde Terrace, Leeds LS2 9LT