Assessing for Adult Psychological Therapy What suits whom ?

1. Assessing for Adult Psychological TherapyWhat suits whom ? Howard Edmunds howardedmunds@me.com Friday 23rd November 2012

2. Introductions • Name • Mode/ type of therapy you practice ?

3. BTC Therapies • Counselling: Psychodynamic, Integrative, Humanistic: J.S, K.W., P.S., • Individual Psychotherapy: Psychoanalytic (E.C. D.O. H.E.) , Integrative (), Psychosynthesis (C.B.), Humanistic (), Gestalt (). • Mindfulness Based Cognitive Therapy: John Mitchell.

4. Step 4. / Secondary Care Psychological TherapiesBrighton Therapy Centre • Group Cognitive Behavioural Therapy: Mind Over Mood. (). • Individual C.B.T 12weeks- 1 yr: (Laura Findlay, Jacquie Patterson, Sarah Arnold, Maz Low) • Cognitive Analytic Therapy 6 months: vacancy to be filled. • Eating Disorders pathway; individual and ‘pre therapy’ group: Laura Findlay. • S.T.E.P.P.S.: Lisa Davies.

5. Art Psychotherapy: Michele Humphrey, Nick May, Duncan Wardlaw • Psychodrama 2 yrs. Mel Bates • E.M.D.R. Michele Humphrey. • Systemic Family Therapy : Mike Lloyd. • Depression and Mood Swings Group. ( mentalization/ CBT/ Psychodynamic ). Jo Laurens 30 months • Group Analytic Psychotherapy Howard Edmunds • Individual Psycho-analytic Psychotherapy E.C., D.O., D.M.,

6. Exclusion criteria for BTC • in midst of acute crisis – crisis support team / acute admission/ C.P.N. ( Tier 4). • organic brain syndromes that affect ability to communicate – medical treatments e.g. Donald Wilson Unit St Richards. • significant risk to others – forensic services.( Appendix 1) • actively using non-prescribed drugs to numb feelings or manipulate thinking- drug rehab. services.

7. Counselling: Psychodynamic, Integrative, Humanistic: J.S, K.W., P.S.,

8. Psychotherapy: Analytic • Indicated for personality problems in several areas of life e.g. work, family, self image. ‘ complex comorbidities that may be present along with depression’ Nice Guidelines. • Long term – 1 year. • Broader goals; tackles underlying causes & gaps in emotional development • Psychodynamic – drives and defences - uses past experiences and their impact on present relationships. • Transference - refers to relationship with therapist & how patient’s past can distort their perceptions in the present. • Focus on internal conflicts as well as strengths. • Patient must have some support / coping strategies for managing distress in addition to therapy.

9. Psychotherapy: Integrative

10. Mindfulness Based Cognitive Therapy: John Mitchell.

11. C.B.T. Anxiety & Depression Group • Disorders; affective, anxiety, personality. • 10 week programme for patients with low self-esteem / depression. • Focus: negative thoughts, assumptions & schemas/core beliefs and how these affect mood and maintain dysfunctional behavioural patterns. Emphasis on understanding of the development of these but focus on here and now. • Psycho-educational model with focus on developing skills to make the difference in quality of life e.g. Self awareness, capturing and reappraising negative thoughts, alternatively letting go, behavioural activation, aspects of mindfulness, recognition of strengths and positive qualities. Practice through ‘homework’ • Group benefits : “ Phew, I’m not the only one !”, peer support, practice, learning from others. • Less focus on group relationships.

12. C.B.T. Obsessive Compulsive Disorders Group • Client who are able and willing to explore and talk in a group about their OCD. • 12 weeks therapy using specific OCD Model. • Focus: building own Exposure and Response Prevention programme, plus distress tolerance. • Experiential model with focus on exploration of intrusive unwanted thoughts and the consequences of these, sharing experiences and supporting group members through group experiments/ exposure. • Often based on a meta-cognitive and schema approach to the maintenance of OCD. • Group benefits: reduce isolation; peer support.

13. Shame and Compassion Group • 10 week closed group for those who have experienced childhood sexual abuse. • Focus on acceptance, validation, safety, trust, power, and esteem. • Exploration of the connection between cognition, development of beliefs, emotion and attachment. • Group benefits: ‘Having a voice’ peer support and acceptance.

14. Eating Disorders • Anorexia nervosa • Bulimia

15. Individual C.B.T. Can’t access group; low level ego strength, logistics. N.I.C.E. ( 2002) guidelines; 100% of individuals with schizophrenia who are experiencing persistent psychotic symptoms should be offered CBT”. Disorders: affective disorders, anxiety disorders, personality disorders. Usually short term – 12-24 weeks. Focus on negative thoughts, assumptions & schemas/core beliefs and how these affect mood. Educational model with focus on skills eg. Self awareness, reality testing, self help, changing thoughts. Does not focus on transference; aims at positive therapeutic alliance with client.

16. S.T.E.P.P.S. • Systems Training for Emotional Predictability and Problem Solving. • Patients with personality disorders; ‘emotional intensity disorder’; patients who lack internal ability to regulate emotional intensity. • Developed in Iowa, 1995 Blum, St John & Pfohl ( 2002). • Stage 1. 20 week basic skills group, plus individual ‘ reinforcement’ sessions to support application of skills to everyday life. • Stage 2. 1 year fortnightly group. ‘Stairways’. • Cognitive Behavioural Skills approach; emotion and behaviour management skills. • Model; CBT, psychodynamic, systemic, attachment, educational. • Skills: Self Awareness, emotional management & behaviour management. • Benefits. Provides long term attachment relationships with peers, trainer and individual therapist.

17. E.M.D.R. 'Eye Movement Desensitisation and Reprocessing'. • Developed by Dr Francine Shapiro, in the 1980s (in Palo Alto, USA). • Length: 12 – 25 weeks individual sessions. (up to a year for complex cases) Patients who have experienced trauma eg. war related, road traffic accidents, natural disaster, workplace accidents, surgical trauma, assault. Can also be used for childhood sexual and/or physical abuse or neglect. • Focus on relief of PTSD symptoms by recounting memory of trauma and ‘re-processing’ this. Eg flash-backs, changed core beliefs, hypervigilance.

18. EMDR • Model. Adaptive Information Processing. Sees brain as processing information but where it can’t needs help. Eg. Flash backs as unprocessed information which subside during treatment. • Approach: Involves discussion of the salient aspects of the trauma from which target images and cognitions are generated. Therapist initiates Bilateral Stimulation (hand movements, tones, taps or buzzers) to facilitate processing and uses verbal/cognitive prompts where necessary. Others aspects of the trauma(s) are also processed e.g., physiological experience of trauma.

19. Cognitive Analytic Therapy • Time limited, focussed, integrative therapy. Forged within the crucible of the British NHS (Tony Ryle). • 16 sessions – ‘neurotic’ problems such as depression, anxiety, eating disorder, bereavement.24 sessions - personality disorders of all types, developing reputation particularly for BPD. • Patient derived focus of ‘target problems’. Collaborative therapy centered around a shared ‘reformulation letter’ describing ‘target problem procedures’ inc ‘reciprocal roles’, ‘snags’ ‘traps’ and ‘dilemmas’. Diagrammatic formulation also. • Psychodynamic i.e. refers to past experiences and works with transference relationship.

20. Behaviour Therapy. • Indicated for specific behavioural problems. • Medium term – 12 weeks to 1 year. • Agree specific behaviours to target. • Educational model – looks at chain analysis of behaviours, thoughts and feelings leading to problem behaviour. Teaches coping strategies. • O.C.D. – Springfield Hospital. • Eating Disorders – Maudsley Eating Disorders Unit.

21. Systemic Family Therapy. • Family relationship problems. • Short/ medium term, with few weeks between meetings. • One or two therapists work with family, supported by consultation team observing via one way mirror. • Focus on family as a system. Encourages verbalisation, awareness of relationship patterns, roles, paradoxical intervention (as family unites to defeat therapists).

22. Drama Therapy Psychodrama is a method of group psychotherapy. Indicators: Relationship problems/ personality problems. Helpful for those who can’t find words, are to vocal, use metaphors or very visual in their communications. Participants are encouraged to explore their problems and life experiences in action. Group members play auxiliary roles. Broad goals – tackles underlying causes & gaps in emotional development. Focus: early life and significant events and how these impact on current relationships. Ego training in action; highlights patterns of relating that emerge in the drama & offers a chance to try out new ways of relating. – Role Training Patients require some support and coping strategies. Time Limited – 2 years

23. Art Psychotherapy “ Through the arts we can express and fulfill ourselves, and engage with other people in ways that other forms of communication do not offer.” ‘(Andy Burnham and David Lammy MPs Foreword to ‘A Prospectus for Arts and Health’ Arts Council and Department of Health 2007) Art Psychotherapy’s aim is to offer to patients a way to express their thoughts, feelings and experiences that does not rely solely on verbal communication. This can be of benefit to those who find expressing themselves verbally difficult or who use language as a defence. Sessions are offered individually or in group. Referrals are accepted for patients who are part of the CMHT or in-patients who it is felt would benefit from time using an arts medium within the structure of a therapeutic relationship. Patients need to have a desire to explore the issues that have brought them into the service and feel able to cope with the space between sessions as well as the process within.

24. Group Analytic Psychotherapy • Indicators: Relationship problems/ personality problems. • Borderline personality disorders – used in day hospitals combined with CBT, OT and therapeutic community model. • Long term – 2-5 years average length of stay. • Broad goals – tackles underlying causes & gaps in emotional development. • Focus: early life and significant events and how these impact on current relationships. • Ego training in action; highlights patterns of relating that emerge in the group & offers chance to try out new ways of relating. e.g. asking for help, giving & receiving feedback. • Multiple transferences; explores how patient relates to group as a whole, conductor and other individuals in group. • In depth focus on interpersonal conflicts in group & negative feelings as well as positives. • Patient must have some support/ coping strategies in addition to group.

25. References