408 final Flashcards
(154 cards)
1
Q
what is the goal of psychodynamic therapies and what are some examples
A
- focus on unconscious processes that impact client’s present behaviour
- originate from psychoanalysis (lacking the analysis part and doesn’t go on for many years)
- short-term psychodynamic
- mentalization-based therapy (understanding your own and others’ emotions, used for BPD)
- transference-focused psychotherapy (focus on therapist-client processes, used for PDs)
2
Q
short-term psychodynamic goals
A
- symptom relief AND limited but significant character change
- long-term psychodynamic makes more personality and interpersonal changes (which necessarily take longer because you need practice to engage in new habits and patterns of behaviour)
- work on one circumscribed area of focus (presenting symptoms, interpersonal problem)
3
Q
short-term psychodynamic structure
A
- once/week for less than one year
- in research, usually 16 sessions (esp. if being compared to CBT)
- therapist must maintain therapeutic eye on chosen focus (guide client to focus on mandate)
4
Q
short-term psychodynamic candidature
A
- patients should be psychologically minded, insightful, motivated
- unable to make meaningful change if the person isn’t ready or able to stay on task
- capacity to engage and disengage readily (from distractors)
5
Q
psychodynamic techniques
A
- supportive
- expressive
- monitoring countertransference
6
Q
psychodynamic supportive technique
A
- defining the therapeutic frame (the boundaries around therapy, your therapist is not your friend, they have a particular role)
- therapist demonstrating genuine interest and respect
- noting gains (helping with self-efficacy and progress = making more success)
- maintain here-and-now perspective
7
Q
psychodynamic expressive technique
A
- offering empathic comments
- confrontation when needed (questioning people if they don’t know how they’re affecting others)
- interpretation: summarizing info, reflecting it back to the client, and suggesting things based on what the client has said based on patterns in relationships, how the past impacts the present + get feedback from client
8
Q
monitoring countertransference psychodynamic technique
A
- can slow therapy down if therapist is having negative feelings toward the client, takes away from progress
- do this in any therapy, but specifically taught for psychodynamic
9
Q
Steinert et al. meta-analysis for psychodynamic
A
- assumption that psychodynamic isn’t as effective as CBT or good at producing symptom change
- meta-analysis of 23 RCTs comparing psychodynamic to an established treatment (CBT or others, comparability across session lengths)
- both treatments using manuals
- primary outcome: target symptoms
- secondary outcome: general symptoms and functioning
- testing for equivalence of two treatments
- results: no meaningful or significant difference between psychodynamic and comparator treatments at post- and FU
- statistical difference (small effect size) favouring psychodynamic treatment for functioning at FU
10
Q
humanistic/experiential therapies origins, focus, and examples
A
- originate from client-centered therapy
- based on the premise that individuals are self-actualizing
- Gestalt therapy, existential therapy, emotion-focused therapy
11
Q
what distinguishes psychodynamic/humanistic/interpersonal from CBT
A
- focus on affect and expression of patient emotions (while CBT does focus on emotions, they’re only relevant in how they lead to automatic thoughts–focus on cognitive change)
- exploration of patient’s attempts to avoid topics or engage in activities that hinder therapy progress
- identification of patterns in patient’s actions, thoughts, feelings, experiences, relationships (beyond the patterns found in thoughts)
- an emphasis on past experiences
- focus on interpersonal experiences
- emphasis on the therapeutic relationship as a vehicle or medium of change
- exploration of patient’s wishes, dreams, fantasies as clues to unconscious functioning
12
Q
focus on affect and expression of emotions (PDT, humanistic, interpersonal)
A
- idea that intellectual insight is not sufficient, we need emotional insight (truly believe)
- encourage expression of emotions rather than management or control (psychic conflict coming from bottled up emotions)
- draw attention to feelings regarded as uncomfortable
13
Q
pattern identification in PDT, humanistic, etc.
A
- how patterns in interpersonal functioning repeat over time, settings, people
- maybe mirroring early childhood relationships
- interacting with the therapist in that pattern
- patterns are identified through interpretations (therapist suggesting a pattern they’ve observed to see if it rings true, then explore patient reaction)
14
Q
emphasis on past in PDT, humanistic, etc.
A
- identify origin of patient difficulties and understand how they have manifested in lifetime (past and present)
- emphasize both pre-adult and adult past
- recent trend for PI (interpersonal?) to be more present-focused (current maintenance so it doesn’t take too long)
15
Q
focus on interpersonal experiences PDT, humanistic
A
- problematic relationships interfere with ability to fulfill needs and wishes
- compare patient functioning with that of others (how is your behaviour impacting other people)
16
Q
therapeutic relationship PDT, humanistic
A
- a good therapeutic relationship can generalize to other relationships
- transference = patient’s projections onto therapist
- therapist elicits feedback about client’s reactions to therapy (how do you feel opening up to another person)
17
Q
emotion-focused therapy basics
A
- originally process-experiential therapy
- 16-20 sessions
- theoretical basis: emotion is a key determinant of self-organization
- emotions are useful from an evolutionary perspective, but how we make sense of our emotional experiences is influenced by culture (tells us when to act/retreat, who to associate with)
- we should re-learn how to make sense of our emotions
18
Q
types of emotions
A
- primary: direct initial reaction (instinctual)
- secondary: our judgment of our emotions, happen after primary emotions (guilt or shame about feeling some emotion) - we work on these emotions
- adaptive: primary emotions that communicate information (fight-or-flight: how we use emotions to navigate our environment)
- maladaptive: ‘old familiar feelings’ that do not change with the situation, experienced habitually (not communicating information) - focus of treatment
19
Q
three principles targeted in EFT
A
- emotion awareness
- emotion regulation
- emotion transformation
20
Q
emotion awareness EFT
A
- become aware of primary adaptive emotions (so we can use that information)
- not thinking about feeling, but actually feeling the emotion (arouse emotional experiences and feel them, don’t talk about them)
- accept, don’t avoid emotions
- express emotions, including what you feel in words (behavioural urges, what does the emotion make you want to do)
21
Q
emotion regulation EFT
A
- which emotions need to be regulated
- some primary emotions don’t need to be regulated (adaptive vs. maladaptive)
- teach emotion regulation skills, including tolerance and self-soothing like deep breathing
- not specific to EFT (cognitive reappraisal is a form of emotion regulation, also very important in DBT)
22
Q
emotion transformation (EFT)
A
- process of changing emotion with emotion: undo a maladaptive emotional response with a more adaptive emotion (fight fire with fire)
- CBT is thinking about the situation differently, but here we throw a new emotion into the mix (this aspect is more specific to EFT)
- techniques: shifting attention, positive imagery, remembering another emotion
23
Q
other techniques in EFT
A
two-chair dialogue for self-critical conflicts
- person is trying to gain confidence, but they’re criticizing themselves (so having trouble merging these two aspects of themselves)
- play out both sides of the conflict, externalize or look at yourself from an outsider’s perspective
empty-chair work for unfinished business
- getting out old familiar feelings by sharing them with a literal empty chair
24
Q
research evidence for EFT
A
- EFT for depression
- similar in EFT and CBT, greater decrease in interpersonal problems in EFT than CBT
- symptom remission greater in EFT compared to client-centered therapy (emotions do matter, not just being supportive like in client-centered therapy)
25
interpersonal psychotherapy
- designed as a control condition, but found it to be as effective as psychopharmacology
- shows good efficacy for depression, BN, BED (interpersonal events triggering negative affect)
26
interpersonal psychotherapy basics
- Klerman and Weissman 1970s
- concerned with interpersonal context (relational factors that predispose (vulnerability factors), precipitate, and perpetuate (maintenance factors) distress)
- 12-16 sessions
- clients should have a secure attachment style, a specific interpersonal focus of distress, and a good support system (you shouldn't do this with an emotionally abusive spouse)
27
IPT problem areas
- role transitions (stressful life events; moving, new job, divorce)
- role disputes (infidelity, unmet expectations)
- grief
- interpersonal sensitivity (pattern of difficulty forming and maintaining relationships): only focus on this if there isn't another target focus, will be difficult to treat because it's a longstanding pattern
28
IPT structure
- interpersonal inventory administered to choose the problem area
- work collaboratively to develop solutions to the problem
- patient implements solutions between sessions
29
IPT techniques
- interpersonal incidents: something happened (like a fight with a partner), so we detail those incidents to understand what happened
- communication analysis: ineffective communication underlying problems people are experiencing (what happened and what would be done differently), understanding communication patterns (but very similar to technique #1)
- problem-solving (practical strategies) and role-playing (rehearsing new ways of interacting)
- encouragement of affect: content (what's happening) AND process (being able to talk about things that are difficult)
30
IPT video example
- what could you have done differently to avoid the conflict
- going through the situation step by step, then problem-solving for the future
- what was her reaction to the situation and what were others' reactions (emotionally and what did you actually say, what could you have said differently)
31
research evidence for IPT
- meta-analysis of 62 RCTs for depression
- d = .62 in favour of IPT compared to control
- d = .06 for IPT compared to other psychotherapies
- can be used for BN and BED
- CBT more rapidly improves BN Sx compared to IPT (slower to improve with IPT), but those treated with IPT continue to improve post-treatment (no differences at FU)
- learning skills for interpersonal situations that they continue to practice when therapy is over
- group IPT comparable to group CBT
32
mindfulness
awareness that arises from paying attention on purpose, in the present moment, and non-judgmentally
33
three components of mindfulness
- attention: full attention to the present moment, not past or future
- intention: knowing why we're doing what we're doing
- attitude: the way in which we pay attention (kind, open, curious)
34
seven attitudinal foundations of mindfulness
- non-judging: impartial witness to your own experience
- patience: letting things unfold on their own without rushing it
- beginner's mind: being receptive to new things that mindfulness might bring you
- trust: yourself, your feelings, the process
- non-striving: not trying to achieve anything or move anything forward, just be where you are
- acceptance: see things as they are now
- letting go or letting be or non-attachment: like letting yourself fall into sleep
35
formal mindfulness meditation practice
- set aside a time, in a certain place
- mindful breathing (counting breaths or breathing in for a set amount of time)
- body scan (notice sensations or pain)
- mountain meditation: picture yourself as a mountain that doesn't move and will always be there, there may be weather around the mountain, but you're always steady
- loving kindness meditation: foster warm kind thoughts for yourself and others
36
informal mindfulness practice
- awareness of thoughts, emotions, bodily sensations, and sensory input during everyday activities
37
mindfulness-based stress reduction (MBSR)
- NOT a psychotherapy
- 8-week workship with 2-3 hour group sessions, daily homework, one-day retreat
- complements traditional medical or psychological treatment
- very commercialized
38
mindfulness-based cognitive therapy (MBCT)
- formal treatment developed for depression relapse prevention
- not yet a first-line treatment for current depression, but was for people who were vulnerable to multiple episodes
- group Tx integrating MBSR with CBT
- different from CBT: moves away from CBT's emphasis on changing content of negative thinking toward attending to the way in which all experiences are processed (thoughts, emotions, sensations)
- early RCT: after CBT, people randomized to TAU or MBCT = MBCT had fewer relapses
39
MBSR and MBCT efficacy
- mindfulness-based therapy for depression and anxiety across a range of conditions (physical and psychological)
- mindfulness has been examined for physical pain
- moderate-to-large Tx effects
- in actual mood and anxiety disorders = very large Tx effects
- MBSR in healthy individuals = medium effect size in change in mindfulness, large effects on stress, moderate effects on depression, anxiety, distress, quality of life
- changing our relationship with our emotional experiences and thoughts
40
ACT (Stephen Hayes)
- therapeutic approach that uses acceptance and mindfulness processes, and commitment and behaviour change processes to produce greater psychological flexibility
- not a Tx for a particular disorder
- works on psychological flexibility: ability to relate to the world in a more open-to-experience way
- ACT perspective on suffering: negative emotions and thoughts are normal human experiences, suffering is due to use to language and our attempts to control our internal human experiences (attempts to change or get rid of them)
- traditional approach: humans are naturally psychologically healthy and, if we experience psychological pain, it means something is wrong and needs to be fixed
41
philosophical foundations of ACT
- based on relational frame theory
- our mind makes arbitrary connections between things, with connections based on history and context (the way we navigate our world is based on what we've learned)
- ex: melon = bigger than apple and not as yummy as an apple (interpreting your experience of a melon compared to your experience of an apple)
- we make sense of our world based on the context we're in and what we're thinking (our thoughts and emotions work in the same way; just words that may differ or diminish in importance based on the context we're in)
- our suffering is based on our use of language (limitation of language is our attaching words to negative emotions and thoughts = they become real so we take them too literally)
42
ACT model hexaflex
- psychological inflexibility to psychological flexibility (the center of the hexaflex)
- cognitive fusion toward defusion
- experiential avoidance toward acceptance
- loss of flexible contact with present toward attention to the present moment
- attachment to the conceptualized self toward self as context (contact with observing self)
- lack of value clarity toward value clarification
- inaction, impulsivity, and avoidance persistence toward committed action
43
cognitive fusion and defusion
- fusion: verbal dominance over behavioural regulation (taking your thoughts too literally, that our thoughts are reality, experiencing your self as your thoughts)
- defusion: mindfully noticing thinking as it occurs ("I am having the thought that..." instead of "I am...")
- watching thoughts go by as if they were leaves floating down a stream (that's the thought, it doesn't mean it's me)
44
experiential avoidance and acceptance
- attempt to alter form, frequency, or function or private experiences, even when doing so is costly or ineffective
- trying to stop, change, suppress negative emotions
- acceptance: adopt an intentionally open and flexible position about moment-to-moment experiences (curious and open and non-judgmental)
45
loss of flexible contact with the present
- fusions and experiential avoidance lead to the desire to be somewhere else (we want to be in the past or in the future, anything but right now with our thoughts)
- attend to what is present in a focused, voluntary, and flexible way
- use language to describe internal events, rather than to predict and judge them
46
attachment to conceptualized self
- idea of ourselves that we hold, maybe from the past or from others or society
- promote contact with sense of self based on here-and-now
- 'noticing self' or 'observer perspective'
47
values problems
- commitment behaviour change
- values are different than goals; not things we achieve, more ongoing and guide our behaviour
- persist or change in behaviour in the service of one's chosen values
- continue acting in ways that promote values or stop acting in ways that don't
- values: predominant reinforcer is intrinsic to behaviour pattern itself; a direction rather than a destination
- problems we can have with values: not your own, unclear to you, based on avoidance (trying to prevent something from happening rather than trying to promote something)
48
inaction, impulsivity, and avoidance persistence
- inaction: depression, impulsivity: SUDs, avoidance persistence: anxiety
- not linked to values
- instead, develop patterns of action linked to chosen values
- set short-term, medium-term, long-term concrete goals that are value-consistent (SMART goal setting)
49
ACT in practice
- psychoeducation isn't explaining a maintenance process or a particular disorder
- due to problems with language, use metaphors to explain ACT concepts (experience the idea rather than talking about it)
- explain creative hopelessness with metaphors
50
creative hopelessness
- bring people into experiential contact with the fact that what they have done so far has not worked
- people have tried to get rid of their suffering, but it's not working = creative hopelessness
- chinese fingertrap metaphor: the more you struggle, the more it tightens
- tug-of-war: right now it's a tug of war with all negative thoughts and feelings = stuckness and exertion of energe (encourage putting down the rope to stop the war = you won't be stuck, but the other side will still be there)
51
ACT evidence
- not RCTs comparing to other treatments
- has evidence for treating depression, mixed anxiety conditions, OCD (people fused with thoughts), chronic pain, psychosis
- research focused on testing processes of change and on functional (not symptom-based) outcomes (since ACT isn't tied to a particular disorder, more about value-based living)
- mediation analyses that examine whether the treatment predicts change in ACT processes, which then predict change in outcome
- medium effect sizes compared to TAU, large effect sizes compared to waitlist
- could be especially useful for comorbid conditions
- psychological flexibility mediating benefits of ACT on depression and anxiety and BPD
52
PDT interpretive interventions vs. supportive interventions and PDT (Steinert)
- interpretive: conscious and unconscious processes or conflict and aim at enhancing the patient's insight in repetitive patterns assumed to sustain their problems
- supportive: aim to strengthen abilities that are temporarily inaccessible to a patient because of acute stress or they aren't sufficiently developed
- PDT: fostering a therapeutic relationship, focusing on affect and expression of emotion, exploring avoidance patterns and resistance to change, identifying recurring themes, discussing past experiences, exploring fantasies and dreams, focus on interpersonal issues
53
original vs. new ACT model
- original: experiential avoidance = avoidance and escape = long-term consequences as the central factor contributing to distress
- now psychological flexibility is the main therapeutic process
54
six core skills cultivated to achieve psychological flexibility
- flexibly and purposefully remaining in the present moment (mindfulness vs. losing contact with the present)
- keeping balanced and broad perspective on thinking and feeling to stop maladaptive avoidance (vs. poor perspective-taking skills)
- clarifying fundamental hopes, values, goals (vs. disconnection from things that matter)
- cultivating commitment to valued actions
- willingly accepting unwanted feelings (vs. trying to control/eliminate difficult internal experiences)
- defusion (steeping back from thoughts that interfere with valued actions vs. seeing thoughts as literal truths)
55
workability in ACT
- helping develop greater awareness of one's behaviours and whether those behaviours are working to solve the problem and moving to valued ends
56
flexible delivery of ACT
- as 1-day workshops: ensures adherence and completion, reduces stigma about mental health, better suited for primary care settings
- embedding ACT in medical settings: more comprehensive and integrative Tx approach for both physical and mental health
- brief: workshops, telehealth calls, online and smartphone interventions, 20-min sessions in primary care visits
57
kinds of mindfulness (Beck reading)
- mindfulness of thoughts: for clients who excessively ruminate, worry, or try to suppress intrusive thoughts or images
- mindfulness of internal stimuli: for intense emotion and other distressing internal experiences
- mindfulness for self-compassion: for clients who experience lots of self-criticism
58
when to use mindfulness in CBT
- if responding to thoughts isn't enough, you use mindfulness to deal with rumination
59
techniques before introducing mindfulness into CBT
- educate about the cognitive model
- advantages and disadvantages of rumination vs. focus on here-and-now
- socratic questioning for the advantages of rumination, how does rumination prevent valued living
- start the thought process in-session (engage with the unhelpful thoughts to simulate the conditions of rumination)
- rate intensity of negative emotion, then do formal mindfulness, then re-rate negative emotion
- draw conclusions about the experience to further challenge dysfunctional thoughts
- set Action Plan to do mindfulness
60
DBT origins
- designed for individuals with chronic suicidality or parasuicidality (cutting NSSI) who didn't respond to CBT or other treatments
- most patients with chronic suicidality have BPD, but not everyone with BPD has chronic suicidality (DBT not designed for BPD patients, but the subset)
- patients engage in behaviours that interfere with therapy (and clinicians experience burnout and have negative reactions to these patients)
61
Linehan's biosocial theory of BPD
- emotionally vulnerable (trait characteristics: strong emotional reactions, quick reactions, trouble disengaging from those reactions)
- invalidating environment (told that emotions are not justified)
- combinations results in problems with emotional skills (emotional tendencies are genetically transmitted AND triggers parent's tendencies = genetic and environmental transmission) like:
- ability to understand and label feelings
- coping skills
- emotion modulation
62
dialectical dilemmas
- emotional vulnerability vs. self-invalidation (feeling like you need someone to pay attention to your pain and recognize it AND telling yourself that your reaction is not valid)
- active passivity (not able to do things for yourself) vs. apparent competence (able to pull yourself together)
- unrelenting crisis (always something going on) vs. inhibited grieving (when something actually stressful occurs, difficulty letting yourself feel the negative emotions)
63
therapist stance to address dialectical dilemmas
- accept client as they are, but also encourage change (this is your experience, how do we improve this)
- centered and firm (maintain boundaries), but flexible when needed
- nurturing, but benevolently demanding (always push the client beyond where they thing they can go)
- balance between change/problem solving and acceptance/validation (client knows you're always there for them in their journey toward change)
64
rational, wise, and emotional minds
- rational: past experience, logic, research
- emotional: feelings, anxiety, anger, fear, sadness, stress
- we want to pay attention to the emotional mind, but we need to balance rational and emotional to get to the wise mind
- wise mind: know and experience truth (knows something to be true, always quiet, knows it in a centered way)--I feel this and I know this, so I will do this
65
DBT treatment package
- weekly individual therapy sessions
- weekly group skills training
- telephone contact: for crisis situations, BEFORE the person engages in suicidal or parasuicidal behaviours to de-escalate
- therapist consultation team meeting (get feedback and feel supported in your work)
- client must commit to all parts of treatment package for at least 1 year (focused experience, but a commitment to longer Tx)
66
individual therapy DBT
- hierarchy of therapy targets (if the higher up items happened in the past week, they take precedence during the session)
1. suicidal and parasuicidal behaviours
2. therapy interfering behaviours (missing a sessions, leaving a session, not doing homework)
3. behaviours interfering with quality of life (substance use, ED behaviours, things that lead to unsafeness)
4. behaviours related to post-traumatic stress
5. improve self-esteem
6. individual targets negotiated with client (we don't spend time with client-initiated targets UNLESS they don't engage in the other behaviours = these contingencies lead to change in the other problematic behaviours)
67
Linehan video for DBT basics
- clients set the goals in therapy (therapist helping client figure out their goals), but then the therapist figures out how to get them there (parasuicidal behaviours will not help you achieve your goal)
- getting the client to agree not to kill themselves for a given amount of time
- goal can be to have a life where you don't want to kill yourself
68
individual therapy: diary card
- tracking behaviours like self-harm, suicide attempts, emotional misery
- used to prioritize session time
- tracks ED symptoms, urges to engage in self-harm (did you? what did you do instead?)
69
skills training modules
1. mindfulness skills: always the thing we start with
2. interpersonal effectiveness skills (problems in relationships are common)
3. emotion regulation skills
4. distress tolerance skills
70
mindfulness skills DBT
- always the thing we start with
- gives people something to turn to
- a base for other skills
- observe, describe (your experience using the five senses), participant (in your everyday experiences in a mindful way)
- how: non-judgmentally, one-mindfully (wise mind), effectively
71
interpersonal effectiveness skills DBT
- each person in the situation has a perspective
- need mentalization skills to understand perspectives
- objectiveness: identify the objectives (what is your goal vs. their goal)
- identify the relationship
- identify your self-respect: your ability to push when necessary, how to say no
72
emotion regulation skills DBT
- identify and describe emotions (see them and react effectively)
- riding the wave of emotion (emotions are temporary, they will decrease eventually)
- opposite to emotion action (act opposite to your emotion)
- Linehan video
73
Linehan video emotion regulation
- inability to regulate emotions (how you feel, the physiology, the experience, the actions related to emotions)
- intense emotional suffering and inability to change that suffering and regulate the behaviour that comes from suffering
- strategies to treat emotions: teach patient to understand what their emotions are
- teach vulnerability factors: you're emotional today because of something that happened yesterday, how to change that
- prompting event (right before the emotion), can you change it (problem-solving)
- interpretation of the event: check the facts (is your interpretation correct? cognitive restructuring)
74
distress tolerance skills DBT
- when distress is so high that it doesn't make sense to use emotion regulation (figuring out what emotion you're feeling, then doing cognitive restructuring), so just wait it out
- distraction, self-soothing, radical acceptance
- trying to lower the intensity of the emotion without thinking about cause of restructuring
75
5 functions of DBT
- enhance the capabilities of the client (improve life skills in group sessions, manage emotions, mindfulness, interpersonal problems)
- generalizing capabilities (beyond therapy using homework)
- improve motivation reduce dysfunctional behaviours (individual therapy behavioural contingencies)
- enhance and maintain therapist capabilities (therapist consultation for support, validation, skill-building, and feedback)
- structuring the environment (maximize client success, reinforce effective behaviour and progress, but not maladaptive behaviour; phone consultation AFTER the self-harm = therapist does not engage), patients need to modify their own environment (change people, places, patterns that are reinforcing behaviour)
76
research evidence DBT (Linehan 2006)
- a lot has been done by Linehan, so investigator allegiance problem
- dismantling study to examine specific ingredients of DBT (controlling for non-specific factors like hours of therapy, availability of group consultation)
- sample: women with BPD with recent suicidal behaviour (matched on five prognostic variables)
- comparison: community therapists nominated based on expertise in treating difficult clients AND identified as nonbehavioural or psychodynamic (not using cognitive restructuring or structuring the environment)
- results: DBT had less dropout, less change in therapist
- DBT had half the rate of suicide attempts (so less use of crisis services and hospital admissions)
- no differences in NSSI
- depression, suicidal ideation, and reasons for living improved in both conditions
77
DBT research evidence
- shortened DBT efficacious for self-harm, suicidal ideation, depressive symptoms
- efficacy data for BN and BED (but no superiority data over CBT)
- preliminary evidence that DBT skills could be a stand-alone treatment for a variety of conditions (problems with interpersonal relationship = teach only those skills)
78
Moore et al., 2018 DBT study
- 8-week skills group in jail setting for male inmates unselected for emotional or behavioural problems, so general application, not for a clinical sample (only 16 full datasets = barriers to implementation)
- mental health problems in inmates have similar underlying threads (self-control, impulsivity, distress-driven maladaptive Bx, poor emotion regulation, interpersonal skill deficits)
- no statistically significant changes in coping skills or emotional/behavioural dysregulation, likely due to small N (and dysregulation measured with personality inventory)
- participant feedback generally positive (high acceptability = promising intervention, but need to reduce logistical problems)
- targeting impulsivity and maladaptive Bx: mindful awareness and relaxation strategies to reduce emotional arousal
- targeting emotiona, dysregulation and anger: identify emotions, reduce vulnerability to emotions, opposite actions, pleasurable activities
- targeting interpersonal skills: make requests, saying no while maintaining self-respect + effectiveness in goal seeking
- measures: ways of coping checklist and personality inventory
- learning adaptive coping can reduce recidivism
- lack of a control group (confounders) and no generalizability (small N)
79
Zalewski et al study
- DBT takes a transdiagnostic approach (treating many different problems)
- emotion regulation is the most important mechanism of change (subdimensions mediate the outcomes in BPD samples)
- neural support: reducing reactivity in brain regions linked to emotional response and sensitivity (amygdala, ACC, insula), increased connectivity of limbic-prefrontal, increased gray matter in emotion regulation regions
- emotion regulation critical in parenting (problems = negative or rejecting parenting, less warmth, more maltreatment)
- parent psychopathology = emotion regulation problems = poor parenting = child emotion regulation problems = child psychopathology (emotion regulation as a generational mechanism)
- DBT can improve emotion regulation, so can be applied to improve parenting and reduce emerging psychopathology in children (increases parenting behaviours like acceptance, effective limit setting, autonomy granting)
80
process-based vs. personalizing psychotherapy
- individualizing therapy based on patient mechanisms
- adapting treatments to the individuals in an evidence-based way
81
mediation
- answers questions about why or how
- testing an explanation for a phenomenon
- mechanism that leads to the outcomes
- relationship between IV and DV is mediated (explained) by another variable
82
moderation
- answers questions about for whom/to what extent
- who benefits the most from CBT vs. psychodynamic for depression
- tells us about individual differences in a response to an intervention
- IV-DV relationship moderated by another variable
83
mediation and moderation studies
- you can't just apply a mediation analysis post hoc and conclude that the variable is a mediator if it's statistically significant
1. mechanism must be malleable (something that doesn't change over time cannot underlie change in symptoms)
2. mechanism related strongly to both intervention and outcome
3. effect is specific (no other mechanism could explain the effect) and replicable across studies
4. temporal correlation: change in mechanism precedes and predicts change in outcome
- we can identify moderators based on knowledge of mechanisms (how a mechanism works = hypothesis about for whom/when is works), instead of identifying moderators of convenience (like demographics)
84
problems with current treatment development
- treatment development has focused on reduction of psychological symptoms and remission of disorders
- based on the DSM, which has many limitations and criticisms for categorical
- excessive co-occurrent among psychological disorders (what do you treat first, treating them as separate things when they influence each other)
- many risk and maintenance mechanisms are common to multiple psychological disorders (avoidance, emotion regulation, experiential avoidance, mindfulness)
85
process-based therapy research
- trying to find the maintenance mechanisms operating for a particular person and designing Tx based on those mechanisms
- not what therapy works better for a specific diagnosis on average (outcome-based), but what treatment (by whom) is most effective for this individual with this specific problem, under which circumstances, and how does it come about
- how does change happen? what are the core change mechanisms? how does treatment assignment relate to outcome?
- what change procedures (therapeutic techniques) are most effective at targeting core mechanisms
- focused on studies designed to identify mediators and moderators (not RCTs)
- moving from nomothetic to idiographic research methods (how is the behaviour maintained and what happens to it when the contingencies are changed = functional analysis, ecological momentary assessment to create personalized maintenance models, passive sensing data)
86
ecological momentary assessment and passive sensing data
- provide data many times a day to get a representative sample of natural environment
- phone can keep track of your screen time and the apps you use, fitness watches
- helping to create personalized models of maintaining processes
- use statistical approaches to understand connections among all the relevant symptoms and maintenance mechanisms
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process-based therapy basics
- identify processes for the person, then use techniques to change them
- Hofmann (CBT therapist for anxiety) and Hayes (developed ACT) dissatisfied with protocolized treatments, so combining the good parts of their fields
- general approach to assessment, conceptualization, and treatment: new framework to organize evidence-based therapeutic techniques along dimensions relevant to adaptation
- using gathered data about personalized concerns and goals to build a model of maintenance and designing treatment to interrupt their loops (and changing questions as concerns change), tracking outcome because the Tx is based on initial data
- attempting to enhance wellbeing instead of symptom-based approach AND targets processes of change, not symptoms, in a certain context (not nomothetic)
- problem: can real-life clinicians feasibly do this?
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change processes and change procedures
- change process: cognitive defusion (goal), and change procedure: mindfulness (technique to get to the goal)
- process: avoidance, procedure: exposure
- process: emotion regulation, procedure: cognitive reappraisal/thought restructuring
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Amy's case (Ong et al., 2023)
- meets criteria for GAD, incessant checking behaviour, indecision about career, strict standards about personal responsibility + guilt
- goals: clarify values around career, increase physical activity, plan to leave job, be more present in interactions, maintain boundaries
- develop conceptual model with black and white arrows to identify maintenance loops using FBA (self as selfish = worry that others see her as selfish if she doesn't take responsibility = behavioural checking = affective pressure to be responsible)
- info gathered with EMA and continued throughout treatment (minutes using mail app, minutes of physical activity, did you feel pressure to be responsible)
- first goal was to target inflexibility around personal standards and attentional control
- as Tx progressed, questions in EMA were updated
- outcome: scores for self-rated progress and trust in herself (too many daily reports = missing data), but we see improvement over time
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network approach to psychopathology
- process-based perspective
- symptoms have causal interrelationships with one another (not caused by some underlying disease), and these are unique to each person
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dimensions relevant to adaptation (Ong et al.)
- based on the dimensional extended evolutionary meta-model (EEMM) to clarify the relationships between processes relevant to dimensions and find optimal treatment strategies
- cognition, attention, affect, behaviour, self, motivation + biophysiological and sociocultural levels
- PBT views psychopathology as maladaptation in a given context to problems in variation, selection, and retention of biopsychosocial processes
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variation, selection, and retention in PBT
- introduce new ways of responding (variation)
- identify which strategies are most effective for a problem (selection)
- help clients persist in useful responding (retention)
- across various dimensions (EEMM), on intra and interpersonal scales, in ways that are sensitive to the person's particular context
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steps of PBT
1. use a network of interrelated variables (not diagnostic labels) to describe presenting problem
2. collaborate with client on conceptualization
3. EMA items administered daily to collect longitudinal data for treatment progress
4. design Tx to target nodes that contribute to other struggles
5. use idiographic statistical analysis to verify hypothesized networks
6. adjust Tx in response to empirical data and contextual shifts
7. aim to establish adaptive network + assess sustainability and resilience of this new network
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personalizing psychotherapy basics
- psychotherapy is always personalized, but on the basis of clinical judgment or patient preferences (adapting EBP)
- but decisions as to where and how to personalize are not evidence-based, so how do we make those decisions?
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dimensions of personalization
- related to moderators
- therapy delivery: online vs. in-person, number of sessions, order of components
- diagnosis: psychosis and MDD treatments look different
- specific symptoms and psychological processes
- personality traits (if someone is very disagreeable)
- pre-existing psychological skills (do you capitalize on strengths or compensate for weaknesses?)
- response to treatment and reason for lack of response
- change in psychological mechanisms over time
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ways to personalize psychotherapy (Sauer-Zavala)
- choosing a different treatment based on some characteristics (some research using demographic and baseline characteristics to predict which treatment some people do better in, but very few characteristics end up being useful) -- treatment selection
- which therapy skills to include based on presenting problem (modular approaches)
- the order of therapy skills (standardized or capitalization vs. compensation)
- treatment changes: how do you know when something is working or not working and what do you change
- session frequency
- treatment termination
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UP for emotional disorders
- transdiagnostic for emotional disorders (internalizing like MDD and EDs, also potential EDs or BPD with adaptation)
- core Tx modules, but don't necessarily need to be done in a particular order
- modules don't all need to be covered
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UP modules
- Understanding Emotions (awareness)
- increasing present-focused emotional awareness (Mindful Emotion Awareness)
- increasing Cognitive Flexibility
- identifying and preventing patterns of emotional avoidance and maladaptive emotion-driven behaviours (Countering Emotional Behaviours--4 sessions)
- increasing awareness and tolerance of emotion-related physical sensations (Confronting Physical Sensations)
- interoceptive- (fear of fear panic) and situation-based emotion-focused exposure
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UP research evidence
- UP outperfoms waitlist control for patients with a principal anxiety disorder
- UP improves anxiety and depression symptoms, levels of negative and positive affect, and symptom interference in daily functioning (works on multiple domains, so broader Tx)
- limitations: no comparison to diagnosis-specific treatments (is transdiagnostic actually better?)
- limitation: lack of longitudinal FU data
- limitation: lack of data in other populations with problems with emotion regulation (ED, BPD, SUD)
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Sauer-Zavala SMART design
- sequential multiple assignment randomized trial: multiple levels of randomization and they happen sequentially
- aim 1: effect of personalized sequence of modules on rate of symptom improvement (3 conditions: standard order, capitalization, compensation)
- aim 2: compare personalized selection of modules to full treatment (after in-Tx for 6 sessions, randomized to either stop or finish Tx, so either they received 2 or 3 modules or all 5)
- 70 patients with an emotional disorder (mean 3 comorbid conditions)
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capitalization vs. compensation conditions (Sauer-Zavala)
- standard order starts with the first (emotion understanding)
- compensation: focus on understanding and mindfulness (this is what was more difficult for most people)
- capitalization: focus on countering emotional behaviour and confronting physical sensations (people are typically better at this)
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Sauer-Zavala results
- people liked the standard and capitalization versions better than the compensation version AND preferred the full treatment
- symptom outcomes: anxiety, depression, clinical severity
- no differences between the conditions = Tx can be shortened AND modules can be moved around to enhance personalization
- self-efficacy as a potential mechanism for change: seeing change in symptoms motivates more change (capitalization)
- telehealth used for many/all participants (because of covid) and outcomes were not affected by this change (UP amenable to remote administration)
- shorter treatment improves treatment efficiency = reduced patient costs and increased mental health service capacity
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modular approach
- patients receive only the treatment components that best fit their presentation
- greatest gains could come from a personalized modular approach with a transdiagnostic intervention
- Unified Protocol
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treatment gap
- difference in people who have a disorder and proportion who receive care
- caries based on location (largest gap in Nigeria, smallest in USA though still large)
- only a third of people receive adequate treatment in the states
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reasons for the treatment gap
- the way psychotherapy is set up according to the medical system (dominant model of treatment delivery)
- one-to-one basis (even though group therapy can be as effective and more cost-effective)
- delivered by highly trained professionals (doctoral degree)
- sessions are held at a clinic, private office, facility (less true now, but can still be a barrier)
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task shifting
- novel model of delivery
- redistributing work to a broad range of individuals with less training and fewer qualifications
- Dimidjian BA delivered by nurses and non-psychologists, Tatham delivered by assistant psychologists
- more categories of people with less training delivering amenable therapies
- challenges: obtaining personnel and trainers who can teach the treatment
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best-buy interventions
- novel model of delivery
- selected interventions based on cost-effectiveness, feasibility, whether they're appropriate to implement in setting
- exercise is a good first-line treatment for mild depression
- best-buy intervention will differ based on context (per the country or disorder) like health-care resources, infrastructure, population
- an economic tool for countries to select among evidence-based strategies based on some criteria
- taking something that's easy to change and reduce the eventual development of the disorder (that will be more costly); prevention
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disruptive innovations
- novel model of delivery
- distinct change from what is being done currently (telemedicine), not incremental steps
- providing simpler, less expensive, or more convenient solutions that can often be scaled to reach inaccessible people
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interventions in everyday settings
- novel model of delivery
- reach people wherever they are (beyond clinics and traditional settings)
- therapists (or active listeners or counsellors) in barbershops, religious settings to deliver information
- overlaps with disruptive innovation
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entertainment education
- novel model of delivery
- embed information in television or radio
- have characters struggle with mental health and reach out for help (using accurate descriptions)
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use of social media
- novel model of delivery
- bring interventions to people online
- social media can be helpful (with recovery) or harmful (perpetuate your disorder) depending on how you use it
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use of technologies
- novel model of delivery
- internet-based or app-based treatment delivery (self-help)
- self-monitoring reports, questionnaires to monitor progress
- can extend the dominant model of therapy so that clients don't need to go into clinics, but still one-to-one OR be core modules completed alone, etc.
- overlaps with social media category
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community partnership model
- novel model of delivery
- partner with community organizations to develop action plans
- what works best, where to go, what do people need help with
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novel models of delivery (Kazdin)
- task shifting
- best-buy interventions
- disruptive innovations
- interventions in everyday settings
- entertainment education
- use of social media
- use of technologies
- community partnership model
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technology in treatment options
- psychoeducation or self-help formats: collection of tools (not treatments) designed to be educational (presented as lessons, not sessions; Stephen Hayes 7-part ACT mini-series)
- digital treatments: retain structure and components of original treatment (or using aspects like self-monitoring online)
- digital assessment: questionnaires automatically scored and interpreted with info transmitted to a clinician (online forms and passively collected information)
- digital training and dissemination: clinical trainings with videos and demonstrations
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digital treatments
- retain structure and components of original treatment
- sessions times set aside and used for intervention
- may have some degree of personalization (based on demographic group or presenting psychopathology)
- machine learning can make greater personalization possible (adapting online Tx)
- user may select components of intervention that are most relevant (opt-in or out if it's a modular treatment)
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digital assessment
- questionnaires automatically scored and interpreted, info transmitted to clinician (or presented to the client in an adapted fashion)
- can self-monitor thoughts, mood, activities with smartphone
- can track non-self-report phenomena like sleep, physical activity, speech, device usage (and transmitted to a therapist)
- potential for real-time intervention (just-in-time adaptive interventions): if someone reports many symptoms or stress, resources deployed to their smartphone at particular times based on their symptoms
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digital training and dissemination
- clinical training websites with videos and demonstrations (role-plays between therapist and client for people to watch)
- reaching more users and lowering costs
- training series for novel treatments for therapists
- standardized training provided: everyone gets the same experience so no differences in dissemination of a new treatment
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research about technology in treatment
- digital interventions are popular and reach a lot of people (MoodGYM) so reduce long waitlists and expenses, but completion rates are low without accompanying support (no accountability)
- online clinics can produce clinically relevant change on a large scale (MindSpot)
- supported interventions have a greater impact than unsupported ones (how much support is necessary? too much support = no longer scalable)
- with support, outcomes for digital interventions are similar to face-to-face (and support isn't to the same level as individual therapy, more small check-ins)
- need larger scale studies to systematically test outcomes of digital interventions (pandemic cohort studies show similar outcomes for online vs. in-person)
- need to test lots of support vs. little support
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examples of digital inteventions
- Pacifica: linked to your therapist, providing mood ratings, health habits, relaxation resources
- MindSpot: free online and telephone service for anxiety, depression, PTSD, OCD
- online assessment (or phone) with feedback, referred to online or in-person courses (severity and presentation)
- 4 courses (10 weeks each): reading new information + homework tasks for mastery and skill learning
- therapists check in once a week
- high acceptability in Australia
- on-site therapists to screen people on whether they're appropriate for online and match them to the sessions
- self-guided + weekly check-in (good balance in therapist support and scalability)
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future research questions for digital interventions
- does the functionality of the interventions impact its efficacy (app developers)
- how can interventions be tailored to the nature of the psychopathology (MindSpot has some tailoring, but not individualized), concentration problems in depression = how can we make sure our technology doesn't require too much concentration
- how to evaluate the efficacy of digital interventions (field moving too fast for RCTs which take too long + too many resources)
- how much support is necessary for improved outcomes
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types of single-session interventions
- pre-therapy or waitlist intervention to provide psychoeducation and/or increase motivation (give people something to make some changes--people in ED clinics tended to improve during this wait time if provided with broad overview of CBT)
- delivered after an assessment and combined with therapeutic resources (testing for ADHD, then go through test results with a therapist who provides resources)
- delivered online with or without support (Schleider research)
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advantages of single-session interventions
- brief
- less costly
- scalable (especially if online)
- reach people without financial resources or with other barriers to seeking traditional treatment
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Schleider et al., 2022 design
- criticisms that her participants were self-selecting into her single-session interventions = this is her first nationwide RCT
- compared single-session growth mindset and behavioural activation interventions to active control
- GM and BA SSIs are the only ones with acceptability and short-term utility
- primary outcomes: hopelessness and agency post-treatment and depressive symptoms 3-month FU (also anxiety and Covid-related trauma as secondary outcomes and post-hoc analysis of restrictive eating)
- Ps: 13-16 years with elevated depression, randomized to the 3 conditions
- recruited on Instagram in late 2020
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conditions in Schleider et al., 2022
- growth mindset: emphasized neuroplasticity, growth mindsets to persevere, personality can change using testimonials from other people (letter-writing by the Ps to consolidate skills), targets hopelessness
- behavioural activation: values assessment, activity action plan, benefits/obstacles, targets activity withdrawal and low agency
- control condition: supportive SSI that encourages emotion expression, but not teaching behavioural or overlapping skills with GM- or BA-SSI
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Schleider et al., 2022 results
- decreases in depression at 3-month FU in GM and BA (relative to control)
- between-group effect size was small and within-group effect size was large
- decreases in hopelessness and increases in agency at post-treatment in GM and BA relative to control (GM also had increases in agency at 3-month FU)
- GM = decreases in anxiety and COVID trauma (not for BA group)
- GM and BA groups had decreases in restrictive eating
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Schleider et al., 2022 implications
- small effect, but large implications considering how many youths could be reached
- 20 minutes one time cannot be expected to provide major changes (and supportive intervention as a control also has an effect)
- 3-month FU suggests maintenance of results
- BA more specific to depression, while GM is non-specific (explains preferential effect on anxiety)
- restrictive eating closely tied to mood problems
- confirms effect size and replicability from previous uncontrolled studies
- acceptability and efficacy of interventions for a diverse sample (sexual minorities)
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characteristics of novel models of delivery
- reach: reaching individuals not usually served by the dominant model
- scalability: applied on a large scale
- affordability: relatively low cost (compared to dominant model relying on trained professionals)
- expansion of the nonprofessional workforce (greater number of providers)
- expansion of settings where interventions are provided: bring them to everyday settings where people in need are likely to be
- feasibility and flexibility: ensure they can be implemented and adapted to various conditions
- flexibility and choice of alternatives for clients: allow many choices to meet criteria of effective interventions
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barriers to mental health care (Kazdin)
- cost of mental health (system factor)
- policy and legal constraints: restricting what conditions can be treated and reimbursed (system factor)
- stigma about diagnosis or treatment (attitudinal factor)
- mental health literacy: not knowing about psychiatric conditions and whether we can be treated (attitudinal factor)
- cultural and ethnic influences: views about warranted treatment, entry into health care, seeking Tx rooted in cultural beliefs (attitudinal factor)
- case identification: not seeing individuals at risk early enough
- model of treatment (dominant model)
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anterior cingulate cortex
- emotion
- decision making
- important region on psychopathology
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hippocampus
- memory
- emotion
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amygdala
- threat
- positive emotions
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cognitive hierarchy
- more frontal areas of the brain are higher in the hierarchy (evolved later)
- back areas of the brain are lower in the hierarchy (shared with more species)
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top-down processing
- slow, deliberate, explicit, strategic processing that uses rule-based knowledge
- gaining new knowledge, studying
- mediated by PFC
- this is the main target in CBT: get people to slow down, reflect and change your perspective instead of automatically react
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bottom-up processing
- automatic, effortless, implicit, and pre-conscious processing based on salient features or stimulus and situational cues
- drawing our attention to things + automatic evaluations
- mediated by lower-order brain structures (amygdala looking out for threat)
- also changes with CBT, but not explicitly targeted (PFC dampening down bottom-up areas like the amygdala via cognitive reappraisal)
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effects of psychotherapy and pharmacology on the brain (in general)
- cognitive restructuring increasing top-down cognitive control over negative emotion
- medication decreasing bottom-up reactivity to emotional stimuli
- antidepressants may = less emotion in general, less emotional reactions
- CBT produces symptom reduction through its impact on higher-order executive functions (problem-solving, cognitive reappraisal, self-referential thinking)
- emotional reaction = think about it differently = change emotional reaction
- cognitive reappraisal involves increased activation of dl/vl-PFC and ACC + decreased activity of amygdala (connections between these regions are changeable)
- using strategies to regulate emotions in experimental studies activates top-down processes just like CBT
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depression effects of CBT on the brain
- CBT alters activity in dorsolateral, ventrolateral, and medial PFC + (anterior) and posterior cingulate cortices (higher order areas)
- modulation of top-down processes involved in encoding and retrieval of negative associative memories, rumination, and over-processing of irrelevant information (deciding what is relevant and what isn't and pushing away the things that used to grab our attention)
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anxiety effects of CBT on the brain
- CBT alters activity in the same areas as depression (dlPFC, vlPFC, mPFC + anterior and posterior cingulate cortices)
- also alters activity in the amygdala, hippocampus, anterior and medial temporal cortices
- more modulation of bottom-up structures in CBT for anxiety
- anxiety is hypervigilance for feared stimuli, so we're trying to reduce that hypervigilance
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PTSD psychotherapy effects on the brain
- increased activity in ACC
- decreased activity in amygdala
- after exposure + restructuring
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social anxiety psychotherapy effects on the brain
- decreased activity in amygdala-hippocampal region after CBT or medication treatment
- amygdala sends signals about emotional relevance to the hippocampus which encodes it into memory to provide the same fear reaction
- changing this fear structure = responses aren't as automatic anymore
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OCD psychotherapy effects on the brain
- behaviour therapy and medication treatment decrease activation in OFC, dlPFC, and ACC
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functional connectivity changes after therapy
- Shou et al.: CBT increased resting state connectivity between amygdala and fronto-parietal network in patients with MDD and PTSD
- Young et al.: symptom improvement in CBT or ACT for SAD correlated with increased connectivity between amygdala and vm-/vl-PFC during emotion regulation task (PFC dampening amygdala response for situations when it isn't situationally appropriate)
- Mason: CBT for psychosis associated with greater connectivity between amygdala and dlPFC in a social threat task
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positive and negative emotions in the brain
- higher activity in left PFC vs. right = optimism, creativity, joy, vitality, alterness
- higher activity in right PFC vs. left = depression, anxiety, distress, worry
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mindfulness in the brain
- meditators had higher left-to-right PFC activity ratios than other subjects
- RCT comparing meditation vs. not = changes in left-to-right ratio (more activity in left when you meditate)
- can change happiness setpoint
- mindfulness increases grey matter in areas for attention, learning, self-awareness, self-regulation, empathy, compassion (cortical thickening with practice)
- helps us create new neural pathways to use instead of relying on the same superhighways of habit (and then this new pathways will get strengthened to become the habit)
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happiness setpoint
- people born with a continuum of happiness that can't really be changed (baseline level of happiness you will always return to)
- for people who aren't born happy, no external circumstances will change it
- but changing the interior landscape by training the mind can make you happier (neuroplasticity = repeated experiences shape the brain)
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MBSR in the brain
- systematic review of 8-week MBSR programs
- increases in volume, activity, and connectivity of PFC, cingulate cortex, insula, hippocampus
- decrease in amygdala activity and increased connectivity with PRFC
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psychopharmacology for depression
- SSRIs recommended as first-line treatment for depression
- compared to tricyclics and MAOIs: milder side-effect profile (less sexual side-effects, less sleepiness), less fatal in case of overdose, no evidence that they are more effective (just preferred for other reasons)
- benefit of SSRIs most pronounced for severe depression (otherwise, possible placebo effect for mild and moderate depression) because you're not well enough to start therapy
- most people discontinue use within 3 months (start feeling better after 6 weeks), but the course of the average major depressive episode is 9 months, so they likely relapse (recommended to keep taking them for at least one year)
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deep-brain stimulation
- neurostimulator implanted in brain sends electrical impulses to specific subcortical regions of the brain (depends where you place it)
- control is built-in: sham vs. active stimulation (just don't turn it on and people won't know)
- not a scalable intervention (invasive, expensive, safety and side-effect monitoring)
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DBS for depression
- Mayberg: targeted subgenual cingulate important in MDD, especially treatment-resistant depression = 4/6 patients achieved sustained clinical response or remission at 6 months
- now DBS being applied to other treatment-resistant conditions like OCD and AN
- not a first-line treatment, it's only for severe and treatment-resistant depression
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scoping review of clinical applications of psychedelic drugs
- including psilocybin, MDMA, LSD, and ayahuasca
- some evidence that they can be helpful
- are there differences based on the mechanism of action
- psychedelics usually act on serotonin 2A receptors (not MDMA or ketamine)
- psychedelic-assisted therapy: prep therapy/time-limited psychotherapy (getting people reader, some safety training) + psychedelic sessions (1-3 with safety accompaniment) processed in integrative therapy
- the current research, these are high doses meant for out-of-body experiences, not microdosing
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Dworkin, 2023
- why combine psychedelics with psychotherapy (why not prescribed)
- psychological and physical safety need to be monitories
- psychotherapy may enhance the magnitude and duration of the benefit (processing the experience, use the experience to think about what may have come up = benefits maintained)
- prep phase and accompaniment + post-psychedelic therapy
- are these synergistic treatments (effect of the whole greater than the sum of its parts)
- or are they additive: effects on the combination = sum of parts
- or they's subadditive: effects of the combination is less than the sum of the components (favourable = greater than the individual components on their own, adverse: combination is less or equal to individual components)
- test using a factorial design: psychedelic + psychotherapy; drug placebo + psychotherapy; psychedelic + psychotherapy placebo; drug placebo + psychotherapy placebo
- psychotherapy placebos are complex (what should we use?)
- drug placebos may not work (people know whether they're on mushrooms)
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psychedelics
- favourable effects on many conditions like depression, anxiety, chronic pain, cluster headaches
- but lacking confirmation of efficacy and safety, info on mechanisms of action, appropriate contexts of use, methodological challenges, whether treatment benefits persist
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possible mechanisms of action of psychedelics + psychotherapy
- psychedelics exerts effects via a psychotherapeutic mechanism (affective and cognitive mechanisms)
- psychedelics could increase the neuroplasticity so that the effects of psychotherapy are facilitated
- psychedelics could enhance the benefits of psychotherapy by increasing openness to experience and readiness to change
- none of these mechanisms are mutually exclusive
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narratives about psychotherapy and the brain (Perricone et al., 2024)
- intervention to change belief that psychotherapy affects the mind, but not the brain (people tend to believe in this mind-brain duality)
- participants with elevated depression (group 1), people from general populations (group 2), mental health clinicians (group 3)
- pre-test (case description for groups 2, 3 and group 1 asked to picture themselves)
- everyone got a biological explanation of depression (focused on the effects of serotonin), then randomized to one of 3 conditions
- condition 1: brain-level psychotherapy description
- condition 2: mind-level psychotherapy description (active control)
- condition 3: inactive control
- bio explanation + inactive control = belief that psychotherapy less effective
- bio explanation + brain-level psychotherapy = belief that psychotherapy more effective (you see it as a good match for treatment)
- bio explanation + mind-level psychotherapy = no change due to psychotherapy
- so it's important for people to know that psychotherapy can affect the brain
