Lecture 7: Intervention

Theoretical Approach
Psychodynamic
• Unconscious, unresolved conflicts from childhood determine how we act and feel
• Methods
• Recall and make sense of early experiences (Freud)
• Hypnosis (regression), dream analysis, talking cure
• Proof
• Hard to prove approach empirically (very limited evidence base) – takes
years so difficult to test if it works.
• BUT – developed idea that emotional problems could be solved with
talking rather than medication
Behavioural
• Based on observable behaviours and psychological problems caused by faulty
learning
• Methods
• Teach people to change or modify behaviours = positive results
• Face up to fearful situations (systematic desensitization) rather than avoid
them
• Proof
• Effective for anxiety disorders – not depression (doesn’t work for
depression)
• Social anxiety – Expose more to other people
• Empirical testing and reporting tradition began here – led to testing of
treatments for proposed clinical outcomes
Cognitive
• Conscious thought processes affect how you feel
• Negative automatic thoughts (NAT)
• Lower mood increased probability of
negative automatic thoughts
• Once depressed, cognitive distortions
influence daily function
• Combines cognitive and behavioural techniques
• Focus on thoughts and how interact with emotional, behavioural and
physiological states
• Method
• Potential role of present thinking rather than past experiences.
 • Therapy teaches client to correct faulty thought processes
• People can choose how to interpret events in life (can change how
someone is perceiving)
• Draws attention to thinking patterns and moods
• Proof
• Effective for a variety of problems

Methods to Assess Effectiveness

Single Case Experimental Designs (Rivsi and Nock, 2008)
 Track client over time
o Baseline (A) – No Therapy
o Intervention (B) – Therapy is provided
o Many different designs
 AB, ABAB …
 Multiple baseline (more than one-person,
different baseline lengths)
 Effectiveness: observed changes in
target behaviour(s) when treatment
present vs. absent
 Pros
o Cheap
o Easy to recruit for
o Give an idea of whether treatment has an effect (show an association
between treatment outcome)
 Cons
o Can’t determine causal link between therapy and outcome
o Ethical issue of withdrawing treatment in ABAB design. (might risk the
participants mental health)
o Carryover effects (continued impact of treatment on later phases) – e.g.
Can’t unlearn CBT techniques given
Randomized Controlled Trial
 Most rigorous way to determine cause-effect relation exists between treatment
and outcome.
 RCTs
o Random allocation to intervention groups and non-intervention group
(prevent selection bias)
o Blinded
 (not always possible) (Researcher and Participants might have to be
blinded, but therapist shouldn’t be blinded)
o Intention to treat analysis
 (look at people who complete the intervention, and people who
don’t complete it)
 o Estimate the size of the difference on pre-specified outcomes between the
intervention groups
 (what are we measuring? Where should the difference of the
therapy make)
 Pros
o Only way to determine causal relationship between treatment and
outcome
o Only way to determine reliable effect sizes
o Protects against bias (if its double blinded)
 Cons
o Large numbers often needed
o Hard to recruit/expensive
o Ethical issues (if you’re using vulnerable patient that really needs
intervention, it’s not ethical) – Give everyone the usually intervention but
add the test-intervention
o Translation to the real world? (Effectiveness vs. efficacy RCTs)

Systematic Reviews (Meta-Analysis if Data Aggregation Possible)

Psychological Intervention Theories

Transtheoretical Model (Harvey,2004)
 Cognition is the most common symptoms in most disorders.
 Key issue here is that many people have co-existing disorders
o Improvements in one disorder seem to be matched by improvements in
others
o co-morbid conditions must be driven by similar processes, amenable to
the same therapeutic interventions
o Psychological models should attempt to determine factors common to
them all, not those specific to each condition
 Harvey at al. identify a number of cognitions (or concerns as they refer to
them) that delineate between conditions:
o panic disorder is associated with concerns about bodily sensations,
o obsessive compulsive behaviour involves intrusive thoughts about
responsibility of harm to others.
o However, their focus is on factors common to the various conditions. They
draw on clinical and experimental cognitive studies to determine the
processes of interest to them: (1) attention; (2) memory; (3) reasoning;
(4) thought; and (5) behavioural processes.

 Errors of attention
o may maintain a disorder when an individual selectively attends to
information that is consistent with their concerns or fails to attend to
information that is inconsistent with their concerns and which would
 change their understanding of the situation or help them cope better with
it

 Errors of memory
o may occur in the encoding or retrieval stages of memory.
o Encoding errors may occur as a result of our attentional bias. We tend to
preferentially attend to stimuli pertinent to our survival.
 A number of reasoning errors may also result in mood disorders.
o These errors map on to those identified by Beck and other second-wave
theorists, and include errors of interpretive reasoning, expectancy
reasoning, and a failure of hypothesis testing (biasing such tests to
support rather than challenge negative beliefs).
 Thought processes
o involved in mood disorders include intrusive thoughts, worry and
rumination.
o Worry is a chain of thoughts and images which trigger negative mood
states.
o Rumination is dysfunctional, redundant, repetitive and stereotypical
thinking.
 A number of behaviours are also implicated in the initiation and continuation of
emotional disorders.
o As noted in the previous chapter, escape from, or avoidance of, feared
situations may serve to maintain long-term anxiety.
o Such avoidance may involve behavioural avoidance; it may involve the
use of cognitive avoidance strategies such as distraction from distressing
thoughts.

S-REF Model

 Wells (2000) argued that the second-generation theories focused on the

content of thoughts and ignored the form that such thinking takes and the
mechanisms that give dysfunctional thoughts their power
 The model focuses on both the content of cognitions and the processes
associated with them across a range of mental health problems.
o In psychological jargon, the theory links schema theory (focusing on the
content of thought) with information processing and self-regulation
theory.
 The model assumes three interacting levels of cognition:
o A stimulus-driven network of processing units, which guide routine
responses to routine events around us.
o ‘On-line’ processing, involving the conscious focusing of attention,
appraisals of events and control of actions and thoughts.
 o Information about the individual stored in long-term memory
 According to Wells, low-level processing is largely automatic, and requires little
active attention. By contrast, on-line processing requires attention and
conscious awareness. In addition, the content and outcomes of this processing
are influenced by self-knowledge derived from longterm memory.

 Wells identified two key ‘modes’ in which these various elements operate:

o Object mode

 thoughts and perceptions are unevaluated and form an accurate

perception of events. They are not subject to analysis and
interpretation. Wells considers this to be our ‘default setting’.

o Metacognitive mode

 The individual is distanced from their thought and perceptions and

actively evaluates them.

 They think about their thoughts, feelings and perceptions and in

doing so may arrive at accurate, or frequently, inaccurate analyses
of them.

 Wells refers to patterns of activation of the system as differing ‘configurations’

and refers to the configuration most closely linked to psychopathology as the S-
REF configuration.

o This involves both an appraisal of a disjunction between an actual state

and a desired state, and the development of plans to reduce or obviate
this discrepancy.

 Many psychopathological conditions result from unsuccessful attempts to reduce

this discrepancy, and/or continued inappropriate attempts at doing so.

o Phobic anxiety, for example, may be maintained over long periods of time
as a result of the individual repeatedly following plans to avoid a feared
situation.

o Continued use of avoidance as a coping strategy prevents the individual

from learning that the feared situation will not actually result in harm.

 S-REF processing is initiated either by some form of external threat or internally

generated threat-related thoughts.

o In response to either of these, we develop plans to reduce the

discrepancy between the actual and desired self. These coping plans are
guided by a series of beliefs – or metacognitive knowledge

o These plans are often unconscious and relatively automatic, although

individuals may be able to verbalize them
  someone with depression may verbalize their plans as, ‘I must be
pessimistic, so I can avoid disappointment’,

o A second type of belief are declarative beliefs about ourselves – ‘I am

worthless, vulnerable’, Part of any plan may be to pay attention to such
beliefs, making them salient at times of stress or distress.

 a spider phobic may pay attention to catastrophizing cognitions

when faced with a spider and in S-REF configuration

o Our emotional response to threat is also determined by metacognitive

processes.

 Anxiety, for example, is linked to thoughts of anticipated failure in

achieving one’s goals

 Individuals with psychological disorders lack problem-solving flexibility and

become ‘locked’ in repeated activation of the same S-REF configuration as a
consequence of a number of factors

o (1) continued use of inappropriate coping strategies which fail to change

our view of our self (e.g. as being better able to cope with a stressful
situation) or the context in which we experience distress (e.g. as being
less threatening);

o (2) setting unrealistic goals, which result in failure and continued negative
cognitive processing.

 The therapy developed by Wells based on the S-REF model is known as

metacognitive therapy. Its aims are to do the following:

o teach individuals to develop more flexible coping strategies to use in

stressful situations – to ‘unlock’ themselves from previous patterns of
inappropriate coping responses

o gain new experiences of mastery and control over previously emotionally

difficult circumstances

o change long-term memory, and beliefs about the self

o teach clients ‘a higher metacognitive mode’ which allows them to process

information in ways that do not trigger high levels of S-REF activity.

 In order to achieve these goals, therapy focuses on either changing the plans
that lead to inappropriate coping responses or changing the individual’s
responses to any metacognitions or declaratory cognitions they may
experience.

o changing inappropriate cognitive content (such as catastrophizing

thoughts)
 o changing the metacognitive beliefs (plans) that drive inappropriate coping
responses

o learning to reduce attention to worries and other unwanted cognitive

content – through the use of attentional control skills learning to adopt
more realistic goals

o learning skills such as detached mindfulness that allow individuals to

access potentially distressing thoughts without triggering high levels of S-
REF activity and distress.

 Wells adopts two supportive strategies to help people achieve any changes they
wish to make: mindfulness and active distraction.

o Mindfulness

 Self-regulation of attention - Mindfulness involves being fully aware

of our current experience, observing and attending to our changing
thoughts, feelings and sensations as they occur.

 This allows us to be aware of these phenomena as they arise,

but not to elaborate on them.

 An orientation toward one’s experiences in the present moment

characterized by curiosity, openness and acceptance.

 The lack of cognitive effort given to the elaboration on the

meanings and associations of our various experiences allows
us to focus more on our present experience.

 Rather than observing experience through the filter of our

beliefs and assumptions, mindfulness involves a direct,
unfiltered awareness of our experiences.

o Attentional Control Skills

 reset maladaptive thought processes at times when the individual is

not experiencing particularly high levels of distress

 This moves the therapist from exploring the A-B-C pattern of antecedents,
cognitions and emotional and behavioural responses outlined to what Wells calls
the A-M-C unit of analysis.

o Here, antecedents (A) lead to

metacognitions (M), which
direct attention to declarative
beliefs, which both drive any
emotional and behavioural
consequences (C)
 o The additional step added by Wells involves metacognitions. In this, the
individual makes a conscious decision to access memories of previous
failures and problems, as well as to ruminate about the situation in an
attempt to try and sort it out. As a result, these significantly add to their
depressed feelings.

 Changing inappropriate beliefs,

behaviours and emotions involves what
Wells calls the P-E-T-S protocol.
o In this, the individual Prepares for
change, is Exposed to the feared situation and Tests new responses to it,
and then Summarizes their responses to the situation as part of gaining
an understanding of the factors contributing to the problem and
developing further interventions.
 The prepare stage involves identifying problematic situations and
the maladaptive responses used to cope with them
 The expose/test stages involve developing and implementing new
plans for coping with difficult situations
 The summarize stage involves reflecting back on the previous
stage, to determine its effectiveness and to develop further
interventions designed to challenge previous inappropriate fears and
coping strategies.

Relational Frames Theory

 Relational frames theory considers cognitions to be relatively unimportant in the

development of pathology
o Key to psychopathology is continued engagement in inappropriate
behavioural responses to contextual cues within our environment.
 Relational frame theory assumes that we naturally attend to, and act on,
relationships between various elements of our environment. These relationships
can be defined in three key ways:
o Relational context: we can identify the direct relationship between two
elements within our environment
 the brighter of two colours, the larger of two people, and so on.
o Combinatorial entailment: this involves logically combining relations.
 For example, if we learned that Stephen is larger than John, and
John is larger than Mary, we also know that Stephen is larger than
Mary.
o Functional context: this involves relating to functions of elements within
our environment, not simply their physical relationships.
 For instance, we may also consider that Stephen is better at
carrying heavy objects than Mary.
 Together, these three features of any context are referred to as its ‘relational
frame’.
o We are able to abstract elements from one set of frames and can transfer
them from one situation to another.
o Although the contexts are very different, the responses are similar
because the relational frame is the same.
 These relational frames are brought on new situations through analogies,
stories, metaphors and rules.
o Recognition of a situation in terms of its relational frame triggers
operantly conditioned responses to that context.
o these relational frames are the dominant determinants of our behaviour
and experience.
o for example, that a child who is trapped inside a wooden box and
experiences great fear may later experience the same fear when trapped
in other contexts, such as relationship
 Relational frames are verbally accessible (i.e. we are able to understand and
describe them), they are also changeable.
o over time we may develop distorted concepts of relationships between
elements within relational frames and begin to respond take our
cognitively distorted view as being an accurate representation of a
relational frame
o This leads to cognitive fusion where we interact with events on the basis
of our cognitively distorted view rather than the real relational frame.
o and experiential avoidance: individuals may begin to avoid contexts in
which negative emotions and behaviours are triggered
 Acceptance and Commitment Therapy (Hayes,2004)
o Uses acceptance and mindfulness processes and commitment and
behaviour change processes to produce a greater psychological flexibility
o ACT encourages clients to focus on living according to their own values
rather than challenging any misconceptions about their situation.
o ACT teaches the individual to be aware of ongoing private events
(thoughts), but not to be driven by them
o ACT does not consider thoughts or feelings to necessarily direct
behaviour.
 Change can be achieved through changing contextual variables
rather than attempts to change internal processes such as
cognitions, emotions, sensation
o ACT interventions aim to increase the individual’s flexibility in responding
to situations they face.This flexibility is established through a focus on
five, related, core processes:
 Acceptance
  involves allowing oneself to be aware of thoughts, feelings,
and bodily sensations as they occur, but not to be driven by
them
 Defusion
 involves teaching clients to see that thoughts are simply
thoughts, feelings are simply feelings, memories are
memories, and physical sensations are physical sensations
 Contact with the present moment
 comprises effective, open and undefended contact with the
present moment through observation and labelling
 Values relates to the motivation for change. In order for a client to
face feared psychological obstacles, they need a purpose
 committed action: relates to clients developing strategies for
achieving desired goals.

Medical Interventions
Brain Areas Involved
 Frontal
o Frontal cortex: EF, speech, motor
coordination, planning, motivation,
o Linked to limbic system through thalamus &
motor system within cortex (reward system).
 Temporal
o Language, Visuo-spatial processing (visual
hallucinations), memory and conscious experience,
o Linked to limbic system
o Link emotions to events &
o Memories
 Occipital and Parietal
o Integration of sensory information

Neurotransmitter
 Serotonin
o Serotonin is involved in
moderating mood, with low
levels leading to conditions
including depression and
obsessive-compulsive
disorder.
o It is found in the striatum,
mesolimbic system,
forebrain, cortex,
hippocampus, thalamus and hypothalamus
 Norepinephrine
o Norepinephrine is a second neurotransmitter involved in depression as
well as a number of anxiety disorders.
 o It is found in the hypothalamus, cerebellum and hippocampus
 Dopamine
o Dopaminergic dysregulation has been associated with conditions as varied
as schizophrenia, autism and attentional deficit/hyperactivity disorders.
o found in the mesolimbic system, in a brain area known as A10, with links
to the thalamus, hippocampus, frontal cortex and the substantia nigra.
 GABA
o Enhance the action of a neurotransmitter known as gamma-aminobutyric
acid (GABA). This carries inhibitory messages: when it is received at the
postsynaptic receptor site, it prevents the neuron from fi ring.
o Sites of GABA include the brain stem, cerebellum and limbic system.
o An effective treatment of anxiety

Autonomic Nervous System

 Autonomic nervous system, is also involved in some conditions such as stress
or anxiety
 The autonomic nervous system links the brain to many of the body organs,
including the heart, gut and smooth muscles. Its job is to control the activity of
these organs
 Overall control of the autonomic nervous system is provided by the
hypothalamus.
o the hypothalamus either increases or decreases activity within the
autonomic nervous system and the various organs it controls based on
input from cortex and limbic system
 The autonomic nervous system comprises two subsystems, known as the
sympathetic and parasympathetic nervous systems. These arise in the medulla
oblongata in the brain stem and travel down the spinal cord
o The sympathetic system is involved in arousal, and its activity within the
brain and spinal cord is controlled by norepinephrine.
 High levels of norepinephrine result in increased arousal and
activation of the target organs.
o The parasympathetic system is involved in calming or reducing arousal,
and its activity is controlled by levels of the neurotransmitter
acetylcholine.
 Neurotransmitters act quickly but are unable to maintain activation for long.
o To enable a sustained response to stress, a second system is activated by
the sympathetic nervous system which is the adrenal glands, to release
hormonal counterparts of the neurotransmitter norepinephrine (and to a
lesser extent epinephrine) into the bloodstream and sustain the action
initiated by the neurotransmitters.
Drugs Treatment
 Types of Drugs
 o Agonist
 Increase availability of neurotransmitter by
 preventing re-uptake
 preventing degradation in synaptic cleft
 replace low levels of neurotransmitter with pharmalogical
equivalent
o Antagonist
 Decrease availability of neurotransmitter by
 reduce levels of neurotransmitter
 replace active transmitters with an inactive chemical
 Antidepressants
o Monoamine Oxidase Inhibitor (MAOIs)
 prevent degradation of norepinephrine (and to a lesser extent,
serotonin) by monoamine oxidase and help sustain its action
 first use was in the treatment of tuberculosis, where they were
found to improve mood in those treated
 standard treatment for depression, with a success rate of about 50
per cent
 Side effects: Influences MAO in other parts of body such as Liver,
have to avoid food with Thymine
o Serotonin
 increase serotonin levels by inhibiting its re-uptake into the
presynaptic terminal
 the tricyclics (for example, imipramine, amitriptyline), SSRIs (for
instance, fl uoxetine, sertraline), and SNRIs (venlafaxine,
milnacipran and duloxetine).
 Tricyclics and SNRIs also increase levels of norepinephrine
 SSRI increase serotonin levels without affecting norepinephrine
levels
 May not be more effective than tricyclics, but has fewer side-
effects such as constipation and dry mouth and they are less
dangerous in overdose
 Tricyclics and SSRIs are the most commonly used pharmacological
treatments of depression
 Because SNRIs work on both serotonin and norepinephrine
levels, they appear to be more effective in the treatment of
depression than are SSRIs.
 like tricyclics, they may have more severe side-effects and
discontinuation symptoms
 The lowest rate of suicide, 4.7, was found among people taking
Lofepramine (a tricyclic); the mean rate was 10.8 suicides per 10
000 years. The highest rate of suicide was found among those
taking Prozac (SSRI): 19.0 suicides per 10 000 years.
 many people taking Prozac were at particularly high risk of
suicide as a result of factors other than their medication,
including a history of feeling suicidal and poor outcome on
other antidepressants.
 Anxiolytics
 o Benzodiazepines (Valium)
 Benzodiazepines appear to enhance the action of GABA, but do not
bind to the same postsynaptic receptor sites.
 When their use is stopped, levels of anxiety frequently return to
pre-morbid levels or above.
 Sudden withdrawal of these drugs typically results in the rapid
recurrence of previous symptoms combined with withdrawal
symptoms, including sweating, shaking, nausea and vomiting.
 80%of people who stop taking benzodiazepines after a long
period of use relapse and require further treatment.
 Benzodiazepine use has also been associated with a number of
undesirable side-effects, including drowsiness, memory loss,
depression and aggressive behaviour including acute rage
 There is increasing evidence that some anxiety conditions, and in
particular panic disorder, are mediated, at least in part, by
norepinephrine. For these conditions, treatment with
antidepressants has proven more effective than with traditional
anxiolytics.

 Schizophrenia (Anti-Psychotic)
o Excessive number of dopamine receptor sites causes over-reactive to
normal levels of dopamine which induces the positive symptoms of
schizophrenia.
o Drugs treat the Positive Symptoms of Schizophrenia
o Drugs reduce the number of receptor sites accessible to the dopamine by
filling them with inert drugs that mimic dopamine’s chemical composition
or reducing the amount of dopamine released.
o phenothiazines, neuroleptics or major tranquillizers work by blocking the
dopamine receptors in the postsynaptic receptor sites
 their use results in a proliferation of dopamine receptor sites adding
further to the sensitivity of the postsynaptic receptors and resulting
in the need for long-term treatment
o Phenothiazines’ main side-effects occur as a result of their impact on the
extrapyramidal areas of the brain, including the substantia nigra involved
in the control of motor activity and coordination.
 most common extrapyramidal symptoms are Parkinsonian
symptoms.
 These include stiffness in the arms and legs, facial expressions that
are fl at and dull, and tremors, particularly in the hands.
 20% of those who take phenothiazines for an extended time
develop a second condition, known as tardive dyskinesia
o Second approach to the treatment of schizophrenia involves reducing the
amount of dopamine available to be released into the synaptic cleft.
 The action of a drug known as reserpine is to inhibit the synthesis of
dopamine
o Atypical neuroleptics (clozapine, risperidone)
  These drugs may also reduce dopamine activity, possibly indirectly
through their influence on serotonin levels, which control dopamine
release at times of stress
 atypical neuroleptics are likely to prove a first-line treatment of
schizophrenia in the future, as they may not only be more effective
than phenothiazines but also cause significantly fewer
extrapyramidal symptoms
o Success rates with phenothiazines of about 65% per cent are typical: for
atypical neuroleptics the success rate is about 85%
 1 and 2 per cent of those who take the drug go on to develop
agranulocytosis, a potentially fatal reduction in white blood cells,
resulting in a need for all those prescribed these drugs to have
regular blood tests so they can be withdrawn before this disorder
becomes problematic.
 Adherence to Medication
o Any drug can achieve its potential only if it is taken regularly and at
therapeutic levels
o This is not always the case: up to 50 per cent of people prescribed
psychotropic medication either do not take the recommended dose or do
not take the drug at all
o The most frequent reason for non-adherence was forgetting.
 More conscious decisions whether or not to take tablets are often
based on a form of cost–benefit analysis, in which the benefi ts of
taking medication, usually in terms of relief from symptoms, are
weighed against the costs of taking it, usually the side-effects that
accompany use of the drug.
 The more side-effects a drug has, the less likely those prescribed it
are to adhere to its use, particularly where there are no immediate
changes in symptoms when doses of a drug are taken or missed, as
is the case for many psychiatric drugs.
o Poor relationship with the prescriber, experience of coercion during
admission and low insight predicted a negative attitude towards treatment
o High adherence to medication to be associated with lower perceived
stigma of taking drugs, higher self-rated severity of illness, being aged
over 60 years, and absence of ‘personality pathology’.
Electro-Convulsive Therapy (ECT)
 Electroconvulsive therapy is the brief discharge of an electric current through
the brain with the aim of inducing a controlled epileptic convulsion to achieve an
improvement in an abnormal mental state.
o people who had epilepsy rarely evidenced any form of psychosis and that
their mood following epileptic seizures often improved
 physical damage, including jaw dislocation and broken bones, and neurological
effects such as memory loss that resulted from the seizures provoked by
treatment.
o Electrodes have been placed over the non-dominant hemisphere only, a
process known as unilateral ECT. result in fewer side-effects.
  ECT may increase the sensitivity of postsynaptic neurons to serotonin in the
hippocampus, increase levels of GABA and reduce levels of dopamine.
Transcranial Magnetic Stimulation (TMS)
 TMS involves passing a series of electrical pulses close to the brain. The coil is
held on the scalp – no actual contact is necessary – and the magnetic fi eld
passes through the skull and into the brain. Small induced currents can then
make brain areas below the coil more or less active, depending on the settings
used
 can influence many brain functions, including movement, visual perception,
memory, reaction time, speech and mood.
o it may result in increases in serotonin and a number of other
neurotransmitters including dopamine
 Have less side-effects than ECT
Psychosurgery
 Prefrontal leucotomy/lobotomy
o 20% of people with schizophrenia and about 50% of those with
depression gained some degree of benefit
 Very risky
o 4% died as a result of surgery, 4% developed a severe loss of motivation
and up to 60% developed ‘troublesome’ personality changes, while 15%
developed epilepsy
 Was used as a result of lack of alternatives
 Currently more precise with electrodes
o Most lesions are created with heated electrodes, with the exception of the
subcaudate tractotomy which involves placing radioactive rods in the
target area, which destroy parts of the subcaudate brain area through a
brief burst of radioactivity before becoming inert.
 Only if other options did not work
o It is usually used for the treatment of severe, intractable depression.
Stereotactic cingulotomy is the most commonly used procedure for the
anxiety disorders, including obsessive-compulsive disorder
 For depression, anxiety and OCD