Unit 6

Lecture 1: DBT
Dialectical behavior therapy (DBT) was developed by Marsha Linehan in the 1980s as a
result of her work with patients with suicidal intentions. She later developed it into a therapy
that has been used primarily with patients diagnosed with borderline disorder. These patients
present difficulties that challenge therapists more than almost any other psychological
disorder. Patients with borderline disorder present with severe mood swings and impulsive
behavior such as drug abuse, sexual acting out, and self-damaging behavior. They may see
relationships as either all good or all bad, including the relationship with the therapist. To
work with these patients using DBT requires at least a year of both individual and group
therapy, as well as phone consultations. Furthermore, therapeutic work needs to be
comprehensive and sophisticated to accomplish what other therapies have not.
Theoretical Backdrop:
Linehan views borderline personality disorder as having biological and environmental
components. Her biosocial theory examines genetics, prenatal conditions, and other factors
that may influence how people regulate their emotions and respond to problems in their
environment. Her theory suggests that individuals with borderline personality disorder
experience a great deal of emotional vulnerability, resulting in intense emotional reactions
that are difficult for the individual to manage. Individuals with borderline personality
disorder generally also have experienced invalidating environments. These may include
neglect from parents or other caregivers, abuse, or abandonment. Such experiences may lead
to people having a poor self-image, being self-critical, lacking trust in others, and having
poor problem-solving skills. Linehan theorizes that borderline personality disorder arises
from the interaction between emotional vulnerability and invalidating environments.
Dialectical refers to the fact that in an argument there is an assertion and a position that
opposes the assertion. To resolve the argument, a synthesis that incorporates the assertion and
the opposition will help to move past the argument and resolve it. For patients with borderline
symptoms, this provides a way to reduce symptoms and find meaning in their lives by
balancing acceptance and change. Behavior refers to the need to use behavioral methods to
change self-destructive behaviors (such as careless driving or cutting one’s arms).
Therapeutic Methods:
Different therapeutic methods are applied in individual and group therapy. Additionally,
phone consultations are made with individuals in crisis.
Individual therapy
The first part of individual therapy in DBT is to assess the client’s problems and to assess her
ability to follow through in meeting therapeutic goals. Both therapist and client must agree on
the goals, target behaviors, and techniques to be used. The client must agree to attend
individual and group sessions. This is important, as dropout from treatment of borderline
personality disorder has a reputation for being high. The therapist may also disclose
supervision arrangements and issues dealing with availability to the client in a crisis. The
therapist then decides which of four stages to start with.
In DBT, the four stages are in order of degree of importance to the goal of keeping the client
alive. Therapists may change from one stage to another depending on the nature of the
problems the patient presents. Since patients with borderline symptoms often experience
crises, changing stages can be frequent. The stages are described here.
Stage 1
Life-threatening behaviors such as suicide attempts, risk-taking behaviors such as driving
recklessly, and intent to harm self or others must be the priority. Assuring safety is important
because self-destructive behaviors are common in individuals with a borderline personality
disorder.
Stage 2
Attention is paid to behaviors that may interfere with therapy. Because of the difficulty of
treatment and the lack of success of treatment for many individuals with borderline
personality disorder, it is important to keep the patient in therapy. In Stage 2, clients work on
experiencing strong emotions with less and less disturbance. They also learn to deal with
problems in their environment in a more effective way.
Stage 3
Clients work on ways to increase their quality of life and decrease their problematic
responses to daily events. For example, they try to reduce symptoms of anxiety and
depression. Dealing with substance abuse may be an issue in Stages 1 and 2 but making
reductions in drug dependence continues in Stage 3. Attention is paid to relationships with
family, friends, and coworkers.
Stage 4.
Clients make changes in their lives to adapt to problems around them. Attention is paid to
finding more happiness, a greater sense of freedom, and the development of spirituality.
Work is done to develop skills in handling problems with others and with unanticipated
events.
Therapeutic skills
In DBT, certain skills are used in individual therapy but may be used in group as well when
appropriate. These skills include validation and acceptance strategies, problem-solving and
change strategies, and dialectical persuasion.
Validation and acceptance strategies
Clients with borderline personality disorder often present behaviors that may be harmful to
themselves. The therapist should communicate empathy toward the client rather than point
out the harmfulness of the behavior. The therapist can point out to the client that the behavior
serves a function to reduce stress or to help in some way, even if the behavior causes other
problems. For example if a client drinks alcohol to the point that she gets sick and can’t walk,
the therapist may say to her : “When you are very upset, drinking seems to help you relax,
and it would be helpful to reduce your stress, which you do by drinking. Perhaps there are
other ways to achieve the goal of relaxation.” In this response, the client’s behavior is
accepted, and a suggestion is made to examine possible changes.
Problem-solving and change strategies
Many different behavioral and problemsolving techniques can be used so that patients with
borderline personality disorder can change behavior that has interfered with their life goals.
Sometimes the therapist may wish to use positive reinforcement or modeling techniques to
help clients achieve their goals. Meichenbaum’s self-instructional training and stress
inoculation (pp. 299–300) provide a means for accomplishing cognitive restructuring. For
certain problems, especially related to phobias or obsessive-compulsive disorders, therapists
may wish to use exposure and ritual prevention (p. 306). Other behavioral and cognitive
techniques can be used as well.
Dialectical persuasion
Dialectical was explained above as trying to find a resolution between two extremes. Using
dialectical persuasion, the therapist accepts the client but gently tries to persuade the client to
use a more effective method to bring about change. This is done by pointing out
inconsistencies in actions, beliefs, and values. The client is helped to change behavior to fit
with values and beliefs.
Group skills training:
Along with individual therapy, clients participate in 2 to 3 hours of group skills training per
week for a year or more. The group leader would not be the client’s individual therapist. The
group leader follows a manual that includes handouts for clients. The group focuses,
especially at first, on Stages 1 and 2: life-threatening behaviors and behaviors that interfere
with individual therapy. Although some of the techniques described above may be used by
the group leader, the skills that are taught are core mindfulness, interpersonal effectiveness,
emotional regulation, and distress tolerance.
Core mindfulness skills: As the word “core” implies, these skills are basic to DBT and are
taught throughout the course of training. These skills are based on Buddhist principles and
techniques. The focus is on being in the present, not judging yourself, and paying attention.
Participants learn about three states of mind:
Reasonable mind: thinking rationally or logically, using facts.
Emotional mind: thinking emotionally, distorted thoughts, determined by mood.
Wise mind: a melding or synthesis of the reasonable and emotional mind.
These three concepts are used to understand and evaluate the thoughts and behaviors of the
participants.
Interpersonal effectiveness skills: Clients learn skills, such as problem solving and
assertiveness, to get what they want while maintaining relationships and not alienating others.
They also learn how to examine those things they desire to do and those they “have to do” so
they are not overwhelmed with having too much to do.
Distress-tolerance skills: Typically, clients with borderline personality disorder have low
tolerance for stress. Clients learn to tolerate stress or emotional discomfort. They learn to
distract themselves when they are upset and then to find ways to soothe or decrease the
emotional upset. To make changes, they may use cognitive restructuring and think of pros
and cons of what to do next.
Dialectical behavior therapy has been shown to meet the criteria for evidence-based practice
for work with people with borderline disorders (Lindenboim, Comtois, & Linehan, 2007;
Linehan & Dexter-Mazza, 2008). For example, DBT was found to be more effective in
treating women diagnosed with borderline disorder and substance abuse than nonbehavioral
therapies (Harned et al., 2008). In a study of women with borderline personality disorder and
high irritability, both medication and DBT were found to be helpful in reducing irritability,
aggression, depression, and self-injury (Linehan et al., 2008). Also, a small study shows the
potential of DBT for reducing symptoms for women with binge eating disorder or bulimia
(Chen et al., 2008). Examining how well participants practiced skills taught in the group
skills component, Lindenboim, Comtois, and Linehan (2007) found that most participants
practiced most of the skills on most days of the week. Many other studies show the
effectiveness of DBT (Linehan & Dexter-Mazza, 2008). Dialectical behavior theory is
considered to be a research supported psychological treatment.
Lecture 2: Play Therapy

Lecture 3: Cognitive Analytical Therapy

Overview and Key Points
Cognitive analytic therapy (CAT) was proposed as a formal psychotherapy model in the
1980s by Anthony Ryle, who viewed conceptual integration as key to the development of a
comprehensive psychological theory. CAT integrated both cognitive and analytic ideas
within its early framework, particularly drawing on personal construct theory (Ryle, 1982)
and object relations theory (Ryle, 1985). In later years, it also incorporated concepts from
Vygotsky and Bahktin (Leiman, 1992). These significant and influential ideas were revised
and harmonised to form a coherent model of psychological functioning, which has
explanatory power in relation to psychopathology, and creates a sound framework for
therapeutic intervention.
CAT proposes that through early social experiences, we develop a repertoire of reciprocal
roles (RRs), which become internalised as working models for conducting relationships.
They are reciprocal in that any role we occupy can only be understood in relation to the
complementary role of another. During interaction both social parts are learnt, and we can
enact these both towards ourselves and others, while creating expectancy that the other
person will occupy the alternate position. When these RRs are activated, they manifest as
repeating patterns (reciprocal role procedures), which are observable in how we relate to
others, and form the basis of self-management and self-regulation.
The key points of CAT are as follows:
CAT aims to develop client self-reflective capacity and recognition of problematic
roles and procedures, to revise them.
CAT is transdiagnostic and has been applied to a wide array of clinical difficulties
(Calvert and Kellett, 2014).
 CAT is commonly used within a 16-session individual therapy format, or 24 sessions
for more complex presentations.
Basic Assumptions
CAT is collaborative, emphasising the importance of joint activity and conceptual
tools (e.g., diagrams and therapeutic letters) in supporting the client to develop a self-
reflective capacity.
CAT involves the therapist’s active use of self (including emotional responses), in
order to build a shared understanding of the client’s roles and procedures, and to
avoid enacting these unhelpfully within the therapeutic relationship.
The client is an active participant in change, engaging in self-monitoring and testing
out what has been learnt within therapy within their ‘everyday’ lives.
Therapy is time-limited, and uses this constraint to mobilise and focus the therapy.

Skills and Strategies

Reformulation
Reformulation involves building a joint understanding with the client of their difficulties and
how these are being maintained by problematic RRs and procedures. This process involves
the creation of a sequential diagrammatic reformulation (SDR) and a prose reformulation
letter. From assessment, the therapist begins mapping the client’s reciprocal roles and
procedures with them to form the SDR. This is amended and elaborated upon as the client
develops new understandings about themselves. Such joint activity, characterised by
curiosity, care and persistence in understanding the client’s inner world, can subsequently be
internalised to form the basis of a healthy self-management procedure. The SDR is based
upon descriptions of the client’s relationship history, functional analysis of current
behaviours and observations of interactions within the therapeutic relationship. It is designed
to provide the client with perspective on their difficulties, to help generate ‘exits’.
An initial reformulation letter is typically read aloud to the client around session four. The
letter outlines target problems and procedures, but it has the added value of placing these
within a historical context, framing them as survival modes that once had appropriate and
protective functions. It aims to connect past neglect, abuse and trauma with the current RRs
and procedures of the client, in a manner which conveys warmth and understanding for the
person’s struggle. This can provide a powerful means of validation and normalisation, which
strengthens the therapeutic relationship early in the alliance.
Recognition
Having built an understanding of their RRs and procedures, the client is encouraged to
recognise them as they occur, as a prerequisite to revision. The therapist may introduce
personalised self-monitoring diaries or mindfulness practice to facilitate this skill
development between sessions. In each session, the client rates their target problem in terms
of how rapidly they noticed the associated problematic procedure, and later how effectively it
was addressed. The SDR tool is used in every session to assist the client to recognise RRs and
procedures as they occur, both in the narratives of their life which they bring to therapy and
within the therapeutic relationship.
Revision
Revision involves the client amending problematic RRs and procedures by finding ‘exits’ to
replace them with healthier patterns of relating to themselves and others. Various change
methods from other therapies may be utilised, generating therapeutic richness and flexibility.
However, methods must be carefully selected and applied to ensure that they are theoretically
consistent with CAT and are reformulation driven.
Outlined below are several change methods and examples of their possible application within
CAT:
Assertiveness skills – Addressing dilemma related to either ‘I am a bully or a victim’.
Self-soothing skills – Addressing a self-harm procedure in which the function of the
behaviour is to manage feelings of distress.
Use of empty chair technique or non-send letters – To process past losses related to dilemma
of ‘I get involved with others and get hurt, or I am in control but totally alone’.
Psychoeducation and cognitive restructuring – Reducing shame in sexual abuse victims who
have a self-sabotage snag based upon feeling non-deserving.
Irrespective of other methods employed, within CAT the therapeutic relationship is the major
vehicle of change. The therapist’s key role is to resist the pull to adopt the expected
reciprocal role. Regular CAT supervision is important, and therapists must be aware of how
their own RRs and procedures may collude with those of the client. Through direct
experience of acknowledging and exploring RRs through the therapeutic relationship, the
client can negotiate new ways of being. These new behavioural styles, and a positive
experience of the therapist, can form the basis of healthier RRs and procedures to be practised
outside the therapeutic relationship. Research indicates that good therapy outcomes are
associated with therapists who recognise problematic enactments within the therapy
relationship and collaboratively work with the client to resolve them.
Ending
The ending is explicitly used to address unresolved grief issues, unhelpful procedures related
to managing loss and RRs characterised by rejection or abandonment. To facilitate the
transition, the client is either offered a followup at one month (16-session CAT) or four
follow-ups over six months (24- session CAT).
Both the therapist and client exchange ‘goodbye letters’. Their key function is to facilitate the
expression of feelings regarding therapy ending, and to keep the experience and learnt ‘exits’
active in the client’s mind following therapy completion.
Both letters can include:
Naming of ‘exits’ with specific examples applied during therapy;
Acknowledgement of challenges that the client found particularly difficult;
Significant moments within the therapeutic relationship, such as resolving reciprocal role
enactments;
Naming possible feelings of disappointment in relation to initial hopes for change;
Naming of thoughts and feelings in relation to ending, and its meaning within the context of
the client’s history; naming of possible problematic rrs and procedures that may be triggered
by ending, with possible ‘exits’;
Indications for future work, particularly during the follow-up period
Lecture 4: Interpersonal and Social Rhythm Therapy
Interpersonal and social rhythm therapy (IPSRT) was designed to directly address the major
pathways to recurrence in bipolar disorder, namely medication nonadherence, stressful life
events, and disruptions in social rhythms.
The basic elements of IPSRT, like those of its predecessor interpersonal therapy (IPT), are
the management of affective symptoms and the amelioration of interpersonal relationships.
When offered as an acute treatment (which is when it appears to be most potent), the goals of
IPSRT are the improvement of the affective symptoms and the resolution of the interpersonal
problem(s) most closely linked to the onset of the current affective episode. When offered as
a prophylactic maintenance treatment, the goals of IPSRT are the maintenance of a euthymic
mood state and improvement and prevention of crises in the patient’s interpersonal life and
social role functioning.
For patients with bipolar I disorder, the management of affective symptoms is accomplished
using pharmacotherapy and through efforts to regularize their social rhythms. For patients
with bipolar II disorder, depending upon the severity of the mood symptoms, IPSRT may be
offered either as a stand-alone intervention or along with pharmacotherapy. In either case,
stabilizing social rhythms is a key aspect of the management of mood symptoms. Resolution
of the patient’s interpersonal difficulties and maintenance of good interpersonal and social
role functioning is accomplished by selecting an interpersonal focus from among the
interpersonal problem areas specified by Klerman and colleagues (Klerman et al., 1984;
Weissman, Markowitz, & Klerman, 2000) and using largely the same strategies and tactics as
those employed in IPT for unipolar patients.
Essential Elements
Social rhythm therapy (SRT)
Regulate daily routines
Emphasizes the link between regular routines and moods
Uses Social Rhythm Metric to monitor routines
Interpersonal psychotherapy (IPT)
Emphasizes link between mood and life events
Focus on interpersonal problem area (grief, role transition, role disputes, interpersonal
deficits)
Psychoeducation to promote medication adherence

Goals
Stabilize daily routines and sleep/wake cycles
Gain insight into the bi-directional relationship between moods and interpersonal
events
Use IPT techniques to ameliorate interpersonal problems related to grief, role
transitions, role disputes, interpersonal deficits
Thereby, reduce the frequency of episode recurrence
Four phases of IPSRT
Introductory Phase
Whether the patient is first seen in an acute episode or in remission, the initial phase of
treatment begins with a focused history-taking that emphasizes the extent to which
disruptions in social routines and interpersonal problems have been associated with affective
episodes, and is intended to develop the rationale for the treatment. In this initial phase, the
therapist also provides the patient (and his or her family, when indicated) with education
about his or her mood disorder, taking into consideration what the patient already has or has
not learned about bipolar illness. The therapist then assesses the quality of the patient’s
interpersonal relationships through a process known as the Interpersonal Inventory and
assesses the regularity of the patient’s social routines by asking him or her to complete an
instrument called the Social Rhythm Metric (SRM; Monk, Flaherty, Frank, Hoskinson, &
Kupfer, 1990).
Finally, the therapist and patient collaboratively select an interpersonal focus, from among
the four IPT problem areas (i.e., grief, role transitions, role disputes, interpersonal deficits),
that will become the initial focus of therapy. This initial phase typically lasts three to five
sessions, depending on the length and complexity of the patient’s affective history and
interpersonal relationships as well as the amount of psychoeducation required.
Intermediate Phase
Having concluded the initial phase of treatment, the therapist moves on to the intermediate
phase of therapy. Here, the focus is on regularizing the patient’s social rhythms and
intervening in the selected interpersonal problem area. Typically, IPSRT is conducted weekly
in the initial and intermediate phases, but other schedules may be appropriate if the patient is
either very symptomatic, in which case more frequent visits may be needed, or fully remitted
and in treatment primarily to improve current functioning and prevent future episodes.
The Continuation, or Maintenance, Phase
The continuation, or maintenance, phase of IPSRT is one in which the therapist works to
establish patients’ confidence in their ability to use the techniques learned earlier in the
treatment. These include maintaining regular social rhythms, even in the face of challenges
such as vacations, job changes, and unexpected life disruptions, and maintaining or further
improving their interpersonal relationships. Specific techniques for accomplishing the latter
of these goals are outlined in the IPT manual (Klerman et al., 1984). As the treatment moves
from the intermediate to the continuation or maintenance phase, the frequency of visits is
typically reduced from weekly to bimonthly, and eventually to monthly.
Final Phase
The final phase of IPSRT involves work toward termination of therapy or further reduction
in the frequency of visits. When termination is seen as an appropriate goal or is necessitated
by financial concerns or relocation, this is usually accomplished over the course of three to
five monthly visits. Alternatively, the final phase may involve a further reduction in the
frequency of visits, such as occasional check-ups or booster sessions.
When the contract is for short-term treatment only, the initial phase of treatment may need to
be somewhat compressed and focus intently on social rhythm regulation. Even when IPSRT
is provided as a short-term treatment, it is probably advisable to reduce the frequency of the
sessions toward the end, allowing for three to four bimonthly sessions during which the
termination work is accomplished.

Presenting Problem/Client Description

Louisa began IPSRT at the age of 20 years, seeking relief from an episode of depression that had
begun 4 months earlier. Louisa had been struggling with bipolar disorder since junior high school,
but prior to this episode of depression, she had been relatively euthymic for more than 2 years,
doing well in her medical assistant training. She had taken her first job 5 months before entering
treatment.

When Louisa’s first paycheck arrived, she decided to move into an apartment with Stacey, a close
friend from high school. A series of problems quickly emerged. Louisa knew Stacey was accustomed
to keeping her living space in immaculate order, but she hadn’t really thought about what effect that
might have on their relationship when she asked Stacey if she would want to share an apartment
with her. They soon began arguing almost daily about the condition of the kitchen or the bathroom,
or both. In addition, Louisa was finding that her paycheck did not stretch as far as she thought it
would, a problem she handled by simply opening an endless series of new charge accounts. Soon,
Louisa was seriously in debt.

As Louisa got more and more depressed, she found it harder and harder to drag herself out of bed
and into the shower in time to get to work, let alone clean the bathroom. When she got home from
work, it was all she could do to microwave some frozen soup before collapsing on her bed. The sink
was filled with dirty soup bowls, and Stacey was losing patience with her. And it wasn’t just the mess
in the apartment that was a disappointment to Stacey. She had expected some company in the
evenings: someone to watch TV with or to go out with. Instead, Louisa was sleeping all evening.
Then, just as Stacey was ready to go to sleep, Louisa would find herself wide awake and, unable to
get back to sleep, would turn on the TV for company, with the sound blaring until the early hours of
the morning. Louisa hated the tension that had developed between them, but she was just too
depressed to do anything about it. She felt like she couldn’t meet any of her roommate’s
expectations even though she knew they were reasonable.

Case Formulation

The patient’s psychiatric history and presenting complaints indicated a diagnosis of Bipolar I
disorder. She had been maintained on lithium (1200 mg) and had bupropion extended release
(titrated up to 300 mg) added in the context of her current depressive episode. She then began a
course of IPSRT on an outpatient basis for 22 sessions over the course of 6 months.

After taking a clinical history, Louisa’s IPSRT therapist could see that a number of things would need
to change for Louisa to recover from this depression. First, she would need to reduce her time in
bed. Second, she would need to set a regular sleep/wake schedule that she could stick to even on
the weekends. Third, she would need to become more active outside of work. Finally, she would
need to either find a way to meet most of her roommate’s expectations or find another place to live.

Since being independent seemed important to Louisa and moving back home would feel like one
more defeat to her, her IPSRT therapist decided to see if she could engage Stacey as a kind of coach
or co-therapist. Louisa’s illness was no secret to Stacey. She had remained a good friend even when
others in their high school shunned Louisa after she was released the first time from the hospital.
Still, Louisa’s therapist assumed that Stacey had little real understanding of depression, its impact on
someone’s life, or of what kind of support Louisa needed on a day-to-day basis.

After carefully setting the stage for this suggestion, Louisa’s therapist asked her whether she would
be willing to ask Stacey to come to her next treatment session so that her therapist could explain to
Stacey what was really going on and how Stacey might be helpful to her. Louisa felt she had nothing
to lose and thought it was worth a try. To Louisa’s surprise, Stacey seemed pleased and even
relieved by the invitation.

Course of Treatment

During that next session, Louisa’s therapist described what depression and depressive symptoms
were. She asked Stacey how Louisa’s depression was affecting her, and then explained that many of
the things Louisa was doing that were so annoying to Stacey were a direct result of depression, not a
function of being lazy or of wanting to be a miserable roommate. The therapist also explained how
important it was that Louisa limit the amount of time she was spending in bed as a first step to
getting over her depression. She then asked the two young women for suggestions on how they
might work on this problem together. Louisa admitted that to get dressed properly, clean up after
herself, and grab something to eat before she left for work, she needed to be up at 6:30 a.m., an
hour earlier than she was typically getting up these days. Louisa’s therapist suggested that she begin
by trying to get out of bed just 15 min earlier each day for 3 days, and if that went all right, she
should then try to be out of bed at 7:00. She then struck a bargain with Stacey: As long as Louisa was
meeting her wake-up time goals, would Stacey be willing to bite her tongue about the bathroom and
kitchen for just 2 weeks? The therapist’s bargain with Louisa was that if she absolutely had to nap
when she got home from work, she would set her alarm and not sleep more than 45 min. She
suggested that the girls establish a routine of having dinner together, sitting down with their kitchen
table set with silverware and napkins, at a specific time agreed upon each night . . . even if it was
only to eat yet another bowl of soup. Finally, she suggested that Louisa find another, less stimulating
way of getting back to sleep if she woke up in the middle of the night . . . and one that would be less
disturbing to Stacey

Within 3 weeks, Louisa found that she was able to get up regularly between 6:30 to 6:45 a.m. every
work day. She signed up for some classes at a nearby YMCA on Saturday and Sunday mornings that
helped her get out of bed by 7:00 even on weekends. If she didn’t always clean the bathroom when
she was done using it, at least her things were put away and Stacey had no trouble finding her own
shampoo and deodorant. Sometimes Louisa did feel that she couldn’t manage without a nap when
she got home from work, but with Stacey’s help, she seldom slept for more than the 45 min they all
had agreed upon. She and Stacey were sitting down to real suppers together most nights and
cleaning up together when they were done. Louisa even had the energy to go out with Stacey once
or twice in the evening during those first 3 weeks after their meeting with the therapist. Most
important, Louisa was getting good, consolidated sleep at night and typically woke up feeling rested
and ready to take on her day.

Outcome and Prognosis

From that beginning, other depressive symptoms began to resolve as well. Louisa found that she
could concentrate better at work, where she got a small bonus for exceeding her productivity
targets. She used her bonus to pay off one of her new credit cards (and close the account!). She gave
the remaining three credit cards to Stacey to hold for her until she was able to pay off those bills as
well. As she got more positive feedback at work, her self-esteem started to rebound. But most
important, as she and Stacey started to get along well again, she found she was able to enjoy their
friendship and a host of other things in her life.

Lecture 5: Motivational Enhancement Therapy

Motivational Enhancement Therapy (MET) is a systematic intervention approach for
evoking change in problem drinkers. It is based on principles of motivational psychology and
is designed to produce rapid, internally motivated change. This treatment strategy does not
attempt to guide and train the client, step by step, through recovery, but instead employs
motivational strategies to mobilize the client’s own change resources.
Treatment is preceded by an extensive assessment battery requiring approximately 7–8 hours.
MET is not intended to be a minimal or control treatment condition. MET is, in its own right,
an effective outpatient treatment strategy which, by virtue of its rationale and content,
requires fewer therapist-directed sessions than some alternatives. It may, therefore, be
particularly useful in situations where contact with problem drinkers is limited to few or
infrequent sessions (e.g., in general medical practice or in employee assistance programs).
Treatment outcome research strongly supports MET strategies as effective in producing
change in problem drinkers.
Stages of Change
The MET approach is further grounded in research on processes of natural discovery.
Prechovaska and DiClemente (1982, 1984, 1985, 1986) have described a transtheoretical
model of how people change addictive behaviors, with or without formal treatment. In a
transtheoretical perspective, individuals move through a series of stages of change as they
progress in modifying problem behaviors. This concept of stages is important in
understanding change. Each stage requires certain tasks to be accomplished and certain
processes to be used in order to achieve change. Six separate stages were identified in this
mode.

People who are not considering change in their problem behavior are described as
PRECONTEMPLATORS. The CONTEMPLATION stage entails individuals’ beginning to
consider both that they have a problem and the feasibility and costs of changing that
behavior. As individuals progress, they move on to the DETERMINATION stage, where the
decision is made to take action and change. Once individuals begin to modify the problem
behavior, they enter the ACTION stage, which normally continues for 3–6 months. After
successfully negotiating the action stage, individuals move to MAINTENANCE or sustained
change. If these efforts fail, a RELAPSE occurs, and the individual begins another cycle
From a stages-of-change perspective, the MET approach addresses where the client currently
is in the cycle of change and assists the person to move through the stages toward successful
sustained change. For the ME therapist, the contemplation and determination stages are most
critical. The objective is to help clients seriously consider two basic issues. The first is how
much of a problem their drinking behavior poses for them and how their drinking is affecting
them (both positively and negatively). Tipping the balance of these pros and cons of drinking
toward change is essential for movement from contemplation to determination. Second, the
client in contemplation assesses the possibility and the costs/benefits of changing the problem
behavior. Clients consider whether they will be able to make a change and how that change
will affect their lives.
In the determination stage, clients develop a firm resolve to take action. That resolve is
influenced by past experiences with change attempts. Individuals who have made
unsuccessful attempts to change their drinking behavior in the past need encouragement to
decide to go through the cycle again.
Understanding the cycle of change can help the ME therapist to empathize with the client and
can give direction to intervention strategies. Though individuals move through the cycle of
change in their own ways, it is the same cycle. The speed and efficiency of movement
through the cycle, however, will vary. The task is to assist the individual in moving from one
stage to the next as swiftly and effectively as possible.
Rationale and Basic Principles
The MET approach begins with the assumption that the responsibility and capability for
change lie within the client. The therapist’s task is to create a set of conditions that will
enhance the client’s own motivation for and commitment to change. Rather than relying upon
therapy sessions as the primary locus of change, the therapist seeks to mobilize the client’s
inner resources as well as those inherent in the client’s natural helping relationships. MET
seeks to support intrinsic motivation for change, which will lead the client to initiate, persist
in, and comply with behavior change efforts. Miller and Rollnick (1991) have described five
basic motivational principles underlying such an approach:
Express empathy
Develop discrepancy
Avoid argumentation
Roll with resistance
Support self-efficacy

Lecture 6: Relapse Prevention Therapy

Relapse prevention (RP) is a strategy for reducing the likelihood and severity of relapse
following the cessation or reduction of problematic behaviours.
The initial transgression of problem behaviour after a quit attempt is defined as a “lapse,”
which could eventually lead to continued transgressions to a level that is similar to before
quitting and is defined as a “relapse”. Another possible outcome of a lapse is that the client
may manage to abstain and thus continue to go forward in the path of positive change,
“prolapse”. Many researchers define relapse as a process rather than as a discrete event and
thus attempt to characterize the factors contributing to relapse.
Relapse prevention (RP) is a cognitive– behavioural approach with the goal of identifying
and addressing high-risk situations for relapse and assisting individuals in maintaining
desired behavioural changes.
RP has two specific aims:
(a) Preventing an initial lapse and maintaining abstinence or harm reduction treatment
goals
(b) Providing lapse management if a lapse occurs such that further relapses can be
prevented
Relapse prevention initially evolved as a calculated response to the longer-term treatment
failures of other therapies. The assumption of RP is that it is problematic to expect that the
effects of a treatment that is designed to moderate or eliminate an undesirable behaviour will
endure beyond the termination of that treatment. Further, there are reasons to presume a
problem will re-emerge on returning to the old environment that elicited and maintained the
problem behaviour; for instance, forgetting the skills, techniques, and information taught
during therapy; and decreased motivation.
Cognitive Behavioural model of relapse

Immediate Determinants of Relapse

High-Risk Situations
A central concept of the RP model postulates that high-risk situations frequently serve as the
immediate precipitators of initial alcohol use after abstinence. According to the model, a
person who has initiated a behavior change, such as alcohol abstinence, should begin
experiencing increased self-efficacy or mastery over his or her behavior, which should grow
as he or she continues to maintain the change. Certain situations or events, however, can pose
a threat to the person’s sense of control and, consequently, precipitate a relapse crisis. Based
on research on precipitants of relapse in alcoholics who had received inpatient treatment,
Marlatt (1996) categorized the emotional, environmental, and interpersonal characteristics of
relapse-inducing situations described by study participants. According to this taxonomy,
several types of situations can play a role in relapse episodes, as follows:
 Negative emotional states
 Situations that involve another person or a group of people (i.e., interpersonal high-
risk situations)
 Social pressure, including both direct verbal or nonverbal persuasion and indirect
pressure
 Positive emotional states

Coping
Although the RP model considers the high-risk situation the immediate relapse trigger, it is
actually the person’s response to the situation that determines whether he or she will
experience a lapse (i.e., begin using alcohol). A person’s coping behavior in a high-risk
situation is a particularly critical determinant of the likely outcome. Thus, a person who can
execute effective coping strategies (e.g., a behavioral strategy, such as leaving the situation,
or a cognitive strategy, such as positive self-talk) is less likely to relapse compared with a
person lacking those skills.
Moreover, people who have coped successfully with high-risk situations are assumed to
experience a heightened sense of self-efficacy (i.e., a personal perception of mastery over the
specific risky situation) (Bandura 1977; Marlatt et al. 1995, 1999; Marlatt and Gordon 1985).
Conversely, people with low self-efficacy perceive themselves as lacking the motivation or
ability to resist drinking in high-risk situations.
Outcome Expectancies.
Research among college students has shown that those who drink the most tend to have
higher expectations regarding the positive effects of alcohol (i.e., outcome expectancies) and
may anticipate only the immediate positive effects while ignoring or discounting the potential
negative consequences of excessive drinking (Carey 1995). Such positive outcome
expectancies may become particularly salient in high-risk situations, when the person expects
alcohol use to help him or her cope with negative emotions or conflict (i.e., when drinking
serves as “self-medication”). In these situations, the drinker focuses primarily on the
anticipation of immediate gratification, such as stress reduction, neglecting possible delayed
negative consequences.
The Abstinence Violation Effect.
A critical difference exists between the first violation of the abstinence goal (i.e., an initial
lapse) and a return to uncontrolled drinking or abandonment of the abstinence goal (i.e., a
full-blown relapse). Although research with various addictive behaviors has indicated that a
lapse greatly increases the risk of eventual relapse, the progression from lapse to relapse is
not inevitable.
Marlatt and Gordon (1980, 1985) have described a type of reaction by the drinker to a lapse
called the abstinence violation effect, which may influence whether a lapse leads to relapse.
This reaction focuses on the drinker’s emotional response to an initial lapse and on the causes
to which he or she attributes the lapse. People who attribute the lapse to their own personal
failure are likely to experience guilt and negative emotions that can, in turn, lead to increased
drinking as a further attempt to avoid or escape the feelings of guilt or failure.
Furthermore, people who attribute the lapse to stable, global, internal factors beyond their
control (e.g., “I have no willpower and will never be able to stop drinking”) are more likely to
abandon the abstinence attempt (and experience a full-blown relapse) than are people who
attribute the lapse to their inability to cope effectively with a specific highrisk situation. In
contrast to the former group of people, the latter group realizes that one needs to “learn from
one’s mistakes” and, thus, they may develop more effective ways to cope with similar trigger
situations in the future.

Lecture 7: Eye Movement Desensitization Therapy

Overview and Key points
Eye Movement Desensitisation and Reprocessing (EMDR) is a comprehensive
psychotherapeutic approach recognised by the National Institute for Health and Care
Excellence (NICE, 2005) for the effective treatment of post-traumatic stress disorder (PTSD).
In her core text, Shapiro (2001) describes EMDR as an integrative psychotherapy, sharing
key elements of traditional approaches. A unique aspect of EMDR is its use of Bilateral
Stimulation (BLS), in the form of eye movements, tapping or tones, to process disturbing
memories.
The theoretical underpinning of EMDR is the Adaptive Information Processing
model.
This posits that the brain has an innate healing process that can be stimulated by BLS.
It is believed that present dysfunction is caused by maladaptively stored memories of
distressing events.
EMDR unhooks the negative emotions from a memory, enabling recall without
distress, and facilitates links to adaptive memory networks.
EMDR consists of a structured eight-phase protocol.
Brief History
EMDR was developed by American psychologist Francine Shapiro in 1987 in something of a
chance breakthrough. While out walking and experiencing some disturbing thoughts, she
realised that her thought patterns were somehow improving. She started to pay attention to
this process and noticed that, when she was affected by negative reflections, her eyes
spontaneously moved from side to side. At the same time, her disturbing thoughts lost their
negative emotional charge. She hypothesised that there was a link between these two events.
Fascinated by this, she tested her theory on colleagues before embarking on rigorous
research.
Basic Assumptions
EMDR is underpinned by the belief that the brain has the same self-healing capacity as the
body. Just as the body fights infection and strives for physical balance, so the brain strives to
move on from traumatic events and regain psychological balance. It is posited that the BLS
used within EMDR triggers this innate healing process.
Many psychotherapeutic approaches hold that the majority of our adult belief systems are
rooted in childhood experiences. The Adaptive Information Processing (AIP) model of
EMDR (Shapiro, 2001, 2007) similarly suggests that most psychopathology has its roots in
distressing past experiences that have been maladaptively stored. This prevents the associated
thoughts, images, emotions and physical sensations being correctly processed, thus remaining
intrusive, easily triggered and leading to current dysfunctions. Such maladaptively stored
memories are not able to link to more adaptive memory networks. An example of this is
someone who, as a child, was humiliated in a classroom situation. The associated shame,
beliefs of defectiveness and physical feelings, such as blushing and anxiety, are kept alive
and easily triggered even as an adult. This may lead to social anxiety or general feelings of
low self-esteem. There is no emotional link with adaptive information, such as ‘I was a child
– the teacher was the one who was defective for allowing this’. EMDR seeks to link the old
negative belief to a more positive one that can be believed both intellectually and
emotionally. This is then ‘installed’ with the desensitised memory. AIP theory suggests that
the mind will not accept a positive cognition that is not ecologically valid. Therefore it would
not be possible to install ‘It’s not my fault’ when processing a road traffic accident where the
client was drink-driving and entirely to blame. Another example of an invalid positive
cognition would be ‘I’m safe’ where the client faces ongoing danger. In such cases, a more
adaptive positive cognition may be ‘I can learn from this’, ‘It’s over’ or ‘I can make
changes’.
Skills and Strategies
EMDR is a structured protocol consisting of eight phases, including history taking and
treatment planning, preparation, assessment, desensitisation, installation, body scan, closure,
and re-evaluation (Shapiro, 2001).
Phase 1: History-taking
In phase 1, the clinician takes a full client history and explores current symptoms, goals and
preferences for therapy. The clinician conceptualises the case in accordance with AIP theory
and, from this, determines which memories to target and in what order. Safety factors and the
client’s current level of functioning are explored and it is particularly important to screen for
dissociative disorders and poor ego strength as the standard EMDR protocol is not
appropriate for these presentations.
Phase 2: Preparation
Although it is important to maintain fidelity within the standard protocol, this is not at the
expense of building a solid therapeutic alliance and ensuring the client has a safe space to
make sense of their distress. In phase 2, the therapeutic relationship is being strengthened and
a clear explanation of EMDR processing given. It is important that the client understands the
process and that any fears or expectations are addressed. As part of this, eye movements or
other forms of BLS are tested and the clinician checks that the client can maintain dual
awareness between past distress and their present safety. This balance of ‘a foot in the past
and a foot in the present’ provides the optimal state for processing.
The clinician teaches self-soothing, affect management and stabilisation techniques so that
they and their client are confident that any disturbance can be tolerated. BLS can be used to
stimulate positive memory networks and are often introduced in this phase. The clinician can
enhance the client’s inner resources, such as states of calm, self-compassion and strength,
with BLS. In reality, phases 1 and 2 may run concurrently and may take several weeks,
particularly for complex trauma.
Phase 3: Assessment
In the assessment phase the client is helped to identify the components of the target memory
in a structured way. This includes:
A target image representing the worst aspect of the memory.
An associated negative belief about the self (the negative cognition) that is a currently
held, irrational and negative thoughts, e.g., I am in danger, I am helpless.
The emotions and body sensations that arise when the memory is accessed.
A positive cognition that the client would prefer to believe about themselves both now
and in respect to the target memory.
This helps activate any adaptively stored material.
The clinician establishes baseline measures so that subsequent progress can be checked. The
Subjective Units of Disturbance (SUD) scale is used to measure the total disturbance and the
Validity of Cognition (VOC) scale measures how much the client believes the positive
cognition at an emotional, not an intellectual, level. Drawing out the components in this way
activates the memory ready for processing.
Phase 4: Desensitisation
In phase 4, the clinician provides BLS while the client processes the memory. As AIP posits
that the BLS stimulates the brain’s innate healing process, the clinician needs to intervene
minimally. Their role now is to reassure the client and maintain optimal levels of arousal for
effective processing. Clients are asked to just notice whatever comes up during processing
and the clinician will take very brief feedback between sets of BLS so as to be able to oversee
the process. Occasionally processing gets stuck and the clinician will have a range of
interventions to facilitate the return to processing. At the end of phase 4, the SUD for the
target will be reduced to 0 or 1 out of 10.
Phase 5: Installation
The clinician helps the client to re-evaluate the suitability of the positive cognition, then,
using BLS, integrates this with the targeted memory, thereby strengthening and enhancing
associations to positive memory networks. The VOC scale is used to evaluate the
effectiveness of the positive cognition.
Phase 6: Body scan
The clinician moves on to check for any residual somatic disturbance that may be raised
when the client holds the original memory in mind while considering the positive cognition.
They help the client to scan for any tension, discomfort or unusual sensations that need to be
processed with BLS.
Phase 7: Closure
Not every target is fully processed in a single session, so the clinician needs to be able to
contain the remaining disturbance and stabilise the client before they leave the session.
Whereas in phase 4, discussion was deliberately avoided so as not to interfere with
processing, now there is an opportunity for debriefing and exploration of insights gained. The
clinician may close with a relaxation exercise and will help the client to identify helpful self-
care strategies for the week ahead. Processing will continue for some time after the session so
clients are asked to keep a log to note any new thoughts, feelings, behaviours, dreams or
memories that arise in between sessions. This information is crucial for the next phase of the
protocol.
Phase 8: Re-evaluation
Re-evaluation is done at the beginning of every session following a desensitisation session.
The clinician reviews the client’s experiences in the week and reassesses the targets that were
processed. All this is fed into the consideration of subsequent targets and the overall
treatment plan. As therapy progresses, the clinician and client will review whether all the
necessary targets have been processed in relation to the past, present and future approach