Current Psychological
Approaches In The
Management of Mental
Health Problems
Toyin Idowu
Cognitive Behaviour Therapist
RN; RMN; BA (Hons) MSc
Overview
• Understanding Mental Health Problems
• Psychopathology of Mental Health
Problems
• Psychological Perspectives
• Evidence-base psychological
treatments
Mental Health Problems
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Daily worries we all experience
To serious long-term conditions
Recovery depend on intervention
Diagnosis Vs Stigma
Quality of life
Mental Health Problems
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Diagnosis symptoms
Differences across cultures
In definition and classification
Standard Criteria Guidelines
Mental Health Problems
One third of people at some point
in their life reported symptoms
which meet criteria for diagnosis of
one or more of the common types
of mental disorder
WHO (2004)
Classification
• Key Issue for researchers and service
providers
• Determines diagnosis of symptoms
• By disorders
• Normal vs Abnormal Behaviours
• Continuum vs Spectrum Approach
• Scientific Vs Subjective Value
Judgement
The function of classification
• Inform effective treatment selection
• Administrative functions e.g. Medical
aids, legal system.
• Provides vocabulary for professionals to
communicate. Clinical shorthand.
• Provides information on prognosis.
Traditional Classifications
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Organic/Functional
Neurosis/Psychosis
Minor/Major
Severe Mental Illness
Modern Classifications
DSM-IV-TR & ICD-10
• DSM-IV-TR
• Larger no. of
discrete categories.
• Uses a multi-axial
system.
• Uses term psychotic.
• ICD-10
• More general
categories.
• Generally single axis.
But uses broad aetiology.
Uses term neurotic.
Psychopathology
• Commonly used in Psychiatry
• Behaviours or experiences indicative of
mental illness
• Disease Process
• Abnormality in responses of cognition,
emotion, physiology and behaviour
• Subsequent effect on functioning
Classifying Psychopathology
DSM – IV – TR
Axis I: Clinical Syndromes
• This is what we typically think of as the diagnosis
(e.g., depression, schizophrenia, social phobia)
Axis II: Developmental Disorders and Personality
Disorders
• Developmental disorders include autism and mental
retardation, disorders which are typically first
evident in childhood
• Personality disorders are clinical syndromes which
have a more long lasting symptoms and encompass the
individual's way of interacting with the world. They
include Paranoid, Antisocial, and Borderline
Personality Disorders.
Axis III: Physical Conditions which play a role in the
development, continuance, or exacerbation of Axis I
and II Disorders
Physical conditions such as brain injury or HIV/AIDS
that can result in symptoms of mental illness are
included here.
Axis IV: Severity of Psychosocial Stressors
Events in a persons life, such as death of a loved one,
starting a new job, college, unemployment, and even
marriage can impact the disorders listed in Axis I and
II. These events are both listed and rated for this
axis.
Axis V: Highest Level of Functioning
On the final axis, the clinician rates the person's level
of functioning both at the present time and the
highest level within the previous year. This helps the
clinician understand how the above four axes are
affecting the person and what type of changes could
be expected.
Example of Diagnosis:
• Patient: John Doe
– Axis I: Major depressive Disorder
– Axis II: Narcissistic Personality Disorder
– some features only
– Axis III: Poor liver functioning, frequent
migraines.
– Axis IV: Recently retrenched
– Axis V: 65
Psychological Perspectives
Before Psychology there were
Philosophers - asked questions about
the mind:
• Plato (427-347 BC): Does perception
accurately reflect reality?
• Aristotle (384-322 BC): Logic forms
the laws of thought
• Descartes (1596-1650): “I think
therefore I am”
The Beginning of Psychology
Wilhelm Wundt (1832-1920)
•Focuses on the scientific
study of the mind.
•First Experimental
Psychological Lab in 1879
•Scientific Method:
Predict what will happen
Systematically observe
events
Do events support
predictions
William James (1842-1910)
•Philosopher and Psychologist
•Focus on understanding mental
Processes
•Theory of Emotion
•Interpretation of stimulus
Ivan Pavlov (1849 – 1936)
•Classical Conditioning
•Stimulus Response Psychology
• "Pavlov's
dog" -Someone who merely
reacts to a situation rather than
using critical thinking
John Watson (1878-1958)
•Theory of Behaviourism
•Understanding animal behaviour
•Little Albert Experiment
(Unconditioned Stimulus)
Sigmund Freud (1856-1939)
•The idea of the UNCONSCIOUS
•Thoughts, memories & desires exist below
conscious awareness and exert an
influence on our behavior
•Psychoanalytic Theory attempts to
explain personality, mental disorders &
motivation in terms of unconscious
determinants of behavior
Contemporary Psychological
Perspectives
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Several theories within an approach
Share common assumption.
No right or wrong approach
Each perspective has its strengths and
weaknesses
• 5 Perspectives
Behaviourist Perspectives
• People are controlled by their
environment
• How environmental factors (stimuli)
affect observable behaviour (response)
• Classical conditioning - Learning by
association
• Operant conditioning - Learning from
the consequences of behaviour (B.R
Skinner)
Psychodynamic Perspective
• Events in our childhood can have a
significant impact on our behaviour as
adults (Frued)
• People have little free will to make choices
in life.
• Behaviour is determined by the
unconscious mind and childhood
experiences.
• Id ego and super ego principle
Humanistic Perspective
• Look at human behaviour from the eyes
of the person doing the behaviour
• The study of the WHOLE person
• individual's behaviour connected to
inner feelings and self-image.
• Uniqueness of the individual
• Individual has free will to change at any
time.
Cognitive Perspective
• Cognition - the mental act or process by
which knowledge is acquired.
• Mental Processing/Function – memory,
perception and attention etc
• Human brains as computers
• Memory stages (encoding, memory and
retrieval)
• Basis for cognitive therapy
Biological Perspectives
• Genetics and evolution play a role in
human behaviour – Charles Darwin
(1859)
• Most behaviours are inherited (Adaptive
function)
• Brain physiology and behaviour
• Abnormal Behaviour
• Dopamine and schizophrenia
Evidence Base Treatments
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Based on Empirical outcome
Science on its own
Eliminates risky practice
Favour better outcomes
Decision Making
Professional practice
Influence outcome
Recovery
Types of Evidences (Muir-Gray,
1997)
• Type 1
Strong evidence from at least one systemic review of
multiple well designed randomized control trials.
• Type 2
Strong evidence from at least one properly designed
randomized controlled trials of appropriate size
• Type 3
Evidence from well designed trials without
randomization, single group pre-post, cohort, time
series or matched case-control studies.
Types of Evidences (Muir-Gray,
1997)
• Type 4
Evidence from well designed non-experimental
studies from more than one centre or
research group.
• Type 5
Opinions of well respected authorities, based
upon clinical evidence, descriptive studies or
reports of expert committees.
Evidence Base Psychological
Approaches
• Practitioners to follow approaches
based on the best available research
evidence (Sackett et al 2000)
• A psychological therapy is efficacious
and specific - evidence from at least
two settings that it is superior to a pill
or psychological placebo or another bona
fide treatment (Chambless and Hollon,
1998)
Evidence Base Psychological
Approaches
• EBT not followed rigorously
• Not all mental health practitioners
trained
• Patients are often unaware that
evidence-based practices exist.
• Consequently, patients do not always
receive the most effective, safe, and
cost effective treatments available.
Berke et al, 2011
NICE Guidelines (UK)
• CBT – Strongest Evidence across mental health
problems
• Dialectical Behaviour Therapy
• IPT – Depression
• Behaviour Couples Therapy - depression
• Counselling - Depression
• Brief Dynamic Therapy - Depression
Psychodynamic Psychotherapy
• Focus on revealing the unconscious
content of a client's psyche in an effort
to alleviate psychic tension
• Internal conflicts and their relation to
development
• Patients develop defences to avoid
unpleasant consequences of conflict
• Psychopathology develops especially
from early childhood experiences
• Causing inter-relational difficulties
Psychodynamic Psychotherapy
• Emerges in Transference and
Counter-Transference in therapy
• No structure in therapy
• Interpreting the dynamics in
therapy to work through the
presenting symptoms
• Ability to trust own insight is
critical to successful outcome
Counselling
• Person Cantered opportunity to vent
feelings and emotions
• Evaluate own situations and behaviours
• Work in a problem solving approach
manner
Behaviour Couples Therapy
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Joint Relationship Treatment
Changing views (Blame-Game)
Modifies Dysfunctional Behaviours
Decrease Emotional Avoidance
Improve Communication
Interpersonal Psychotherapy
(IPT)
• Focuses on the interpersonal context
• Building interpersonal skills
• Interpersonal factors contribute to
psychological problems
• Interpersonal not Intra-psychic
• Change in behaviour through adaptation
to current roles and situations
What is CBT ?
Mental health problem
involves on-going
interactions amongst
• Biological factors
genes; biological state
• Psychological factors
cognitions; affects;
overt behaviours
• Social factors
immediate social
environment & culture
Biological
Mental Health
Psychological
Social
What is CBT ?
• CBT addresses
Psychological aspect
of mental health
issues
• Based on idea that
thoughts create
moods, influence
behaviour &
alter physiological
state
Feelings & behaviour
depend
on interpretation of
events
What is CBT ?
• In CBT we help clients
learn that we all have
inherent tendencies to
certain cognitive styles
that can evoke mood and
behaviour disturbance
• We can learn to spot
unhelpful cognitions as
they come up; then
challenge and re- think
them
Cognitive Behaviour Therapy
(CBT)
• Cognitive Therapy is combined with behaviour
‘experiments’
• These help clients act on their new ideas.
Disconfirm original idea and confirm
alternative beliefs e.g. asserting self usually
does not end in hostility but engenders
respect
• Reduce behavioral excesses (e.g. avoidance) &
deficits (e.g. problem-solving)
• When combined, termed Cognitive Behaviour
Therapy
First Generation CBT
Skinner
Pavlov
Watson
BEHAVIOUR THERAPY
Second Generation CBT
•Beck
•Ellis
•Social psychology and developing cognitive Sciences
•Cognitive therapies
Depression
Aaron Beck
Christopher Martell
Generalised Anxiety Disorder
Tom Borkovec
Michel Dugas
Obsessive Compulsive Disorder
Steketee/Kozac/Foa Protocol
Panic Disorder
•Clark
•Barlow
PTSD
•Ehlers
•Foa and Rothbaum
Psychosis
•Garety et al 2001
•Morisson 2001
New Wave CBT
• Acceptance and Committed Therapy (ACT) – Steven
Hayes
Chronic Pain; Depression
• Dialectical Behaviour Therapy
• Mindfulness Based Cognitive Therapy (MBCT) Mark
Williams et al
Recurrent Depression
• Compassion Focussed Therapy (CFT) – Paul Gilbert
Shame and Self attack in PTSD
Mastery
Deal with Life Challenges
Change our approach to
problems
What is IAPT
I – Improving
A – Access to
P – Psychological
T – Therapies
A commissioner led, outcome focused
programme to deliver and improve access to
psychological therapies for people suffering
anxiety and depression
Depressed/Anxious????
• “Would you
rather have
medication now
or Psychological
Therapy in 18
months time?”
Four Year Plan (DOH, 2011)
• Children and young people,
• Physical health long-term conditions (LTCs)
and mental health.
• Medically Unexplained Symptoms (MUS)
• Severe mental illness (SMI)
• Complete roll out to adults
• Equitable access for under-represented
(older adults, BMEs etc)
• 100% sustainability
Workforce Integration
BME
Orgs
CAMHS
GPs
IAPT
University
Adult
CMHT
Specialist
Acute Trust
Clinics
CMHTE
CBT for BMEs
• Main Critics in current model
• Main focus of researchers in the last 5
years
• Ongoing Community Integrated CBT
Model – Southampton Model
Implications for Africa
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Huge
Gargantuan
Brain Gain
Individual Professional Contributions
Focus in Future of Recovery Model
Drive for the Third World
IAPN N and other Orgs.
Thank You
• ????????
• !!!!!!!!!!!!
• Email – idowuT@aol.com
• Concept Consultancy Services
• 07917264355