Cognitive-Behavioral Therapy



Cognitive-Behavioral Therapy

Cognitive-Behavioral Therapy (CBT) is an empirically supported treatment that focuses on patterns of thinking that are maladaptive and the beliefs that underlie such thinking. For example, a person who is depressed may have the belief, "I’m worthless," and a person with a phobia may have the belief, "I am in danger." While the person in distress likely holds such beliefs with great conviction, with a therapist’s help, the individual is encouraged to view such beliefs as hypotheses rather than facts and to test out such beliefs by running experiments. Furthermore, those in distress are encouraged to monitor and log thoughts that pop into their minds (called "automatic thoughts") in order to enable them to determine what patterns of biases in thinking may exist and to develop more adaptive alternatives to their thoughts. People who seek CBT can expect their therapist to be active, problem-focused, and goal-directed.

Studies of CBT have demonstrated its usefulness for a wide variety of problems, including mood disorders, anxiety disorders, personality disorders, eating disorders, substance abuse disorders, and psychotic disorders. While a full description of the treatment and presenting problems for which it is useful is beyond the scope of this brief overview, a brief summary of several treatments will be presented.

CBT has been shown to be as useful as antidepressant medication for individuals with depression and is superior in preventing relapse. Patients receiving CBT for depression are encouraged to schedule activities in order to increase the amount of pleasure they experience. In addition, depressed patients learn how to restructure negative thought patterns in order to interpret their environment in a less biased way. CBT for Bipolar Disorder is used as an adjunct to medication treatment and focuses on psychoeducation about the disorder and understanding cues and triggers for relapse. Studies indicate that patients who receive CBT in addition to treatment with medication have better outcomes than patients who do not receive CBT as an adjunctive treatment.

CBT is also a useful treatment for anxiety disorders. Patients who experience persistent panic attacks are encouraged to test out beliefs they have related to such attacks, such as specific fears related to bodily sensations, and to develop realistic responses to such beliefs. This treatment is very effective for those who experience such problems. Patients who experience obsessions and compulsions are guided to expose themselves to what they fear and beliefs surrounding their fears are identified and modified. The same is true for people with phobias, including phobias of animals or phobias of evaluation by others (termed Social Phobia). Those in treatment are exposed to what they fear and beliefs that have served to maintain such fears are targeted for modification.

Over the past 10 years, CBT for schizophrenia has received considerable attention in the United Kingdom. While this treatment continues to be in its infancy in the United States, the results from studies in the United Kingdom have stimulated considerable interest in therapists in the U.S., and more therapists are conducting the treatment now than just a few years ago. In this treatment, patients are encouraged to identify beliefs and their impact and to engage in experiments to test their beliefs. Treatment focuses on thought patterns that cause distress and also on developing more adaptive, realistic interpretations of events. Delusions are treated by developing an understanding of the kind of evidence the person uses to support the belief and encouraging the patient to recognize evidence that may have been overlooked that does not support the belief. Furthermore, the assumed omnipotence of "voices" is tested, and patients are encouraged to utilize various coping mechanisms to test the controllability of auditory hallucinations.

While the above summary is certainly not comprehensive, it provides a brief overview of the principles of CBT and how it applies to various presenting problems. CBT’s focus on thoughts and beliefs are applicable to a wide array of issues. Because CBT has excellent empirical support, it has achieved wide popularity both for therapists and consumers. Those who may receive CBT training include psychologists, psychiatrists, social workers, and psychiatric nurses. Those seeking treatment using a CBT approach are encouraged to ask their therapist what CBT training they have had or to contact a Center for Cognitive Therapy and request a referral in their geographical location.

Reviewed by Debbie M. Warman, Ph.D. and Aaron T. Beck, M.D., June 2003

Source: Information from NAMI's Website ()

PSYCHOTHERAPY

Psychotherapy is a process of discovery whose medical goal is to eliminate or control troubling and painful symptoms so that the patient can return to normal functioning. It also can be used to help a person overcome a specific problem or to stimulate overall emotional growth and healing. In regularly scheduled sessions-usually 45-50 minutes in length-a patient works with a psychiatrist or other therapist to identify, learn to manage, and, ultimately, overcome emotional and mental problems. Discussions between patient and psychotherapist reveal the basis of problems and enable the patient to better understand him- or herself and gain relief from specific issues. Psychotherapy is an active process requiring concentration, energy, and commitment by both parties. Many patients complete psychotherapy in 16 or fewer sessions, especially for behavior-specific problems. Individual psychotherapy takes place in the privacy of the doctor-patient relationship. Psychotherapy also may be conducted in the context of group, marital, or family treatment.

Although the majority of people who undertake psychotherapy experience significant improvement, there is nothing magical about psychotherapy. It is not a procedure done by a therapist to a patient; rather, it is a process between a therapist and a patient in which the two work together.

Psychotherapy is initiated after an individual has had a thorough medical and psychological evaluation by a psychiatrist or other physician and has received an initial diagnosis. The psychiatrist will review the patient's medical records-or, if these are not available, will take a medical history and conduct a physical examination to identify any medical conditions that might be affecting the individual's mental and emotional functioning. Emotional disorders can be caused by neurological or hormonal problems, can be related to chronic illnesses such as heart disease, or can represent the unwanted side effects of certain medications. As is done with all illnesses, the psychiatrist will interview the patient, asking for details about symptoms-their severity and duration-and obtaining a personal and family history. After all of this information has been collected and analyzed, a diagnosis is made. In many cases, psychotherapy will then be prescribed.

Many kinds of emotional and mental problems can be helped with psychotherapy: mood disorders (depression, bipolar disorder [also known as manic depression]), anxiety disorders (phobias, panic disorders, obsessive compulsive disorder, posttraumatic stress disorder), eating disorders (anorexia nervosa, bulimia, obesity), problems associated with abuse of alcohol or drugs; problems related to life circumstances and events, such as loss and grief, marital difficulties, abuse or traumatic events, or dealing with aging parents or adolescent children; mental and emotional problems related to nonpsychiatric medical illness; sexual disorders; sleep disorders; difficulties in developing intimate relationships; disorders involving disruptions in the functions of consciousness, identity, and memory (dissociative disorders); personality disorders; problems with functioning at work. In the case of severe mental illness such as schizophrenia and other psychotic disorders, psychotherapy is frequently used to help patients understand and manage their illness. Armed with this understanding, the patient is more likely to remain in treatment and thus to avoid relapse.

Types of Psychotherapy

Several types of psychotherapy are available, and-apart from a few exceptions for specific conditions-no one type is "better" than any other. As with other medical situations, the psychiatrist's choice of therapies depends on the patient's particular illness and circumstances. Some types of psychotherapy concentrate on the here and now; others focus on past experiences to achieve insight into how problems arose and how they can be overcome in the present.

In determining which therapy or therapies are likely to be most effective for a given patient, a psychotherapist will take into account the nature of the problem being treated and the patient's personality, cultural background, and experiences. A therapist may use one type of therapy to treat specific kinds of problems-for example, an individual with an unreasonable fear of water is likely to respond best to behavioral therapy. For other types of problems, a therapist might use techniques derived from several types of psychotherapy to treat the patient's illness.

The most frequently prescribed psychotherapies are psychodynamic, interpersonal, cognitive, and behavioral.

Psychodynamic therapy is used in treatment to help patients understand themselves more fully. This approach may involve uncovering-and learning to deal more effectively with-unconscious conflicts. It may also involve assisting patients to understand how certain types of adverse childhood experiences have left them feeling incomplete, anxious, or plagued with low self-esteem that interferes with realistic adult functioning. This form of therapy is based on the premise that our mental well-being is influenced by unconscious conflicts, significant childhood experiences, and painful feelings that are hidden behind a variety of defense mechanisms.

Interpersonal therapy is designed to improve the quality of the patient's interpersonal world. The therapist helps the patient to understand the underlying interpersonal themes that appear to be involved in the onset and maintenance of the illness. Common themes include unresolved grief, transitions from one social or occupational role to another, conflict between the patient and significant individuals in his or her life, and deficiencies in the capacity to relate to others.

Cognitive therapy is employed in treatment to help patients recognize and change thinking patterns that are harmful or ineffective.

Behavioral therapy is used to address a patient's specific behaviors, substituting positive behaviors for harmful or inappropriate ones.

Each of these types of therapy may be conducted by a psychiatrist in an individual, family, couples, or group setting. Self-help groups also are available to patients and to family members; such groups can supplement-but should not be considered a substitute for-psychotherapy.

Medication

Medication is often used in conjunction with psychotherapy, and in many disorders the combined treatment is better than either alone. Both psychotherapy and medication appear to act by altering brain functioning. With severe disorders, various forms of psychotherapy can help the patient to remain on medication and follow other elements of the treatment plan.

Who Provides Psychotherapy? Psychiatrists, psychologists, clinical social workers, family and marriage counselors, and other mental health professionals are trained and licensed to provide psychotherapy. Highly skilled and effective therapists may be found in each discipline. However, psychiatrists are medical doctors with specialized training in the diagnosis and treatment of mental and emotional disorders. Only psychiatrists, as physicians, are medically trained to perform and analyze medical diagnostic tests, to evaluate the physical symptoms of mental illness, and to take into account any other medical illness occurring concurrently with the mental disorder. Psychiatrists and other medical doctors may prescribe medication. Child psychiatrists specialize in working with children and adolescents; geriatric psychiatrists work with older people.

Choosing a Psychotherapist

For prospective patients, finding a psychiatrist with whom they can work well is important. Good sources for referrals include one's family physician, local psychiatric societies, medical schools, and community mental health centers. Friends and family members, too, may be able to provide names of therapists about whom they have heard or with whom they have worked successfully. As is true when selecting other physicians-for example, a pediatrician or internist-it is appropriate to speak with several candidates. When choosing a psychotherapist, prospective patients should assess their comfort level with the therapist-can they feel relatively at ease sharing intimate, personal feelings, thoughts, and experiences with this person? Also important is the therapist's education and training: the more, the better.

When choosing a psychiatrist, patients need to understand the terms and restrictions of their health care plan. Many managed health care plans and fee-for-service insurance plans limit patients' choice. Some plans restrict members' choice to "inside the network" or plan psychiatrists and require that patients first be evaluated by a "gatekeeper"-a family doctor, or a social worker or other nonphysician plan representative-to determine whether specialist care is needed. Other plans permit patients to choose a psychiatrist outside the plan's network but may require patients to pay a larger portion of the cost. Patients limited to selecting an inside-the-network psychiatrist should seek recommendations from their primary care physician.

Many insurance plans pay a certain percentage-often 50%-of a therapist's fee, up to a stated maximum; limit the number of visits covered; and have an annual or lifetime cap on the amount paid. Managed care companies often limit the number of psychotherapy sessions a patient may attend (e.g., 5-20 per year) and place restrictions on the type of therapist a patient may see. Individuals considering therapy should be aware that a new federal law requires employers who offer mental health benefits and who have 51 or more employees to provide the same financial coverage for mental health problems-within the same annual and lifetime limits-as for other medical disorders. For more information on choosing a psychiatrist, request a copy of Let's Talk Facts About Choosing a Psychiatrist from the American Psychiatric Association.

When selecting a health care plan, it is important that consumers clearly understand the mental health benefits and coverage provided. In addition to considering the size and quality of the plan's "panel of providers," questions to ask include whether the plan provides equal coverage for mental and physical disorders, how many therapy sessions are covered, how much copayment is required per visit, whether members can consult a psychiatrist without first being seen by a general-care "gatekeeper," whether the plan covers sessions with a psychiatrist who is outside the plan's network, and whether the plan protects confidential information. Patients' mental health needs are best met when they have easy access to a psychiatrist who is either the provider of treatment or an intrinsic part of the treatment team.

Working Effectively With a Psychotherapist

The relationship between patient and therapist is a unique partnership. Psychotherapy can be successful only when both partners are dedicated to achieving the agreed-upon goal. Important to this partnership is mutual trust, respect, and confidentiality. Confidentiality is a basic requirement of psychotherapy and is emphasized in the code of ethics of the American Psychiatric Association and other professional mental health organizations. Patients need to know that insurance companies and managed care firms may ask for reports from a psychotherapist to determine whether to continue to provide reimbursement. Some patients prefer to pay for psychotherapy from their own resources to avoid this violation of confidentiality.

Both patient and therapist have clear responsibilities. The patient must be candid and honest, willing to reveal sometimes uncomfortable feelings and thoughts, to address problems, to be open to new insights, and sometimes to carry out prescribed "homework" activities. The therapist must listen carefully; clarify, interpret, and point out associations that may not be obvious; and guide the patient to recognize and, where indicated, modify patterns of behavior. Because the patient and the therapist are full partners in the psychotherapy process, both participate in making treatment decisions, including the decision to end therapy.

The patient-therapist partnership is truly special, but it is not a friendship or a business relationship-the therapist does not socialize or conduct business with the patient. Although the patient is likely to share very personal feelings and thoughts, under no circumstances is intimate contact-most especially sexual relations-between a patient and a therapist appropriate, acceptable, or useful.

How Long Does Psychotherapy Take?

The amount of time a patient spends in therapy depends on several factors, the most important being the nature of the illness or problem being treated and, for many patients, the coverage terms and restrictions of the health care delivery system. Depending on the mental illness and the type of therapy selected by the therapist and the patient, psychotherapy can require a few sessions or can take much longer. Generally speaking, the more severe or complicated the mental disorder, the longer amount of time needed to complete psychotherapy. Short-term therapy (16 or fewer sessions) is often prescribed for relief of specific symptoms.

Depending on the patient's problem and the type of psychotherapy used, the process can sometimes be time-consuming and expensive. However, several studies have demonstrated that psychotherapy is ultimately cost-effective for patients, their families, and society. The benefits of undergoing treatment include decreased visits to other doctors' offices, diagnostic laboratories, radiology departments and hospitals for physical ailments that are based in psychological distress; reduced need for psychiatric hospitalization; lower use of sick days and disability; and increased job stability. Conversely, the costs of not treating mental disorders can be measured in ruined relationships, job loss or poor performance at work, personal anguish, substance abuse, unnecessary medical procedures, psychiatric hospitalization, and even suicide.

Despite the personal and economic benefits of psychotherapy, many insurance firms and managed care companies have stringent limits on coverage and access to mental health care. Such limits are short-sighted and harmful to patients, families, employers, and society as a whole, because mental disorders are often very responsive to treatment.

How Do I Know if I Need Psychotherapy?

If you or someone you care about is experiencing emotional or mental problems, professional help should be sought. Only a thorough examination and evaluation by a family physician or a psychiatrist can identify whether physical conditions or medication side effects might be causing or contributing to emotional problems.

Warning Signs of Mental Illness

• Marked personality change

• Inability to cope with problems and daily activities

• Strange or grandiose ideas

• Excessive anxieties

• Prolonged depression and apathy

• Marked changes in eating or sleeping patterns

• Thinking or talking about suicide or harming oneself

• Extreme mood swings, high or low

• Abuse of alcohol or drugs

• Excessive anger, hostility, or violent behavior

A person experiencing one or more of these warning signs should be evaluated by a psychiatrist or other physician as soon as possible-it's the first step toward feeling better.

Bibliography

Bloch, Sidney, Julian Hafner, Edwin Harari, et al. The Family in Clinical Psychiatry. New York: Oxford University Press, 1994.

Copeland, M. The Depression Workbook. Oakland, CA: New Harbinger, 1992.

Hales, Diane, and Robert E. Hales. Caring For The Mind: The Comprehensive Guide to Mental Health. New York: Bantam Books, 1995.

Mermier, Martha Brinton. Coping With Severe Mental Illness: Families Speak Out. Lewiston, NY: Edwin Mellen Press, 1993.

Quinn, Brian. The Depression Sourcebook. Los Angeles, CA: Lowell House, 1997.

Soukup, James E. Understanding and Living with People Who Are Mentally Ill: Techniques to Deal With Mental Illness in the Family. Springfield, IL: Charles C Thomas, 1995.

Turnbull, Ann P., Joan M. Patterson, and Shirley K. Behr. Cognitive Coping, Families, and Disability. Baltimore, MD: Paul H. Brookes, 1993.

Source: © Copyright 1999 American Psychiatric

Electroconvulsive Therapy

 

 

Electroconvulsive therapy (ECT) is a medical procedure that is used to treat a range of mental illnesses such as severe depression, catatonia and some forms of mania and schizophrenia. The treatment induces controlled seizures in the patient via small electrodes placed at specific locations on the head. ECT has been used for over half a century in many different countries, and its effectiveness is well documented. Approximately eight out of 10 patients who undergo ECT will experience dramatic improvement.

The reason why this treatment is so effective is still mysterious. The brain functions using electrochemical messages, and it is thought that ECT-induced seizures interrupt these messages and 'reset' the brain. ECT is generally used when other forms of treatment, including medication and psychotherapy, have failed. However, ECT is often the first treatment of choice in life threatening situations, such as a potential suicide, because of the rapid results. Sometimes, ECT is prescribed for older patients who can't tolerate medications.

The procedure

Usually, ECT is performed under supervision by the prescribing psychiatrist.

The patient is anaesthetised and given muscle relaxants. The electrodes are placed at strategic points on the patient's skull. Depending on the patient, one or both sides of the head will be stimulated, known as unilateral or bilateral ECT respectively. A series of brief, low frequency electrical pulses prompt a convulsion. The patient won't feel the convulsion because of the anaesthesia, and won't have muscle spasm or move because of the muscle relaxants. The patient wakes up after a few minutes. ECT is typically administered three times per week for six to nine treatments, but the exact course of treatment depends on the nature of the illness and the patient's response to treatment.

Risks and complications

Research has shown that ECT doesn't cause brain damage because the amount of electricity used is too small to harm tissue. Like any operation involving anaesthesia, ECT carries a small degree of risk. Some of the immediate side effects of ECT (these tend to resolve within a few hours) include headache, sore muscles, queasiness and confusion. During the course of the treatment, many patients experience problems with short term memory, but this side effect only lasts a few days or weeks. A few individuals, however, experience long term difficulties with memory. This effect is more common in patients who undergo bilateral, rather than unilateral, ECT.

Patient rights

If your psychiatrist suggests that a course of ECT therapy may be helpful, you have certain rights under Victorian law. These rights include:

• A full explanation of the procedure and associated benefits and risks

• A second opinion

• Legal advice

• Representation by a friend or relative

• Having a person of your choice with you during discussions with your psychiatrist or doctor

• The right to complain

• The right to refuse.

Informed consent

If your psychiatrist considers you are capable of giving informed consent, you can only undergo ECT if you agree. If you are incapable of giving informed consent, or if your health professionals consider that ECT treatment is potentially life saving, then your psychiatrist can consent on your behalf, even if you don't want the treatment. If you are detained as an involuntary patient under the Mental Health Act, you can appeal to the Mental Health Review Board against your involuntary status.

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