Clinical Psychology Midterm 2: Interventions for Internalizing Disorders

Assessment

Gathering information to support conclusions, answer a question, diagnose

Assessments lead to individualized recommendations for interventions

Assessments seek to measure and describe psychopathology, not to change or treat it

Intervention

Therapy, providing active treatment for a patient

Intervention= therapy

Neuropsychological and other forms of assessment are not interventions

Intervention refers to all forms of therapy provided by a clinical psychologist

Internalizing disorders

Emotional disorders with too much negative emotionality (ex: MDD, GAD, phobia, OCD, EDs, sexual dysfunction, BD— Sexual problems, eating pathology, fear, distress, mania)

Correlate with neuroticism

Very common— anxiety disorders are the most common MH disorders worldwide

Neuroticism

personality tendency towards negative emotions/avoiding threats

Depression: Behavioral Activation

A type of CBT where therapists help patients do more helathy behaviors

• theoretical mdoel of depression: unhealthy behaviors → depression

Goal: disrupt this cycle by increasing healthy behaviors: value-driven, enjoyable, fulfilling

Clinical materials: behaviorla activation weekly monitoring

BA can treat severe, intractable depression, in some cases better than medication

The healthy behaviors between sessions are considered the active ingredient of therapy

Depressiong: CBT

• CBT is efficacious in treating Major Depressive Disorder (MDD)

  • Effects are small to moderate

  • Dismantling design RCTs of CBT have found that BA treats MDD as well as antidepressants and slightly better than full CBT

  • BA is also better for severe depression 

Beginning BA treatment for depression

1. Begin treatment with intake interview

2. Get to know patient’s context and treatment goals

3. Check on suicidality/safety

4. Assess which healthy behaviors patient has stopped doing

5. Assign behavioral self-monitoring homework to measure frequency of un/healthy behaviors

BA Intervention for Depression

After self-monitoring, assess realtionships between behavioral patterns and moods

Help pt brainstorm personal values in different life areas

• values: ideals, guiding principle

• Life areas: important areas of fundtioning and well-being (e.g., relationships, education, career, health, daily routines, recreation)

Key processes:

• translate pts values to healthy behaviors

• assign healthy behaviros as between-session homework

• brainstorm strategies for addressing barriers to healthy behaviors

BA’s idiographic functional analysis

Idiographic= tailored to pts life

functional analysis= functions of behaviors in pts lives, trying to increase frequency of positive reinforcement

BA for Bipolar

• bipolar disorders (I and II) involve depressed mood

• when treating BPD, therapists focus on increasing regularity of routines

• consistent sleep itmes, eating times, healthy behaviors

• maintaining regularity of routines can lessen mania

BA challenges

• Patients not doing their homework

• Patients believing they are incapable of enjoyment

  • It can be easy to lose hope

• Behavioral homework might need to start very small and simple

  • People can feel insulted 

• BA is simple, but not easy– behavior change is hard

CBT Model for Generalized Anxiety

• CBT Model:

  • emotions, thoughts, and behaviors all affect one another, event -> cognition -> feeling

• BA also works for GAD (worrying can be construed as a behavior)

• However, GAD can also be very cognitive

• CBT is effective for treating GAD, and more cognitive intervention strategies can be helpful

• Anxiety is thought to come from cognitive distortions 

Beginning treatment for generalized anxiety

1. Begin with an intake interview, assessing context, symptoms, and treatment goals

2. Assess:

   1. the focus of worries (routine topics? personalized topics?)

   2. What their stuck-points are (where do the person’s worries stat to feel unresolvable or overwhelming?)

   3. what impaiments their anxiety brings (what important activities/goals is anxiety blocking them from doing?)

Intervention techniques for generalized anxiet

Cognitive strategies for addressing GAD may involve facing the worst-case scenario

• If your worst nightmare came true, what would that mean and could you still be okay? 

• If _____, then _____, and then ____, and then _____…

May involve examining evidence

• cognitive flexibility is the active ingredient helping disarm anxiety

Ultimately these strategies target negatively-skewed core beliefe

• core beliefs= deep-seeded, long-term beliefs central to a person’s experience

Challenges of CBT for GAD

• patients may have many worries that change week-to-week

• patients may be unwiling to face worst-case scenarios

• cognitive strategies (examining evidence) can make some patients feel invalidated

generally though, anxiety patients are one of the easist groups to treat

Treating OCD

• For conditions like MDD/GAD, psychotherapy is often considered equally effective compared to medications

• OCD is different: exposure therapy is the treatment of choice, over and above psychiatric meds

  • Half of OCD patients no longer have OCD after 1 course of Exposure and Response Prevention (ERP)

    • ERP is a form of exposure therapy 

  • Exposure therapy may be the most effective psychotherapy

Exposure therapy for OCD

• OCD is a behavioral process

• Trigger -> Obsession -> Anxiety -> Compulsion -> Temporary Relief

• Exposure therapy intentionally induced anxiety so that patients can practice resisting compulsions

• Goal is: 

  • Get patients to sit with anxiety so long they get bored (habituation)

  • Challenge irrational beliefs about necessity of compulsions

Exposure hierarchy

• After mapping out behavioral cycle of triggers/compulsions, an exposure hierarchy will be made

• EHs have the situations the patients will expose themself to 

• Exposures from this hierarchy will then be chosen for in-session exposure and homework

• Exposure must be at least moderately distressing to be useful 

• Patients must also refrain from all compulsions, even mental self-reassurance, for exposure to work

• Therapists should not reassure or comfort patients during exposure either

• Reassurance = a safety cue, makes exposure less effective by decreasing anxiety

• The goal is to increase anxiety 

Exposure therapy: phobias

• Exposure therapy for phobias is very similar to ERP for OCD

• Both phobias and OCD are treated with exposure to feared stimuli

• Key difference: people with phobias do not do compulsions

• Exposure therapy for phobias does not have to focus on preventing compulsions

Exposure therapy: challenges

• Because exposure therapy must be unpleasant to work, patient motivation can obviously start out low

• Therapists typically start treatment with attempts to increase motivation through techniques like motivational interviewing (MI)

• Therapists may also feel guilty about distressing their patients

• Patients may also engage in mental compulsions/self-reassurance without noticing, which also makes exposure less effective

Transdiagnostic interventions

• Some treatment elements- like preventing compulsions- are rather disorder specific (to OCD)

• In general, however, the same general elements do work for all internalizing disorders

  • Elements like

    • Intentionally facing feared stimuli

    • Challenging irrational/rigid beliefs

    • Engaging in values-driven behaviors