ADDC 1509 - Theories, Models, and Approaches to Mental Health

Mental illness vs. Mental health issues

• Mental illness 

  • Refers to mental health struggles significantly infleunced by biologiy, genetics, exposure to toxins, rain injuries, etc 

  • Objectively measured, different from person to person, agreed upon ideas of what it is or isnt 

  • Base don a medical modle, objective set of symptoms, if symptoms are observabe, they say you have a mental illness, if you don't have those symptoms you don't have mental illness 

  • may be defined by brain scans 

  • Specific tx such as medication 

  • Typcially has a very specific label (I.e. depression) 

  • Significant psychotic symptoms attached but not always (serious mental illness) 

  • Interventions are more medical  

• Mental wellness or mental health issues 

  • Tend to be influenced by biologically but can be influenced by psychology (the way you think, expectations, social expectations, cultural expectations) 

  • Very subjective or contextual 

  • May not fit the diagnosis for a speciic mental illness 

    • Subjectively we know when we're struggling mentally 

  • Contextual (these mental health struggles) often casued by smt that has happened in our life 

    • e.g. burnout, persistant anxiety, break up  

  • Very subjective, self-defined, observe it in our selves 

  • Often there is a context as opposed to serious mental illness 

  • Tend to have much more to do with ppl's sense of purpose, meaning, sense of belonging 

    • Much more to do with social or spiritual, humanisit cfactors,  

  • They're (mental illness and mental health issues/wellness) not separate but on a continuum mental illness has a much stronger biolgoical copotnent and is easily objectively observed whereas mental wellness is infleunced by bioligy but much more infleunced by psychological, contextual, social factors and things like meaning and belnoging 

  • Often the solutions are unique from person to person 

    • Same pill might work for severe clicnical depression, might be a dif solution for ppl who are feeling a little depressed 

  • Interventions are more psychosocial 

    • Involve diologue, counselling, therapy, as well as changes in ppl's social environment or the focus of what they're doing with their time  

  • Most broad mental health issues is a combo of both 

The mental health continuum

• Less detailed model of mental health  

• Created from the community mental health agencies/compaigns and social worker community realizing that not everyone has time to read the DSM-V to figure out if they have amental healht issue 

• Many times ppl trying to asses if someone has a mental ehalth problem, are usually a parent, employer, colleague (don’t have a professional background) 

• Lay person could use to asses their own mental health or  

• Developed by the mental health health commission of canada 

• Simpler model such as this exist to enhance self-awareness and help ppl seek support for themselves or someone they know  

• Used to encourage and motivate population to seek support 

• Used to reduce stigma/shame 

How does the mental health continuum work?

• Allows ppl to identify others or themselves as mentally healthy, mentally reacting, mentally injured, or mentally ill 

  • Mentally healthy 

    • This person seems okay with normal functioning 

  • Mentally reacting 

    • Having a hard time but this is a common reaction  

    • e.g. someone got demoted, someone going through a breakup  

    • Feeling depressed, anxious, expected given the context, not so intense that it can't be overcome in time 

  • Mentally injured 

    • More serious mental struggles 

    • Someone with significant mental impairment 

    • Something traumatic has happened, some genetic predisposition has been triggered by something major in their life 

    • Seeing significant functioning impairment 

  • Mentally ill 

    • Someone has a clinical disorder when it’s a severe and persistent impact on their ability to function 

  • How functional is this person?' it’s a continuum, not this person has this, ppl can move from injured to healthy, etc 

    • Ppl don’t tend to go from health to ill 

    • Will see these transitions from one state to another and another  

• Suggests there's an ability to move 

  • Once you're mentlaly ill deosnt mean you cant leave that category 

  • There's a typical progression 

Categories (mental health continuum)

• Healthy 

  • Normal mood fluctuations 

    • Get a lil anxious, ticked off, etc 

  • Takes things in stride 

    • Isn't floored by small failures 

  • Consistent performance over time 

  • Normal sleep patterns 

  • Usual self-confidence 

  • Comfy around others 

• Reacting 

  • More irritable and impatient than usual  

  • More nervousness, sadness, increased worrying 

  • Procrastination, forgetfulness 

  • Trouble sleeping  

  • Lower energy 

  • Difficulty in relaxing 

  • Intrusive thoughts 

  • Decreased social activity 

  • Reach out for informal support from friends, counsellors, engage in self-care activities 

  • More of a warning to not enter injured category  

• Injured 

  • Seeing notable anger and anxiety 

  • Lingering sadness, hopelessness, feelings of worthlessness 

  • Preoccupation with some topic 

  • Decreased performance in academics or at work 

  • Significantly disturbed sleep (falling asleep and staying asleep) 

  • Avoidance of social situations, withdrawl  

• Ill 

  • Significant difficulty with emotions, thinking 

  • High leels of anxiety, panick atacks 

  • Depressed mood, feeling overhwlemed 

  • Constant fatigue 

  • Disturbed contact with reality 

  • Signficant disturbances in thinking 

  • Suicidual thoughts/intent/behaviour 

  • Need signifcant medical intervention 

• Mentally health and reacting 

  • Focus is on self care and reaching out to social supports or envourgaing another to engage in these 

  • Much more informal  

• Mentlaly injured and ill 

  • Role is to get help from professionals or really encourage and get friends/fam connected to that professional care  

The dual continuum model

• CMHA Canada uses this model 

• Incorporates this idea of mental wellness and mental illness into one piece 

• Tries to create mor ehope or resiliency/empower for those living with a mental illness 

  • Mental illness often has to do with things beyond our control 

  • getting a label of mentally ill, associated with what are your limits/symptoms 

  • Trying to look at mentla health along a continuum, can ave mental illness (smt that happens to you) but even within having a metnal illness we all have the ability to improve our metnal welness, something that is always within our control 

• A person can have good mental health/metnal wellness even though they are living with a mental illness by making life choices that help to imrpove their overall metnal health  

• Can also have a person who registers low on the metnal illness scale, and yet if they're nto being attentive to what they put in their body, their attidues, who they surroudn themselves with, etc, they can struggle with their mental wellness 

• Horizontal axis (across the page) 

  • Far left end, maximum mental illness 

    • Signficant geentic and neurlolgical predispositions to mental illness and is demonstrating a lto fo symptoms 

  • On the right, minimum mental illness 

    • Someone who neurolgoically is well 

• Vertical axis 

  • High end, optimal wellbeing 

    • They feel great about their life 

  • Low end, minmal mental well being 

    • Not very satisfied with their life 

• Possible for a person with max mental illness to achieve optimal metnal wellbeing  

  • Through psychosocial factors (i. e changes in attidues, changes in expectations), having meaningful relationships and amnaging mentla illness with proper meds and nutrition, significant harm reduction  

• Main focus: What can we do despite where someone falls on that continuum of mental illness to help them reach optimal mental well-being 

• Focusing on optimal well-being part 

  • Mental illness part is managed by medical system (I.e. psychiatrist, fam GP, clinical psychologist) 

  • Counsellors, case managers, therapists, etc., looking at well-being part 

  • Where we're workign is enhancing well-being, not treating mental illness 

Defining mental health

• Most common factors/categories to identity/define mental health status: 

  • 1) Things happening with mood (low mood/major fluctuations) 

    • General idea of low mood  

    • Smt abt mood that moves outside of the normal range or even for that person 

    • Often around depression 

  • 2) Concerning behaviours  

    • Things around suicidality, suicide attempts, self-harm, addiction, heavy risk taking (lack of judgement, hidden suicidal impulses) 

  • 3) Nature of cognitions (concerning thoughts) 

    • Thinking 

    • How do we know what someone's thinking? Usually by what they're thinking 

      • What they're texting, posting, writing 

    • If there's a distoriton in cognitions in area of paranoia, anger, depression, fihts of idealism, or compelte psychosis  

  • 4) Nature of social interactions (concerning social interactions) 

    • How od they interact with other human beings 

    • Often a withdrawal 

    • Or no boundaries, risky sexual behaviour 

  • 5) Detatchment from psychosis 

    • Is this person talking abt things that havent happen, things that arent there, etc 

The MSE – the mental status exam

• It’s a snapshot of how this client is presenting to me in this moment, not a diagnosis but this is what I'm noticing in their behaviours, body language, etc 

• Gives us a hint of what their mental status or state is in this moment 

• Something tangible that you can observe, can be fleeting, something you notice in the moment  

• Do to an official MSE, need proper training (what psychologists and psychiatrists do) 

• Important to know language when taking notes 

• Part of note is having a sentence or two relating to what you'd see in MSE  

• Pick anything that stands out to you that's worth noting 

  • A way of signaling to another clinician (psychologist) that a client may for example have depression without steering out of your lane (as a psychotherapist for example) 

  • Helps ppl who diagnose by providing something tangible, sending signals to other professionals who are interviewing them 

• Some common areas of assessment include: 

  • General appearance 

  • Behaviour/body language 

  • Speech style and focus 

  • Interaction style with interviewer 

  • Mood and emotional range/expression 

  • Perception  

The DSM-V definition of mental disorders

• Mental illness/disorders 

  • Disturbance in an ind's cognition (thinking), emotion regulation, or behaviour 

    • Disturbance - Something out of the norm for society or that person 

    • Disturbance or a shift in thinking behaviour or emotional behaviour 

  • Caused by a dysfunction in the psychological, biological or developmental processes underlying mental functioning 

    • Could be things in your life that could be happening 

      • Ex. Spouse passed away 

  • Associated with significant distress in social occupational or other important activities 

    • Not expected or culturally approved response or social rebellion  

  • Not expected, sometimes there are disturbances that actually make sense  

  • Have to take into account the context of the person 

Ways of defining mental health

• Things like the DSM have a specific label 

  • Advantages  

    • Specific 

    • Creates a sense of direction 

  • Disadvantages 

    • Reduces ppl to a label 

    • Ppl overly identify with the label 

    • Confirmation bias 

    • Stigma 

    • Requires an expert which cuts ppl off  

• Continuum/spectrum 

  • advantages 

    • Quick/easy/subjective 

    • Relative/contextual  

    • Not permanent 

    • Normalizes reactions 

  • Disadvantages 

    • Imprecise 

    • Simplistic 

  • Self-assessment/family/workplace 

• Psycho-social wellness (Dual continuum model) 

  • Advantages 

    • Allows for wellness within illness and illness within wellness 

    • Strengths-focused subjective, contextual and objective 

  • Disadvantages 

    • Imprecise 

    • Simplistic 

    • Doesn’t provide specific direction  

  • Most likely to be working with this model in a team  

The role of theories and models

• Theories help us to create a context/form a story before the person comes in order to better make sense of client's stories 

• Helps us focus our attention more so that we don't feel lost and not scramble to understand  

• Theories help us to put in that invisible context that isn't there 

• Theory gives us a hint but you should always check in with the client 

  • Don’t assume it's true  

• Theory gives you a sense of what you're listening for 

  • If emotion focused you're listening for emotion words, looking at body language, listening for cognitive distortions, I wonder why they picked that word, noticing where they're pausing, etc 

• Theories allow us to organize seemingly random info 

• Allows us to exert some influence over the session  

• Help us to organize what we're hearing, what to listen out for before the client speaks 

• Theories give us a sense of direction  

Empirically supported treatments (ESTs) + Evidence based practices (EBP)

• Empirically supported treatments (ESTs) 

  • A type of psychotherapy/counselling/theory that has research support that says its effective  

  • Bar for empirical support in our field is pretty low  

• Evidence based practices (EBP) 

  • Empirical support PLUS 

    • Plus - is it says not only is this thing useful, but its extra useful than other theories for a specific population  

    • Not only is it good compared to other treatments, but it's extra good for this population  

• CBT is EST but on top of that it's considered a best practice (+) for depression 

• Sometimes it's culturally based  

• Best practices 

  • Have to always ask, best practice for who? There should always be some sort of population  

The limits of theories and models

• Confirmation bias 

  • The human tendency to attend to our environment in a way that confirms our existing beliefs 

  • Stop seeing the person  

  • Problem with theory is that it can give you a confirmation bias 

  • If you're CBT therapist, you're gonna think you're gonna listen to thought distortions and think that the root of the problem and not open to the fact that there are other things going on that have nothing to do with this  

• Long standing debate abt the effectiveness of the dif models 

  • If you went to school to become a therapist/counselling you had to choose ahead of time which model you'd want, and strictly learn that one 

  • Constant debates abt which one was better 

  • Lots of debates ab specific theories – which ones are better 

• Research is starting to be done to figure out if there's something common among all therapies  

• Most outcome studies show 

  • There are few difference between therapies and 

  • Most therapies are effective 

• There are common factors among all therapies 

• Components of counselling/psychotherapy that 

  • Are associated with positive outcomes 

  • Are shared by all effective counselling/therapy models  

• All junk food as a magical combo of salt, sugar, and fat in dif forms 

  • That’s what makes them tasty to us 

  • Each one will have a dif combo of them  

The 4 primary common factors

• The therapist 

  • The therapies most effective require the therapist to have some degree to be perceived by the client as being warm and having empathy 

  • If you feel this way towards the client, and the client gets the sense that you're genuinely a warm and empathetic person 

  • If you don’t come across that way, it's not gonna help the client 

  • If you think you're warm and the client doesn’t perceive it  

• The client 

  • Client factors, theories that pay attention to how motivated the client is and how to address it  

  • does the therapy address motivation and their sense of hope  

  • Therapies that try to increase hope or motivation tend to be more effective 

• Structural features 

  • When you ask your integrated model, make sure it's encouraging you to come across as warm and empathetic 

  • Some degree is attuned to and increase motivation and hope 

  • Make sure it's consistent 

    • As long as your consistently person centered, warm and empathetic, etc that's what's effective 

    • If you decide to be client centered one day, but focus on DBT another day that's ineffective 

    • If you're switching gears and theories overtime, will be less effective 

  • Ghas to be coherent, consistent 

• Strategic processes 

  • Having homework to do between sessions is more effective 

    • Ex. Behvaioural homework or written 

  • More effective therapies don’t just depend on that hour 

  • Models that involve teaching the client smt abt their disorder, etc 

  • A certain amount of sharing tend to have good results 

  • Feedback - asking is this helping, is this working 

    • You checking in with hem to ask if what you're doing is helpful to them  

    • Not just assuming its great  

• When you look at the factor 40-50% 

  • The relationship is a huge factor in the effectiveness  

    • This is what we have control over regarding the effectiveness of therapy for the client 

  • Client factors 30-40% 

    • I.e. Socioeconomic status, severity of the mental health issue 

    • Completely outside of our control regarding our effectiveness 

  • Theoretical approach 5-10% 

    • Doesn’t matter as much  

Empirically supported relationships

• New idea – Empirically supported relationships (ESR) 

  • Findings which arose from research abt what relational factors are associated with positive therapy outcomes 

• Relational factors which have empirical support for contributing to positive outcomes include therapist ability to: 

  • Ability to demonstrate warmth and empathy 

  • Some power of persuasion  

  • Express support and reassurance 

  • Model active coping

Biological Factors in Mental Health

• Mental health has often been viewed form one of two contrasting perspectives 

  • One is the physical sciences (biological factors, neurochemistry, seeing mental health as biological, biochemical phenomenon) 

• In the past, biomedical was a huge advance from thinking that ppl were just possessed or having an imbalance of humors, or was a moral failing 

• Most helpful shift in understanding and treating mental health  

  • Huge paradigm shift starting in early 60s, social sciences, sciences, arts, social norms, etc 

    • We're still in this shift in many ways 

  • In the world of psych (late 60s to early 90) shift from biomedical, seen as too reductionist 

    • Think ppl are more complex in terms of what causes issues, must be ways to treat ppl beyond medication and electroshock therapy 

    • Heavy swing over to everything being abt social constructions, impact of culture, social expectations, what you learn from your fav 

    • Psychological and social based theories 

    • Shift back/correction back towards biomedical approach 

      • Started in the 70s with valium, but particularly with prozac 

      • Despite all these therapies/psychosocial approaches, ppl were still struggling with depression, then this med came out that was effective  

    • Made us say we're overcorrected and underestimated the power of biology in the cause and treatment of mental health disorders 

• With computing happening and advances in how much power we had to study and look at things, research exploded in being able to understand what was happening in the brain 

• Even if not within our scope, understanding that maybe some aspects of their mental health issues are biological and predetermined can reduce stigma and shame 

• Two main reasons to be aware of biolgoical factors 

  • So you know and can talk to other professionals, understand their lenses and be open to it (have some context) 

  • Can share the basic versions cause it can help clients feel some sense of relief 

The biomedical model

• Was the prevailing viewpoint among the entire range of mental health professionals up till the early 50s (still the predominant model) 

• Asserts that abnormal thoughts and behaviours result from faulty biochemical processes in the brain 

• We identify or categorized smt by symptoms 

  • Ex. If someone has pain in arm, and upon further examination we observe a fracture, person says they fell off bike, doctor can safely diagnose person with a broken art 

  • Very methodical process 

• Tx tied to the diagnosis and the determination 

  • Ex. Broken arm – would set it 

  • But if osteoporosis - would set it and there'd be some sort of meds they would suggest to treat it  

• Used in mental health 

  • Figure out based on the set of symptoms what kind of diagnosis the person has using DSM 

  • Then we try to determine the cause 

    • Ex. If everything in their life is going okay, and they're experiencing depression, that's different from someone's spouse just having passed away and they seem depressed 

      • Depending on the cause, that effects the tx  

  • Symptoms of depression are also regular symptoms in regular life, those can be caused by a number of contexts and physical things that have nothing to do with mental health 

    • Every culture defines what's the normal range of the spectrum differently  

    • Even when you are depressed you might have days when you aren't  

      • Behaves very differently from most medical disorders that tend to be consistently  

  • Many mental health symptoms and behaviours are adaptive in the right contexts 

    • Don’t wanna eradicate them, wanna move them down the spectrum where they aren't maladaptive or disruptive  

Neurochemistry

• This model asserts that much of our mood and behaviour is influenced by the presence or absence of specific neurotransmitters in the brain  

• Tx arising from this model are primarily pharmacological  

  • bc the medicines given are there to boost or reduce certain levels of neurotransmitters, or act at the receptor level by blocking certain levels 

• This model is oversimplified (issue) 

  • and makes it seem like all mood is abt neurotransmitter and every neurotransmitter has one function  

  • Most mental health and addiction issues are based on multiple transmitters and other factors  

  • Part of the marketing for prozac 

    • Came from marketers oversimplifying complex concepts to oversell meds  

• Neurotransmitter levels are imapcted by non bilgoical factors 

  • If a certain neurotransmitter is low or high, what you do or what's happening in your social level or eat will affect levels of neurotransmitters and activities in synapses  

• Tendency to think that the only way to change neurotransmitter activity is through a medication but that’s not true  

• Main theory you hear is the catecholamine hypothesis  

  • The catechalomines (CA), norepinephrine (NE) and dopamine (DA), and serotonin in the right balance are what maintain mood in the normal range between the extremes of mania and depression  

  • Reduces mental health to – underactive norepinephrine or serotonin pathways = more likely to be somewhere on the depression spectrum 

  • Overactive dopamine pathways = more likely to have manic or psychotic symptoms 

  • Recreational drugs can affect these neurotransmitters bc they mimic them  

Neuro-plasticity

• Research started to come to head in the early 2000s indicating that the brain has a much greater ability to heal, change and grow than was previously thought 

• Old theory used to be that brain cells start to die off starting from the age of 30 or smt 

  • Starts to shrink and slowly die off 

  • Once you lose something its gone 

• Through research – brain cells start to prune themselves, but brain plasticity – brain's ability to change its function in response to changes in the environment or brain itself 

  • Doesn’t grow new parts or replace cells but able to grow new pathways 

    • Communication network (brain) 

    • Can through practice or learning or automatic brain will find a new pathway to that same function through natural ? 

• The brain that changes itself – book that brought this into the public  

• How this affects mental health 

  • Neuroplasticity is often used as a scientifically based rationale for using behaviour change as a way to change our neurobiology  

    • If we put ourselves into dif environments (foods we eat and sleep, how much stress and support we have) and behave in dif ways, our brain starts to require itself and recalibrate pathways 

      • Can create positive changes in mood and behaviour and habits of thought through practice and putting ourselves in different environments 

  • Argument for the psycho-social art of the bio-psycho-special model 

  • As we start to behave in new ways, behaviours that used to take effort can start to act automatically  

Genetics/Epi-Genetics

• Vulnerability to mental health issues and addictions is heritable 

  • Both in general (vulnerability to mood swings or temperament) but also for specific diagnosis (I.e. bipolar and addiction) 

• Heritability is very complex, not a specific gene 

  • Mental health is multiple genes working together to create the susceptibility 

• Epigenetics is another important factor 

  • Refers to the fact that the environment in which a person lives or exposed to is a key factor influencing whether the gene expresses itself 

    • When it comes to mental health and addictions, genetics predetermine our susceptibility to developing a mental health issue or addiction 

      • Very inherited 

    • Can come into this world genetically with a high susceptibility to developing specific mental health or addiction disorders 

      • However the environment that you live in can turn on or turn off the influence of these genes 

        • Could pass on to your children and not know you have that susceptibility  

  • Environment refers to the outside world (life, stress levels, trauma, etc) and the inner biological world (what happens in utero, diet, environment (toxins in the air)) 

• Told that our best understanding is that genetics play a key role in predetermining our vulnerability or susceptibility to mental health issues but lifestyle and life events (aren't predetermined) have a significant impact on how likely mental health issues are to be expressed 

  • Life events – can influence the things that happen in our life, luck is also a factor  

  • Good/fortune, life events and behaviours can make a genetically predisposed person less likely to experience mental health issues 

  • Poor/unfortunate life events and behaviorus can make a person with low genetic pre-disposition more likely to experience mental health issues 

Hormones

• Another biological factor that significantly influences our mental function and behavioiur 

  • Hormones can be thought as controls on a music sound system like those controlling volume or tone  

• Can spread up, slow down, intensify or diminish our emotional responses, the way we make choices, etc  

• Influenced by genes or natural processes like puberty and menstruation  

  • Can be impacted by illness or chronic stress 

Bio-psycho-social model

• Refers to not taking just a biological/medical approach to mental health  

• Social facets of mental health were the second last  

• Idea of plus (spiritual, etc) were last to be added 

• Neurochemistry is a big one 

  • Serotonin, dopamine 

• Effects of meds can create psychiatric symptoms  

• Psych  

  • Ability to learn, etc can impact behaviour and mental health  

  • Personality factors can have an impact 

  • What behaviours are reinforced, how you behave, are we impulsive, etc 

• They all over lap (bio, psych, social)  

• This approach is seen as superior to just bio-medical bc: 

  • More holistic/considered more factors/less reductionistic 

  • Less stigma, more empowering  

  • Makes more room for diverse perspectives particularly regarding causal factors and routes to wellness 

    • Important to take into account context 

    • One person with anxiety will differ from another person dealing with anxiety in terms of the cause 

  • Allows a broader range of professionals to work in mental health  

    • In the past, if you were working with mental health you had to have extensive medical training 

• Now that it's been the dominant model, most critiques centre around the idea that recent advances in genetics and brain research suggest that biology is a much stronger factor than the BioPsychoSocial models 

  • May have been underestimating the power of genetics and biology in mental health  

  • e.g. struggling with rumination - Not just a psychological habit, may be smt going on with your serotonin that's causing symptoms 

• A lot of overlap between categories, not as distinct 

• Psychosocial factors are often based on subjective theories and biases 

  • Seen as unscientific/not 100% confident in treatments 

  • Somewhat subjective 

• Too broad 

  • Some argue that the Biopsychosocial + says the cause of mental health issues is everything 

• No specific unifying model of tx arises from it  

  • Focuses more on causes than solutions 

Social factors and mental health

• Family and social factors are viewed as separate in psych 

• Cultural factors are in the plus part of bio-psycho-social plus 

  • Dif factors from social  

• Micro-social  

  • Absence or presence of family/social networks 

    • Isolation and marginalization or boredom can have a negative impact on mental health 

  • Conneciton to cultural or religious communities 

  • Level of social involvement (+ relation to mental health or addictions) 

    • The more you're out spending time with ppl  

  • Social resources 

    • I.e. education, etc 

  • Influence of friends/social norms/peer pressure  

    • What are the behaviours that they normalize or pressure you into doing, are those harmful or helpful 

  • Social norms within cultural or sub-culture (or media sub culture) 

    • Those social norms will impact what you do and how you think 

    • Can be protective or harmful  

  • Family (its own category)  

• Counsellros/therapists and case managers are most likely to focus on micro social factors/proximal factors 

  • They have access to being able to change it, can suggest alternatives, the broader societal things are good to acknowledge them, but are bigger and slower to change  

• Macro-social 

  • More abt population mental health  

  • Things like economics, how much money you make (U shaped curve) 

  • 12 key social determinants of health relevant to most Canadians developed by Raphael (2008) (what are the factors within your society, things you as an ind don’t have much control over and has an impact on you) 

    • Income and its distribution 

    • Access to housing 

    • Access to education 

    • Early life living conditions 

      • Stresses of fam struggling with meeting basic life needs 

    • Gender* 

      • How you get treated and how the culture teaches you to feel about your self 

    • Employment and working conditions 

    • Unemployment and employment security 

    • Aboriginal status* 

      • Depends on if you feel like you're a part of a culture that displaced your original culture  

    • Social equity* 

    • Social safety net  

    • Food security 

    • Health care services  

    • * Depends on the culture and how they react 

• Social determinants of mental health impact both individuals and entire populations or communities  

• Most research studies suggest that social determinants of health have a greater impact on heath than behavioural risk factors for most inds 

  • Most psychotherapies focus on ind behaviour change – not social change 

• Most factors within the list of social determinants are correlated with one another and interact with/influence one another (I.e. income impacts housing, food security) 

• It has been found that the more inequity (material and social) in a pop or society, the more mental health and addictions issues will tend to arise 

  • Security/insecurity has a significant impact on mental health 

  • Inequity can create extreme insecurity for any  

  • Sense of agency/helplessness has a huge impact on mental health  

  • Health security and education ion early childhood/youth has a major impact on mental health – inequity can create lack of access to these things for many  

    • Feelings of security in those early yrs can set a norm in your body  

• Relative wealth has more impact on mental health than absolute wealth once basic income allowing access to housing community, health services, social role and education has been met 

Before social ecological models of mental health treatment

• Early approaches to mental health and addictions focused on models of mental health tx which focused on treating the ind with the mental health issue 

  • Includes individual and group tx 

  • Not taking into account any broader social factors  

• These models also work on the assumption that the ind is the primary locus of change 

  • Problems primarily arise within the ind's mind/body/spirit and solutions are primarily generated from the same place  

• The new social-ecological models arose from social-work perspectives/family systems (systemic ways of thinking abt MH and addictions) 

• MH problems and solutions are viewed as arising from various points within the ind's ecological system  

  • Broad and complex sort of idea 

  • Looks at sources of mental health issues more broadly and in a complex way 

• These tx models, focus on BOTH the ind and changing ways of thinking, person centered counselling AND focus on helping the person navigate systems 

  • Case managers - help ppl find housing, might give resume help, write a letter to help them access some sort of system  

  • Wlll help them with their MH as much or more as providing counselling, etc  

The recovery model

• Most of the mental health services in our province are built around the recovery model  

  • CMHA + John Howard – use this recovery model  

• Developed as an alternative to a purely medical/biological model 

• More aligned with social-ecological apporaches to MH tx 

• Very much a social ecological approach  

• This model focuses on living a satisfying, hopeful and contributing life, even when the person may be experiencing ongoing symptoms of metal health and/or addiction problem or illness 

• Recovery model focuses not on changing the presence or absence of changing symptoms of a MH and/addiction problem or illness 

• Dual continuum from last week 

  • How can we help increase their wellness, what can we do within the context of their life to make them better despite the fact that they may be living with a mental health problem  

• The model has been supported and championed by many in the survivor/consumer movement and is built on the core concept of hope, dignity, self-determination, and responsibility  

  • Lots of stuff abt empowering ppl where they're at  

• The recovery model is based on the dual continuum model 

  • More attention is paid to mental well-being  

  • Move ppl up the mental wellness scale (?) 

  • Harm reduction is a form of recovery oriented tx 

    • Meeting them were they're at  

    • Often doing case management 

    • Looking for ways to enhance wellness despite continued additive behaviour 

Recovery oriented practice

• Defined as an approach to mental health care which encompasses principles of self-determination and personalized care 

• Emphasizes hope, social inclusion, community participation, personal goal setting and self-management 

• Lit on this practice promotes a coaching or partnership relationship between ppl accessing MH services an MH professionals, whereby ppl with lived experience are considered experts on their lives and experiences while MH professionals are considered experts on the available tx services  

  • Our job/expertise is abt helping ppl navigate services  

Social ecological models of mental health tx

• 1) Policy 

  • These models like to start with trying to change governments and larger policy (provincial or federal gov)  

    • Would be things like ways you can focus on changing policy to improve MH  

      • Creating financial incentives for there to be better MH services and support 

      • developing better systems for measuring/tracking helpful and non-helpful MH interventions, etc 

      • Advocate for mental health funding 

      • Create long-term system goals/plans 

  • Social ecological approaches take a public health perspective  

• 2) Community 

  • Try to intervene at the community level (municipal politics, creation of agencies that don’t exist, etc) 

  • Moving out into the community to create campaigns or education to reduce stigma or crate more inclusive spaces 

  • Creating new community agencies and services for MH clients 

  • Talking to the press, having community events to raise awareness about MH and addictions to reduce stigma 

• 3) Organizational/institutional 

  • Interventions at this level occur within existing organizations and institutions to change the culture of MH within them 

    • Trying to have MH services embedded in places they're not normally offered  

      • e.g. MH services in a jail  

    • Intra-organizational campaigns/education to reduce stigma/create more inclusive spaces 

    • Changing institutional policies and proceedures to reduce barriers for those with MH issues 

      • e.g. trying to not have ppl feel guilty, ashamed, or scared to ask for sick time for MH issues 

• 4) Interpersonal/family 

  • These models started was, a lot of ppl that did that started as fam clinicians 

    • Often what helps make it easier for an ind living with MH is to work with the fam to make changes 

  •  Interventions at this level focuses on: 

    • Psycho-education that provide education for fam members ot help increase understanding of what they're going through  

    • Psycho-education for fam members to help increase skills in supporting loved ones with MH issues 

    • Support/respite services for fam members 

    • Case management and system navigation services for fam members 

    • Fam counselling services 

• 5) Individual 

  • Ppl who take a sociol ecological view try to not have all the pressure for change on the ind, but focus to shift some of that pressure for change to the systems around that ind 

    • Heart of all socio-ecological models around MH tx 

Recovery oriented practice (6 defining features)

• 1) Creating a culture of language and hope 

  • About the importance of not focusing on what are your symptoms or diagnoses 

  • Much more concerned with what is still possible while you're living with this diagnosis, or continuing to use addictive substances 

  • Truong to create a culture within your clinical room, agency, and ideally your community that is hopeful and inclusive for those living with MH and addictions 

• 2) Recovery is personal 

  • Idea that there's a unique approach to recovery for each ind rather than a one size fits all  

  • Tries to individualize the approach to helping improve the quality fo life  

    • Idea isn't abt treating the client/curing, it's abt moving them up that vertical axis of quality of life  

  • Always focusing on a holistic approach, that treats dif aspects of the ind's life and dif parts of their system, and is focused on the strengths they already possess 

• 3) Recovery occurs in the context of one's life 

  • Idea of the system piece 

  • Most of a person's recovery journey occurs outside of the MH system,  

  • Importance of integrating family, peers, and community into tx 

    • Should be trying to create pressure to change within fam, the community, the peers to take all the pressure off the ind and spread it out 

    • Can do this through advocacy work 

  • Includes importance of addressing stigma and taking down barriers so that there more access to services and spaces in our community that will allow our client to have an increased quality of life  

• 4) Responding to the diverse needs of everyone living in Canada 

  • Important that this practice acknowledges the experiences of ppl from diverse backgrounds and identities  

    • Offering tx and services that meet the needs of diverse cultural backgrounds, gender identities/sexual orientations and developmental stage 

  • Looking for marginalized populations who often don’t make it into the mainstream system, and create inclusive spaces so they have some place to fit in  

• 5) Working with first nations, Inuit and Metis 

  • About reconciliation work  

  • Reduce those barriers and create more inclusive spaces 

  • Further allow this pop's cultural norms to shape our systems and become more mainstream 

• 6) Recovery is about transforming services and systems 

  • Reducing barriers to services, trying to help marginalized populations to have more access 

  • Transforming services to increase quality of life 

  • Refers to integrating recovery-prompting service partnerships with other systems and organizations 

Psychiatric system survivor/consumer advocacy: a critical literature review

• Survivor consumer movement can also be referred to as consumer/survivor x patient movement 

• Main def – survivor consumers csx clients are ppl who have been or were in the past in direct contact with the psychiatric institutions or mental health system as a pt, client or consumer (of services) 

  • Someone with lived experience of MH and lived experience in having their MH addressed through the formal MH system 

• These movements focus on self-advocacy (for themselves or whatever pop they align with, e.g. mad pride Toronto) 

• Run a lot of peer support services, provide resources for self-help  

• Much of the politics of these movements is to encourage ppl to rely on themselves and each other more than trust/depend on just formal MH systems to help them  

• Social and political movements 

• Trying to help the broader society and MH system realize the subtle ways in which they've marginalized those living with MH 

  • Trying to raise consciousness and change ppl's awareness of what it means to live with MH 

• Wanting the voices of those who consume the services to be what guides services as opposed to always having experts who may not have the levied experience, always making the most important decision abt the system at large  

• History of the movement 

  • Historical records of similar movements as far back to 1845 

  • Current versino fo this movement started in thr 60s due to 

    • Discontent abt the ineffectiveness of psychiatry  

    • Closure of big mental health institutions, period of heavy medicalization of MH issues 

    • De-institutionalization movement – which re-located many CSZ clients in the community as major hospitals were shut down 

    • A general rise in political and social movements by marginalized populations in the 60s 

  • Movement gained momentum again in the 80s and 90s but has slowed again 

    • Part of slowing is that they've done a good job and there's been a real shift in the public awareness of what MH is and isnt, decreasing of stigma, integration of voices of those with MH into services 

Peer support workers

• One of the ways the Recovery Model is attempting to transform systems and services is to include ppl with lived experience to work alongside those trained in educational settings 

• Peer support worker 

  • An ind who has experience living with a MI who acts as a recovery guide  

  • They share knowledge and experiences – something that a counsellor or medical professional who doesn’t share these experiences may not be able to do  

• Our role as the trained worker would be to work alongside peer support workers and/or to create/manage services run by peer support workers 

Solution-focused approaches

• Defining characteristics 

  • Many of the brief psychotherapies focus on the importance of language/choice of words in the therapy process 

    • When we talked abt those 6 key characteristics of recovery oriented practices, the choice of words and using empowering language was one of the 6 key characteristics 

  • When it comes to language, therapists are encouraged to focus attention on strengths and resources in the present as well as possibilities and hopes for the future 

    • The ppl who develoepd solution focused approaches are part of a type of approach to coiusnelling called constructivist 

      • Constructivists approach think its improtant how we talk abt thigns has a huge impact on our emotions and behaviours 

        • Not just the exact words, but what we notice and what we pay attention to in the stories we tell 

      • Certain areas are essential to focus on in helping ppl answer questions 

      • Areas they focus on: 

        • What are strengths/what's going well instead of what do you wanna fix, what's going wrong 

          • Theory – will make ppl more aware abt what they have, their resources, what they do well, will actually create their own solutions and won't need guidance on us 

        • Asking questions that prompt ppl to focus on strengths, asking questions like what's working or what has worked in the past 

          • Asking questions that pull out strengths and solution focused language from the person we're working with  

          • Don't spend as much time reflecting or paraphrasing problems 

        • Asking what was better or what went better this week 

          • Will pull out strengths and achievements 

        • Asking if our sessions go well, how will you know that things are better 

        • Asking abt small steps you can take now to focus on solutions which are possible in the present + focus on small change instead of large change  

  • Brief therapies aren't based on doing things quickly, but built on the idea that significant changes can be brought about relatively quickly given the right type of client, problem, and use of effective techniques 

Generic components of all brief psychotherapies

• 1) relationship is important 

  • Important you're working together  

  • We're an expert in teaching them to access their own problem solving capabilities  

    • Actual solutions, we need them to come up with them, need them to break them out of the trance and ask them the right questions to make them aware of their strengths and solutions 

• 2) Focality (there's a focus) the clear specification of achievable tx results an goals 

• 3) clear definition with a relatively high level of therapist activity and pt participation 

  • Therapist activity 

    • Good questions and questions that break the trance 

  • Pt participation  

    • Providing the solutions, responding correctly to what we're saying  

• 4) ask questions that help clients focus on their strengths and how they can adapt 

• 5) we believe that faith is within the client's grasp 

• 6) here and now and next 

  • Focus is not on digging up the past or why you got into this situation/what happened in childhood 

  • Focused on how you're thinking and talking abt things rn and what we can do next 

• 7) time sensitivity 

  • The idea is making the most of each session  

  • We can solve bigger problems by solving smaller problems one at a time 

  • Research abt this psychotherapy was focused on asking clients what they thought helped in session and what therapists were doing (who got good results)  

    • Noticed that as such as therapists like the idea of working with clients for a long time, the average amount of sessions that clients attend is 5-6 (effective sessions!) 

    • What's a way that's the most effective way to use 5-6 sessions? 

    • Argument in developing this model – we need to find a way to be as effective as possible with a limited number of sessions bc that's how the average person uses counselling as opposed to psychotherapy 

Concept of psychological health and pathology

• Brief therpaies arent ocnscerned with diagnosis or pathology, they're focused on what is the problem 

  • Focus is not on the person as a problem, but they frame the problem as the problem  

• The pathology is seen as external to that client and the solution is seen from coming from the client  

  • Client is the source of the solution, problem is happening outside of them that they need to try to solve with direction and guidance from the therapist  

• Becoming healthy is not the goal of brief psychotherapies 

  • The goal is to solve an external rpobelm using the inner and external resources which one has available to them  

Therapeutic stance

• In rbeif therapy, our role is 

  • 1) make the problem seem solvable 

    • Void epxloring deep roots, not uncovering truama, not analyzing way the problme happened 

    • Our job is to help pull from the client, concrete reachable goals so they know what they're doing in between sessions 

  • 2) help the client to become more aware of the solutions they have 

    • Guiding the clients through questions ot help them become aware of solutions they already posess 

    • What worked this week to make it a 2/10 instead of 1/10 

    • What are your strengths 

    • How are you coping? 

    • NOT suggesting solutions to th client  

  • 3) help the client to get a sense of direction moving forward 

    • Includes encouragement/helps them develop self-efficacy 

Historical background (Person-centred psychotherapy)

• Developed by Carl Rogers 

• Also called Rogerian therapy 

• Developed in the 40's 50's 

• Differed from other approaches bc of its focus on growth and self-actualization 

  • Most therapies during that time were abt symptom reduction  

  • He realized ppl can still beenfit from therpay even if they don’t have a significant mental health issue  

  • Paved the way for most of the counselling we see in this day and age 

  • Counselling to help you self-actualize 

• Some of his influences to develop this model 

  • Very concrete and believed in scientific method (trial and error) 

  • Originally studied agriculture and theology (and the idea of higher power) 

  • At the time Abraham Maslow was very influential  

    • His ideas of self-actualization/the spiritual or hgiher self 

  • Thought that one of the most powerful thigns abt being a human was to live in a way that aligns with your porpuipse 

  • Was doing psychodynamic work, working in community mental ehalht settings 

    • Realize not everyone wants psychiatry  

    • Some ppl aren't mentally ill, but smt abt my life isn't right  

• Maslow's hierarchy of needs 

  • Very much so influenced by Maslow's hierarchy of needs 

  • Talks abt the idea that as humans we have all these dif needs 

  • The higher up the hierarchy we go, the closer we are reaching up towards self-actualization  

    • Real privilege to achieve the top 

  • You need the bottom level before you can move up  

  • Recovery model says we can't do the therapy up at the top, when we don't have the lower aprt 

    • This model focuses on the foundation (I.e. food, security, physiological needs, etc) 

    • Can't skip a step  

Psychological health and pathology (PCT)

• They don't subscribe to diagnostic categories 

• A lot of rogers is focused on self-actualization  

• It’s a solution focused approach assuming that the client has a lot of solutions and room to grow, just need to remove exterior and interior barriers 

• He assumed that most psychological problems that most ppl have (aside from neurological disorders) are related to no longer learning and evolving 

  • Stuck and stopped – might manifest as depression, whereas for someone else it might manifest as addiction, anxiety, marital issues, etc  

  • He says it doesn’t matter what disorder it manifests as, we're focused on the stuckness 

• Big on what is it that you feel called to do in your life, to be, and whats getting in the way of that  

• When ppl come in for therapy, the stuckness is being incongruence 

  • Incongruence 

    • The way you present to the world is called self-concept (not good in rogers theory) 

      • A bit of a false self/persona, how I think I should be in order to fit into the world  

      • The need to love and belong and need to self-actualize clash with each other  

      • I'm living my life in a way that's not aligned with who I am right now 

      • Pathology comes from beign incongruent 

      • If im lviing a life that's not aligned in who I am and how I want to live, it's gonna produce incongruence 

• Need more overlap 

  • Congruence 

    • How I currently present myself is very close to or consistent with ideal or true self  

    • The more confruent we become, the more full functioning we become 

Incongruence

• Rogers felt that its part of us growing/a painful part of growing 

• I don’t feel like my full self I wanna do this, I do all this work and build my life around this, and then what was a congruent life, is no longer congruent 

  • I'm gonna have to leave some things behind that gave me comfort 

  • It's a real dilemma and difficult to take that risk 

  • Usually the things that keep us from making those changes are grieving, fear of judgement, etc 

  • He said this is a normal part of the human process, not a mental health issue 

• We're growing till the day we die, when we stop growing that might be the mental health issues 

• It’s a common part of the development process to feel incongruent at times 

• Incongruence is seen as a challenge to be met in order to grow 

  • To either develop one's self-concept to better adapt to the situation or to change one's path in order to feel more congruent 

  • Maybe its time for you to go to different places where the version of you is more accepted  

Dysfunction

• If a person stay stuck in incongruence then some kind of pathology will develop (he defined this as dysfunctional) 

• Dysfunction 

  • Defined by being rigid or static in one's ways of thinking, behaving and/or feeling or by an unfeeling, impersonal experience of the world 

    • months or years of going through the motion  

• This idea of being stuck is a big part of what Rogers was working on  

Full functioning

• Psychological health is defined by rogers as full functioning 

• Wanna move ppl towards full functioning 

  • Being open to change, having a broad range of emotions and behaviours and easy aces to feelings and intuition 

    • It's not about being happy all the time (might be I'm afraid to feel angry and sad) 

    • Not a clinical disorder of being always positive/happy  

  • Some mix of resilience and full scope of emotional expression  

    • Even though some of those emotions might be anger, sadness, fear 

    • Not stuck in one way of feeling or not feeling at all 

    • Able to take risks 

• Doesn’t necessarily mean that one is content or happy 

• But they're in touch with and trusting of their feelings, reactions, and intuitions 

• Have some access and trust their own feelings and intuitions 

• Big criticism that this idea is that it has a strong western bias 

  • Bc its very individualistic, self-centered 

  • Its saying ignore your elders and culture 

  • Distinctly western cultural bias  

  • Takes away all other voices except my own 

Key concepts of PCT

• Incongruence and congruence

  • When the self ocncept is too far apart form the ideal self, this is the theory of pathology 

    • Might be anxiety, depression, addictions, 

    • When you're living a life that's not congruent smt is gonna come up 

  • Rogers doesn’t care what you call it (the pathology), we're looking for for what the root of the problem is  

  • Sees our job to help the client move to confruence 

  • Might be changing the aspects of how you present in the world 

  • Might invovle changing the world so youre around ppl where its not much work to be whoyou truly are 

  • Someitmes its abt your true self coming out  

• Self concept

  • Usually in psych, when we have self – it’s a good thing 

  • But this one is the version of yourself you need to be to fit in 

  • A bit of a false/constructed self 

  • The person's current personality as they've contracted it in real time  

  • Not seen as pathological to have a self that you shape to your envrionment 

    • But its human nature for your personality to evolve and grow 

  • Becomes a problem when the self concept is too far from your ideal self  

• Agency 

  • Part of our job is to help ppl become aware of their ideal self/true self and maybe how they're not living it or unable ot rpesent it or don’t have access to oit 

  • Other improtant pat is to help ppl develop a sense of agency 

  • Same as self-efficacy (=agency) 

  • Want clients to develop a sense that they can meet chalelnges and become more congruent, can take the steps, and it will pay off  

    • Be open to challenge  

    • Importance of developing self-efficacy and belief in things and accepting that it'll be hard (concept that occurs across dif psychological apporahces) 

      • Element of good therpay 

      • Seems to be one of the most useful things ppl take from therapy and lasted beyond when they stopped therapy  

  • Helping the clients vuild a sense of self acceptance/unconditionally accepting who they are AND a sense of agency 

The therapeutic relationship (PCT)

• This therpay thinks that one of the most improtant therapeutic elements is the relationship 

• Not too heavy on these are the skills you need to teach 

• Essential foudnatino for good therpay is being a good therpaists who's: 

  • Has unconciditonal positive reagrd 

    • Someone who is warm and accepts others for exactly who they are  

  • Is empathetic and understanding  

  • Seems genuine and congruent themselves 

    • Sometimes genuineness means being honest with someone (saying I'm not sure, might be risky) 

• Therapist tries as best as they can to understand the client's feeling and motives and to be accepting of them  

  • A lot of it is reflecting back in an unconditional way and have to be doing it in a non judgeemntal way 

  • An important distinction – as in parenting – is to accept/like/prize the person – but not necessarily like or prize certain behaviour that person engages in 

• It is strongly asserted that if the client doesn't feel accepted by the therapist, they will not feel safe to explore and grow in therapy 

  • It's essential that the therapist is able to create a warm, safe, and accepting envrionment for the client 

• Therapists are directive, not tellign them what to do, not analyzing, just reflecting back 

• Sometimes just reflecting back to the client, they'll start to figure things back  

  • When you're refelcting its not willy nilly 

  • Being strategic, listening and refelcting bc its imrpotant that they hear smt back, they may have skipped over smt improtant (perhaps a feeling) 

  • Soemtimes you refelct back casue you think they might wanna correct me 

  • Very much I'm refelcting smt so you hear it and feel what you say instead of thinking past it, or prompting to think more, or suspect you might be corrected and they will realize that doesn’t make sense 

• Clients can start to feel thigns without using some special technique  

• Part of what we want clients to feel is that they figured out smt abt themselves, not us  

• Hardcore Rogeran therapists won't give advice, less common now 

  • There are times where they'll give expert advice  

The practice of counselling

• Esp in particualr Rogers thinks its improtant to constantly be refelcting on theories 

  • How does that make you feel is from this perspective 

  • Saying "I get the sense youmight be feelings this, or I get the sense that you might be" 

• Includes increasing awareness of one's feeligns and develoing more trust in one's feelings 

  • Emotions but also gut feeling 

  • Smt feelign off is not a standard emotion, but also that idea  

  • Migth not say a feelign, but it could be the tone of voice 

    • I get the sense/impression that this is difficult for you to answer 

  • Very much  "I'm not tellign you this is hwo you feel" I'm picking it up  

• 
  No set prescription for how oftne or hwo logn clients attend therpay 

  • Common practice is once a week 

• Goals for therapy are set by the client 

  • Client is asked to set some set of goals 

• Person centred and experiential therpaists believe that it’s the client who, at some level knows 

  • Big thing in theray is to help clients admit feelings (I.e. what they want or don't want, etc) 

  • Admiting that that feelign is swirling around in there 

• Core philos is tha thte clients heal themselves, but speed it up thorugh refelction  

• Primary role is for us to create optimal concditions for change 

  • Ask right questions, refelct the right things, create a space for them to admit things that are difficult or that they cant say around others, say things that may be taboo 

Historical background (Behaviour Therapies)

• Started around the 50s and 60s 

• A lot of human behaviour isn't just what happens in the first 5 years, a lot of our behaviorus are shaped by reward and punishment schedules,  

• applied learning theory 

  • Classical conditioning 

  • Operant conditioning 

  • Don’t always have dee 

• Can learn new ways of thinking and feeling or dysfunctional ones much later in life  

• You can teach ppl dif ways of behaving, how to express feelings, can make changes without insight 

• Feelings, intuition, not scientific 

  • Too fluffy for us, idea of unconscious motives and idea of what does your gut issue tell you 

3 primary characteristics of behavioural approaches

• 
  Work a lot with the environment, what in the environment is triggering us, what is helping the problem behaviour from happening 

  • Focusing a lot on environment, moved away from what happened during your childhood, etc 

  • What's happening in the here and now and is shaping your behvaiours and thoughts 

  • Important word – immediate! Here and now 

• Therapist is directive 

  • Okay here's the skills I think you need, you should start doing this, be around these ppl 

• Rooted in empirical research 

  • Study, let's see if this works, gets results, let's see if behaviours and moods changed 

  • Measuring are the things we're trying to do, making a change in the person's life  

Behaviour therapies: Context

• Range of behvaioural techniques used in other forms of psychotherapy 

  • Not just in traditional beahviour therapy 

  • e.g. exposure therapy 

  • Relaxation training 

  • Social skills training 

  • Mindfulness based strategies 

  • Emotion regulation based strategies 

  • Biofeedback etc 

Psychological health and pathology (Bhevaioural Therapies)

• Traditional behaviour therapists emphasize 

  • Role of previous learning (recent past) in current thoughts, emotions and behaviours 

    • Not back in childhood, it's what experiences you have that make you anxious in this situation, why is this a trigger, how have you learned to associate this with threat, helplessness 

    • Not just early life might be v recent 

  • Looking at the context, who you're around, situational factors is v important 

• Operant conditioning 

  • Patterns of reinforcement and punishment have an impact 

    • Becoming anxious – how does that harm you, but does It play a bit of a function for you, does it get reinforced? 

    • If I'm socially anxious and I don’t go it, it is rewarding bc I don’t have a negative interaction, there is smt rewarding in that avoidance that prevents me from having a painful experience 

    • Part of understanding what supports part of avoiding, how is it also punishing? Trying to get the client look at it that way as well 

• Takes into account social learning 

  • What do we see as a social norm 

  • Notes the impact of observational learning – or modelling on our behaviour  

• Focused on someone comes in, says they have problem, break that problem down into a ton of behaviours  

• Say someone is socially avoidant  

  • How is that adaptive and rewarding and how is it maladaptive 

  • How often does it happen? 

  • Hopeful assumption – can change some of the maladaptive behaviorus and create other... 

  • Analyzing maladaptive behaviour, figuring out that are the negative consequences that make it maladaptive and what's supporting it 

  • Wanna decrease maladaptive behaviorus and increase adaptive behaviours 

The therapeutic relationship (Behavioural therapies)

• Relationships are important, but they're seen as slightly less important in this type of therapy than in other apporahces  

• The therapist is more directive - Much more of a teacher/coach - than in other approaches 

  • The therapist will have an agenda for what they want to cover in sessinos 

  • They may spend some time listneing to the client and/or collaborating on material but the therapist decides most of the focus of the session 

Traditional Behavioural Therapy: Pathology/problems

• The essence of this approach and looking at what the problems are, the assumption is that the thoughts, emotions, and behaviorus are  

  • 1) Learned approaches 

    • We've mimicked how to do things, but in particular when talking abt learning from a behavioural perspective, focusing on what has been reinforce by the environment 

      • Often its helped us to get a reward or we were shape to behave a certain way or expression of feelings in a certain way gets us things, or thinking in certain ways may have been adaptive 

      • What was reinforcing or adaptive in one setting, suddenly isn't adaptive in another setting 

        • How we've behaved in the past may not work anymore 

    • Thinks of humans have been shaped by our environment, most of the way we think, behave and feel are shaped and created by our environment and reinforcers/punishers around us 

      • Sees us more closer to animals in the way we think, behave, as opposed to spiritual beings (Rogerian approach) 

  • 2) Thoughts, emotions and behaviours are therefore thought to be triggered by certain situations 

    • Looking at what is the situation and how is it impacting how you're behaving 

    • looking at changing your response to certain triggers and trying to go into situations more often where you are not going to be triggered 

  • 3) Behaviours serve some sort of function 

    • We think and behave (the way we do or don’t express our emotions) has a purpose 

      • We're trying to get smt we want or we're doing smt that used to get us what we want 

    • Once we've been shaped to a certain behaviour/function, it's hard for us to change that even when we're in a new environment where it's not happening anymore 

Tx/solutions in Traditional Behavioural Therapy

• 1) Encourage a client to enter new contexts 

  • If you're avoiding things, try to not avoid them and exposure yourself to adaptive environment 

    • e.g. if socially anxious, often there'll be an encouragement to talk in certain environments where they think it'll be a beneficial thing 

  • Being aware of the ppl, places, things you're around 

  • Trying to encourage ppl to engage rather than avoid 

  • OR for other clients we need ot encourage them to avoid ppl, places, things creating maladaptive thoughts and behaviours and be mindful abt the situations they put themselves in 

• 2) Teaching 

  • You as the counsellor or therapist is the expert when teaching wellness skills, self-care skills, psychoeducation or talking abt coping strategies, self-talk as a cognitive behaviour 

  • Counsellors role is to provide expert info and to teach new strategies and new ways of understanding  

  • Might ask what coping strategies they've been using, but when focusing on strategies, coping, responding to triggers, this is a behavioral approach  

• 3) trying to get ppl to replace maladaptive behaviorus with more adaptive behaviours 

  • Figuring out the function of the behaviour 

The practice of therapy/common techniques (Behavioural therapies)

• Functional analysis

  • Definition: 

    • Analyzing what a seemingly maladaptive behaviour helps the client to achieve that is of value to them 

      • Rlly important piece 

    • What is the function of this behaviour? What do I get out of this or what am I trying to get out of this? 

    • Idea of figuring out what the function is, bc in behvaiourism, if we want this maladaptive behaviour to decrease or stop, we need to find a new adaptive behaviour that serves the same function  

      • e.g. If part of what you get from extensive social media use, is relaxation, social connection and healthy escape, might need to find replacement behaviours that are less maladaptive/more adaptive 

    • Type of insight we want our clients to build with us when taking a behavioural approach 

  • E.g. Gambling 

    • Wanna determine what the function of the behaviour is 

      • Analyze what is helps the client to achieve that is of value to them AND the context in which behaviours are likely to occur 

    • Part of what we need to figure out is that the person is spending. A lot of money and are losing money and yet they keep doing it 

      • Still smt reinforcing abt gambling even if they're losing money 

    • Function is the positive consequences that the person is getting 

      • In the case of gambling what are they getting? 

        • Could be a sense of excitement/dopamine rush, may be social and make them feel connected, when they win it might help them to feel important/like a winner, casinos work hard to make high earners feel special (feeling like a community/important/attached to that can be reinforcing) 

    • Changing that behaviour – need to figure out what the person is getting from this 

    • Behaviours are analytical 

      • Analyzing what happens right now while you're doing it that makes it a reinforcing behaviour for you  

      • ALSO analyzing if you didn’t do it, what wouldn’t you get? What would be the drawbacks 

Functional analysis: The A-B-C Model

• With any given behaviour, behavioural therpaists use the ABC model 

  • A – antecedents (what triggers the behaviours) 

    • Trigger/context

    • What creates the desire to e.g. gamble:? 

      • Emails/letters from the casino, ads/commercials, feeling lonely or bored 

    • What are the types of things that trigger their anxiety? 

      • e.g. needing to go somewhere where they feel like they might fail or be at threat 

  • B – Behaviour 

    • The thing we’re trying to change

    • The addictive behaviour or behaviour related to the mental health symptom

    • Related to addiction or mental health  

      • e.g. trying to change avoidance, with anxiety there's avoidant behaviours  

  • C - Consequences 

    • The negative consequences and positive results

    • What are both the rewards of gambling and the drawbacks? 

      • Loss of money, fatigue, etc 

    • e.g. positive consequences - don’t exposure yourself to the threat, don’t embarrass yourself 

      • Drawbacks – lose opportunities to grow and be engaged with life  

• This model is used to figure out ways we can change the context in order to decrease the maladaptive behaviour 

  • Wanna figure out context and consequences which can be used to increase new adaptive behaviours 

  • Often we need to figure out new adaptive behaviours that actually serve a similar function and gives similar reinforcers for that client  

The practice of therapy/common techniques (behavioural therapies)

• Exposure based strategies 

  • Commonly used for anxiety related disorders  

    • Ppl with depression often need exposure based strategies too 

    • Often have a fear of exposing themselves to certain situations (I.e. afraid of driving, social interactions, snakes, etc) 

    • Anxiety related disorders are often based in fear and how ppl address that fear is to avoid those situations  

  • These strategies are based on classical conditioning concepts 

    • e.g. What created the fear is the person has that first event where they said smt stupid and were laughed at 

    • Start to associate groups of ppl in the classroom with shame and ridicule, associate those situations with punishment, therefore you start to avoid those dif situations 

  • Often used for phobias, OCD, and PTSD 

    • Dif anxiety based disorders 

Categories of exposure based strategies

• Imaginal exposure 

  • Using guided imagery to get the client to image being exposure to the feared object, thought, memory or situation while using relaxation strategies 

    • Before having the client exposed to anxiety provoking situations, need to teach strategies for coping with physiological anxiety and from calming down 

    • Important to realize you need to pair relaxation strategies with exposure 

    • There's dif levels of exposure you can do, imaginal exposure is the safest ones 

    • e.g. First step is can you just picture a spider in your head or holding a spider and keeping your anxiety in check 

  • They need to picture a success not a calamity 

• In vivo exposure 

  • In vivo – means in real lie 

  • Exposing a client to a feared object in real life while using relaxation strategies  

  • Might go with looking at pictures or videos of spiders, until eventually you're able to be in the real life situation AND staying calm 

    • Very important to go slowly and that the person is able to stay relaxed and use whatever skills taught in the session to have a non-anxiety provoking exposure experience 

  • Mix of teaching new relaxation skills and exposure with an aim of having a successful experience 

    • Having exposure without being overwhelmed   

• Interospective exposure 

  • Exposing the client to feared internal sensations – often by triggering those sensations – while using relaxation strategies 

    • Based on the finding that ppl with anxiety (specifically panic) are afraid of anxiety overwhelming them 

    • Often what made them anxious was noticing cues in their body that made them anxious  

  • Doing things in your office that create the various symptom that the person reacts to but helping them to stay relaxed when it happens 

    • e.g. if the person says that they're triggered when they notice their heart is racing and starts panicking abt having a panic attack  

    • Might have them run on the spot and have their heart rate get really high, but sit down and feel the high heart rate and not have it escalate  

• Virtual reality exposure 

  • Newer technique 

  • A way of taking a step towards in vivo, is to give ppl video or pic exposure to things they're afraid of  

  • Can teach them to have these experiences and stay relaxed before they're in the real situation 

  • Useful when it’s a situation they can't go back to  

    • e.g. computer generated reenactments to 9/11 

  • Part of exposure is trying to have a corrective learning experience  

    • Learning this isn't bad or as bad as I thought  

Psychological health and pathology

• Behavioural approaches say you've got maladaptive behaviours you need to stop and you need to learn more adaptive behaviours  

  • Not abt deep work, its abt changing the way I behave 

• Behavioural therapists always looking at behvaiours and trying t pick out the maladaptive ones we need to decrease or stop completely and what are the adaptive ones thatll help manage their life better 

• Is there smt triggering their maladaptive behaviours and why do they engage in them 

  • Maladaptive behaviours can be unlearned, adaptive behaviours can be learned 

Traditional behavioural psychologists focus on

• Analyzing maladaptive behvaiorus and seeing what are the negative consequences/symptoms that make it maladaptive 

  • 1) What are the here and now issues that it's causing that make it maladaptive 

    • Helping client become aware of the negative consequences 

  • 2) IMPORTANT – what's the person getting out of it, if they get smt out of it, we're gonna have to teach them some new adaptive behaviours to help them relax instead 

    • Smt that serves that same function  

    • Really trying to find this one out 

• Wanna decrease maladaptive behaviours and replace them with adaptive behaviours  

Pathology/problems (behavioural therapy

• Thoughts, emotions and behvaiours are thought of as: 

  • 1) Learned responses 

    • Not learned necessarily from parents, can be  

    • They've been reinforced 

      • e.g. If I don’t go out, I feel less anxious bc I don’t ave to worry abt the mistakes I've made 

  • 2) Trigged by specific situations 

  • 3) Often serves a function 

    • e.g. someone comes into therapy with anxiety, they prob avoid certain things 

    • This has worked for them, someone's/or smt is reinforcing it, certain situations will make a person want to avoid those situations 

    • Serves a function - nothing bad happens if I don’t try – becomes rewarding 

• Pays a lot of attention to physiological stuff 

  • Managing your body, breathing exercises, etc 

• Always looking for feedback loops in behaviourism 

Tx/solutions (behavioural therapies)

• Encourage clients to enter new contexts 

  • Go into new situations that might be adaptive that you tend to avoid 

• Lots of skill teaching 

  • Stuff abt managing your body/regulating nervous system, practicing communication or assertive skills, coping with craving skills + saying no (addiction)  

• Replace maladaptive behaviours with more adaptive behaviours  

The therapeutic relationships 

• You as a therapist are more in the lead, will teach more, will say here's what's going on 

• Therapist is more directive and playing more of a teaching and coaching role  

  • More of a coach, more of a doctor kind of (figuring out what's wrong, will give strategies) 

  • Relationship is still important, can't be cold (will get into the way of the  

  • Other approaches say that relationship is the key, this one says just be good enough 

  • You have to have knowledge, teaching, have to be an expert 

• Therapist often has na agenda or a sense of what they'll cover in sessions 

  • Not following the clients lead 

• Gonna listen, collaborate/have a relationship but its not a big aspect 

Response prevention 

• Preventing behvaiours that are designed to decrease anxiety, fear, or tension until the urge to perform these overprotective behaviours subsides 

  • Used with ppl who have OCD 

    • e.g. knocking on table, nothing bad happens, seems like it's working 

• One of the best practice for OCD tx 

• Preventing the person form engaging in their safety behaviour  

• Trying to prevent the person from responding in a way that they're tempted to do it  

• Also used with avoidance behaviours, addiction or self-harming behaviours  

• Most effective when used as part of exposure therapy  

• Expose the person that increases their desire to participate in the behaviour, but not give in  

• Response prevention for addictions  

  • The compulsion is when I respond to a trigger, I have to use (using is the safety behaviour) 

  • What we're asking is how can you not react to feeling triggered/a craving 

  • Help prevent clients from responding to urges to use/trigger for use by engaging in their addictive behaviour 

    • Common strategies include developing skills for coping with cravings and/or distraction from cravings 

    • Usually involves avoidance of triggers for the urge 

    • Also includes conducting a functional analysis of the addictive behaviour  

Contingency management 

• Reducing rewards for unwanted behaviours or creating rewards for desired behaviours 

  • i.e. Shaping/operant conditioning  

• Other operant strategies 

  • Trying to get clients to build that into their own life 

  • Extinction  

    • Removing rewards in response to unwanted behvaiours  

      • e.g don't reward the behaviour you don’t wanna have 

  • Shaping 

    • Specifically rewarding successive approximations of a desired behaviour that the client has never performed  

  • Stimulus control 

    • Trying to figure out what triggers the behvaiour, and helping the person to control that trigger 

    • Finding cues or triggers for behaviours and avoiding these cues 

Psychoeducation 

• Teaching clients abt how specific aspects of behaviour therapy techniques or concepts apply to their specific issue 

• The practice of therapy/common techniques 

  • Might include discussing concepts such as 

    • The ABC model 

    • Triggers 

    • Coping strategies 

    • Wellness/self-care strategies 

  • Suggesting readings 

Behavioural activation  

• Non-technical term – getting ppl to do shit 

• Big the world of depression and anxiety 

• The clinical process of increasing clients contact with positive reinforcers and breaking patterns of avoidance 

  • e.g. Don’t stay home in bed on your phone everyday 

• The practice of therapy/common techniques 

  • Used for clients with depression and/or anxiety 

    • They tend to shrink their world 

  • Simila efficacy to medication or CBT for anxiety and depression in research studies  

  • Mix of exercise, eating properly, having some sort of social contact, engaging in smt where you have some sort of learning, etc even if you don’t feel like it 

  • Often involves schedules which are co-created for specific activities 

 Modelling 

• Demonstrating a particular behvaiour in the presence of a client to show how it's done, usually before asking the client to perform the same behaviour  

• Important for exposure therapy too 

  • e.g. if you ask a client to put their hand in a toilet, you have to do it too and be calm 

  • If you're gonna teach breathing exercises, you wanna do it with them 

• Anything you can do to show them that it's safe to do it, you do it too (within reason) 

• Power of seeing someone doing smt can help teaching them how to do it and that it's okay 

• The practice of therapy/common techniques 

  • Demonstrating a particular behaviour in the presence of a client, usually before asking the client to perform the same behaviour  

  • Social learning is more likely to occur when we observe others we perceive as similar to us  

  • Why groups are useful 

    • Client might think we're different from them, but if they see someone similar doing it in a group,  

  • Often used for social skills training and for exposure therapy with phobias (to demonstrate how to respond in a non-fearful way in the presence of the feared stimuli) 

Relaxation-based strategies  

• Behaviourists work a lot with managing the central nervous system 

  • e.g. calming down when angry or anxious/triggered and getting re-centered, grounding exercises, not being on autopilot (goes back to maladaptive behaviours) 

• Purpose/aim 

  • Stimulate the relaxation responses as a tx for anxiety or physical symptoms related to anxiety  

    • I.e. IBC, headaches, chronic pain 

• Common types 

  • Teaching ppl breathing exercises, progressive muscle relaxation, guided imagery and paced, abdominal breathing 

• Often used in combination with exposure therapies to help reduce the fear response prior to or during exposures  

• Important to remember 

  •  A lot of ppl just do the relaxation technique once they're triggered 

  • It's more likely to work if you can catch the trigger way earlier 

    • If you wait until your anxiety and cravings are way up there, you need to practice it before hand, and practice often 

• 1) early cue detection 

  • Anticipating triggers or noticing when triggered 

• 2) practicing  

  • PMR or paced breathing when not anxious 

• 3) applying PMR  

  • or paced breathing when triggered