psychotherapies

TreaTmenT sTraTegies

PsychotherapiesPaul gilbert

AbstractPsychological therapies focus on memories, thoughts, feelings and be-

haviours and provide new opportunities for learning and change. There

are a range of therapies: some focus on unconscious conflicts and the

construction of the therapeutic relationship, others focus on specific

problematic behaviours and how to modify them, while others focus

on people’s stream of thoughts and beliefs. There is currently limited

research into the efficacies of different types of therapy.

Keywords behaviour therapy; cognitive–behavioural therapy; psychody-

namic therapies; psychotherapy

Psychological disorders arise from interactions between innate dispositions, acquired vulnerabilities (both physiological and psychological) and current life stresses.1,2 Some people carry negative beliefs about the self, others, the world and the future. Rumination on negative or feared aspects of life can maintain psychological disorders, stimulate physiological systems mediat-ing threat processing, and interfere with problem solving. There is now good evidence that psychological interventions are very helpful to people.3

General principles – in the context of a supportive therapeutic relationship, psychotherapies help clients learn how to understand and cope in new ways with their thoughts, emotions and behav-iours, and reduce distress and symptoms. The basic principles are: • create a therapeutic relationship in which the client feels safe

enough to explore and share feelings, thoughts and memories, can ‘risk’ the challenges of change, and feels cared for

• formulate the client’s problems in psychological terms, col-laboratively share the rationale and procedures for treatment with the client, and agree ‘steps forward’

• instigate the tasks of treatment • monitor the client’s progress and modify the formulation and

tasks in light of the ongoing therapy • prepare for the end of therapy and to take the new learning

into everyday life • the tasks and procedures of different therapies vary widely

depending on the therapist’s ‘school’ of approach, but most include these general principles.4

Paul Gilbert PhD DipClinPsych is Professor of Clinical Psychology at the

University of Derby, UK and Consultant Psychologist to the Derbyshire

Mental Health Trust. He qualified from the University of Edinburgh. His

research interests include depression, social anxiety, psychosis and

shame. Competing interests: none declared.

meDiCine 36:9 49

Types of psychotherapy

Psychological therapies can be delivered to individuals, to fami-lies or in groups. Each mode of delivery can be structured around particular approaches (Table 1).

Psychodynamic therapies: these psychotherapies share the idea that psychological difficulties are often related to unresolved internal conflicts, repressed memories and difficulties in forming relationships. The therapist’s role is to: • help these themes to emerge • develop the client’s awareness and insight • desensitize them to fears of internal fantasies and emotions • use the therapeutic relationship to inform him/her of the

underlying difficulties and provide the basis of the therapy intervention.

Attachment linked therapies: John Bowlby suggested that peo-ple form their internal sense of self, and the helpfulness or hos-tility of others, from early experiences with parents and carers. These are then carried forward as templates for later relation-ships. Attachment theory suggests that psychological difficulties are linked to disrupted relationships.5 The aim of therapy is to: • create a safe base • help people understand the relational aspects of their negative

thoughts and feelings • build supportive relationships.

Linked to attachment theory and psychodynamic approaches is a new approach called ‘mentalizing’ which involves helping people focus on and think about the thoughts, feelings and inten-tions ‘in the minds of others.’6

Behaviour therapy and cognitive therapy: behaviour therapy has its roots in animal learning models of over a hundred years ago in the work of Pavlov and Thorndike. There are two ele-ments of behaviour therapy. One focuses on helping the client

• Psychotherapy theory and research is increasingly being

influenced by genetic, psychological, neurophysiological and

psychological research leading to new models of ‘how the

mind works’ and new interventions

• Psychotherapies are now included in niCe guidelines for many

disorders

• Psychotherapies are now developed and are developing

for working with complex cases (e.g. personality disorders,

psychosis)

• Psychotherapies are becoming more integrative, partly

because they are all now drawing on the same scientific

research base of ‘how the mind works’. Hence as we

understand psychological processes better, and develop

therapies based on this understanding, the differences

between therapies will fade

What’s new?

6 © 2008 elsevier Ltd. all rights reserved.


expose themselves to feared and avoided situations in order to desensitize to them. The second element of behaviour therapy is based on the use of rewards and punishments, although punish-ments are generally not recommended as agents of behavioural change. The therapist helps people develop a series of steps or graded tasks to achieve certain goals with reinforcers built in to support each step. For example, individuals with depression disengage from activities that could give them pleasure or more control, thereby becoming more depressed and more disengaged. The therapist tries to change clients’ behaviour, helping them become more active, more focused and more reward-oriented. This is sometimes termed ‘behavioural activation’.1,3 Problem-solving therapies help clients to prioritize difficulties, break them down into manageable issues, and explore solutions.

Cognitive therapy emerged during the 1950s and 1960s. According to this view, individuals with psychological difficulties engage in negative thinking. Negative thoughts tend to be auto-matic (they just ‘pop into the mind’) and distorted. Distortions

Types of psychotherapy

Individual therapies

These focus on the one-to-one relationship, and personal focus.

Typical forms are:

• Cognitive therapy focuses on people’s interpretations and

thoughts about situations. especially useful for people who

can monitor and articulate thoughts and feelings.

• Behaviour therapy focuses on people’s behaviour, commonly

avoidant, disruptive or self-destructive behaviours. explores

the function of these behaviours and teaches and encourages

problem-solving skills and new behavioural repertoires which

impact on mood and thinking.

• Cognitive–behavioural therapy: a combination of all cognitive

and behavioural interventions

• Dialectical behaviour therapy: uses cognitive, behavioural,

mindfulness and acceptance strategies. Developed for self-

harming behaviour and people with borderline personality

difficulties but increasingly used for a variety of problems.

• Interpersonal psychotherapies: focus on specific difficulties

linked to loss, grief, role transitions, conflicts, and social

relationships.

• Emotion focused therapies focus on exploring and expressing

problematic emotions, where there is avoidance or over-

reliance on specific emotions.

• Psychodynamic therapies focus on internal conflicts and the

therapeutic relationship as a way of understanding those

conflicts and resolving them. Large number of different

schools, focusing on different aspects of the patient’s inner

world.

Non-individual therapies

There are two forms of non-individual focused therapy; group and

family. These may run in combination with individual therapies or

as a therapy in itself. each of these can follow one of the above

approaches. For example, group therapy can be cognitively or

psychodynamically orientated. similar for family therapies.

Table 1

meDiCine 36:9 49

might take the form of dichotomous thinking (‘either I am a success, or I am an abject failure’), or over-generalization (‘this relationship did not work, so no relationship will’). Thoughts related to anxiety are linked to harms and threat (‘If my heart rate goes up, I will have a heart attack and die’); thoughts related to depression focus on defeat and loss (‘I am a failure and will never succeed’). This leads to a vicious cycle of negative thinking and feeling worse.Therapists are trained to help their clients: • re-focus, re-attend, re-attribute, re-evaluate • generate alternative thoughts and test out beliefs • try new behaviours (behavioural experiments) • problem-solve.1,3

Clients train themselves in monitoring their thoughts as they emerge in their minds and on their ruminations, and re-evaluate their automatic thoughts, by keeping thought records and engag-ing in specific tasks to elicit and test their thoughts and beliefs. Today cognitive and behavioural models and interventions are often combined and used in integrated ways. A useful introduc-tion is by Willson and Branch (don’t be put off by the title).7

Developments and integrationsIn addition to the basic principles of CBT, other associated con-cepts and approaches include: • meta-cognition (how individuals think about and interpret the

meaning of their feelings and thoughts)8

• safety behaviours (how individuals behave and think to avoid perceived danger and threats)1

• changing the relationship to thoughts and feelings rather than changing the content or accuracy of these thoughts. This is achieved by developing ‘mindfulness’, whereby the client pays attention to his or her thoughts and feelings but learns not to react to them8

• cognitive behavioural systems analysis9 – a CBT approach that focuses on relationships and the cognitive and behav-ioural processes activated in social interactions has with a good evidence base and – used in the NICE guidelines

• interpersonal psychotherapy – originally developed for depres-sion but is now used for many other disorders. It focuses on specific life difficulties such as role transitions and conflicts and losses10

• cognitive analytic therapy – another hybrid therapy that ex-plores social behaviour, thinking and self in relationship to others, and reciprocal roles and processes11

• therapies that focus on trauma and traumatic memories work-ing with body and affect systems12

• developing inner compassion – this has become a focus in some therapies, especially for those people high in self- criticism and from harsh backgrounds.1

The future

Increasingly, psychotherapies are hybrids that ‘borrow’ ideas and interventions from each other. The future of psychotherapy will involve improved research into psychological processes (con-scious and non-conscious) to inform theory and models. In addi-tion, greater understanding of how early experience interacts with genetic vulnerability, and the power of social environments to regulate values, beliefs and emotions, will help psychotherapists



conceptualize theories of mental function and thereby develop better ‘focused’ therapies.13 ◆

RefeReNces

1 gilbert P. Psychotherapy and counselling for depression, 3rd edn.

London: sage, 2007.

2 Kiesler DJ. Beyond the disease model of mental disorders. new

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5 mikulincer m, shaver Pr. attachment in adulthood: structure,

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6 allen Jg, Fonagy P, eds. Handbook of mentalization-based

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9 Williams m, Teasdale J, segal Z, Kabat-Zinn J. The mindful way

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12 Ogden P, minton K, Pain C. Trauma and the body: a sensorimotor

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13 Cozolino L. The neuroscience of psychotherapy. Building and

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