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DClinpsy interview, What - story telling So What - analyse the situation …

- - - - Forumlation
        
        Dynamic
        all behaviour is purposeful and motivated; all human activity is meaningful, and has potential significance.
        Dynamic formulation is a process of discovering (or constructing) meaning in confusing and unclear areas of experience. It re-tells the client’s story as intentional and meaningful.
        
        Structural
        
        Developmental
        
        Adaptive
      - Therapy
        
        Interpersonal therapy
        
        Brief and long term psychodynamic psychotherapy
      - Underpinning theories
    - - Underpinning theories - systemic theory and social constructionism
    - - Underpinning theories = cognitive theories(e.g. schema theory) and behavioural theories (operant conditioning/classical)
        
        Underpinning Model - Cognitive behavioural Model (e.g. 5 areas approach)
        
        Therapy = CBT (graded exposure, behavioural activation, cognitive restructuring etc)
        
        Formulation
        
        The five Ps of CBT formulation The five Ps Relationship to therapy
        
        Presenting issues. Statement of the client’s presenting problems in terms of emotions, thoughts and behaviours. This process goes beyond diagnosis in that we begin to define the current problems the person faces. This introduces specificity and individualisation. We also define short-, medium- and long-term goals that can help identify the likely end point of therapy. This process helps to develop the therapeutic relationship, clarifies problems and instils hope.
        What are the main issues/present difficulties/problems
        
        Precipitating factors. The proximal external and internal factors that triggered the current presenting issues. Introduces the cognitive model and provides initial focus for CBT interventions. If successful builds clients’ confidence in themselves, therapy and therapist.
        What triggered the most recent episode?
        
        Perpetuating factors. The internal and external factors that maintain the current problems. Provides a focus for intervention by breaking the maintenance cycle.
        What factors keeps the problem going? Can do Hot Cross Bun here
        
        Predisposing factors. The distal external and internal factors that increased the person’s vulnerability to their current problems. Provides a longitudinal understanding of the problems and a focus for more in-depth interventions that aim to maintain change and prevent relapse.
        What has happened in the past that is relevant to how we understand this?/ What made someone vulnerable in the first place?
        
        Protective factors. The person’s resiliency and strengths that help maintain emotional health. Provides a path of least resistance by suggesting interventions that build on existing resiliency and strengths. Also provides pathways to long-term recovery.
        What strengths/positive things exist that protect against the problem?
        
        Hot cross bun - Padesky!
      - Critique
  - - - Operant conditioning
        Operant conditioning, also known as instrumental conditioning, is a method of learning, where the consequences of a response determine the probability of it being repeated. Through operant conditioning behavior which is reinforced (rewarded) will likely be repeated, and behavior which is punished will occur less frequently.
        
        Think pigeons pressing the button for food
        
        Positive Reinforcement
        Positive reinforcement is a term described by B. F. Skinner in his theory of operant conditioning. In positive reinforcement, a response or behavior is strengthened by rewards, leading to the repetition of desired behavior. The reward is a reinforcing stimulus.
        
        Negative Reinforcement
        Negative reinforcement is the termination of an unpleasant state following a response. This is known as negative reinforcement because it is the removal of an adverse stimulus which is ‘rewarding’ to the animal or person. Negative reinforcement strengthens behavior because it stops or removes an unpleasant experience.
        
        Punishment
        Punishment is defined as the opposite of reinforcement since it is designed to weaken or eliminate a response rather than increase it. It is an aversive event that decreases the behavior that it follows. Like reinforcement, punishment can work either by directly applying an unpleasant stimulus like a shock after a response or by removing a potentially rewarding stimulus, for instance, deducting someone’s pocket money to punish undesirable behavior.
      - Classical conditioning
        Classical conditioning is learning through association. In simple terms, two stimuli are linked together to produce a new learned response in a person or animal.
        
        Think Pavlovs dogs
        
        Stage 1: Before Conditioning:
        In this stage, the unconditioned stimulus (UCS) produces an unconditioned response (UCR) in an organism.
        
        Stage 2: During Conditioning:
        During this stage, a stimulus which produces no response (i.e., neutral) is associated with the unconditioned stimulus at which point it now becomes known as the conditioned stimulus (CS).
        
        Stage 3: After Conditioning:
        Now the conditioned stimulus (CS) has been associated with the unconditioned stimulus (UCS) to create a new conditioned response (CR).
      - Social Learning theory
        Social learning theory, proposed by Albert Bandura, emphasizes the importance of observing, modelling, and imitating the behaviors, attitudes, and emotional reactions of others. Social learning theory considers how both environmental and cognitive factors interact to influence human learning and behavior.
    - - Attachment theory
        
        The attachment theory argues that a strong emotional and physical bond to one primary caregiver in our first years of life is critical to our development. If our bonding is strong and we are securely attached, then we feel safe to explore the world. If our bond is weak, we feel insecurely attached. We are afraid to leave or explore a rather scary-looking world. Because we are not sure if we can return. Often we then don't understand our own feelings.
        
        Secure attachment
        Parents who consistently (or almost always) respond to their child's needs will create securely attached children. Such children are certain that their parents will be responsive to their needs and communications.
        
        Within romantic relationships, a securely attached adult will appear in the following ways: excellent conflict resolution, mentally flexible, effective communicators, avoidance of manipulation, comfortable with closeness without fearfulness of being enmeshed, quickly forgiving, viewing sex and emotional intimacy as one, believing they can positively impact their relationship, and caring for their partner how they want to be cared for.
        
        Adult attachments
        
        Secure adults tended to hold positive self-image and positive image of others, meaning that they had both a sense of worthiness and an expectation that other people were generally accepting and responsive.
        
        Adults who demonstrated a secure attachment style during the attachment interview valued relationships and affirmed the impact of relationships on their personalities.
        
        Secondly, they displayed a readiness of recalling and discussing attachment that suggested much reflection prior to the interview. Finally, they showed objectivity in assessing their attachment figures and past experiences without any idealization.
        
        Notably, many secure adults may in fact experience negative attachment-related events, yet they are able to objectively assess people and events and assign positive value to relationships in general.
        
        Insecure avoidant
        Children usually develop this attachment style when their primary caregivers are not responsive to or are even rejecting of their needs. Children learn to pull away emotionally as a way to avoid feelings of rejection.
        
        As adults, they become uncomfortable with emotional openness and may even deny to themselves their need for intimate relationships. They place high value on independence and autonomy and develop techniques to reduce feelings of being overwhelmed and defend themselves from a perceived threat to their “independence.” These techniques include, but are not limited to: shutting down; not saying “I love you” even though their behaviors indicate that they do (i.e., mixed messages); keeping secrets to maintain some semblance of independence. These coping techniques end up becoming detrimental to their adult relationships.
        
        Adults who hold a positive self-image and a negative image of others. They prefer to avoid close relationships and intimacy with others in order to remain a sense of independence and invulnerability.
        They deny experiencing distress associated with relationships and downplay the importance of attachment in general, viewing other people as untrustworthy.
        
        With romantic relationships: Avoidant lovers were characterized by fear of intimacy, emotional highs and lows, and jealousy. Avoidant lovers were often unsure of their feelings towards their romantic partners, believed that romantic love could rarely last, and felt that it was hard for them to fall in love.
        
        Insecure ambivalent
        Children develop this form of attachment usually when their parents have been inconsistent with their responses to them. At times, these parents exhibit nurturing, caring, and attentive behaviors. Other times they can be cold, rejecting, or emotionally detached. As a result, the children don’t know what to expect
        
        They become adults who desire a lot of connection within their relationships, sometimes to the point of being “clingy.” They are highly aware of any slight changes in the relationship. These changes, however minute, can significantly increase this individual’s anxiety. As a result, he or she will focus energy on increasing connection with that partner. Individuals who have this attachment style needs more validation and approval than the other attachment styles.
        
        Preoccupied adults hold a negative self-image and a positive image of others, meaning that they have a sense of unworthiness but generally evaluated others positively.
        As such, they strive for self-acceptance by attempting to gain approval and validation from their relationships with significant others. They also require higher levels of contact and intimacy from relationships with others.
        
        With romantic relationships: Ambivalent lovers characterized their most important romantic relationships by obsession, desire for reciprocation and union, emotional highs and lows, and extreme sexual attraction and jealousy. Ambivalent lovers believed that it was easy for them to fall in love, yet they also claimed that unfading love was difficult to find.
        
        Insecure disorganised
        children who have developed this style may have been exposed to prolonged abuse and/or neglect. Primary caregivers are the people children often turn to as a source of comfort and support. In a situation involving abuse, these primary caregivers are also a source of hurt.
        
        These children grow up to become adults who fear intimacy within their relationships but also fear not having close relationships in their lives. They recognize the value of relationships and have a strong desire for them, but often have a difficult time trusting others. As a result, they avoid being emotionally open with others for fear of being hurt and rejected.
        
        Critical evaluation
        
        It must be kept in mind that one may exhibit different attachment styles in different relationships. A study conducted on young adults revealed that participants possessed distinct attachment patterns for different relationship types (parent-participant, friendship, and romantic relationship) and did not experience one “general attachment orientation,” except for some overlap in anxiety experienced in both friendship and romantic relationships (Caron et al., 2012). Such empirical evidence serves as a reminder that attachment style may be context-specific and that one should not regard results from any assessments as the sole indicator of one’s attachment style.
        
        It is also noteworthy that one’s attachment style may alter over time as well. Across different pieces of research, it was found that around 70% of the people had more stable attachment styles, while the remaining 30% were more subjected to change. Baldwin and Fehr (1995) found that 30% of adults changed their attachment style ratings within a short period of time (ranging from one week to several months), with those who originally self-identified as anxious-ambivalent being the most prone to change.
      - Object relations theory
        
        It is concerned with how people understand and mentally represent their relationships with others. The "objects" in object relations theory are representations of people (how other people are experienced, represented and remembered by the person doing the objectification). According to object relations theory, people's moods and emotions (and many other aspects of their personalities) can only be properly understood against the backdrop of the relationships those people have experienced. It is a foundational assumption of object relations theory that early relationships tend to set the tone for later relationships.
      - Drive Theory
      - Ego Psycholology
      - Self Psychology
      - DEFENCE MECHANISMS
        https://www.simplypsychology.org/defense-mechanisms.jpg?ezimgfmt=rs:610x450/rscb24/ng:webp/ngcb24
      - Transactional Analysis
  - - - Humanistic Theories
        
        Maslows Hierarchy of needs
        
        The self actualizing human being has a meaningful life. Anything that blocks our striving to fulfil this need can be a cause of depression.
        
        Self-actualization - achieving ones potential
        Esteem - feeling of dignity, achievement, mastery, independence respect from others (e.g., status, prestige).
        Belongingness and love - intimate relationships, being part of a group, acceptance
        Safety - security, stability in finances, community, property, freedom of fear
        Physiological - food, water, warmth, rest
        
        The self actualizing human being has a meaningful life. Anything that blocks our striving to fulfil this need can be a cause of depression.
        
        As adults self-actualization can be undermined by unhappy relationships and unfulfilling jobs. An empty shell marriage means the person is unable to give and receive love from their partner. An alienating job means the person is denied the opportunity to be creative at work.
      - Behavioural theory
        
        Learned helplesness
        
        Can occur after experineecing repeated incidents of trauma i.e. childhood or domestic
        
        Attributional or explanatory styles play a large role in the development of learned helplessness
        
        Attribution theory
        
        Fundamental Attribution Error
        which refers to the tendency to over-emphasize the role of personal traits in shaping behaviors. For example, if someone is rude to you, you may assume that they’re generally a rude person, rather than assuming that they were under stress that day.
        
        Self-Serving Bias
        which refers to the tendency to give ourselves credit (i.e. make an internal attribution when things go well, but blame the situation or bad luck (i.e. make an external attribution) when things go poorly. According to recent research, people who are experiencing depression may not show the self-serving bias, and may even experience a reverse bias.
        
        Weiners Three Dimensional model
        
        people examine three dimensions when attempting to understand the causes of a behavior: locus, stability, and controllability.
        
        Attribution is a three stage process: (1) behavior is observed, (2) behavior is determined to be deliberate, and (3) behavior is attributed to internal or external causes.
        Achievement can be attributed to (1) effort, (2) ability, (3) level of task difficulty, or (4) luck.
        
        An external attribution assigns causality to situational or external factors,
        while an internal attribution assigns causality to factors within the person
        
        A stable attribution occurs when the individual believes the cause to be consistent across time.
        An unstable attribution occurs when the individual thinks that the cause is specific to one point in time.
        
        A global attribution occurs when the individual believes that the cause of negative events is consistent across different contexts.
        A specific attribution occurs when the individual believes that the cause of a negative event is unique to a particular situation.
        
        Those with an internal, stable, and global attributional style for negative events can be more at risk for a depressive reaction to failure experiences.
        
        Causal dimensions of behavior are;
        
        Locus
        refers to whether the behavior was caused by internal or external factors.
        
        Stability
        refers to whether the behavior will happen again in the future.
        
        Controllability
        refers to whether someone is able to change the outcome of an event by expending more effort.
        (Globality when discussing attribution styles)
        
        The cognitive deficit refers to the subject’s idea that his circumstances are uncontrollable. The motivational deficit refers to the subject’s lack of response to potential methods of escaping a negative situation. The emotional deficit refers to the depressed state arises when the subject is in a negative situation that he feels is not under his control.
        
        Learned helplessness is a phenomenon observed in both humans and other animals when they have been conditioned to expect pain, suffering, or discomfort without a way to escape it.
        When humans or other animals start to understand (or believe) that they have no control over what happens to them, they begin to think, feel, and act as if they are helpless.
        
        Treatment
        
        identify negative thoughts that contribute to learned helplessness
        
        identify behaviors that reinforce learned helplessness
        
        replace thoughts and behaviors with more positive and beneficial ones
        
        Improve self-esteem
        
        Lewinsohns behavioural theory
        
        Depressed people usually become much less socially active. In addition depression can also be caused through inadvertent reinforcement of depressed behavior by others.
        
        For example, some spouses may take pity on their partners with depression. They may start to do their chores for them, while the person with depression lays in bed. If the person with depression was not thrilled to be doing those chores in the first place, remaining depressed so as to avoid having to do those chores might start to seem rewarding.
        
        For example, when a loved one is lost, an important source of positive reinforcement has lost as well. This leads to inactivity. The main source of reinforcement is now the sympathy and attention of friends and relatives.
        
        However this tends to reinforce maladaptive behavior i.e. weeping, complaining, talking of suicide. This eventually alienates even close friends leading to even less reinforcement, increasing social isolation and unhappiness.
        
        Critique:
        Behavioral/learning theories makes sense in terms of reactive depression, where there is a clearly identifiable cause of depression. However, one of the biggest problems for the theory is that of endogenous depression. This is depression that has no apparent cause (i.e. nothing bad has happened to the person).
        An additional problem of the behaviorist approach is that it fails to take into account cognitions (thoughts) influence on mood.
        
        Depression is caused by the removal of positive reinforcement from the environment (Lewinsohn, 1974). Certain events, such as losing your job, induce depression because they reduce positive reinforcement from others (e.g. being around people who like you).
        
        For example, a child who has moved to a new home and has lost touch with old friends might not have the social skills necessary to easily make new friends and could become depressed. Similarly, a man who has been fired from his job and has trouble finding a new job might become depressed.
        
        People with depression typically have a heightened state of self-awareness about their lack of coping skills. This often leads them to criticize themselves and to withdraw from other people. If the person lacks social skills or has a very rigid personality structure they may find it difficult to make the adjustments needed to look for new and alternative sources of reinforcement
        
        Downward spiral > maintaining depression
      - Cognitive Theories
        
        Becks cognitive triad
        Beck developed a cognitive explanation of depression which has three components: a) cognitive bias; b) negative self-schemas; c) the negative triad.
        
        b) Self-schemas
        A schema is a ‘package’ of knowledge, which stores information and ideas about our self and the world around us. These schemas are developed during childhood and according to Beck, depressed people possess negative self-schemas, which may come from negative experiences, for example criticism, from parents, peers or even teachers.
        
        a) Cognitive Bias
        Beck found that depressed people are more likely to focus on the negative aspects of a situation, while ignoring the positives. They are prone to distorting and misinterpreting information, a process known as cognitive bias.
        
        c) Negative Triad
        Beck claimed that cognitive biases and negative self-schemas maintain the negative triad, a negative and irrational view of ourselves, our future and the world around us. For sufferers of depression, these thoughts occur automatically and are symptomatic of depressed people.
        
        It is important to remember that the precise role of cognitive processes is yet to be determined. The maladaptive cognitions seen in depressed people may be a consequence rather than a cause of depression.
        
        Treatment: CBT, schema therapy (derives mainly out of cognitive-behavioral theory, but also includes elements of attachment theory, and object relations theory)
        Challenging negative automatic thoughts, shifting core beliefs
      - Psychodynamic theory
    - - Behavioural Theories
        
        Classical conditioning
        
        Anxiety can be learned through a type of learning called classical conditioning. This occurs via a process called paired association. Paired association refers to the pairing of anxiety symptoms with a neutral stimulus. A neutral stimulus can be any situation, event, or object that is does not ordinarily elicit a fearful response.
        
        Because the person experienced a significant amount of distress and discomfort when the attack first occurred, the symptoms themselves now represent a threat.
        
        The individual has now "learned" to fear the symptoms themselves, as well as any situation that might trigger the symptoms.
        
        Operant conditioning
        
        Avoidance refers to behaviours that attempt to prevent exposure to a fear-provoking stimulus.
        
        Escape means to quickly exit a fear-provoking situation.
        
        Avoidance and escape are called negative reinforcement. The removal of unpleasant symptoms (negative) leads to an increase in that behavior (reinforcement).
        
        Both coping strategies are highly reinforcing of the anxiety response because they remove or diminish the unpleasant symptoms. Unfortunately, they do nothing to prevent the symptoms from re-occurring again in the future.
        
        Avoidance becomes the reward by removing unpleasant feelings > more likely to use avoidance in the future
        
        When maladaptive coping strategies that serve to maintain an anxiety disorder are discontinued, these behaviors become extinct.
        
        Critique:
        It can be a reductive approach, it reduces complex human behaviour to simple cause and effect.
      - Cognitive Theories
        
        The assumption of cognitive theory is that thoughts are the primary determinants of emotions and behavior.
        
        The core concept of cognitive appraisals and information processing; cognitive processes include the ways that people select, interpret and remember information from their environment.
        
        Cognitive theory has explained anxiety as the tendency to overestimate the potential for danger and may have cognitive bias. Patients with anxiety disorder tend to imagine the worst possible scenario and impacts on their behaviour by avoiding situations they think are dangerous, such as crowds, heights, or social interaction.
        
        Cognitive therapy is thought to work by identifying and modifying the cognitive processes that maintain a particular anxiety disorder
        
        Catastrophic thinking of the stimulus / consequence
        
        Overestimation on how likely the bad thing will happen
        
        Overestimating the cost of the bad thing happening
      - Social Learning Theory
        
        focuses on the effects that others have on our behavior.
        
        People learn by observing others—a process known as vicarious learning—not only through their own direct experiences.
        
        People are more likely to follow the behaviors modeled by someone with whom they can identify. The more perceived commonalities and/or emotional attachments between the observer and the model, the more likely the observer will learn from the model.
        
        The degree of self-efficacy that a learner possesses directly affects their ability to learn. Self-efficacy is a fundamental belief in one’s ability to achieve a goal. If you believe that you can learn new behaviors, you will be much more successful in doing so.
- - - - Supervision conflicts with AG
    - - SS - 20yo male presenting with low mood and lack of motivation, wanting to do BA with him
      - Cedar House, secure hospital, incident where someone had to be restrained
      - Lady coming through for stress management - actually OCD
      - Consultant doctor coming for GAD work
    - - Bagshot park
        One SU from a pakistani background, broken English, care was not as good as other SU. What I did to support that and I was motivated to change this.
      - Stone Bay School
        ABA analysis for student who was segregated from rest of class - looking at what happenes before and after the behaviour and the purpose of it - how can we modify the environment to improve behaviour/learning
        
        Antecedent, Behaviour, Consequence to first analyse behaviour
        
        Already had a Picture Exchange Communication System (PECS) in place by SALT team - working together to add objects/scenarios