Introduction

to
Psychosocial
Interventions
Heike van Klinken
Clinical psychologist/ lecturer
Department of Psychiatry and Mental Health
Learning outcome
Students will:
• Know what a (bio)psychosocial approach means and what psychosocial interventions
are
• Appreciate the importance of forming a therapeutic alliance and the importance of
empathy and a non-judgemental, self-reflective attitude, be aware of the
importance of confidentiality
• Know about the importance of self-awareness
• Know a few basic interventions to use as doctors like psycho-education, self
management, motivational interview, some CBT interventions and involving family
• Be aware of different therapeutic approaches used in management of mental health
problems
• Know which approaches are most effective and recommended for specific disorders
Basic conditions for an effective treatment
• Forming a working alliance is the basis for efficient treatment
• Your attitude is important (often being the first contact were a patient
experiences treatment for mental health problems
• Respect and empathy
• Confidentiality (that should only be broken in very exceptional
situations)
• Reliability
• and a non-judgemental attitude.
• Safe environment, relationship is limited to therapeutic relationship / keep
boundaries/ stay safe and keep the patient safe
• Be really interested in your patient
Basic conditions for an effective treatment
• To function efficiently:
• Important to be aware of your own condition, stress
level and how to intervene and help yourself first to be
able to support others sufficiently
• Our responsibility to take care of ourselves in order to
stay healthy, but also to be able to approach a patient
correctly
• Important to reflect on a regularly base on yourself
(your own condition, your own values and coping might
impact your therapeutic relationship and your
treatment)
 The bio psychosocial model
Bio psychosocial model
takes biological, Physical health
psychological and social
aspects and their Biological
influence on
Genetic
each other into
account Temperament
Drugs
IQ
Peers
Mental
Health
Coping
Social
Family
Relations
Psychological
Family Biopsychosocial
Circumstances Model
Self-esteem
School/work Trauma
Social skills
Bio psychosocial model background
• The bio psychosocial model regarding Mental Health states that
there are biological, psychological, and social determinants
to mental health and looks at the interconnections between those
factors which influence mental illness and wellbeing.
• Emerged from dissatisfaction with the biomedical model (which is
often still dominant in certain areas of healthcare).
• Engel developed the model in 1977
• He also discussed importance of a dialog between professional and
patient to come to the most effective treatment solution
• Is used in a broad range of helping professions in health and social
care settings as well as by medical and social science researchers
Case
Mary (20 year old female) with panic and depression
• Intelligent, sensitive
• College student (but avoiding classes)
• Lack of adequate tools to manage her condition
• alcohol as self-medication low self- esteem as consequence
• Mother struggled with depression too, “weak spot”
• Mother relied on her for support, impact of her depression
In this case you might have recognized:
 Biological component: her possible predisposition, her temperament
and IQ
 Psychological: lack of adequate coping, self esteem
 Social: family aspects, impact of experiencing mums struggle, impact
of and on school and of the other family circumstances
For Mary’s support it’s important to take all those aspects into account.
 Psychosocial Interventions
• Include e.g. public/ community education, training,
family education and support to self- help networks
and capacity building
Clinical treatment: e.g. psycho education,
structured counselling, motivational enhancement,
case management, care-coordination, (coping
skills) training, psychotherapy and relapse
prevention.
• The intervention could be individual or group-
based, delivered face-to-face or at distance and in
different settings
• Can focus on the individual, the (family) system,
(members of) the village, the community or
society
• Important: to match level of context, language of
the individual or group you are aiming on
 Psychosocial interventions in clinical care
Include and focus on:
• Early recognition and preventive interventions to promote health, pay
attention to warning signs and risks and specific treatment
• Psycho-education preventive or supportive (could use e-Health)
• Self-management
• Motivation
• Training in (life and coping) skills
• Counselling
• Psychotherapy
• Relapse prevention
 1) Psycho education - preventive or supportive
• Psycho education is an intervention with systematic, structured,
and didactic knowledge transfer
• It can focus on:
• Preventing illness: promoting health and support to stay
healthy
• An illness and its treatment: integrating emotional and
motivational aspects to enable patients to cope with the
illness and to improve its treatment adherence and efficacy
• Its an important first step and should be included in almost all
approaches.
 Psycho-education practically
• Provide information about the symptoms of specific mental health problems or
disorders
• Normalize (someone is not the only one with that problem)
• Give hope and inform about tools to deal with a specific problem
• Motivate to prevent or cope adequately and let them know how they can get extra
support
• Increase Mental Health Literacy in individual patients, systems and communities
• Refer a patient to specialist treatment (like a psychologist, psychotherapist or
psychiatrist), make them aware of which specialist treatment is available and where
and explain why referral is needed
• It’s an important task for an GP and any other doctor to be able to provide psycho-
education.
Psycho education and use of e- Health

• E-health stands for electronic health, or care via internet

and could be used for psycho-education
• Also more and more attention is paid to so-called "blended
care", where regular face-to-face conversations are
combined with online interventions such as chat, video
calling, online treatment modules
• Examples: Relaxation exercises and Mindfulness apps,
Headspace
Take a short time to think
1.How do you recognize whether you yourself are feeling
mentally well?
2.What do you do to improve your own mental wellbeing?
3.What are constructive tools to feel mentally well and what
are destructive coping mechanisms?
4.What are your preferred coping mechanisms?
Characteristics of good mental health

• Respond adequately to situations

• Able to participate well in day to day activities, can work efficiently
• Positivity: able to really enjoy things
• Muscle tension: relaxed
• Able to think, decide and act to own ability
• Able to regulate emotions and not being overwhelmed by emotions
• Able to build stable relationships
2) Self management
• Important is a certain degree of self-awareness (being able to recognize
own feelings, emotions, character, signals) and to have the wish to
increase the ability to restrain yourself in difficult situations
• Examples:
• (Learn to) be mindful (and exercise mindfulness), it will help to slow
down, look at situations in a more balanced way, appreciate what
you are experiencing in the moment, can have a very positive
impact on thoughts, feelings and behaviour
• (Learn to) regulate emotions, respect them and do not ignore them
and deal with them instead of avoiding
• Think positively and realistically
• Work on increasing resilience
• Use tools such as Relaxation exercises, writing, exercising
Exercise: Progressive relaxation (Jacobson)
• In the handouts will be a relaxation exercise which can be used in your
clinical practice as a preventive intervention but also as one of the
first interventions to teach a patient in treating anxiety, panic, to
reduce the stress level. You can use it for yourself but also for your
patients
• The essence of the technique: tensing certain parts of the body and
then immediately relaxing them. Paying attention to the sensations of
tension followed by relaxation helps experience a pleasant sense of
well-being which moves over into emotional and mental state.
• Important to feel the sensations, not only tensing and relaxing;
learning how to become deeply aware of the sense of contraction and
release during these movements. Can be carried out in any
comfortable seated position or while lying down or even standing.
• It’s a learning process, will take time, will work quicker with more
experience.
 Self management
• Examples for constructive tools to use :
• Regular exercise can reinforce self-esteem, can help concentrate, sleep, and feel
better. Exercise keeps the brain and other vital organs healthy and helps to ventilate
emotions
• A healthy diet that’s good for physical health is also good for mental health.
• Stay in contact with friends
• Ventilate emotions in an early stage (talking, writing)
• A change of scene or change of pace is good for mental health – so pause
• Doing an activity you enjoy probably means you’re good at it, and achieving
something boosts your self-esteem
• Challenge negative thoughts
• These are tools that you can apply to yourself but that you also want to teach a patient
to use
3) Expectations, motivation and Motivational
interview
• Suffering pressure is often the reason to seek help,
but does not necessarily mean that patient has the power and desire to
change
• Patients often want to get rid of their complaints, but do not know how to
deal with, are afraid to give up habits, get caught up in negative thinking and
cannot imagine that another reality is possible.
• Patients often have lost confidence in being able to learn from other people
or to change their circumstances
• Important to motivate
• Take time in order to build a working alliance
• Work in stepped-care (medication to stabilize and support when needed)
• Make the patient also responsible for his own process and be clear about
what you can do and what not
Motivational interview
• Often used for patients with substance abuse
• You need:
• To have respect for patient’s autonomy and values
• Make attempts to collaborate, search for ideas and solutions in the patient
• What you can do:
• Start a conversation about the problems that the patient experiences and that the
environment experiences without taking a position who is right
• Stimulate to discover advantage and disadvantage for change
• Ask the patient what he wants to change and, if necessary, put it next to what his
environment expects and, if necessary, repeat this a number of times
• What you should not do:
• To convince the patient that he has a problem instead psycho- educate the patient
• Expand on all the benefits of change instead explore together
• Tell the patient what and how he should change instead look for solutions together
• Warn the patient of the consequences if he does not change, instead look for
disadvantages and consequences together.
 4) Training in life and coping skills
There are different trainings to increase skills to promote mental health and wellbeing
either for prevention or as part of treatment.
One example is Competitive Memory Training (COMET) for Treating Low Self-Esteem.
But there are many more skill trainings with focus on
• Self awareness, Mindfulness
• Decision making and problem solving
• Emotion regulation (ER) – DBT skills
• Effective communication Skills
• Interpersonal relationship Skills
• Training for social skills and assertiveness
Those can be individual based or group based trainings.
Counselling and psychotherapy

• Counselling: PREVENTIVE and Brief intervention

• Psychotherapy: REMEDIATIVE (curing)

5) Counselling
• Usually refers to:
• A brief treatment that centres around behaviour patterns
• Focus on present time
• Supportive, educational, provides guidance
• Focus on problem-solving, conscious awareness, normalization
• Clients choose goals, counsellor supports client to explore and
understand the situation
• Supports in making decisions, to accept personal responsibility,
• Usually for less complex or acute issues (for example One Stop
Centre)
6) Psychotherapy
• Psychotherapy: usually for more complex, severe problems
• Counselling can be part of psychotherapy
• Working with clients for a longer-term and draws from insight
• Focus on symptoms, (severe) emotional problems and disorders
• Present time but also emotional problems and patterns originating
in early experience
• Focus on a deeper awareness of emotional issues
• Looks at the foundation of the problem and mobilizes solutions in
the patient to change maladaptive patterns
Psychotherapy – an overview
• Psychotherapy takes place in a series of conversations in which the
trained therapist deliberately influences moods, cognitions and
behaviour of a person by:
• using the therapeutic relationship methodically
• systematically applying psychotherapeutic methods
• Psychotherapy is done by a psychotherapist, (clinical) psychologist or
a psychiatrist, but you might use basic psychotherapeutic
interventions as doctors as well
• Nature, severity and cause of the psychological problems, the
provisional explanation of the problems and the treatment goals of
the patient are leading for which target and which approach is
chosen, whereby we look at what is the most effective approach
Overview of psychotherapeutic approaches
• CBT/ BT Cognitive Behavioural Therapy
• Psychoanalytic psychotherapy/ Psychodynamic psychotherapy
• Client focused psychotherapy
• Solution focused
• Schema focused therapy
• Interpersonal Psychotherapy
• EMDR (Eye Movement Desensitization and Reprocessing)
• DBT (Dialectical Behaviour Therapy)
• ACT (Acceptance and Commitment Therapy )
• Family therapy
• Eclectic/ integrated psychotherapy
Assessment and start treatment

Establishing a
relationship

Diagnostics Collecting
information

Treatment plan together

Understanding the
with the patient person
 Cognitive Behavioural Therapy (Background)
• Started with Behaviourism (Pavlov, Thorndike, Skinner): focused (only) on (deviant)
observable behaviour.
• Cognitivism (Piaget, Vygotsky, Gagne) then tried to correct the simplistic view of
behaviourism, tries to open the black box and focuses on core beliefs, ways of thinking
and reasoning, as a starting point for predicting and correcting behaviour. In the end,
these two movements merged into cognitive behavioural therapy
• Behavioural therapy (first generation) and cognitive therapy (second generation)
developed a trend focused on mindfulness skills (third generation). The emphasis is on
acceptance and learning to deal more effectively with emotions and cognitions. The
third generation includes Acceptance and Commitment Therapy ACT, the dialectical
behaviour therapy DBT, the attention-focused behaviour therapy and the schema-
oriented therapy SFT
Cognitive Behavioural Therapy
• Structured, often with an agenda set
• Complaint , problem, goal-oriented
• Effect is often measured throughout therapy
• Emphasis is sometimes more on the way of thinking and sometimes
more on the way of doing
• Time-limited
• Weekly or ones in two weeks
• Based on a learning model
• Includes homework assignments to enhance skill acquisition, often
in combination with self-help manuals
• Relapse prevention
• Individually or in a group
CBT as approach of preference (whether
or not in combination with medication)
• Anxiety disorders
• Trauma – CBT / EMDR
• Depression
• Substance abuse and dependence
• Binge eating disorder, bulimia (IPT is also an effective approach)
• Burn out
• Obsessive compulsive disorder
• Low self esteem

• Personality disorder
Cognitive Behavioural Therapy approach – more explained
• Is based on a cognitive model, where thoughts and behaviour determine
emotional reactions to stressful life events
• Emphasizes on all the three main components implicated in psychological
problems: thoughts, emotions, and behaviours
• Exercises are designed to intervene on all three often simultaneously.

Thoughts Feelings

Behaviour
Example: Exam
Thoughts:
Feelings
I will fail
Stress, Anxiety
I am not good enough
I don’t belong here

Reinforcement of
the thought I will Circle can start at any of
never make it, I these three
am a failure) components, as well as
Behaviour treatment
Avoidence (avoid
studying, report sick for
the exam)

Can you think of other examples where those 3

components influence each other?
CBT approach (Cognitive restructuring - overview)
• When a particular negative thought seems to be the starting point causing negative
emotion and behaviour:
• The best approach to start might be to re-examine and challenge that thought
(cognitive restructuring)
• Track dysfunctional automatic thoughts, and devise adaptive alternative responses
• Use a diary to record thoughts
• Use a pie chart to write thoughts down and look at alternative thoughts which could
be a possible explanation too
• For example: Heart palpitations – I will get a heart attack (what other explanations are
possible instead of getting a heart attack), put percentage for each explanation in pie – which
opens the opportunity to discuss the automatic thought and challenge it
• (Creating a visual representation can often be even more effective in impacting
unhelpful thought patterns than just talking or writing)
Cognitive Interventions more in detail
• Cognitive restructuring is a therapeutic process to help the patient to discover,
challenge, and modify or replace negative, irrational thoughts into more
realistic thoughts
• Some techniques used are:
• Socratic questioning, a technique that can help to challenge irrational thoughts
• Is the thought based on facts or emotions?
• What evidence is there that the thought is accurate?
• What is the worst that could happen?
• How could I respond if the worst would happen?
• What other ways could this information be interpreted.
• Is this really as black and white, all or nothing or is there an in between?
• How likely is each possible outcome?
It helps to consider that there are other outcomes, options or thoughts possible.
Cognitive Interventions more in detail
• Write down the supporting facts for and against this thought (like in court)
• What proof is there that this thought is accurate?
• What proof exists for the opposite?
• Gather evidence, list facts that show the thought/ belief is correct/ not
correct (evidence might show that it has (partly) nothing to do with the
patient themself.
• You can then make a judgment on this thought, specifically whether it is
based on evidence or opinion. Weigh the evidence for the thought and the
evidence against the thought (as done in court)
• Formulate a more realistic thought
• Pie chart technique (explained next slide)
Pie chart technique
• Identify the automatic thought (being hard on yourself for something
going wrong) : I failed because I’m stupid
• Think of as many alternative explanations as you can. Often all of them probably
played some role in the outcome.
• (If the patient is able to) assign a percentage to each explanation. The
percentage should reflect the degree to which each explanation contributed to
the situation. Add up the percentages to make sure they add up to 100%. If they
don’t, reassign the percentages until they do.
• Finally, draw a pie chart (use the percentages) .
• By considering other factors implicated in the situation, you might feel more
empowered to do something to solve the problem, or change your behaviour
next time in a similar situation (e.g. I had less time to prepare. Next time I start
earlier and ask for help if needed)
Behavioural experiment

• After cognitive restructuring its important to use behavioural

experiments to gain new learning experiences and prove the more
realistic thoughts and to increase self-confidence.
 CBT approach (Exposure)
• When a behavioural pattern like avoidance seems
responsible for the persisting problem, a new
behavioural response/ learning experience to the
situation would be helpful. (E.g. Specific Phobia)

• Behavioural experiment / exposure could be used to

get other learning experiences and gain self
confidence
• Formulate together with the patient an experiment,
take small steps, otherwise the patient might avoid
again and reinforces patterns.
• Discuss when, where, how often the patient will do/
repeat the agreed assignment
CBT approach

• If someone can not think or is not able to change

actions because stress reactions in the body are too
overwhelming: then start with exercises which bring
the stress down (e.g. panic)

• For example Relaxation- and breathing

techniques might be used (Progressive muscle
relaxation - Jacobson) to manage the physical
stress first
CBT interventions
• Psycho education including how feelings, thoughts and behaviour influence each
other
• Teach relaxation exercises (like progressive relaxation after Jacobson) or mindfulness
• Let the patient keep a diary and challenge cognitions about the situation
• Example:
• patient registers unpleasantly experienced situations and describes the associated
unpleasant feelings and thoughts and behaviour as a consequence
• Ask: how sure the client is that what he/she thinks is true
• Search together for proof of correctness of the thoughts to discover which experiences
there are and which errors there are
• think of other interpretations of the situations described and examine what kind of
evidence there is for or against these alternatives
• for the most plausible alternative, he/she has to score credibility
• check effect of this on the feelings and actions of the patient
CBT interventions (con)
• Behavioural experiment practically:
• Ask: How convinced are you about what you think?
• If we want to test a new learning experience to see if it's true, what could you try?
Suppose it's true what would happen then, if it is not true, what would happen? If
we want to test that, what are you going to do and when, do this several times.
Create a behavioural experiment together with the patient
• Agree on small steps for exposure to get confidence while doing it
• How to do it:
• Change of thoughts for example “I am not able to handle the situation .... “.
• Explore what does proof this assumption, look together with the patient for
alternative thoughts
• Train the patient in tools to calm himself down
• Set up together a plan for exposure to gain confidence about the new thought
• If traumatic experience – you need to address them as well before exposure
and challenging thoughts will work fully
Relapse prevention
• Every change process takes place in different phases:
1. Development of motivation
2. Phase of active change (Old problems are overcome during this phase,
New behaviour is acquired, new emotions are discovered, new ways of thinking are
learned)

• Relapse does not take place out of the blue

• Everyone has times that things are not going well. Setbacks in the family, problems at work.
During difficult times relationships can give a lot of stress and tension.
• Patient should learn to ask themselvess if this is normal stress of daily life, or the
beginning of a relapse. That is why it is good to consider what the first signs of relapse are
for him/ her and what action the patient can take themselves.
• Often a written plan is made together with the patient before treatment ends
Relapse prevention plan
• Describe:
1) situations that you think will evoke psychological symptoms again
2) relapse signals: signs you notice meaning you have a relapse.
3) helping actions (resuming certain exercises, calling in help (partner, boyfriend /
girlfriend), more

• Ask the patient to discuss with someone whom he/ she trusts for support.
He or she might be able to help to signalize/ recognize that he is not doing
well.
Involving family/ support systems
• Important to get support for changing processes and assure
sustainability
• Involve them in:
• psycho-education
• Evaluation of the treatment
• Family therapy sessions to help family members to improve communication
and resolve conflicts, change patterns, cope with internal and external
problems, support developmental tasks, support healthy relationships
• Relapse-prevention
Case Mary – What could you offer her ?
• Mary, 20 years old, is struggling with panic attacks, withdrew herself from
her study, started to get depressed as a consequence, tried to use alcohol or
food for self-medication, felt ugly afterwards.
• Panic occurs whenever she is under pressure or in unexpected situations.
She things she can not handle the situation, is afraid to lose control and “to
become crazy” and no one will support her.
• She is afraid to get another panic attack when at college where she got the
first one during exams. She is afraid to be alone.
• Mary did see how mother struggled with depression, tried to support her
when she was a kid, felt responsible for other siblings. Mother relied mainly
on her for support. But as hard as she tried she was not able to prevent that
her mother became more ill.
• Mary wants to go back to college and wants to be in control of herself and
her life and does not want to let panic an anxiety influence her life so much.
She finally seeks help by seeing you. What could you offer her to support
her?
Case Mary
• Psycho-education
• Relaxation and breathing exercises to help her to manage the panic
symptoms
• Challenging thoughts and expectations
• Processing impact of traumatic experiences
• Gradually exposure in situations she now avoids (together with the
patient you make a plan, you choose small steps)
• Reinforce positive experiences (what do they tell the patient about
herself, her abilities) and thoughts
• Increase confidence
• Relapse plan could be made
• Involving mum and/ or other supportive people close to her
Summary
• Working alliance is the basis for efficient treatment
• Biopsychosocial model: there are biological, psychological, and social
determinants to mental health which are interconnected and influence
mental illness and wellbeing
• Psychosocial interventions are:
• Psycho-education preventive or supportive, informing about symptoms
and about preventing and treatment options
• Self-management: stimulate self-awareness and increase adequate tools
like relaxation exercises, mindfulness, exercising, journaling or tools the
patient already uses which are helpful)
• Motivation: Start a conversation about the problem without taking a
position , explore advantage and disadvantage for change, achieve
commitment what the patient wants to change
Summary
• If needed add a training in (life and coping) skills
• Counselling: A brief treatment that centres around behaviour
patterns
• Psychotherapy: Focus on symptoms, (severe) emotional problems
and disorders, looks at the foundation of the problem and mobilizes
solutions in the patient to change maladaptive patterns
• Relapse prevention: discuss with the patient and describe together in a plan
situations they think will evoke psychological symptoms again, relapse signs and
helping actions resuming certain exercises, calling in help, share with supporting
network
• Involve family and/ or other support (friend, school, community) in psycho
education, treatment and relapse prevention
Questions