CASC Knowledge Essentials12 · Psychological therapies: models, mechanisms and distinctions
12 · Psychological therapies: models, mechanisms and distinctions
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Written by Resident Doctor Committee · Published
12.1 The models at a glance
Therapy | Main focus | Characteristic work |
|---|---|---|
CBT | Meanings, feelings, bodily responses and behaviour | Formulation, thought records, experiments, between-session practice |
Behavioural activation | Withdrawal and loss of meaningful activity | Activity monitoring and planned action |
ERP | Fear/incompleteness maintained by rituals | Exposure while reducing neutralisation and avoidance |
Psychodynamic | Recurring emotional/relational patterns, including unconscious processes | Feelings, defences and the therapy relationship |
IPT | Depression in its current interpersonal context | Grief, disputes, transitions or isolation |
Family/systemic | Interactions within social context | Perspectives, communication and recurring patterns |
DBT | Intense emotion and damaging coping | Acceptance, change and skills |
MBT | Understanding behaviour through mental states | Curiosity about one's own and others' minds |
CAT | Repeated ways of relating to self/others | Reformulation, diagrams, recognition and revision |
Models may share techniques without becoming interchangeable.
12.2 CBT: the five-part model
Situation → interpretation → emotion, bodily response and behaviour, with each part influencing the others.
An error during a presentation becomes “I am incompetent; everyone will reject me”. Shame, tension and palpitations follow. The person stops contributing and replays the error. Withdrawal prevents corrective experiences; rumination strengthens the negative view. CBT can work on both the meaning and the avoidance.
Level | Example |
|---|---|
Core belief: broad view of self/world | I am unworthy. |
Intermediate belief: rule or conditional assumption | I must perform perfectly to be accepted. |
Automatic thought: immediate interpretation | This error proves everyone will reject me. |
CBT tests ideas; it does not prescribe positive thinking. An experiment states a prediction, tests it through action and reviews the result. A thought record weighs existing evidence. Between-session practice takes the learning beyond the therapy room.
Cognitive errors worth recognising
Pattern | Error | Example |
|---|---|---|
Dichotomous thinking | Only extremes count | Anything below perfect is failure. |
Overgeneralisation | One event becomes a rule | Every meeting will go badly. |
Selective abstraction | One detail represents the whole | One frown cancels an encouraging audience. |
Arbitrary inference | Conclusion without sufficient evidence | A delayed reply means anger. |
Catastrophising | Worst outcome treated as likely | One mistake will end my career. |
Personalisation | Excessive personal responsibility | The team's failure is entirely my fault. |
Magnification/minimisation | Failures enlarged, successes discounted | Years of good work count for nothing. |
Global labelling | An event defines the whole person | I performed poorly, so I am worthless. |
These patterns overlap and are not diagnoses. Strong conviction alone does not prove delusion: OCD, BDD and depressive beliefs may leave little room for doubt.
Beck's negative triad = self, world, future. Reattribution considers other contributors; the double-standard technique compares self-judgement with judgement of a friend. A balanced view can acknowledge genuine mistakes and adversity.
12.3 Behavioural activation and avoidance
Low mood → withdrawal → less pleasure, mastery and connection → lower mood. Behavioural activation schedules manageable, meaningful activity rather than waiting for motivation. It examines what avoidance achieves; it is more than “keep busy”.
In anxiety, escape gives immediate relief, reinforcing avoidance and preventing new learning. A safety behaviour (continually checking an exit, for example) may preserve the belief that disaster was avoided only through that precaution.
Treatment targets exaggerated threat responses, not sensible protection. Exposure does not require abandoning necessary treatment or ignoring real danger.
12.4 Exposure, systematic desensitisation and ERP
Exposure approaches feared experiences in a planned way: real situations, imagination, memories or bodily sensations. Interoceptive exposure is particularly useful in panic because it tests catastrophic meanings attached to sensations.
Systematic desensitisation, associated with Wolpe, pairs graded exposure with relaxation. The original mechanism was reciprocal inhibition: relaxation competes with anxiety. Modern exposure does not require relaxation at every step; relaxation can itself become a safety behaviour.
ERP adds response prevention. The person encounters the trigger without overt or covert ritualising. Silent prayer, reassurance and mental checking can undo an apparently successful exposure. The goal is a different response to intrusive thoughts, not their complete disappearance.
Habituation and new learning
Habituation is reduced responding after repeated/sustained exposure. An anxiety curve may rise, peak and fall, but distress does not have to halve in every exercise for learning to occur.
Inhibitory learning means building new learning that competes with threat expectations: the feared outcome is less likely than predicted, or distress and uncertainty are tolerable. Fear returning in a new setting does not mean earlier learning was erased. Practising across settings matters.
Agree clinically appropriate exposure. A hierarchy organises practice; it does not justify forced confrontation with the worst fear. Reduce family accommodation of rituals gradually while preserving support.
12.5 Psychodynamic therapy: relationships and emotional meaning
Psychodynamic therapy connects present difficulties with earlier relationships and recurring emotional patterns, including processes outside awareness. The therapy relationship can reveal them. Its purpose is greater understanding and flexibility, not proving childhood caused every symptom or recovering a presumed hidden memory.
Concept | Meaning | Clinical caution |
|---|---|---|
Transference | Earlier expectations/relational patterns appear with the therapist; a neutral pause may feel like criticism | Explore the interpretation without dismissing a legitimate complaint. |
Countertransference | Therapist's emotional response, influenced by the patient, situation and therapist's history | Reflection/supervision may make it useful; it is not objective proof of the patient's feelings. |
Resistance | Processes making painful material or change difficult to approach | Missed sessions may equally reflect transport, illness, misunderstanding or an unhelpful relationship. |
These concepts guide exploration, not moral judgements.
Defence mechanisms
Defences manage threatening feelings/conflicts, often outside awareness. They may help temporarily and become restrictive when rigidly used.
Defence | Core idea |
|---|---|
Displacement | Directing emotion towards a safer target: work anger expressed at home |
Projection | Attributing an unacceptable impulse/feeling to another person |
Denial | Not acknowledging a painful reality |
Repression | Material remains outside awareness; suppression is deliberate |
Intellectualisation | Abstract analysis distances the associated feeling |
Splitting | Difficulty integrating opposing qualities; another person becomes all good or all bad |
Sublimation | Channelling an impulse into constructive activity |
An unconscious interpretation is a hypothesis within a model, not an established historical fact.
Suitability and endings
Consider ability to reflect, attend and tolerate the work, realistic aims and available support. Acute mania, delirium, severe cognitive impairment or unstable psychosis may prevent exploratory work at that time, without excluding adapted psychological care.
Short-term and longer psychodynamic treatments differ in commitment. Weekly sessions around fifty minutes are common; duration/intensity vary. Endings may bring earlier loss and separation into focus, but practical reasons for stopping remain valid too.
12.6 Interpersonal therapy
IPT treats depression through its current interpersonal context. It does not claim that relationships are the only cause. Usually one main focus is selected.
Focus | Meaning |
|---|---|
Grief | Adapting to an important person's death |
Role dispute | Conflicting expectations in a significant relationship |
Role transition | Parenthood, retirement, divorce, illness or another role change |
Interpersonal sensitivity/isolation | Difficulty building or maintaining supportive relationships |
Initial phase: link depression to context and agree the focus. Middle phase: examine communication and try changes, sometimes with role-play. Ending: review gains, vulnerabilities and continuing support.
IPT does not primarily interpret transference or test cognitive distortions.
Courses are time-limited, often 12–16 sessions. NICE includes IPT for less and more severe adult depression, adjusting sessions to need. Medication may continue. Psychotic depression, bipolar illness and substantial substance dependence also need their specific clinical treatment; generic outpatient IPT does not replace stabilisation.
“Psychological mindedness” should not mean sophisticated vocabulary. Accessible language and adaptation can support collaboration.
12.7 Family and systemic therapy
Circular causality: one response becomes the next person's trigger. Worry leads to checking; checking feels controlling; withdrawal follows; worry grows. Therapy examines the repeating interaction while preserving individual responsibility.
“Family” means the people important to the individual. Work may involve everyone, selected members or individual meetings according to need and safety. Involvement does not imply that relatives caused the illness.
Model | Main ideas and methods |
|---|---|
Structural (Minuchin) | Subsystems, hierarchy and boundaries. Enmeshment involves excessive involvement; disengagement, excessive distance. Joining, enactment and changing entrenched arrangements are characteristic. |
Systemic/Milan | Hypotheses, multiple perspectives and circular questions: how does one person's response alter relationships between others? |
These are models within the field, not rules for every family.
For adolescent depression, parental illness, conflict and interactions maintaining withdrawal may affect recovery. Family therapy is an option when individual CBT does not fit. NICE describes at least fifteen fortnightly sessions of systemic therapy as one further-line option after multidisciplinary review of unresponsive depression. This is indication-specific, not a universal course length.
Abuse and coercive control change the suitability of joint work. Circular formulations must not turn abuse into shared responsibility or displace safeguarding.
12.8 Other models that recur in the scenarios
DBT: mindfulness, distress tolerance, regulation and interpersonal skills, supported by individual therapy, coaching and a therapist team. Its priorities and structure differ from CBT for a single anxiety disorder.
MBT: restores the ability to consider one's own and others' thoughts/feelings when attachment-related emotion creates certainty about another person's intentions. The therapist models curiosity rather than supplying the “correct” reading of a mind.
CAT: integrates cognitive and relational ideas through shared narrative and diagrams. Recognise repeating patterns, then revise them. Reformulation letters, reciprocal-role maps and goodbye letters are characteristic. Courses commonly run 16–24 weekly sessions, with shorter/longer adaptations.
Schema therapy: a schema is an enduring pattern of meaning/coping, often linked to unmet needs; a mode is the current emotional/coping state. Cognitive, experiential and relational methods build more adaptive responses.
Therapeutic communities: relationships and shared responsibility within a structured group form part of treatment. Programmes may be residential or daytime; they provide more than accommodation, with service-specific rules and suitability criteria.
12.9 Interpreting session numbers and treatment outcomes
A treatment dose is not a promised cure. NICE gives approximately eight individual CBT sessions for less severe depression, around sixteen for more severe depression. IPT and short-term psychodynamic courses also vary with severity; complexity may justify more.
Check the unit: OCD recommendations often specify therapist hours; family intervention for psychosis specifies sessions and a time span.
Outcomes include symptoms, functioning, tolerance of distress and harmful behaviour. Preference, a useful formulation, the therapeutic relationship and ability to attend all affect engagement. No therapy is universally superior or guarantees freedom from relapse.