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Psychological therapies



Types Used In Managing Injuries and Pain Management



Health professionals from a range of backgrounds will utilise the theories and techniques of a range of therapies when treating injured workers with psychological injuries or physical injury related psychological problems. In the following section the main theories and therapies that are applied are overviewed.



Behaviour therapy


Behavioural theory is remarkably simple and is based upon the idea that a person’s behaviour is an indication of their psychological health. It is based upon a theory of learning that explains that behaviours are both learned and can be unlearned. With behavioural theory and therapy there is no recognition of unconscious processes or even of the thinking process underlying behaviour, rather the important link is between stimulus and response that leads to the development, shaping and maintenance of a behaviourAvery.B.

Psychological health problems are the result of a faulty stimulus-response link eg a simple phobia such as a child’s fear of a dog may be shaped by it having barked loudly (contrary to expectations of other soft furry things being associated with pleasure) resulting in the child experiencing shock and then fear. The child then associates dogs with fear and avoids situations where meeting dogs may occur.


Avery.B. (1996) Thorson’s Principles of Psychotherapy; Harper Collin. London


The aim of behaviour therapy is to break the cycle of avoidance of the stimulus. This may be done by gradually exposing the person to the feared stimulus in a form that is mildly anxiety provoking and then increasing the level of exposure until the stimulus no longer produces an overwhelming physical or psychological response. Specific relaxation techniques are usually taught and applied at the same time to make exposure more tolerable and to help the client feel control and an increasing sense of mastery in dealing with their fear.


The good points of behavioural therapy are that it is time efficient and does not need a highly trained therapist. It is highly adaptable and results can be easily measured. It is often used for psychological difficulties where overt behaviour is the chief problem.


It's bad points according to Brice Avery in his book Principles of Psychotherapy include it being relatively superficial, not addressing the deeper underlying hurts and neurosis that can be the cause of unwanted behaviour. He believes that ignoring these issues can result in new or unwanted behaviours surfacing or a return to the original problem.



Cognitive Behaviour Therapy

Cognitive approach to therapy goes beyond the behavioural approach in that it acknowledges and attempts to understand the conscious thoughts that result in behaviour. It does not however give acknowledgement or credence to unconscious thoughts or processes.


Cognitive therapy sees psychological health difficulties a result of negative distortion of available information in the environment – for example a person who receives a job rejection letter may think that “I’m a failure, I’m not good enough, I’ll never get a job”. An adaptive response in contrast would be to analyse what might have gone wrong, what can be learnt from the experience and what could be done different in the future. There are 6 ways according to therapists that this can occur. These include arbitrary inference, selective abstraction, overgeneralisation, magnification and minimilisation, personalisation and absolutist dichotomous thinking.


Cognitive therapy involves a deliberate problem solving sequence and has the following objectives:


  1. To understand the patient’s problems

  2. To tailor therapeutic strategies to individuals

  3. To use behavioural techniques to compliment cognitive interventions

  4. To asses the efficacy of treatment on regular basis


Techniques utilised included challenging underlying assumptions:


  1. Socratic reasoning

  2. Identification of automatic thoughts

  3. Reality testing

  4. De-catastrophosing, analysing advantages and disadvantages of a decision or course of action


The good points of cognitive therapy are that it is easy to comprehend and make use of. It is well focussed for depression that does not have a large biochemical basis. Its bad points according to Avery are that it is not always lasting in its benefits, which imply that it is the contact with the therapist that produces the benefit rather than the therapy itself. It also tends to ignore deeper underlying problems - eg. Contributing depression and emphasis is on the individual being dysfunctional rather than the social or economic system that may be contributing significantly to the patient’s current difficulties.



Mindfulness Therapy

Mindfulness is a modern reworking of ancient meditation traditions, principally Buddhist. It is designed to help people deal with day to day difficulties by putting you in control of your own mind, rather than being “run” by your mind..

In difficult situations such an injured person is in great pain, or they are approaching an anxiety provoking situation (e.g. a work capacity review) very strong emotions may be experienced. e.g. sadness, anxiety or anger. Sometimes these emotions incapacitate us by overwhelming us or lasting a very long time. Unhelpful thoughts may accompany these emotions such as “I’ll never get over this” or “I must be stupid if I’m so scared of this exam”. Such thoughts are often believed uncritically and tend to perpetuate the strong emotions so that we are no longer in control of our minds and we can’t cope.

The aim of mindfulness therapy is to enhance awareness of thoughts and bodily sensations and in so doing be able to better cope with day to day emotions and problems. An example of the new awareness is as follows:


  • I have thoughts but I am not my thoughts

  • I have bodily sensations but I am not my bodily sensations

  • I have feelings but I am not my feelings

  • "Bringing one's complete attention to the present experience on a moment-to-moment basis" (Marlatt & Kristeller)

  • "Paying attention in a particular way: on purpose, in the present moment, and non-judgmentally" (Kabat-Zinn)

  • "The non-judgmental observation of the ongoing stream of internal and external stimuli as they arise" (Baer)

  • "Awareness of present experience with acceptance" (Germer, Segal, Fulton)


Practising mindfulness can help help you:

  • to be fully present, here and now

  • to experience unpleasant thoughts and feelings safely

  • to become aware of what you're avoiding

  • to become more connected to yourself, to others and to the world around you

  • to become less judgmental

  • to increase self-awareness

  • to become less disturbed by and less reactive to unpleasant experiences

  • to learn the distinction between you and your thoughts

  • to have more direct contact with the world, rather than living through your thoughts

  • to learn that everything changes; that thoughts and feelings come and go like the weather

  • to have more balance, less emotional volatility

  • to experience more calm and peacefulness

  • to develop self-acceptance and self-compassion



Interpersonal Therapy


Interpersonal therapy focuses on the interpersonal relationships of the person undergoing therapy. The idea of interpersonal therapy is that psychological ill health can be treated by improving the communication patterns and how people relate to others.


Techniques of interpersonal therapy applicable in a workers compensation context are:


  • Identification of Emotion — Helping the person identify what their emotion is and where it is coming from.


Example — David has a lower back injury, has been off work for 8 months and is upset and fighting with his wife. Careful analysis in therapy reveals that he has begun to feel guilty that she must now work to supplement the family income when they have 3 children under five as well as undertake a number of family chores David can no longer do. Instead of being appreciative and tolerant of her fatigue at the end of the day he is impatient and unsupportive. Analysis of his situation and underlying emotions, David becomes aware that he feels useless, non productive, neglected and unimportant since his wife started working outside the home. Knowing that the relevant emotion is depression and feeling inadequate and guilty David can begin to address the problem.


  • Expression of Emotion — this involves helping the person express their emotions in a healthy way.


Example — When David feels ignored by his wife he responds with anger and sarcasm. This in turn leads his wife to react negatively. By expressing his frustration and sadness appropriately and in a calm manner, David can now make it easier for his wife to react positively and with reassurance.


  • Dealing with Emotional Baggage — often, people bring unresolved issues from past relationships to their present relationships. By looking at how these past relationships affect their present mood and behavior, they are in a better position to be objective in their present relationships.


Example — growing up, David’s mother was not a nurturing woman. She was very involved in community affairs and often put his needs on the back burner. When choosing a wife, David subconsciously chose a woman who was also similar particularly when under pressure.  While he agreed that the family needed the increased income, he did not anticipate how his relationship with his own mother could affect his reaction to his wife’s own difficulties and ways of coping.



Solution Focused Brief Therapy (SFBT)


Solution focused brief therapy (SFBT), often referred to as simply 'solution focused therapy' or 'brief therapy', is a type of talking therapy that is based upon social constructionist philosophy. It focuses on what clients want to achieve through therapy rather than on the problem(s) that made them seek help.[1] The approach does not focus on the past, but instead, focuses on the present and future. The therapist/counselor uses respectful curiosity to invite the client to envision their preferred future and then therapist and client start attending to any moves towards it whether these are small increments or large changes. To support this, questions are asked about the client’s story, strengths and resources, and about exceptions to the problem.


Solution focused therapists believe that change is constant.[2] By helping people identify the things that they wish to have changed in their life and also to attend to those things that are currently happening that they wish to continue to have happen, SFBT therapists help their clients to construct a concrete vision of a preferred future for themselves.[1] The SFBT therapist then helps the client to identify times in their current life that are closer to this future, and examines what is different on these occasions. By bringing these small successes to their awareness, and helping them to repeat these successful things they do when the problem is not there or less severe, the therapists helps the client move towards the preferred future they have identified.



Relaxation Therapies


Physiological arousal occurs when a person perceives threat and/or is under stress. It is associated with sympathetic nervous system stimulation and changes in core body functioning such as increased heart rate, muscle tension, dilation of pupils and changes in rate and depth of breathing to take in more oxygen - a primitive evolutionary fight or flight response mechanism to a physical threat.


The types of threats we experience in the 21st century in urbanised western technology driven societies are less likely to be of immediate and imminent life threatening danger than the types of dangers we would have experienced in the millions of years of our evolution. Rather they are a symbol of threat – a letter regarding loss of job and/or wages = potential loss of house, food or shelter, loss of security for immediate family, a response that requires a cognitive rather than a physical response. The ways our bodies respond to threats however have not kept up with our pace of social development and as a result we may experience symptoms we are familiar with - acute or chronic stress.


In order to reduce stress levels there are a range of techniques that can be taught and applied to reduce physical and psychological distress. These include:



Breathing techniques


Control over breathing is essential for all other forms of stress management techniques to work. Under extreme stress – e.g. panic, a person’s breathing cycles can be severely disrupted to the point where ineffective breathing may lead to dizziness, agitation, severe palpations, and sometimes fainting. In such states it is very difficult for the sufferer to feel in control.

Education and demonstration of breathing techniques for slowing down and normalising the breathing are essential. All forms of meditation require initial control and regulation of breathing - a pre-requisite for slowing down and redirecting the mind.



Progressive Muscle Relaxation


Progressive muscle relaxation is a technique where the individual is taught techniques to tense and relax groups of muscles in the body until eventually the whole body is relaxed.





Visualising techniques are introduced to manage anxiety and stress. The may be general such as imagining a relaxing place or situation, e.g. a tropical beach or peaceful sunset. Visualisation may also involve “walking through” a feared situation imagining a state of confidence and a successful outcome – e.g. a goal kicker fearful of missing goals may be asked to imagine and go through each step of successfully kicking a goal for his team.

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