Psychotherapy

Deanna Mercer MD FRCPC

Jan 16 2011dmercer@toh.on.ca

Objectives

• Introduction to psychotherapy

• Psychological Defense Mechanisms

• Understanding transference, countertransference and therapeutic alliance

• Review of common psychotherapies

INTRODUCTION TO PSYCHOTHERAPY

Why do psychotherapy?

What is Psychotherapy ?

“The attempt to relieve suffering and psychological disability by inducing changes in patients’ attitudes and behavior”

Frank JD, Frank JB Persuasion and Healing; a comparative study of psychotherapy, 1991

Emotion

• Emotions move us to action, communicate to others and provide us with important information about ourselves

• Emotions result in suffering and psychological disability when they are intense, long lasting or result in behaviours that are contrary to our goals.

• Example: test anxiety

How Does Psychotherapy Work?

• Therapists capitalize on brain plasticity to produce change at the neural level.

• Therapists train the brain to develop new neural associative networks that help the individual respond in ways that are more adaptive and healthy.

Psychotherapy: Essential Ingredients

1. Diagnostic assessment: Clarify symptoms and problems. Assess the context (biological, psychological and social) in which symptoms are occurring.

2. Understanding: Theory underlying the therapy must provide a way to understand why the patient has developed these symptoms now.

3. Build hope/increase motivation: Alleviate the patient’s sense of powerlessness to change themselves or their environment

4. Facilitate experiences of success and mastery

Objective # 5245

Describe the general psychiatric indications for psychotherapy

Psychotherapy Indications• Most axis I and II disorders either as a stand alone

treatment or in combination with medications• Alone or in combination with medications

– Depression, anxiety disorders, eating disorders, sexual disorders, dissociative disorders, paraphilias, addictions, personality disorders

• In combination with medications– Schizophrenia, bipolar disorder

• Contraindications: – delirium, dementia, psychopathy

Effectiveness of Psychotherapy

• Most psychotherapies have RCT’s demonstrating that they are more effective than treatment as usual

• Psychotherapy versus no treatment: ES 0.67 – 0.85

• Many psychotherapies have been compared to pharmacotherapies and found to be equal (ST) or superior (LT) to treatment with medications

• Many have documented changes in brain function (PET scans)

Objective 5246

List the general characteristics that are associated with good outcomes in psychotherapy

Effectiveness of psychotherapy

• Patient factors 40% : motivation, capacity for relationships

• Relationship factors 30% : therapeutic alliance

• Technical factors 15%: approach• Placebo, hope, expectations 15%:

patient’s expectation that they will receive help or recover

Miller 1997

Patient factors

• Disorder is suitable for psychotherapy

• Patient sees the problem in themselves

• Patient believes that change is possible and is ready to make changes

• Patient is able to participate in treatment

• Patient is able to be self-observant

• Patient’s environment supports change

Therapeutic Alliance

Collaborative alliance between patient and therapist, depends on three factors

1.Patient –therapist agreement on goals

2.Patient – therapist agreement on tasks that each person is to perform

3.Strength of attachment

Therapeutic Alliance: Empathy

Carl Rogers 1980

“Perceiving the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as if one were the person but without ever losing the “as if” condition”

Objective #5247

Describe boundary issues that may come up in the course of

psychotherapy

Boundary Issues: Setting Boundaries

• Creating an atmosphere of safety and predictability

• 3 tasks: 1.Establish and maintain a treatment frame

2.Establish and maintain a professional relationship

• responsibility of the clinician to maintain boundaries, even if a patient requests, demands or provokes a boundary violation

3.Protect patient privacy and confidentiality

Boundary Definition

• Usually describe boundaries in terms of our roles (behaviour): What is and what isn’t okay to do with a patient.

• Boundary violation: A boundary violation occurs when a patient is clearly harmed or feels exploited

• Example: sexual relationship with a patient

Harm to patients

• Doctor-Patient sexual relationships

• Similar to incest in nature of relationship and patient response– Shame, guilt, depression, PTSD, suicide,

substance and alcohol use disorders, relationship break up, loss of employment, difficulty trusting physicians, future health is compromised

Behaviour that is clearly acceptable to everyone

Behaviour that is acceptable in some circumstance and not othersdepends on situation: personal comfort, location, nature of practice:

-using first names-attending patient funeral-disclosing personal information-hiring patient to do work on your house-accepting gifts from patients-attending events where patients will be present

Behaviour that is harmful or exploitativesexual behaviour with a patient

Boundary CrossingBoundary Violation

Boundary Crossing in Psychotherapy

• Behaviours that do not cause patient harm and are often helpful

• Example: in psychotherapy therapists do not usually touch patients. A patient stumbles as she leaves the office, the therapist helps the patient up

• Example: therapists do not usually disclose personal information about themselves: patient asks if the therapist has children, the therapist responds that they do and asks” why do you ask?”

Preventing Boundary Violations

1. Recognize and understand the impact on patients of boundary violations

2. Recognition amongst physicians that we all have potential to do this behaviour when under stress with insufficient emotional support

3. Teaching physicians to be aware of when boundary crossings are helpful and when they are not

4. Improve MD access to psychological health and supports

Two Main Strategies in Psychotherapy

Validation/acceptance Change

Change Strategies

• 4 potential solutions to problems causing painful emotions

1. Change the problem

2. Change how you feel about the problem

3. Choose to accept both the problem and how you feel about it

4. Stay miserable

In psychotherapy which of the following are true?

a) Diagnosis is unimportant so you do not have to worry about doing a diagnostic assessment

b) Theories in psychotherapy provide a way of understanding why a patient has developed these symptoms now.

c) Patients must be hopeful and motivated prior to entering therapy for therapy to be successful

d) Since therapy primarily involves talking one does not pay attention to the patient's experiences outside of therapy.

Psychotherapy is contraindicated in which of the following disorders?

a) depression

b) paranoid personality disorder

c) psychopathy

d) schizophrenia

The therapeutic alliance depends on

the following except:

a) The patient and therapist agree on goals

b) The type of psychotherapy being provided

c) The patient and therapist agree on tasks that each person is to perform

d) Strength of attachment

Setting boundaries refers to all of the following except:a) Creating an atmosphere of safety and

predictability

b) Establishing and maintaining a professional relationship

c) Ensuring the patient is aware of therapist boundaries so that the therapist no longer has to worry about them

d) Protecting patient privacy and confidentiality

TYPES OF PSYCHOTHERAPIES

Psychodynamic

Cognitive Behavioural Therapy

Supportive

Objective # 5248

Define the purpose of a psychological defense mechanism and describe: denial, splitting, projection, reaction

formation, rationalization, dissociation

Objective # 5250

Briefly Describe the following Psychotherapies: Psychodynamic, Cognitive therapy and Supportive

therapy

Glenn O Gabbard

Peter Fonagy

Psychodynamic Psychotherapy

Psychodynamic Psychotherapy: Principles

• Problematic interactions derive from early relationship difficulty

• “how to” of relationships is learned in early life, and repeated over and over again throughout life (repetition compulsion)

Psychodynamic Psychotherapy

• Balance between here and now relationships and early relationships

• Once per week

• Face to face

• 6 months to several years

• Anxiety and depression, personality disorders, somatoform disorders, sexual dysfunction

Psychodynamic Psychotherapy

• 3 areas addressed • Ego psychology: Drive gratification (desire

and aggression) Freud

• Object relations: How we perceive our relationships Klein, Fairburn, Winnicott

• Attachment theory: Basic need for affirmation, safety, reassurance and self esteem Bowlby, Mahler, Fonagy

Understanding Psychological Defense mechanisms

• Core Concepts: – Conscious, unconscious– Defenses

Psychodynamic Psychotherapy Core Concepts

Conscious: material that is in our awareness

Preconscious: can be aware of this information by shifting attention

Unconscious: material that is not brought into awareness easily because it causes distress

Is there an Unconscious?

Memories are explicit or implicit

• Explicit : with conscious awareness

• Implicit: without conscious awareness

Procedural memory: “how to” /skills

Declarative memory: “knowledge of”/facts

Structural Model

“Drive Theory”

• ID (basic drives: “I want what I want!”)

• In conflict with

• SUPEREGO (society: I want you to do what I want!)

• Results in anxiety

• Ego produces defenses: a compromise (usually unconscious) between the id and the superego

Defense Mechanisms

Less Effective (immature)• Denial • Projection• Regression• Splitting• Reaction Formation • Intellectualization• Displacement• Rationalization• Dissociation

Healthy• Sublimation• Religiousness/asceticism• Humor• Altruism• Suppression• anticipation

• Denial: ignoring an undesirable situation or information and believing as though it did not exist

• Projection: attributing to others unwanted ideas or feelings that are experienced within oneself

• Splitting: seeing things as all good or all bad• Reaction Formation: transforming an

unacceptable wish or impulse into it’s opposite• Intellectualization: Using excessive, abstract

thinking to avoid painful emotions

Less Effective Defense Mechanisms

Less Effective Defense Mechanisms

• Rationalization: Justification of unacceptable attitudes, beliefs or behaviours to make them acceptable to oneself

• Dissociation: Disrupting one’s sense of continuity in the areas of identity, memory or consciousness.

Healthy Defense Mechanisms

• Sublimation: Transforming socially or internally objectionable aims into socially acceptable ones.

• Asceticism/Religiousness: Attempting to eliminate pleasurable aspects of an experience due to internal conflicts produced by that pleasure

• Humor: Finding comic/ironic elements in difficult situations

• Altruism: Committing oneself to the needs of others over and above one’s own needs

• Suppression: Consciously deciding not to attend to a particular feeling or impulse.

• Anticipation: Delaying of immediate gratification by planning and thinking about future accomplishments

•inflexible

• may have been adaptive in the past, but is not adaptive in the present

• severely distorts understanding of the present situation

• causes significant problems in relationships, functioning, and enjoyment of life

What makes a defense pathological?

Objective 5249

Describe what is meant by transference, countertransference

and therapeutic alliance

Transference

Freud: “stereotype plate”- sexual desires from childhood are directed at the therapist

Current view: Patient’s perception of the therapist is a mixture of the real characteristics of the therapist and aspects of figures from the patient’s past

Countertransference

Freud• therapist unconsciously experiences the patient as

someone from her past. • interferes with treatmentCurrent• Therapists are human beings with conflicts and

emotional struggles of their own• Therapist’s “total” emotional reaction to the patient

(based on current and past learning)• Important source of information regarding the patient’s

effects on others, particularly if the therapists responses are normative

Cognitive Behavioural Therapy

Cognitive - Behavioural Therapy

Two central premises1. Thoughts have a controlling influence on

behaviour and emotions

2. How we behave can strongly affect our thought patterns

CBT

CBT: Social Phobia

Objective # 5251

Describe the important elements of cognitive therapy

CBT: Cognitive Errors• Habitual ways of thinking in response to

internal and external events

• influence how we see ourselves, our world and our future (negative cognitive triad)

• arise in the context of mental illness and perpetuate the illness

a.Cognitive distortions: “black and white thinking”

b.Schemas: “I am unlovable”

CBT : Behavioural Methods

• Break patterns of avoidance or helplessness – behavioural activation

• Gradually face feared situations – systematic desensitization

• Build coping skills – graded task assignments

• Reduce painful emotions and physiological arousal – breathing and relaxation training

Case Study: Gina

• Presents for treatment of anxiety

• Always worried

• Panic attacks, increased since episode of fainting several months ago

• Panic attacks in crowds, driving, on elevators, eating in the cafeteria

• Avoiding these activities

CBT

• Length: 5-20 sessions

• Focus is on the here and now

• Primary treatment for depression, anxiety, eating disorders

• Combined treatment for severe or treatment resistant depression, schizophrenia, bipolar disorder

All of the following are true regarding cognitive behavioral therapy except:

a) The two central premises of CBT are:

1) Thoughts have a controlling influence on behaviour and emotions

2) How we behave can strongly affect our thought patterns

b) cognitive errors have a negative influence how we see ourselves, our world and our future

c) Cognitive errors occur prior to the onset of mental illness and are responsible for causing mental illness

d) Systematic desensitization refers to gradually facing feared situations.

Supportive Psychotherapy

Supportive Psychotherapy

• Reduction in anxiety through empathy, concern and understanding

• Strengthen “healthy” or effective mechanisms of coping

• Helpful for most psychiatric disorders

• Often used in conjunction with other treatments

ALEXPsychodynamic Psychotherapy Case Study

Patient factors

• Disorder is suitable for psychotherapy

• Patient sees the problem in themselves

• Patient believes that change is possible and is ready to make changes

• Patient is able to participate in treatment

• Patient is able to be self-observant

• Patient’s environment supports change

Therapeutic Alliance

Collaborative alliance between patient and therapist, depends on three factors

1.Patient –therapist agreement on goals

2.Patient – therapist agreement on tasks that each person is to perform

3.Strength of attachment

Countertransference

Current• Therapists are human beings with conflicts and

emotional struggles of their own• Therapist’s “total” emotional reaction to the patient

(current and based on past learning)• Important source of information regarding the patient’s

effects on others, particularly if the therapists responses are normative

• Denial: ignoring an undesirable situation or information and believing as though it did not exist

• Projection: attributing to others unwanted ideas or feelings that are experienced within oneself

• Splitting: seeing things as all good or all bad• Reaction Formation: transforming an

unacceptable wish or impulse into it’s opposite• Intellectualization: Using excessive, abstract

thinking to avoid painful emotions

Less Effective Defense Mechanisms

Which is true regarding defences ?

a) Defences are problematic when they are inflexible and when they severely distort the understanding of the present situation

b) Defences are thought to be a compromise between the superego , representing basic drives and desires and the ego representing societal wishes

c) Maladaptive defences include: denial, splitting, reaction formation and altruism

d) In psychodynamic psychotherapy defences are considered unchangeable and are therefore ignored.

References

• Persuasion and Healing, JD Frank and JB Frank 1991

• Long Term Psychodynamic Psychotherapy: A Basic Text, Glen Gabbard 2004

• Learning Cognitive-Behavior Therapy: An illustrated guide, Jesse E Wight 2005