Overview of Psychotherapy Back to Basics 2008

1. Overview of PsychotherapyBack to Basics 2008 Tin Ngo-Minh, MD PGY2 Psychiatry University of Ottawa

2. Objectives • Overview of psychotherapy • Review of defense Mechanisms • MCQ

3. Common Psychotherapies • Supportive Psychotherapy • Conginitve behavioral Therapy - CBT • Interpersonal Psychotherapy - IPT • Dynamic Psychotherapy • Other Psychotherapies • Behavioral Therapy • Mindfulness-Based Cognitive Psychotherapy • Dialectical Behavior Therapy - DBT • Acceptance and Commitment Therapy - ACT

4. Therapeutic Alliance • Commitment in therapy • Better to disclose information • Pt feels valued as an individual • Development of a meaningful relationship • By trying to genuinely understand the patient, being empathic

5. Supportive Psychotherapy • To maintain, restore and improve self-esteem, ego-function and adaptive skills • Self-esteem: praise, reassurance, encouragement, normalization • Ego-function: rationalization/reframing, advise/teaching, naming the problem, clarification, confrontation, interpretation • Adaptive skills: preventing anxiety, anticipatory guidance, problem solving

6. Cognitive-Behavioral Therapy (CBT) (A. Beck) • People perceptions and automatic thoughts about situation influences their emotional and behavioral reactions • Depression: negatively biased judgements patient have of themselves (themselves, world and future – internal-global-stable) • Educative, collaborative and empirical approach - examination of distorded cognitions • Time limited (6-16 sessions)

7. CBT goal • Teach patients how to respond to their dysfunctional thinking. Guide patients in evaluating the validity of their thoughts, seeking alternative explanations or perspectives, decatastrophizing, examining the utility of their thinking, getting distance from their thoughts through reflecting on advice they would give to others, and planning a course of action.

8. CBT Techniques • Socratic questioning, clarification, exploration, use of specific examples, « downward arrow » • Problem solving, relaxation, graded task assignement, graded exposure, activity monitoring (M + P), scheduling, behavipral activation, psychoeducation, guided discovery, dysfunctiuonal thought record, behavioral experiements, weighting advantages and disadvantages, coping cards, imagery work, response prevention • Homework, weekly visits (6-12 sessions x 1hr)

9. CBT – Thought Record

10. Interpersonal Psychotherapy – IPT(Sullivan) • Focus on interpersonal relationship • Improve maladapted communication skills • Change expectations in relationship • Discrepencies between support and its needs during time of crisis • Symptom reduction Here and Now • Based on attachment theory • Teach skills, problem solving, to continue to build new relationships and releave the distress • Indication: anxiety – depression • Time limited (12-20 sessions)

11. IPT - Techniques • Analysis of communication pattern • Convey their needs more clearly and effectively • Ex: explore a conflict: reactions – consequences • Transference in therapy • Feedback – role paying • How ask for help • Explore the perception of the other

12. IPT – Area of expertise • Grief and loss • Resolution of grief – description (good/bad) of the lost person • Facilitate mourning, new or change in interpersonal relationship, seek support • Interpersonal dispute • Better communicate attachment needs • Role transition • Give up old role

13. Dynamic Psychotherapy • Change ingrained pattern of interpersonal relatedness and personality style • Learn a more flexible and independant manner of interacting • Object relation theory • image of self and other evolve out of human interaction • Therapist as a participant-obsever • Transference (repetion of past conflict into therapeutic relationship)

14. Dynamic Psychotherapy - Assumptions • Maladaptive relationship patterns are learned from the past • Dysfunctional patterns are reenacted in vivo in the therapy • Therapist, through a new emotional experience (experiencial learning) – attempt to alter the dysfunctional interactive style • Invitation for metacommunication (what’s happening between therapist and patient) – highlight dysfunctional reenactment

15. Assessment of maladaptive pattern • Thoughts, feeling, perception and behaviors of the patient of an interpersonal nature • Expectation of other’s reactions • Behavior of other people and interpretation • Patient’s behaviours and attitudes toward the self – how the person treat himself

16. Other Psychotherapies

17. Behavioral therapy(Skinner) • Little attention in gaining insight • Time limited therapy • Anxiety management skills • Relaxation/breating • Structured problem solving • Behavioral rehearsal • Exposure therapy • Phobias, OCD, PTSD

18. Mindfulness-based Cognitive Therapy (MBCT)(Kabat-Zinn, Segal) • Mindfulness is a meditative practice from Buddhism, which aims to help people identify their thoughts, moment by moment, but without passing judgement on the thoughts. • “We can respond to situations with choice rather than reacting automatically” • Little emphasis on changing the content of thoughts (unlike CBT) • Body scan - meditation

19. Dialectical Behavior Therapy (DBT)(Linehan) • For borderline patients • Behavioral principle to promote change and mindfulness to promote acceptance • Extreme behaviors and emotions: Learn a middle ground • Mix of individual and structured group therapy • 1) enhance patient motivation • 2) enhance patient capabilities • 3) ensure that new capabilities generalize to the patient’s natural environment

20. DBT - Goal The goal is to bring out the opposites, both in therapy and the client’s life, and to provide conditions for synthesis. Strategies include extensive use of stories, metaphor, and paradox; the therapeutic use of ambiguity; viewing therapy, and indeed all of reality, as constant change; cognitive challenging and restructuring techniques; and reinforcement for use of intuitive, nonrational knowledge bases.

21. Acceptance andCommitment Therapy (ACT)(Hayes) • ACT attempts to teach clients to accept, rather than control or eliminate, private experiences (i.e., negative emotions, thoughts, memories) • "self-as-context“ Here and Now — the you that is always there observing and experiencing and yet distinct from one's thoughts, feelings, sensations, and memories. • Acceptance, defusion, being present, a transcendent sense of self, values, and committed action.

22. Review of defense mechanisms

23. Splitting • Dissociation • Intellectualization • Rationalization • Reaction Formation • Repression • Altruism • Humor • Identification • Introjection • Sublimation • Suppression • Denial • Distortion • Delusional Projection • Fantasy • Projection • Somatization • Acting out • Idealization • Displacement • Dissociation • Isolation

24. MCQs

25. A 42-year-old man has just been informed that he has poorly differentiated small cell carcinoma of the lung. When asked if he understands the serious nature of his illness, the patient proceeds to tell his physician how excited he is about renovating his home. This patient is exhibiting • A. denial • B. displacement • C. projection • D. rationalization • E. reaction formation • F. sublimation

26. A 55-year-old male begins group therapy. After the first session, he befriends one of the other clients, and begins telling her how extraordinarily intelligent and talented the facilitator is. At the next session, he and the facilitator disagree. After the session, he tells his fellow group member that the facilitator is utterly incompetent and that they should sue for malpractice. This is an example of • displacement • fixation • reaction formation • regression • splitting

27. A 17-year-old girl loses her best friend in an automobile accident. After the death, she starts writing for hours daily in her diary. This would most likely be an example of which of the following defense mechanisms? A. Identification B. Projection C. Rationalization D. Regression E. Sublimation

28. A 27-year-old swimmer who feels insecure about her athletic abilities harshly criticizes her teammates' techniques. Which of the following ego defense mechanisms is she displaying? • Displacement • Projection • Reaction formation • Repression • Sublimation

29. There is a classic zoo story about a cage with three monkeys in it. The largest monkey steals the middle-sized monkey's banana. The middle-sized monkey then screams with rage, hits the smallest monkey on the head, and then steals his banana. The middle-sized monkey is using which of the following mechanisms of defense? A. Displacement B. Projection C. Reaction formation D. Regression E. Repression

38. Good luck on the Exam!