Psychotherapy

1. Psychotherapy Dr. Rashmi Singh Assistant Professor Dept. of Psychology Mahatma Gandhi KashiVidyapith, Varanasi- 221002

2. What is Psychotherapy? • Psychotherapy, or talk therapy, is a way to help people with a broad variety of mental illnesses and emotional difficulties. Psychotherapy can help eliminate or control troubling symptoms so a person can function better and can increase well-being and healing. • Problems helped by psychotherapy include difficulties in coping with daily life; the impact of trauma, medical illness or loss, like the death of a loved one; and specific mental disorders, like depression or anxiety. There are several different types of psychotherapy and some types may work better with certain problems or issues. Psychotherapy may be used in combination with medication or other therapies.

3. Historical background: Beliefs and treatment of the mentally ill • Greek physician Hippocrates (ca. 400BC) promoted humane treatment. Tx based on healing powers of nature: Mentally ill patients were placed in pleasant surroundings and given soothing baths. • Lack of balance between positive and negative energies • Illness attributed to a disturbance in the balance of bodily fluids (humorism).

4. Middle Ages-17th century: A spiritual matter • Madness = in league with devil, possession by spirits • Diagnosis based on hearsay, unreliable “tests” • Treatment • Prayer, exorcism, magic incantation • Torture, starvation, and exile (sent to sea) • Treated like animals and sentenced to burn or hang

5. 18th century: Moderate enlightenment • Mentally disordered people = degenerates • Treatment: • Isolate mentally ill from society • Sometimes bloodletting

6. The 19th century: Attempts at reform • Philippe Pinel (1745-1826) • Reformed Paris mental hospitals: • Removed restraints • Treated mentally ill more humanely • Some patients got better enough to leave hospital • Stressed “moral” understanding • Developed individualized therapies based on diagnosis and life history • Insisted on drugs only as last resort

7. The 19th century (cont.) Dorothea Dix (1802-1887) • Reform of U.S. system • Moral-treatment movement advocating humane care • Led to large, state-supported public asylums • But problems persisted • Overcrowding • No effective treatments • Eventually…interest waned Freud introduces psychoanalysis in 1890s

8. The 20th century • New biological therapies introduced in 1930s • Insulin-coma therapy (ICT) • Electro-shock therapy (ECT) • Frontal lobotomy • Anti-psychotic drugs introduced in mid-1950s • Deinstitutionalization follows in early 1960s • get people out of asylums and back into community • general mood of optimism in country • Community mental health centers established in 1961

9. ECT Today Therapy for severely depressed patients in which a brief electric current is sent through the brain of an anesthetized patient Side effects of ECT include slowing of information processing speed and short-term memory loss, but it is painless and there is no risk for death or brain damage. 70% of depressed patients who did not respond to other treatment respond positively to ECT.

10. Somatic Treatments in the 1920s and 1930s

11. 20th Century: Advances in psychotherapy • Psychoanalysis introduced by Freud in 1890s • Adler (1930s) and other neo-Freudians follow • Variety of new approaches introduced in 1950s • Behavioral (Wolpe, Watson, Skinner) • Rational Emotive Therapy (RET, Ellis) • Humanistic (Rogers) • Existential (May) • Gestalt (Perls) • Cognitive therapy introduced in 1960s (Beck) • Group therapy also gains popularity in 1960s • Family Therapy comes in the 1970s • Motivational Interviewing (1983) and MBCT (1991)

12. Modern Treatment Facilities/Trends • Hospitals • Mental disorders led to 2.4 million hospitalizations (6.9% of total) • Psychoses was the 3rd most common reason for hospitalization • Heart disease (4.2 million) • Child delivery (4.1 million) • Psychoses (1.7 million) • Pneumonia (1.2 million) • Malignant neoplasms (1.2 million) • Fractures (1.1 million) • Average length of st-hospital stay is about 7 days (see next slide) • Community Mental Health Centers • Out-patient mental health clinics • Nursing homes • Private offices

13. Many forms of treatment are available for people experiencing psychological difficulties 2 Broad Types of Therapy: Somatic therapy (biological) – Drugs ECT Psychosurgery Psychotherapy - Various techniques of “talk” therapy Therapy Comes in Many Forms

15. What is psychotherapy? • Psychotherapy is a form of treatment for problems of an emotional nature in which a trained person deliberately establishes a professional relationship with a patient for the purpose of removing, modifying, or retarding existing symptoms, of mediating disturbed patterns of behavior, and of promoting positive personality growth and development (Wolberg, 1967). • Psychotherapy is a planned activity of the psychologist1, the purpose of which is to accomplish changes in the individual that make his/her life adjustments potentially happier, more constructive, or both (Frank, 1982). 1or other professional mental health service provider

16. What is psychotherapy? • Interpersonal, relational intervention by trained therapists to aid in life problems • Goal: increase sense of well-being, reduce discomfort • Employs range of techniques based on relationship building, dialogue, communication and behavior change designed to improve the mental of individual patient or group

17. What is psychotherapy? • Some therapies focus on changing current behavior patterns • Others emphasize understanding past issues • Some therapies combine changing behaviors with understanding motivation • Can be short-term with few meetings, or with many sessions over years

18. What is psychotherapy? • Can be conducted with individual, couple, family or group of unrelated members who share common issues • Also known as talk therapy, counseling, psychosocial therapy or, simply, therapy • Can be combined with other types of treatment, such as medications

19. Objective of Psychotherapy • To Improve • Daily Activities - Therapist's objective is to improve daily activities. • Family Relations - Improve family relationship with spouse and other family members. • Perceptive Functions - Improve awareness, self esteem, mood and clear thinking. • Performance Strategies - Improve emotions, behavior, try to be safe and well-being.

20. Objective of Psychotherapy • Manage - Discomfort or distress. • Perception - Improve sensitivity, thoughts and expectation of reality. • Encourage Grieving - Grieving and expression of feelings helps to minimize internal sufferings. • Improve Medication Response - Psychotherapy improves response to medications. • Good Sleep - Sleep helps to improve behavior, self esteem and mood.

21. What can psychotherapy accomplish? • Learn to identify and change behaviors or thoughts that adversely affect life • Explore and improve relationships • Find better ways to cope and solve problems • Learn to set realistic goals

22. Psychotherapy: Four Areas of Emphasis • Distorted thoughts • Disturbed emotions (Inner Conflicts) • Maladaptive behaviours • Interpersonal and life situation difficulties

23. Goals of Psychotherapy • The primary goals of Psychotherapy are: • 1) To know yourself better.2) Alleviate emotional pain or confusion.3) Assist you in developing a more complete understanding of your psychological issues.4) Establish more effective coping mechanisms.5) Foster a more accurate understanding of your past and what you want for your future.

24. FUNDAMENTAL PROCESSES in psychotherapy • There are THREE FUNDAMENTAL PROCESSES in psychotherapy that will facilitate your reaching these goals. • 1. To develop trust or a “therapeutic alliance” with your therapist. During this period the treatment goals are defined and mutually agreed upon. The purpose at this point is to fashion a method of doing therapy that fits best with your personality.

25. 2. In the second phase or “working through” process, the emphasis is on resolving confusions about past experience, and developing ideas about what you want and who you are. The desired outcome is to trust your intuitive process, feel unobstructed about the direction your life is taking, and to advance your efforts to enjoy a more healthy and productive life. The expected outcome from psychotherapy should be that you feel more “at home” in the world, more accepting of yourself and with your life choices.

26.  3. The third or termination phase of therapy is to evaluate your progress, solidify what you have learned, resolve any remaining conflicts, and hopefully feel satisfied with your life and yourself. All three phases are essential to maintaining your psychological gains.

27. The more interested and involved you are in your therapy the more you will progress. Psychotherapy can at times evoke anxiety, fear, anger, frustration, loneliness and dependency feelings. Unpleasant realities if faced, can be worked through. • The emphasis is in replacing fantasy, myth, and untruths with reality. Reality and truth can at times, be painful, but will ultimately lead to more personal happiness and healthier relationships. • The goal of psychotherapy is not to change you, change is your choice, but it is to build awareness, compassion, understanding, respect, empathy and acceptance toward yourself and others. (William Cloke, Ph.D.)

28. Common Themes Among Psychotherapies • Emotional defusing • Interpersonal learning • Self-knowledge • Therapy as a step-by-step process • Therapy as socially accepted healing

29. Evaluating Therapeutic Outcome:

30. Placebo Effects • A placebo effect is a therapeutic change that occurs as a result of a person’s expectations of change rather than as a result of any specific treatment. • Some patients in psychotherapy may show relief from their symptoms simply because they are in therapy and may expect change

31. DOES PSYCHOTHERAPYWORK? • In a 1952 paper, Hans Eysenck challenged the effectiveness of psychotherapy • Eysenck claimed that psychotherapy produced no greater change in maladjustment than natural life experiences • He was WRONG!

32. All psychotherapies provide: • A working alliance between patient and therapist • An emotionally safe setting where the patient can feel accepted, supported, un-criticized • A therapeutic approach that may either be strictly adhered to or modified according to patient needs • Confidentiality as integral to therapeutic relationship except with safety issues

33. Who seeks therapy…and why? • Children: behavioral, school, family issues • Adolescents: as above and issues of separation and peer relationships • Young adults: all of above plus career issues • Mature adults: all of above plus issues of changing relationships, family alignments, health, work and social status • Older adults: all of above plus end of life issues

34. How does therapy work? • Research: quality of therapist/client relationship effects outcome more than specific therapy • Lambert (1992) estimates 40% client changes due to motivation or severity of problem; 30% to quality of therapeutic relationship; 15% to expectancy (placebo) effects, and 15% to specific techniques. • Tallman (1999): Outside therapy people rarely have friends who listen for more than 20 minutes. People close often involved in problem and can’t provide safe impartial perspective

35. Who can really be a psychotherapist? Adequately trained and certified • Psychiatrist • Psychologist • Social worker Untrained persons not tested for competence! • anyone can call themselves a “therapist!” • Nurse practitioner • Physician assistant • Minister, priest

36. Schools and types of psychotherapy

37. Think of psychotherapy on a continuum Psychoanalytic Behavioral

38. Psychoanalysis • Focus on unconscious as it emerges in treatment relationship • Insight by interpretation of unconscious conflict • Most rigorous: 3-5 times/week, lasts years, expensive • Patient (analysand) lies on couch, analyst unseen to eliminate visual cues • Must be stable, highly motivated, verbal, psychologically minded and be able to tolerate stress without becoming overly regressed, distraught, impulsive

39. Psychoanalysis • Analyst neutral • Goal: structural reorganization of personality • Techniques: interpretation, clarification, working through, dream interpretation

40. Prominent early psychoanalysts Sigmund Freud (1856-1939) Carl Jung (1875-1961)

41. Psychoanalysis: Terms • Transference: unconscious redirection of feelings for one person to another (including the therapist) • Countertransference: redirection of therapist’s feelings for the patient • Therapeutic alliance: therapist and patient trust • Resistance: ideas unacceptable to conscious; prevents therapy from proceeding • Free association: patient says what comes to mind uncensored. Clues to unconscious

42. Defense mechanisms • Everyone uses them • They are usually identified as more mature, neurotic or less mature • Under duress people tend to use less mature defense mechanisms

43. Mature defense mechanisms • Altrusim: deal with stress or conflict through dedication to meeting other’s needs • Anticipation: anticipate possible adverse events and prepare for them • Humor: deal with stress by seeing irony • Sublimation: channel potentially maladaptive impulses into socially acceptable behavior • Suppression: avoid thinking about stressor • Affiliation: turn to others for support

44. Neurotic defense mechanisms • Displacement: transfer negative feelings about one object to another • Externalization: blame problems on another • Intellectualization: rely excessively on details to maintain distance from painful emotions • Repression: expel disturbing thoughts from consciousness • Reaction formation: do opposite of what you feel

45. Primitive defense mechanisms • Denial: refuse to acknowledge aspect of reality • Autistic fantasy: excessive day-dreaming • Passive-aggressive: indirectly express aggressive feelings towards others • Acting out: engage in inappropriate behavior without consideration of consequences • Splitting: compartmentalize opposite affective states • Projection: falsely attribute unacceptable feelings to another • Projective identification: falsely attribute to a second individual who in turn projects back to patient

46. Psychodynamic psychotherapy • Also called “expressive” and “insight-oriented” • Based on modified psychoanalytic formulations • Couch not used • Less focus on transference and dynamics • Interpretation, encouragement to elaborate, affirmation and empathy important • 1 – 2 sessions/week; open-ended duration • Limited goals

47. Supportive psychotherapy • Offers support of authority figure during period of illness, turmoil, temporary decompensation • Warm, friendly, non-judgmental, strong leadership • Supports ultimate development independence • Expression emotion encouraged

48. Cognitive/behavioral therapies General features Examples • Are manualized • Are time limited • The therapist is more directive sometimes “coach like” • Client often is given homework • Interpersonal psychotherapy (IPT) • Cognitive behavior therapy (CBT) • Dialectical behavior therapy (DBT) • Behavioral therapy

49. Interpersonal psychotherapy • Time-limited treatment for major depressive disorder • Developed in 1970’s • Assumes connection between onset mood disorder and interpersonal context in which they occur • Used for variety depressed populations: geriatric, adolescent, HIV-infected, marital discord • Can be combined with medication • Duration: 12 – 16 weeks • Efficacy demonstrated in randomized trials

50. What IPT does to the brain • Study of 28 pts with MDD found after 6 weeks of IPT vs venlafaxine increased blood flow in the right basal ganglia. In IPT group also saw an increase in posterior cingulate activity. • Underscored the importance of limbic and paralimbic recruitment in psychotherapy-medication mediated changes. Martin Sd. t al. Brain blood flow changes in depressed patients treated with interpersonal psychotherapy or venlafaxine hydrochloride: preliminary findings. 2001 Arc Gen Psych 58:641-648