PSYCHOTHERAPY AND ITS CLINICAL IMPLICATIONS

PRESENTORDR.A.GODSON,MD( Psychiatry)

DEFINITION

Psychotherapy is the treatment, by psychological means ,of problems, of an emotional nature, in which a trained person deliberately establishes professional relationship with the patient ,with the object of

1.removing,modifying or retarding the existing symptoms

2.mediating disturbed pattern of behaviour and 3.promoting positive personality growth and

development

HISTORYBased on the concept of psychoanalysis Freud- Psychoanalysis,unconscious,defence

mechanisms which provided the first model of understanding and subsequent treatment of neurosis.

Carl Jung- analytical psychology based on interpretation of fantasy and dreams

Adler-Developed a theory called Individual Psychology which concerned with how the patients life style is developed. He also emphasized the social factors in human development.

Melanie Klein, Winnicott, Fairbairn-Developed Psychoanalytic psychotherapy based on elaboration,modification and extension of Freuds ideas.They defined that the basic drive is neither instinctual or purely social, but based on a desire to relate to others-to love and to be loved

Franz Alexander- Brief psychodynamic psychotherapy

Based on Human potential movements(therapy and theory aim to be accessible and useful for as many people as possible)

Carl Rogers- Developed Person centered therapy that based on every one is whole and good and well motivated .The task of the therapy is to draw this out.

Rolo May-Existential therapy Fitz perls- Gestalt therapy Janov –Primal therapy Jacob Moreno - Psychodrama

Based on learning theories Skinners , Eyesenk– Behavioural therapy Wolpe – Systemic desensitization Becks – cognitive therapy Master Johnson – Sex therapy

Based on conceptual space between Human potential movements & learning theories Rational emotive therapy Couple therapy-Nathan Ackerman Bereavement counseling Sex therapy Behavioural modification groups

PSYCHOANALYTIC PSYCHOTHERAPY

It based on psychoanalysis Use of insight oriented methods only. Two types of techniques-expressive

and supportive. Brief treatment for selected problem or

highly focused conflicts Long treatment for chronic condition or

intermittent episodes

PSYCHOANALYTIC METHOD INVOLVES FOLLOWING:

Free association: A technique in which invite the patient to say whatever thought came to their minds without censoring their thoughts

Transference: displacement of patients early feelings and wishes toward a person from past ,onto the therapist.

Countertransference: opposite to transference in which therapist’s feeling towards the patient

EXPRESSIVE PSYCHOTHERAPY One to three times a week for several sessions Patient and therapist face to face /couch can be

used to gain access to fantasy or dreams Indications and contraindications: mild to moderate

ego weakening including neurotic conflicts, nonpsychotic character disorders like narcissistic behavior disorder and narcissistic personality disorders,recommended for borderline personality disorder

Goals : to increase the patient's self-awareness ,to improve object relations through exploration of current interpersonal events and perceptions.

Major techniques: Limited free association, confrontation, clarification, and partial interpretation

SUPPORTIVE PSYCHOTHERAPY Chief form used in the general practice of

medicine and rehabilitation, frequently to augment extratherapeutic measures

Goal: to support reality testing, to provide ego support, maintain or reestablish usual level of functioning.

Selection criteria: very healthy patient faced with overwhelming crisespatient with ego deficits

Duration : days, months, or years—as needed

TECHNIQUE:

1. Therapist predictably available. 2. Interpretation used to strengthen defenses. 3. Therapist maintains working reality based

relationship based on support,concern and problem solving.

4. Suggestion,reinforcement,advice,reality testing,cognitive reconstructing,and reassurance.

5. Psychodynamic life narrative.6. Medications 

INDICATION For those patients for whom classic psychoanalysis or

insight-oriented psychoanalytic psychotherapy is typically contraindicated ,poor ego strength, potential for decompensation is high.

Amenable patients fall into the following major areas: (1) acute crisis or a temporary state of disorganization

and inability to cope whose intolerable life circumstances have produced extreme anxiety

(2) patients with chronic severe pathology with fragile or deficient ego functioning

(3) patients whose cognitive deficits and physical symptoms make them particularly vulnerable and, thus, unsuitable for an insight-oriented approach

(4) individuals who are psychologically unmotivated, although not necessarily characterologically resistant to a depth approach

INDICATIONS

EXPRESSIVE SUPPORTIVE

Strong motivation to understand

Significant suffering Tolerance for frustration Capacity for insight Intact reality testing Meaningful object

relations Good impulse control Ability to sustain work Reflective responses to

trial interpretations

Significant ego defects of a long-term nature

Severe life crisis  Poor frustration

tolerance Lack of insight Poor reality testing Severely impaired

object relations Poor impulse control Low intelligence Organically based

cognitive dysfunction

BRIEF PSYCHODYNAMIC PSYCHOTHERAPY

Time-limited treatment- 10 to 12 sessions.

Based on psychoanalysis and psychodynamic theory.

Used for Depression, anxiety, and posttraumatic stress disorder.

Franz alexander and thomas french identified the basic characteristics

MALAN AND THE TAVISTOCK GROUP: BRIEF FOCAL PSYCHOTHERAPY   Goal: Clarify the nature of the defense, the

anxiety, and the impulseLink the present, the past, and the transference

Selection criteria : Patient able to think in feeling termsHigh motivation,Good response to trial interpretation

Duration: Up to one year,Mean of 20 sessions Focus: Internal conflict present since childhood Termination: Set definite date at beginning of

treatment

MANN: TIME-LIMITED PSYCHOTHERAPY Goal: Resolution of the present and chronically

endured pain and the patient's negative self-image Selection criteria: High ego strength

Able to engage and disengageTherapist quickly able to identify a central issueExcludes major depressive disorder, acute psychosis, and borderline personality disorder

Duration: 12 treatment hours Focus: Present and chronically endured pain

Particular image of the self Termination :Specific last session set at beginning

of treatment,Termination is a major focus of the therapy work

DAVANLOO: SHORT-TERM DYNAMIC PSYCHOTHERAPY

Goal: Resolution of oedipal conflict, loss focus, or multiple foci

Selection criteria Psychological-mindedness

At least one past meaningful relationshipAble to tolerate affectGood response to trial transference interpretationHigh motivationFlexible defensesLack of projection, splitting, and denial

Duration: usually 5–25, Longer durations for seriously ill

Termination: No specific termination date Patient is told that treatment will be short

SHORT-TERM ANXIETY-PROVOKING PSYCHOTHERAPY   Goal: Resolution of oedipal conflict Selection criteria: Above-average intelligence

At least one past meaningful relationshipHigh motivationSpecific chief complaintAble to interact with evaluatorAble to express feelingsFlexible

Duration: A few months Focus: Oedipal conflict Termination: No specific date given

GROUP PSYCHOTHERAPY Created by joseph pratt The main aim is to increase personal knowledge and

understanding when relating with others thus permanent change in attitudes.

Duration: 6-18 months , weekly once or twice meeting last for 90 mts

Organising group psychotherapy After selection of patient he should be examined

individually by the conductor Patients should not meet socially outside the hospital Any significant life change should be informed to the

group Repeated disruptive behavior may lead to expulsion from

the group Severly psychotic,paranoid,excessively narcissistic

should not be included

THERAPEUTIC PHENOMENA COMMON TO ALL GROUPS

Cohesiveness-The feeling of belonging to and being accepted by the group which is essential for curiosity and self revelation

Interaction- By observing their own and each others behavior their awareness and insight is increased which was motivated by interaction

Universality- Members discover that others are very similar to them in feelings and actions. This counters the fear of being singled out for criticism and leads to trusting ,sharing

CONT….

Hope- if one person is discouraged ,others may increase the hope by encouragement

Guidance- Either by example or directly members make suggestions to one another

Vicarious learning- everyone has the chance to learn some idea or difficulty from others

Corrective emotional experience-some person in the group may be identified as parent figure

Stages in the life cycle of groups Dependency- Anxiety is at its highest when

the group forms ,due to expectation of who is the leader ,what are the rules. Such anxiety leads to find out some person as leader

Conflict- Lateness,absence,non-cooperation, aggressive criticism, of other members are characteristic of this stage. If the stage passed successfully trust and tenderness developed.

Intimacy-little by little reality creeps into groups. The surest sign of this stage is that opposites can be allowed to exist together, thus avoiding childlike extremes.

TYPES OF GROUP PSYCHOTHERAPY

Supportive group therapy Analytically oriented group therapy Psychoanalysis of groups Transactional group therapy Behavioral group therapy

Group psychotherapy effective for- Relationship difficulties Problems in groups Compulsive repetition of self depriving

behavior General dissatisfaction with life Family therapy Marital counseling

PSYCHODRAMA

Method of group psychotherapy Viennese-born psychiatrist Jacob moreno Personality makeup, interpersonal relationships,

conflicts, and emotional problems are explored by means of special dramatic methods.

Therapeutic dramatization of emotional problems includes the

Following roles: Protagonist -patient in conflict Auxiliary egos- persons who enact varying aspects

of the patient,who represent some experience of pt The director- psychodramatist, or therapist, the

person who guides those in the drama toward the acquisition of insight.

BEHAVIOUR THERAPY Based on theory of learning which Explains how

behaviours are learned and unlearned. It views symptoms as a part of behavior which have

maladaptive learning. Behavioral views differ from cognitive views in holding

that physical, rather than mental, events control behavior.

Aim : To abolish an undesirable response to a normal life stimulus and replace it with desirable behavior.

Three phases of behavioural analysis Identification of nature of the problem that the trigger of

the behavior ,the behavior itself,and the consequences. Intervention at a particular target point of maladaptive

behavior Impact of the behaviour on life style ,relationships

SYSTEMATIC DESENSITIZATION Developed by Wolpe, based on the behavioral

principle of counterconditioning.Relaxation Training: Most methods use so-called progressive relaxation,

developed by the psychiatrist Edmund Jacobson. Suggestions to relax major muscle groups in a fixed

order, beginning with the small muscle groups of the feet and working cephalad or vice versa

Relaxation produces physiological effects opposite to those of anxiety

Hierarchy Construction: determine all the conditions that elicit anxiety, then patients create a hierarchy list of 10 to 12

scenes in order of increasing anxiety.

CONT…

Desensitization of the Stimulus: patients proceed systematically through the

list from the least, to the most, anxiety-provoking scene while in a deeply relaxed state.

Indications: Clearly identifiable anxiety provoking

stimulus- Phobias, obsessions, compulsions, and certain sexual disorders

THERAPEUTIC-GRADED EXPOSURE

Relaxation training is not involved treatment is usually carried out in a real-life context

Flooding Similar to graded exposure but no hierarchy. Based on the premise that escaping from an anxiety-

provoking experience reinforces the anxiety through conditioning. Thus, clinicians can extinguish the anxiety and prevent the conditioned avoidance behavior by not allowing patients to escape the situation.

No relaxation exercises are used. Contraindicated when intense anxiety would be hazardous

to a patient e.x, Those with heart disease or fragile psychological adaptation.

Implosion or imaginal flooding is a variant of flooding in which the feared object is confronted only in the imagination.

Participant Modeling In participant modeling, patients learn a new

behavior by imitation, primarily by observation Useful with phobic children who are placed with other

children of their own age and sex who approach the feared object or situation. Used successfully with agoraphobia

Assertiveness Training Assertiveness is defined as follows: Assertive

behavior enables a person to act in his or her own best interest, to stand up for herself or himself without undue anxiety, to express honest feelings comfortably, and to exercise personal rights without denying the rights of others

Social Skills Training: Conversation, conflict management,

assertiveness, community living, friendship and dating, work and vocation, and medication management.

Useful in negative symptoms in patients with schizophrenia,depression,social phobia.

Aversion Therapy When a noxious stimulus (punishment) is

presented immediately after a specific behavioral response, theoretically, the response is eventually inhibited and extinguished.

Used for alcohol abuse, paraphilias, behaviours with impulsive and compulsive qualities, Opioid addicts

Positive Reinforcement When a behavioral response is followed by a

generally rewarding event, such as food, avoidance of pain, or praise, it tends to be strengthened and to occur more frequently than before the reward. Combined with Social Skills Training used in schizophrenia

Sex therapy Developed by William Masters and Virginia Johnson,

is a behavior therapy technique used for various sexual dysfunctions, especially male erectile disorder, orgasm disorders, and premature ejaculation. It uses relaxation, desensitization, and graded exposure as the primary techniques

Advantages of behaviour therapy: used successfully for a variety of disorders and can be

easily taught It requires less time than other therapies and is less expensive to administer 

Behaviour therapy –use in psychiatric disorders Anxiety disorder Agoraphobia and panic disorder Social phobia& simple phobia Obsessive- compulsive disorder Post traumatic stress disorder Mood disorder&schizophrenia Somatoform disorder Eating disorders Psychosomatic &psychosexual disorders Substance abuse Conduct disorder&ADHD

COGNITIVE THERAPY

Cognitive therapy is a short-term, structured ,therapy that uses active collaboration between patient and therapist to achieve its therapeutic goals, which are oriented toward current problems and their resolution.

It is designed to change the behaviour directly as many behaviours are maintained by consequences

Abnormal thinking is due to Intrusive thoughts(automatic thoughts)-provoke an

immediate emotional reaction Dysfunctional beliefs and attitudes-Determine the

way of perceiving and interpreting situations. Maintained by-selective attention to unfavorable

outcome,thinking illogically ,safety seeking behaviour

General features of CBT Pt is an active partner ,therapist only guides the pt Attention to provoking & maintaining factors by ABC

approach-anticidents,behaviour,consequences.The main aim of therapy is to break this chain.

Making attention to way of thinking by daily thought records

Investigation itself make insight to problems and gives solutions.Even failure also have benefits

Pt given with home work assignments and behavioural experiments

The highly structured sessions involves-review,teaching,summarization

Progress should be monitored Treatment manuals should be given to patient

Cognitive model of information processing

Perception of an event ↓ Activation of relevant schema ↓ Altered information processing ↓ Automatic thoughts ↗ ↙ ↖ ↘Behavioural symptoms ↔ Emotional symptoms

Schemas-Relatively stable cognitive pattern that are the result of

ones beliefs,attitudes and behaviour

COGNITIVE DISTORTIONS Arbitrary inference - Drawing a specific conclusion

without sufficient evidence     Specific abstraction- Focus on a single detail while

ignoring other, more important aspects of an experience    

Overgeneralization - Forming conclusions based on too little and too narrow experience

Magnification and minimization – Over or undervaluing the significance of a particular event    

Personalization - Tendency to self-reference external events without basis    

Absolutist, dichotomous thinking - Tendency to place experience into all-or-none categories

.

BECK’S TRIAD

Aaron Beck postulated a cognitive triad of depression that consists of (1) views about the self—a negative self-precept; (2) about the environment—a tendency to experience the world as hostile and demanding, and (3) about the future—the expectation of suffering and failure. Therapy consists of modifying these distortions

Effective for: Depression Obsessive compulsive disorder Anxiety disorder Eating disorders Schizophrenia Phobias Panic disorder Post traumatic stress disorders Suicidal behaviour Somatoform disorders

REEDUCATIVE PSYCHOTHERAPYCLIENT CENTRED THERAPY Developed by Carl Rojers. The therapy is based on the

idea that a human being is possessed of innate goodness and actualizing tendencies ,leading to a balanced,realistic behaviour.

The guiding principle of this therapy is oriented around the fact that the client is the one responsible for his own destiny and he possesses the right choice to solve his own problems, irrespective of the choice of the therapist

Therapy consist of : Attentive listening of clients feeling and contents, accepting it in a tolerant nonjudgemental way, avoiding any attempt to impose directions,

Effective for: general dissatisfaction in life, difficulties due to painful past events, relationship difficulties, bereavement, adjustment to illness

CRISIS INTERVENTION The crisis may precipitate around any incident

that overwhelms ones coping capacities. During that time the immediate response is denial ,accompanied by numbness and detachment. The mind attempt to protect itself by repressing what had happened.

Goal: Main goal is rapid emotional relief but not basic personality modification. Normally six therapy is sufficient

Techniques: Reassurance, confrontation, narcoanalysis, environmental manipulation, hypnotic probing, guidance ,psychotropic medications, at times brief hospitalization

BIOFEEDBACK Useful for those who are fearful of the labels of psychotherapy

and psychiatric illness. Biofeedback involves the recording and display of small

changes in the physiological levels of the feedback parameter. The display can be visual, such as a big meter or a bar of lights, or auditory. Patients are instructed to change the levels of the parameter, using the feedback from the display as a guide.

Biofeedback is based on the idea that the autonomic nervous system can come under voluntary control through operant conditioning. In which the person is gradually learns to how to protect the physiological effects of distress.

Neal Miller demonstrated the medical potential of biofeedbackTechniques : Instrumentation, Jacobson progressive muscular

relaxation ,Applied technique,Useful in : migraine, hypertension, phobia ,chronic pains,

cerebral palsy, irritable bowel syndrome, asthma

FAMILY THERAPY Family therapy can be defined as any psychotherapeutic

endeavor that explicitly focuses on altering the interactions between or among family members and seeks to improve the functioning of the family as a unit, or its subsystems, and/or the functioning of individual members of the family.

Goals: To resolve or reduce pathogenic conflict and anxiety within

the matrix of interpersonal relationships; To enhance the perception and fulfillment by family members

of one another's emotional needs; To promote appropriate role relationships between the sexes

and generations; To strengthen the capacity of individual members and the

family as a whole to cope with destructive forces inside and outside the surrounding environment;

To influence family identity and values so that members are oriented toward health and growth.

Techniques: Initial consultation to overcome the resistance due

to fears by parents that they will be blamed for their child's difficulties, that the entire family will be pronounced sick, that a spouse will object, and that open discussion of one child's misbehavior will have a negative influence on siblings.

Avoiding free association and careful channeling of identified problems in family between family members.

Sessions held for once a week lasting for 2 hrs.

Indications: Problems in relationship within family-primary marital

discord,communication gap. Interdependence of symptoms-wifes depression being

contigent on husbands alcoholism. Emotional disorder in child resulting from conflicting

parents. Failure of individual therapyPsychiatric illness requiring assessment for family therapy: Neurosis, adjustment disorders, conduct/emotional

disorders of children, substance abuse, sexual dysfunction

Contraindications: Major psychopathology in family. Extramarital/homosexual tendencies, Non availability of key family members

COUPLE THERAPYGoal: The goals of therapy for partner relational problems are to

alleviate emotional distress and disability and to promote the levels of well-being of both partners together and of each as an individual.

Indications: Problems in communication between partners are a prime

indication for couples therapy. Unresolved conflict or stress in relationship. One partner having mental illness resulting in emergence of

symptoms in healthy partner when the sick on starts resolving. Difficult or failed individual therapy. Conflicts in one or several areas, such as the partners' sexual lifeContraindication: Unwillingness of one partner. Inability to control hostility in one or both partners. Paranoid partner,severe form of psychosis, When really want for divorce

HYPNOSIS Anton Franz Anton Mesmer first described hypnosis

as a therapeutic modality Sigmund Freud used hypnosis as part of his

psychoanalysis, Ernst Simmel a German psychoanalyst, developed a

technique for accessing repressed material that he named hypnoanalysis.

Definition: Hypnosis is currently understood as a normal activity of a normal mind through which attention is more focused, critical judgment is partially suspended, and peripheral awareness is diminished.

The process of hypnosis takes the hypnotizability trait and transforms it into the hypnotized state

Experiencing the hypnotic concentration state requires a convergence of three essential components:

Absorption - is an ability to reduce peripheral awareness that results in a greater focal attention.

Dissociation - is the separating out from consciousness elements of the patient's identity, perception, memory, or motor response as the hypnotic experience deepens.

Suggestibility - is the tendency of the hypnotized patient to accept signals and information with a relative suspension of normal critical judgment

Indications Hypnosis are clinically useful in diagnosis

and in treatment. Facilitating acceptance of new thoughts and

feelings makes it useful in treating habitual problems and also with symptom management.

Smoking, overeating, phobias, anxiety, conversion symptoms, and chronic pain are all indications for hypnosis

Hypnosis can also aid in psychotherapy, notably for posttraumatic stress disorder, and it has been used for memory retrieval

INTERPERSONAL PSYCHOTHERAPY Interpersonal psychotherapy (ITP), a time-limited treatment

for major depressive disorder tested in randomized clinical trials by Gerald L. Klerman and Myrna Weissman.

The overall goal of ITP is to reduce or eliminate psychiatric symptoms by improving the quality of the patient's current interpersonal relations and social functioning.

The typical course of ITP lasts 12 to 20 sessions over a 4- to 5-month period.

ITP moves through three defined phases: (1) The initial phase is dedicated to identifying the problem

area that will be the target for treatment (2) The intermediate phase is devoted to working on the

target problem area(s)(3) The termination phase is focused on consolidating gains

made during treatment and preparing the patients for future work on their own

Common interpersonal problem areas: Grief -Complicated bereavement after the death of a loved one Interpersonal deficits -A history of social impoverishment,

inadequate or unsustaining interpersonal relationships Role transitions -Economic or family change—the beginning or end

of a relationship or career, a move, promotion, retirement, graduation, diagnosis of a medical illness

Interpersonal role disputes -Conflicts with a significant other—a partner, other family member, coworker, or close friend

Group format of interpersonal therapy ITP delivered in a group format has many potential benefits in

comparison with individual treatment. For example, a group format in which membership is based on diagnostic similarity (e.g., depression, social phobia, eating disorders) can help alleviate patients' concerns that they are the only one with a particular psychiatric disorder, while offering a social environment for patients who have become isolated, withdrawn, or disconnected from others. Group size consists of 6-9 members lasts for 20 sessions over a 5 months period.

GESTALT THERAPY It’s a type of reconstructive psychotherapy based on post

Freudian psychoanalytic method. According to this theory ideally an object (figure)and its

field(ground) should blent in harmonious assemblage(gestalt).

The therapy requires a search for repressed material, the mechanism through which repression is maintained ,as well as the specific needs of the repression.

To organize a mature figure-ground gestalt the dissociated aspects of an individual should be restored to his total being. Guidance in bringing these to awareness is the important step.

Empty chair technique: The pt was urged to imagine a parental figure or any important figure sitting in nearly empty chair and then talk to reproach or question the imaginary occupant, followed by changing the seats and acting the part of the person known as role reversal.

TRANSACTIONAL ANALYSIS

Suggested by Eric Berne . There are 3 different ego states in every person:

Child within a person, Parent, Grownup mature reasonable adult self.

Each of these aspects perceives the reality differently. The 3 are constantly operating in response to the need of a person and the kinds of past times.

During therapy the 3 ego states are displayed in the relationship with the therapist, are interpreted to the patient. The function of the child and the parent within the pt and the origin of these in life history are ventilated. Ultimately the adult becomes stronger by displacing the child and parent

EXISTENTIAL THERAPY

This is more philosophical than form of psychotherapy developed by Rollo may. Existential therapy seeks to understand how something is experienced by person himself instead of interpretation designed to fit a patients experience into a particular framework.

Aim: To help the pt to discover their own response to life and to be able to accept life’s limitations and possibilities.

Technique: Exploration through honest reflection ,of the attitudes, feelings, and world view of the pt

Effective for- Dissatisfaction with life, interest in growing as a person, and realizing personl potential.

CHARACTERISTICS OF GOOD ENOUGH THERAPIST

Genuine &Respectful Encouraging Understandable sensitive practical& interested relaxed and in control Confidential Able to finish the interview

Common contraindications for psychotherapy Older age Low intelligence poor motivation Antisocial personality disorder

Conclusion: No psychotherapeutic method exists today that is

acceptable to all patients or easy to operations for all therapists. The technique by which transformation comes about accord with the skill of the therapist who applies them and with the facility of the patient to accept & utilize preferred interventions .Since psychotherapy is a learning process ,it works best if the patient coordinate with his unique method of learning.

References Kaplan and Sadock’s Synopsis of Psychiatry Text book of postgraduate Psychiatry-Ahuja Thorson’s principles of Psychotherapy-Brice Avery Short text book of Oxford

THANK YOU