Overview of Psychotherapies

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Overview of Psychotherapies

• Dr. Ravi Paul

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Psychotherapies

• Outline
• Definition
• Goals/aim of psychotherapy
• Different therapy modalities
• Indications contraindications and goals
• limitations

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psychotherapy

• Is defined as any psychological service provided
  by a trained professional that primarily uses
  form of communication and interaction to assess,
  diagnose and treat dysfunctional emotional
  reactions, ways of thinking and behavior
  patterns,( American psychological Association).

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Goals/aims

• 1. strengthening the patients motivation to do
  the right things
• 2. to reduce emotional pressure by facilitating
  the expression of the feelings
• 3. releasing the potential of patients for growth
  and development
• 4. helping in changing the undesirable and
  inappropriate habits
• 5. facilitate interpersonal relations and
  communication
• 6. changing the social environment of the patient
• 7. altering the presence state of unconsciousness.

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Therapy modalities

• Psychoanalysis derived from Sigmund Freuds
  psychoanalytic theory of the mind.
• Sigmund proposed that behaviors or symptoms
  results from unconscious mental process,
  including defense mechanism and conflicts between
  ones ego, identity, superego and external
  reality.
• Psychoanalysis is based on the theory of sexual
  repression and traces the unfulfilled infantile
  libidinal wishes in the individuals unconscious
  memories.

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Cont..

• It involves bringing to the surface repressed
  memories and feelings through scrupulous
  unraveling of hidden meanings of verbalized
  material and of the unwitting ways in which the
  patient wards off underlying conflicts through
  defensive forgetting and repetition of the past.

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Indications of psychoanalysis therapy

• Anxiety disorders
• Obsessional thinking
• Compulsive disorder
• Conversion disorder
• Sexual dysfunction
• Depressive states

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requirements

• Significant suffering must be present so that
  patients are motivated to make sacrifices of time
  and financial resources for psychoanalysis.
• Patients must have genuine wish to understand
  themselves, not a desperate hunger for
  symptomatic relief.
• Able to withstand frustrations, anxiety and other
  strong effects that emerge in the analysis
  without fleeing or acting out of their feelings
  in a self-destructive manner.
• Must have a reasonable, mature superego allow to
  be patient with the analyst.

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contraindications

• Absence of suffering
• Poor impulse control
• Inability to tolerate frustrations and anxiety
  and low motivation
• Presence of dishonesty or antisocial personality
  disorder contraindicates analytic treatment
• Concrete thinking or the absence of psychological
  mindedness
• Physical illness
• Close relationship with the analyst.

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Cont

• Goal to resolve unconscious conflicts by
  bringing repressed experiences and feelings into
  awareness and integrating them into the patients
  conscious experience.
• Duration 4-5 times per week and long
  term(several years)
• Setting the environment us designed to promote
  relaxation and regression.
• Use of a coach in reclining position, associated
  with sleep and eases the patients conscious
  control of thoughts.

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limitations

• Economic high cost in time and money for
  patients and training of future practitioner.
• Restricted to diagnostically, socioeconomically
  or intellectual advantaged patient population.

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QUESTIONS

• 1. What is the aim of psychotherapies?
• 2. Give 2 indications of psychoanalysis?

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Psychoanalytic psychotherapy (expressive)

• Is based on fundamentals dynamic formulations and
  techniques that derive from psychoanalysis.
• Is the use of insight-oriented method only
• Currently, its approach ranges from expressive
  (insight-oriented, uncovering, evocative or
  interpretive) techniques.
• Unlike in psychoanalysis, psychoanalytic rarely
  use a couch, instead is patient and therapist are
  face-to face.
• Duration generally slower and more variable than
  psychoanalysis.

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indications

• Psychopathology with mild to moderate ego
  weakening , examples neurotic conflicts, symptom
  complexes
• Disorders of the self, examples Narcissistic
  behavior disorders and Narcissistic personality
  disorders
• Patients with Borderline disorders

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Patient requisites

• well integrated egos
• Capacity to sustain and detach from a bond of
  dependency and trust
• Motivated, and generally able to temporarily
  tolerate doses of frustrations without
  compensating
• Must have the ability to manage the re-arousal of
  painful feelings outside the therapy hour without
  additional contact.

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Cont..

• Goal to increase the patient self-awareness and
  to improve object relations through exploration
  of current interpersonal events and perceptions.
• Limitations
• A general limitation of expressive psychotherapy,
  as ofpsychoanalysis, is the problem of emotional
  integration of cognitiveawareness.
• The primary danger for patients who are at the
  more disorganizedend of the diagnostic spectrum,
  however, may have less to do with the
  overintellectualization that is sometimes seen
  in neurotic patients than with thethreat of
  decompensation from or acting out of, deep or
  frequentinterpretations that the patient is
  unable to integrate properly.

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Supportive therapy

• This is a very directive method of psychotherapy,
  withthe focus clearly on existing symptoms
  and/or currentlife situations.
• The aims of the therapy arei. Correction of the
  situational problem.ii. Symptom
  rectification.iii. Restoring or strengthening
  defenses
• iv. Prevention of emotional breakdown.v.
  Teaching new coping skills.

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indications

• Patients with poor strength and whose potential
  to decompensate is high.
• Amenable patients
• Individuals with acute crisis or temporarily
  state of disorganization
• Patient with chronic severe pathology with
  fragile or deficient ego functioning (e.g latent
  psychosis)
• Patients who cognitive deficient and physical
  symptoms make them particularly vulnerable,
  unsuitable for insight-oriented approach
• Psychologically unmotivated individuals

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contraindications

• Rarely contraindicated
• Supportive therapy tend to be disregarded as
  relatively restricted and superficial.
• Limitations
• Superficial than depth approaches
• Because those patients attend therapy sessions
  intermittently andless frequently, the
  interpersonal commitment may not be as compelling
  on the part of either the patient or the
  therapist .

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Question

• 1.What are the aims of supportive therapy?

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Behavior therapy

• Behavioral therapy, pioneered by B. F. Skinner,
  seeks to treat psychiatric disorders by helping
  patients change behaviors that contribute to
  their symptoms.It can be used to extinguish
  maladaptive behaviors (such as phobic avoidance,
  compulsions, etc.) by replacing them with healthy
  alternatives.
• The time course is usually brief, and it is
  usually combined with cognitive therapy as CBT.

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Cont..

• Behavioral therapy is based on learning theory,
  which states that behaviors are learned by
  conditioning and can similarly be unlearned by
  deconditioning .
• The total duration of therapy is usually 6-8
  weeks.
• Initial sessions are scheduled daily but the
  later sessions are more spaced out.

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Important behavioral techniques

• Systematic desensitization The patient performs
  relaxation techniqueswhile being exposed to
  increasing doses of an anxiety-provoking
  stimulus.Gradually, he or she learns to
  associate the stimulus with a state of
  relaxation.
• Commonly used to treat phobic disorders.
  (Example A patient who has a fear of spiders is
  first shown a photograph of a spider, followed by
  exposure to a stuffed toy spider, then a
  videotape of a spider, and finallya live spider.
  At each step, the patient learns to relax while
  exposed to anincreasing dose of the phobia.)

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Cont..

• Aversion therapy A negative stimulus (such as an
  electric shock) is repeatedly paired with a
  specific behavior to create an unpleasant
  response.
• Used to treat addictions(e.g smoking) or
  paraphilias(e.g pedophilia.
• Example An alcoholic patient is prescribed
  Anti-abuse, which makes him ill every time he
  drinks alcohol.

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Cont..

• Flooding and implosion Through habituation, the
  patient is confronted with a real (?ooding) or
  imagined (implosion) anxiety-provoking stimulus
  and not allowed to withdraw from it until he or
  she feels calm and in control.
• Throughthe process of habitation, the person
  becomesaccustomed to the stimulus and is no
  longer afraid.
• Relaxation exercises are used to help the patient
  tolerate the stimulus.
• Example A patient who has a fear of ?ying is
  made to ?y in an airplane ?ooding or imagine
  ?ying implosion.

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Cont..

• Token economy Rewards are given after specific
  behaviors to positively reinforce them. Commonly
  used to encourage showering, shaving, and other
  positive behaviors in disorganized patients or
  individuals on addiction rehabilitation units .

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Cognitive therapy or cognitive behavior therapy

• Cognitive behavior therapy (CBT) is a type of
  psychotherapy which aims at correcting the
  maladaptive methods of thinking, thus providing
  relief from sequent symptoms.
• The therapist plays an active role, unlike in
  psychoanalysis .

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indications

• In treatment of depression, anxiety disorder,
  panic disorder, phobias, eating disorders,
  anticipatory anxiety, and also for teaching
  problem-solving methods.
• Also used in some centers for management of
  psychotic symptoms such as delusions and
  hallucinations .

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cont..

• A typical cognitive therapy schedule consists of
  about 15 visits over a three-month period.
• Techniques
• Cognitive techniques such as recognizing and
  correcting negative automatic thoughts, teaching
  reattribution techniques, increasing objectivity
  in perspectives, identifying and testing
  maladaptive assumptions, and decentering .

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Cont..

• Behavioral techniques such as activity
  scheduling, homework assignments, graded task
  assignment, behavioral rehearsal, role playing,
  and diversion techniques,
• Teaching problem-solving skills.

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Dialectical Behavioral therapy (DBT)

• DBT was developed by Marsha Linehan, and its
  effectiveness has been demonstrated in research
  trials. Once-weekly individual and group
  treatment can effectively diminish the
  self-destructive behaviors and hospitalizations.
• Effective in patients with borderline personality
  disorder.
• It incorporates cognitive and supportive
  techniques, along with the mindfulness derived
  from traditional Buddhist practice.

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Group therapies

• Three or more patients with a similar problem or
  pathology meet together with a therapist for
  group sessions. Involve the use of combined
  psychotherapies , including behavioral,
  cognitive, and supportive.
• Group therapy is useful in the treatment of
  substance use disorders, adjustment disorders,
  and personality disorders.
• Advantages of grouptherapy over individual
  therapy include Patients get immediate
  feedback and support from their peers.
  Patients gain insight into their own condition by
  listening to otherswith similar problem

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Family and Marital therapy

• In family therapy and marital therapy (also
  called ascouples therapy), the focus of
  intervention is not on the individual but is
  instead on the family as a unit or the marital
  unit.
• The goals of family therapy are to reduce
  con?ict, help members understand each others
  needs (mutual accommodation), and help the family
  unit cope with internally destructive forces.

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Cont..

• Couples therapy is useful in the treatment of
  con?icts, sexual problems, and communication
  problems within the context of an intimate
  relationship. The therapist sees the couple
  together (conjoint therapy), but they may also be
  seen separately (concurrent therapy).

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Hypnosis

• Hypnosis is a state of artificially induced (by
  self orothers) increased suggestibility.
• There is a constriction in the peripheral
  awareness with increased focal concentration on
  task at hand .

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indications

• As an adjunct to psychotherapy.
• Psychosomatic disorders
• Conversion disorder ( hysteria)
• Dissociative disorder
• Eating disorders ( anorexia nervosa,
  bulimianervosa and obesity)
• Habit disorders (smoking)
• Pain
• Anxiety disorders

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Relaxation therapies

• The aim of these therapies is to induce
  muscularrelaxation.
• Since anxiety produces muscular tension, which in
  turn reinforces (and thus increases) anxiety.

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techniques

• Jacobsons progressive muscular relaxationThis
  is the most frequently used technique.
• The patient first tenses and then relaxes major
  musclegroups of the body in a prefixed and
  systematic order, usually beginning at the top of
  the body and progressing downwards.

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Questions

• 1. Mention any 2 indications of hypnosis in
  psychiatry
• 2. mention the most frequent used relaxation
  technique?

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references

• Kaplan sadocks synopsis of psychiatry, 12th
  edition
• Psychiatry clerkship, 4th edition
• A short textbook of psychiatry, 20th edition
• American Psychological association