PSYCHOTHERAPIES

Types of Therapies
1- Psychoanalysis and Psychoanalitic Psychotherapy. 2- Brief Psychotherapy and Crisis Intervention. 3- Group Psychotherapy. Combined Individual and Group Psychotherapy Psychodrama. 4- Family Therapy and Couples Therapy. 5- Biofeedback Therapy. 6- Behavioral Therapy. 7- Hypnosis. 8- Cognitive Therapy. 9- Psychosocial Treatment and Rehabilitation. 10- Combined Psychotherapy and Pharmacotherapy.

General Guidelines for referral for Psychotherapies.

Exhibit enthusiasm. Choose a psychiatrist/psychologist you know and you could coordinate with personally. Present the referral as part of the patient ongoing medical care. Make an appointment for the psychiatric evaluation while patient is in your office. Be sure to schedule a follow-up with you to check on patients reaction towards the psychiatric evaluation. Unless the patient expresses explicitly refusing to work with a male/female therapist, the therapists gender is not an issue.

Psychoanalysis and Psychoanalytic Psychotherapy

S. Freud, M. Klein, D. Winnicott, R. Fairban, C.G. Jung...
It is a treatment derived from the psychoanalytic theory. It is also called Psychodymanic Psychotehrapy or Insight-Oriented Psychotherapy. It is intensive: one to 4 times a week. It is relatively long: 6 months to years. Expressive subtype: aims at interpreting unconscious conflicts and gain insight. Supportive subtype: aims at restoring and strengthening patients defenses and directing them. Expressive-Supportive Continuum: towards a healthy adaptive life.

Psychoanalysis and Psychoanalytic Psychotherapy Treatment Method

Therapeutic alliance: agreement and mutual commitment. Free Association: saying whatever comes to mind. Transference patients displacement of past attitudes and feelings on the therapist. Resistance: withholding relevant information consciously or unconsciously. Contertransference: therapist, feelings toward patients material. Interpretation: explanatory statement that brings unconscious feelings, thoughts, behaviors to the conscious. Confrontation: addressing something patient does not want to accept. Clarification: reformulation, pulling together of patients formulation. Encouragement to elaborate: open ended non directive questions. Advice and praise: suggestion and confirmation. Affirmation: succinct comments showing support.

Psychoanalysis and Psychoanalytic Psychotherapy Treatment Method

Expressive
Indication - Strong motivation to understand. - Tolerance to frustration. - Neurosis-character problems mild to moderate. - Ability for therapeutic alliance. - Psychosis. - Sever character disorder. - Lack of motivation. - Low IQ. - Severe life crisis. - Incapacity for therapeutic alliance.

Supportive
- Some motivation. - Ability for therapeutic alliance. - Accute illness. - Psychosis and severe character disorder. - Physical illness.

Conter Indication

Brief Psychotherapy and Crisis Intervention (1950)

F. Alexandre, Th. French, D. Malan, J. Mann. It is derived from psychoanalytic and learning theories. To answer the great pressure to contain treatment costs. To simplify research methodology on treatment efficacy. 5 to 40 sessions; average of 20 sessions. Specific Goal-Directed, g. Improving interpersonal skills, problem-solving, training, resolving oedipal conflict, developing adaptive responses to crisis.

Group Psychotherapy
It is a treatment in which carefully selected people who are emotionally ill, meet in group, guided by a trained therapist, and help one another effect personality change. It encompasses the theoretical spectrum of therapies in psychiatry: supportive, structured, cognitive behavioral, interpersonal, family, and analytically oriented groups. Duration can vary from weeks to years. Frequency is usually once a week for a pre-set one or two hours. It can be combined with individual therapy. Initial clinical evaluation is usually performed for suitability criteria and for preparation phase, essential for the therapy success. Size of the group may vary from 3 to 15, 8 to 10 individuals being the optimal size. Open v/s closed types of groups. Inpatient v/s out patient types of groups.

Group Psychotherapy
Learning from behavioral Patterns in the Social Microcosm of the Therapy Group. Display of interpersonal pathology. Feedback and self observation. Sharing reactions. Examining the results of sharing reactions. Understanding ones opinion of self. Developing a sense of responsibility. Realizing ones power to effect change. High affect potentates change. Problem spotting occurs. Isolation is decreased. Patient feels helpful.

Family Therapy and Couples Therapy

It is a special form of group therapy that come into common use in the 1950s. The therapists goal is to improve group interactions and thereby, help each member to function better, encouraging individual change and growth. - Frequency: usually once a week. - Duration of each session: a pre-set time of one to two hours. - A set of criteria is used to decide about treatment completion. These criteria are related to specific skills to be learned in therapy.

Family and Couple Therapy Models of Intervention

- Psychodynamic - Experiential Model: It may metaphorically be called family sculpting. Therapist tries to bond with each member and promotes clarity of communication and honestly admitted feelings. Feedback is given to increase insight, and towards the end, family members may be even encourage to change their seats, touch each other, and make direct eye-contact. - Bowen Model (Family Systems): The goal is to promote individuals to differentiate from their family of origin and to be their true selves in the face of familial or other pressures that threatens the loss of love or social position. Emotional. Triangles are identified and analyzed.

Family and Couple Therapy Models of Intervention

- Structural Model: The family is assessed in terms of significant alliances and splits among family members, hierarchy of power, clarity of boundaries, and family tolerance. - General Systems: Combination of the Bowen and the Structural Model. Families are assessed in their internal rules and external bowderies. Importance is given to the fact that every action in the family produces a reaction in one or more of its members.

Family and Couple Therapy Models of Intervention

- Conjoint Couple Therapy: Either one or two therapist treat the partners in joint sessions. Cotherapy with therapists of both sexes prevents a particular patient from feeling ganged up on. - Four Way Session: Each partner is seen by a different therapist with regular point sessions in which all four people participate.

Biofeedback Therapy
Neal Miller demonstrated the medical potential of biofeedback by showing that the normally unvoluntary autonomic nervous system can be operantly conditioned, by using appropriate feedback. By means of instruments (EMG, EEG, GSR,) the patient acquire information about the states of unvolontary biological functions, and learn to regulate these functions. Seeing the concrete biological change (i.e., the feedback) is expected to condition the person to better control the symptom.

Behavior Therapy
- It focuses on ameliorating peoples maladaptive behavior without theorizing about their inner conflicts. - Assessment focuses on observable factors that have been learned or conditioned, and can therefore be unlearned or unconditioned and replaced by new adaptive behavior. - It is based on the principles of Learning Theopy and Classical Conditioning. - It is usually directed at specific habits of reaching with anxiety to objectively non dangerous stimuli, such as phobias, compulsions, psychophysiological reactions, and sexual dysfunctions. - The duration is generally time limited, specific to specific targets. - Analysts have criticized behavior therapy by noting that simple symptom removal may lead to symptom displacement.

Behavior Therapy Treatment method

- Systematic Desensitization. Relaxion Training, Hierarchy Construction, Desensitization, Adjunctive Drug use. - Graded Exposure. Same as above without the relaxation training. - Flooding or confrontation: Remain in the fear generating situation until they care calm and feel a sense of mastery. - Participant Modeling: Role Play. - Assertiveness Training: The patient takes turn in the role play. - Postive Re-inforcement: Feed-back through verbal statements.

Hypnosis
History: Austrian physician Friedrich Mesmer (1734-1815) originated the phenomenon of hypnosis which he called mesmerism and believed to be the result of animal magnetism. Today, hypnosis is used as a form of therapy, a method of investigation to recover lost memories, and a research tool. Patients in hypnotic transe can recall memories that are unavailable to consciousness.

Hypnosis
Indications: - Obesity - substance related disorders- management of chronic pain - phobias - addictive behaviors. Contra indications: - Suspicious, paranoid, obsessive patients are not good candidates for hypnotherapy because of their need for control. - A secure ethical value system is essential in hypnotherapy as the patient may develop strong dependence or transference towards the therapist.

Cognitive Therapy
Aaron Beck: Cognitive Therapy is a short term (about 25 sessions) structured therapy that uses active collaboration between patient and therapist to achieve therapeutic goals. Depressive disorders have initially been the main focus of cognitive therapy. More recently, treatment models addressing other specific disorders have been developed.

Cognitive Therapy
Perception and experiencing in general are active processes that involve both inspective and introspective data. The patients cognitions represent a synthesis of internal and external stimuli. How persons appraise a situation is generally evident in their cognitions (thoughts and visual images). Those cognitions constitute their stream of consciousness or phenomenal field, which reflects their configuration of themselves, their world, their past and future.

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Cognitive Therapy
Alterations in the content of their underlying cognitive structures affect their affective state and behavioral pattern. Through cognitive therapy, patients can become aware of their cognitive distortions. Correction of those faulty dysfunctional constructs can lead to clinical improvement.

Primitive versus Mature Thinking

Primitive Thinking Nondimensional and global: I am fearful Mature Thinking Multidimensional: I am moderately fearful, quite generous, and fairly intelligent. Relativistic and Nonjudgmental: I am more fearful than most people I know.

Absolutistic and moralistic: I am a total coward.

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Primitive versus Mature Thinking

Primitive Thinking Invariant: I always have been and always will be a coward. Mature Thinking Variable: My fears vary from time and from situation to situation. Behavioral diagnosis: I avoid situations too much, and I have many fears. Reversibility: I can learn ways of facing situations and fighting my fears.

Character diagnosis: I have a defect in my character.

Irreversibility: Since I am basically weak, theres nothing that can be done about it.

Cognitive Therapy

Cognitive Techniques: - Eliciting Automatic Thoughts. - Testing Automatic Thoughts. - Identifying Maladaptive Assumptions. - Testing the validity of Maladaptive Assumptions. - Finding Alternative Adaptive Thoughts. - Behavior Modification. - Role Play and Imagery.

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Cognitive Errors Derived from Assumptions

Cognitive errors Overgeneralizing

Assumption If its true in one case, it applies to any case that is even slightly similar.

Intervention Exposure of faulty logic. Establish criteria of which cases are similar and to what degree. Use logic to identify successes patient forgot.

Selective abstraction

The only events that matter are failures, deprivation, etc. Should measure self by errors, weakness, etc.

Cognitive Errors Derived from Assumptions

Cognitive errors

Assumption

Intervention Disattribution Technique.

Excessive responsibility I am responsible for all (assuming personal bad things, failures, etc. causality) Assuming temporal causality (predicting without sufficient evidence) If it has been true in the past, its always going to be true.

Expose faulty logic. Specify factors that could influence outcome other than past events.

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Cognitive Errors Derived from Assumptions

Cognitive errors Self-references

Assumption I am the center of everyones attention- especially my bad performances. I am the cause of misfortunes.

Intervention Establish criteria to determine when patient is the focus of attention And also the probable facts that cause bad experiences. Calculate real probabilities. Focus on Evidence that the worst did not happen.

Catastrophizing

Always think of the worst. Its most likely to happen to you.

Cognitive Errors Derived from Assumptions

Cognitive errors Dichotomous thinking

Assumption Everything is either one extreme or another (black or white, good or bad).

Intervention Demonstrate that events may be evaluated on a continuum.

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Psychosocial Treatment and Rehabilitation

It involves the following aspects: - Social Skills Training: aiming at teaching the needed skills required for community survival, independence, relationships. Role playing and field training are used. - Milieu Therapy: it implies that a 24 hour a day program is tailored for the patient to help him manage his daily living. It also implies working with the primary care takers to provide help and support. - Rehabilitation: aiming at the reintegration of the patient in a community system where he can feel useful and interact constructively with others. Assessment of assets and weaknesses of the patient is essential.

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