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psychotherapies in psychiatry


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    DR.A.GODSON,MD( Psychiatry)
    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
  • 3. HISTORY
    Based 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.
  • 4. Melanie Klein, Winnicott, Fairbairn-Developed Psychoanalytic psychotherapy based on elaboration,modification and extension of Freudsideas.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
  • 5. 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
  • 6. Based on learning theories
    Skinners , Eyesenk– Behavioural therapy
    Wolpe – Systemic desensitization
    Becks – cognitive therapy
    Master Johnson – Sex therapy
  • 7. Based on conceptual space between Human potential
    movements & learning theories
    Rational emotive therapy
    Couple therapy-Nathan Ackerman
    Bereavement counseling
    Sex therapy
    Behavioural modification groups
    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
  • 9. 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
  • 10. 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
  • 11. 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
  • 12. Technique:
    Therapist predictably available.
    Interpretation used to strengthen defenses.
    Therapist maintains working reality based relationship based on support,concern and problem solving.
    Suggestion,reinforcement,advice,realitytesting,cognitivereconstructing,and reassurance.
    Psychodynamic life narrative.
  • 13. 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
    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
    Time-limited treatment- 10 to 12 sessions.
    Based on psychoanalysis and psychodynamic theory.
    Used for Depression, anxiety, and posttraumatic stress disorder.
    Franz alexander and thomasfrench identified the basic characteristics
    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
    Goal: Resolution of the present and chronically endured pain and the patient's negative self-image
    Selection criteria:
    High ego strengthAble 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
    Goal: Resolution of oedipal conflict, loss focus, or multiple foci
    Selection criteria
    Psychological-mindednessAt 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
    Goal: Resolution of oedipal conflict
    Selection criteria:
    Above-average intelligenceAt 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
    Created by josephpratt
    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
    Severlypsychotic,paranoid,excessively narcissistic should not be included
  • 21. 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
  • 22. 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
  • 23. 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.
  • 24. Types of group psychotherapy
    Supportive group therapy
    Analytically oriented group therapy
    Psychoanalysis of groups
    Transactional group therapy
    Behavioral group therapy
  • 25. Group psychotherapy effective for-
    Relationship difficulties
    Problems in groups
    Compulsive repetition of self depriving behavior
    General dissatisfaction with life
    Family therapy
    Marital counseling
    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.
    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
    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.
  • 29. 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.
    Clearly identifiable anxiety provoking stimulus- Phobias, obsessions, compulsions, and certain sexual disorders
  • 30. Therapeutic-Graded Exposure
    Relaxation training is not involved
    treatment is usually carried out in a real-life context
    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.
  • 31. 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
  • 32. 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
  • 33. 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
  • 34. 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 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
  • 36. 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
  • 37. 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
  • 38. 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
  • 39. 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
  • 40. Effective for:
    Obsessive compulsive disorder
    Anxiety disorder
    Eating disorders
    Panic disorder
    Post traumatic stress disorders
    Suicidal behaviour
    Somatoform disorders
    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,realisticbehaviour.
    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
    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
    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 biofeedback
    Techniques :
    Instrumentation, Jacobson progressive muscular relaxation ,Applied technique,
    Useful in : migraine, hypertension, phobia ,chronic pains, cerebral palsy, irritable bowel syndrome, asthma
    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.
    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.
  • 45. 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.
  • 46. 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 therapy
    Psychiatric illness requiring assessment for family therapy:
    Neurosis, adjustment disorders, conduct/emotional disorders of children, substance abuse, sexual dysfunction
    Major psychopathology in family.
    Extramarital/homosexual tendencies,
    Non availability of key family members
    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.
    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 life
    Unwillingness of one partner.
    Inability to control hostility in one or both partners.
    Paranoid partner,severe form of psychosis,
    When really want for divorce
  • 48. HYPNOSIS
    Anton Franz Anton Mesmer first described hypnosis as a therapeutic modality
    Sigmund Freud used hypnosis as part of his psychoanalysis,
    Ernst Simmela 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
  • 49. 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
  • 50. 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 (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
  • 52. 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.
    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.
    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
    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.
    Genuine &Respectful
    practical& interested
    relaxed and in control
    Able to finish the interview
    Common contraindications for psychotherapy
    Older age
    Low intelligence
    poor motivation
    Antisocial personality disorder
  • 57. 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.
    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
  • 58. THANK YOU