May is Mental Health Month! Have I said that already? Anyway, this is yet another one of my Dirty Dozen lectures. It’s on Psychodynamic Psychotherapy.
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Dirty Dozen on Psychodynamic Psychotherapy by Jim Amos, MD
Psychodynamic Therapy Core Beliefs
-We feel and behave as we do for specific reasons.
-We’re often unaware of why we feel and behave in certain ways.
-Past experiences, often outside our awareness, determine how we feel about ourselves and our world.
-The need to master psychological pain is compelling and accounts for why many of us behave consistently and predictably in often self-defeating ways.
Psychodynamic Therapy Core Beliefs, cont.
-The power of the therapeutic relationship is built on the physician’s ability to provide a safe environment for examining emotions and psychological problems in a nonjudgmental, empathic way, i.e., rapport.
-The past experiences of both patient and therapist play a role in determining the power and valence (positive or negative) of the therapeutic relationship.
-Successful treatment must integrate both affective and cognitive components of patient’s self-awareness and includes supportive as well as interpretive interventions.
Essential Assumptions
-Maladaptive relationship patterns are learned in the past.
-Such maladaptive patterns are maintained in the present.
-Dysfunctional relationship patterns are reenacted in vivo in the therapy.
-The therapeutic relationship has dyadic quality.
-The therapeutic focus is on the chief problematic relationship pattern.
Behavior Is Not Haphazard
-Therapists ask “Why is the patient expressing this topic now?”
-Process communication (complementary to content)
-Listen for understanding
-Patients communicate on multiple levels and often indirectly
-Jokes, revelations at end of session, metaphors, sudden shifts in topic
Behavior Is Not Haphazard, cont.
-Resistance: Paradoxical phenomenon of ambivalence that all pts have about treatment
-Tends to provoke subtle, covert, and sometimes overt oppositional behavior that prevents deeper understanding of problems
-Protects pt against threatening feelings and fantasies
-A form of defense mechanism-a way of relating to internal and external worlds in an attempt to avoid unpleasant and strong feelings. There are both adaptive and maladaptive defense mechanisms
Defense Mechanisms
-Defenses (or resistance, which amounts to the same thing) are one of the three different means by which people cope with threats, the other two being social supports and cognitive coping strategies.
-Defenses are coping processes. They are unconscious distortions of inner and outer reality for protecting the ego from disorganizing anxiety and depression. They may seem odd. They may also mature over time.
-Confronting people with their defenses can be unwise. Recognizing them in order to make sense of otherwise inexplicable behavior and to make rough predictions about response to therapy is helpful.
Defense Mechanism Examples
-Denial: refusal to appreciate information about oneself or others
-Projection: attribution of conflicted thoughts or feelings to another or to a group of people
-Identification: patterning of oneself after another
The Past is Present
-Implicit memory and the need to avoid unpleasant, disruptive feelings
-May explain why some traumatic experiences are not accessible
-Transference & countertransference: responding to someone in the present as if that person were an important figure from the past.
-Used for corrective experiences and encouraging more adaptive behavior as pt becomes of aware of this phenomenon
Self-Defeating Behavior
-Making the same mistake repeatedly, e.g., marrying abusive, alcoholic partners
-Might understand this as attempts to master enduring conflict or trauma in order to finally resolve the painful experience
-Remembering can replace reliving-challenge of psychodynamic therapists is to foster this
Essential Operations of Psychodynamic Psychotherapy
-Accepting: Therapist affirms the pt’s past and present subjective experience.
-Understanding: Therapist appreciates both the conscious and unconscious contributions to the pt’s emotional problems.
-Explaining: Therapist expresses, through interpretations, his or her understanding to the pt.
References
-Core Competencies in Psychotherapy. The Art and Science of Brief Psychotherapies: A Practitioner’s Guide, eds. Dewan, Steenberg, Greenberg. APPI 2004
-Focus: The Journal of Lifelong Learning in Psychiatry. Psychotherapy. Ed. Jerald Kay, MD. Spring 2006. Vol. IV, No.2.
In keeping with May being Mental Health Month, here’s another slide set on psychotherapy. This one is on the basics of Cognitive Behavioral Therapy. Once again, it’s in WordPress shortcode. A few pointers: click in the lower right hand corner of the slide if you want to view the slides full size. Use the directional arrows on your keyboard to click through the slides. You can also just use the arrow handles on the slides if you don’t want to see them full size.
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Dirty Dozen on Cognitive Behavioral Therapy by Jim Amos MD
Origins of CBT
–Psychoanalytic theory dominant in 1960s
–A. Beck, the creator of CBT, was trained as a psychoanalyst
–Conducted experiments in late 1950s and early 1960s intended to support psychoanalytic constructs-found the opposite to be true
CBT Definitions & Assumptions
–Focused therapy based on model that psychological disorders involve dysfunctional or unhelpful thinking
–We often feel what we think and behave accordingly
–Assumes that modifying dysfunctional thinking improves or resolves symptoms
–Modifying dysfunctional beliefs that underlie dysfunctional thinking produces more sustainable change
Overview
–Pragmatic, action-oriented treatment approach
–Initially developed for depression and anxiety
–Empirically validated brief psychotherapy shown effective in over 350 outcome studies
–Effective in treatment of many medical and psychiatric conditions
Examples of Automatic Thoughts
–I should be doing better in life
–I’ve let him/her down
–I can’t handle it
–I feel like giving up
–Something bad is sure to happen
–I’ll never be able to get this done
Examples of Maladaptive Schemas
–I must be perfect to be accepted
–I’m a fake
–I’m unlovable
–I must always be in control
–Other people will take advantage of me I’m stupid
Key Behavioral Concepts
–Depressive behavior can be modified with behavioral techniques
–Exposure therapy and related methods can be effective interventions for anxiety disorders
–Behavioral interventions can be useful for helping patients improve coping, social, and problem-solving skills
Principles of CBT
–Overall goal is to help achieve remission of disorder by solving problems and relieving symptoms.
–Achieved through collaborative empiricism
–Approach which teaches patients to view reality more clearly by examining their distorted cognitions
–Correcting faulty ideas leads to improvement in mood and function
–CBT is educative in nature; it teaches patients to be their own therapists. CBT is goal oriented.
CBT Methods
–Socratic questioning
–Stimulate curiosity to engage in learning, less didacticIdentifying cognitive errors
–Thought change record
–Guided discovery-series of inductive questions to reveal unhelpful thought patterns
–Examining the evidence
–Generating rational alternatives
–Role play and rehearsal
Behavioral Methods Used in CBT
–Activity and pleasant event scheduling
–Graded task assignments
–Exposure and response prevention
–Relaxation training
–Breathing training
–Coping cards;example: suicide safety plans
References
–Dewan, M. J., MD,, B. N. Steenbarger, PhD,, et al., Eds. (2004). The Art and Science of Brief Psychotherapies: A Practitioner’s Guide. Core Competencies in Psychotherapy. Washington, DC, American Psychiatric Publishing, Inc.
–Garland, A., R. Fox, et al. (2002). “Overcoming reduced activity and avoidance: a Five Areas approach.” Advances in Psychiatric Treatment 8(6): 453-462.
–Temple, S., PhD, and S. Stuart, MD (2010). Psychotherapy for the hospitalized medically ill patient. Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry. J. J. Amos, M.D., and R. G. Robinson, M.D. New York, Cambridge University Press: 242-248.
References cont.
–Whitfield, G. and C. Williams (2003). “The evidence base for cognitive–behavioural therapy in depression: delivery in busy clinical settings.” Advances in Psychiatric Treatment 9(1): 21-30.
–Williams, C. and A. Garland (2002). “A cognitive–behavioural therapy assessment model for use in everyday clinical practice.” Advances in Psychiatric Treatment 8(3): 172-179.
–Williams, C. and A. Garland (2002). “Identifying and challenging unhelpful thinking.” Advances in Psychiatric Treatment 8(5): 377-386.
In observance of May being Mental Health Month, this is one of my Dirty Dozen lectures. It’s on the elements that are shared among some of the important psychotherapy methods.
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Dirty Dozen on Common Elements of Psychotherapy by Jim Amos, MD
What is Psychotherapy?
-Change facilitation
-Self awareness development
-Doesn’t necessarily have to occur in formal therapy encounters
-Can happen between patients and a wide range of professionals
Patient Variables and Relationship Factors
-Ability to relate, psychological mindedness
-Therapeutic alliance
-Readiness to change
-Respect, listening for understanding
Placebo, Hope, and Expectancy Effects
-Power of providing a “treatment experience”
-An emotionally charged relationship in which therapy instills hope for change
-A particular set of procedures that enhance belief in the therapist’s competency
-A therapeutic explanation of the problems that fits the patient’s belief system
Motivational Interviewing
-Intended to raise patient’s awareness of ambivalence between opposing thoughts and behaviors
-Accepts the “yes, but” responses without confrontation
-Emphasizes validation, reflection, reframing
-Source: Miller, W. R. and S. Rollnick (1991). Motivational interviewing : preparing people to change addictive behavior. New York, Guilford Press.
Motivational Interviewing cont. Stages of Readiness to Change
-Precontemplation
-Contemplation
-Preparation
-Action
-Maintenance
-Termination
Cognitive Behavioral Therapy (CBT)
-Foci of treatment are internally based cognitions and challenging, unhelpful or harmful thoughts and behaviors.
-Time limited
Interpersonal Therapy (IPT)
-Focus on interpersonal communications with others
-Focus on helping improve communication and social support in the present
-Time limited
Psychodynamic Psychotherapy
-Focus of treatment is on understanding contributions of early life experiences to psychological functioning and unhelpful or harmful behaviors
-Can be lengthy or open-ended
Essential Operations of Psychodynamic Psychotherapy
-Accepting: Therapist affirms the patient’s past and present subjective experience
-Understanding: Therapist appreciates both the conscious and unconscious contributions to the patient’s emotional problems
-Explaining: Therapist expresses, through interpretations, his or her understanding to the patient
Integrating Therapies
-Skillfully staged combinations of approaches may be more successful than one used alone
-Cognitive behavioral or interpersonal approaches first for more immediate symptom relief
-Psychodynamic approaches first for increasing self-awareness and exploring the need for change
References
-Dewan, M. J., MD,, B. N. Steenbarger, PhD,, et al., Eds. (2004). The Art and Science of Brief Psychotherapies: A Practitioner’s Guide. Core Competencies in Psychotherapy. Washington, DC, American Psychiatric Publishing, Inc.
-Miller, W. R. and S. Rollnick (1991). Motivational interviewing : preparing people to change addictive behavior. New York, Guilford Press.
May is Mental Health Month. This would be a good month for me to practice giving myself and others grace. Here’s a link to a very nice article about grace. It’s really about giving each other a break from slamming one another and letting go—sort of like what you need to do in juggling. The author of the article on grace suggests a short list of ways to practice grace. They’re just the guidance I welcome for Mental Health Month and any other month for that matter.
The one about compassion and forgiving myself and others is difficult to do. I should do it anyway.
Buttoning my lip before criticizing, complaining, or venting other harsh utterances is a nice way to avoid the slamming mode I see in the news every day.
It’s tough not to expect the worst from others, especially when you read the news. Hey, let’s stop reading the news.
I don’t get much recognition, and that’s actually a good thing. Sometimes the last thing I need is attention.
I can think of many persons who have probably gently and silently helped me over the years.
While it may feel good to get my digs in on people I don’t agree with, it’s not satisfying for very long. People do remember how you made them feel.
Let’s give each other grace. We all need a break.
Go Retire Psychiatrist 