Psychotherapy Flashcards
What is psychotherapy and what are the types?
The systematic use of a relationship between a patient and a therapist - as opposed to physical and social methods - to produce changes in feelings, cognition and behaviour.
Use of work patient - one who suffers. Client may inmply transactional, financial basis
Type A - psychological treatments as an integral part of mental health care, not a psychotherapist
Type B - Eclectic psychological therapy & counselling. Very flexiable, probably not of one type
Type C - Formal psychotherapies, a specialist intervention
- *Congnitive-behaviour therapy** (CBT)
- *Psychoanalytic/psychodynamic therapies**
- *Systemic and family therapies** - look at invididuals within a system
Describe Fredian Theory.
Topographical Model
- *Conscious** level : Thoughts, perceptions
- *Paraconscious**: Memories, stored knowledge
- *Unconscious** level: Fears, violent motives, unacceptable sexual desires, irrational wishes, selfish needs, shameful experiences
Id, Ego, Superego
- *Id** : Basic urges like anger and desire which are almost animalistic. Buried in the unconsciousness.
- *Superego**: Similiar to conscience - ideas taken on about how you want to behave and is very demanding. Accessable to consciousness.
- *Ego** : rational part of the personality that is trying to reconcile the two sides. Accessable to consciousness.
What are the Ego’s defence mechanisms?
The ego sometimes has difficulty reconciling to Id and and Superego. It provides defence mechanisms to help manage this.
Repression: Deployed by the ego to stop disturbing thoughts from becoming conscious.
Denial: Blacking extenal events from awareness
Projection: Attributing unnaceptable thoughts, feelings, or motives to another person
Displacement: Satisfying an impulse with a substitute object
Regression: Acting child-like when facing stress
Sublimation: Satisfying an impulse, but in a socially acceptable ways
When these are excessive, or too rigid, can be problematic
What did Bowlby, Winnicot and Malan contribute to Freudian theory?
Developed the concept of attachment.
Intenal working model
The first relationship provides that infant with an attachment template
Continuity Hypothesis
The attachment behaviours in the internal working model continue to follow the same template in the future
Attachment, identity and emotions are increasingly seen as interlinked and are all adversely affected by childhood abuse or neglect.
Malan triangles
One triangle involves the hidden feelings (urges, memories), and the defence mechanisms that try to control the anxiety. The therapist will try and understand the defence menchanisms to see what is going on in the unconsious. By making them consious, which can be very destressing, one can begin to make changes, but this must be done within a very trusting relationship.
Another triangle descriebs how events of the past might be projected onto the present by transferrence.
Define transference and counter transference
Transference
Unconsious transfer of feelings and attitudes from the past into the therapist.
Someone with recurrent problems will replay some of those problems in your relationship. They will transfer only to therapist some things that might be better understood in relationship to the past…
…Seeing things through the eyes of the past
The therapist will try and spot the transference e.g. irritation, anxiety and work out how it relates to unconscious / early life.
Counter transference
All the feelings the therapist has in relation to the patient. They will potentially relate some of their feelings onto the patient, so the therapist needs to know what their stuff is.
Therefore all have to undertake their own therapy.
What does psychodynamic psychotherapy attempt to do?
Classical psychoanalysis is a long term, intensive treatment (most days of the week over many years) that attempts to restructure the entire personality. It is usually not available within the NHS.
The psychodynamic psychotherapy approach is a less frequent treatment (once or twice weekly sessions of usually 50 minutes), which may be brief (from 4 months, to a year or more) or long-term, and is often a more focused therapy (aiming for circumscribed character and behaviour change).
Based on psychoanalytic therapy that has developed over time, taken in attachment theory and object relations theory and become briefer with a focus on transference
The therapy centres on the evolution of conscious understanding, primarily by interpreting what the patient does and says through the inter-subjectivity of the therapeutic relationship. It thus addresses issues of transference and psychological defence mechanisms.
Therapy sessions are unstructured and the therapist takes a position of benign neutrality having had their own personal therapy to become aware of the emotional issues that they bring into the therapeutic relationship.
The patient’s emotional experience of the therapist being able to tolerate thoughts and feelings previously considered intolerable may also be a significant therapeutic factor.
Such therapies aim for the resolution of unconscious conflict and increased understanding of personal problems which may consequently initiate symptomatic change
It has less evidence base than CBT but more difficult to do the research. Not necessarily ineffective.
Used in recurrent and chronic inter-personal difficulties and psychological conflict or alienation
The presenting problem is understood in the light of past experience (e.g. childhood trauma or deficiency) and the dynamics of the internal world (hence psychodynamic)
Try and understand what patients present with in terms of their past and their ‘internal world’ i.e. their unconscousness
It can helpfully contribute to the management of personality disorders (whose roots are in early life), depression, eating disorders and some presentations of anxiety disorders.
How does behaviour therapy work?
Eposure therapy (systemic desensitisation): Graded, focused, prolonged, repeated exposure
- First exposure is very stressfull. Resolves more quickly if you run away, but this reinforces the neurosis
- The therapist does not not reassure, they encourages to go with it.
- Encourage focusing on the things that are difficult and rate anxiety
- After 5 exposures anxiety is markedly reduced - extinctive learning.
- Get people to overlearn - push them beyond what they want to do on a day to day basis as then they will be well adjusted
- Focus on the anxiety, not getting away - not a nice experience so not everyone wants to engage
- Patient must trust the therapist. Not forcing, need self-efficacy, not dependence, so they can deal after the therapy.
Flooding
Rapid exposure to the phobic object without any attempt to reduce anxiety beforehand. Continuous exposure is given until the anxiety deminishes
Relaxation Therapy
Particularly good in stress and anxiety disorders.
Asked to use techniques causing muscle relaxation during times of stress and anxiety
They also learn to imagine themselves in situations that they find relaxing
Exposure and response prevention
Particularly good for OCD and phobias
Patients are repetedly exposed to the situation which causes anxiety and are prevented from performing the compulsive actions which lessen anxiety.
Levels of anxiety gradually habituate and decline
Behavioral activatoin
Used for depression. Patients avoid doing thigns as they feel they will not enjoy them or fear failure in completing them.
Involves making realistic and achieveable plans to carry out activities and then gradually increasing the amount of activity.
Describe the CBT model
Behavioral therapies are based on learning theory. recognising conditioning and operant learning.
It uses techniques usually involving some form of exposure to reduce avoidance and permit habituation. It remains the treatment of choice for simple phobic disorders and for sexual dysfunctions and has a role in other anxiety disorders, eating disorders and depression.
Cognitive therapy directly addresses the role of dysfunctional thoughts and beliefs in producing and maintaining undesirable emotional states and behaviours. It is a very structured, problem orientated and time limited therapy (usually requiring between 6 and 15 weekly sessions each of an hour) aiming for defined symptomatic change.
An explicit formulation of the origin and maintenance of the patient’s problems is developed which guides therapeutic intervention. The therapy is very active and the patient will complete homework tasks (e.g. experimenting with new behaviours, identifying and challenging negative thoughts, collecting evidence for or against beliefs, etc.) between sessions.
The aim is to help challenge automatic negative thoughs and then to modify any abnormal underlying core beliefs - this reduces relapse
There is a good evidence base for its use in depression, various anxiety disorders and eating disorders. There is a developing evidence as part of a comprehensive package in schizophrenia and bipolar affective disorder.
Interaction between thoughts, emotions, physiology, behavior, triggered by the environment
Anxiety
- Formulate a model that explains the response
- Reduce avoidance
- Cease safety-seeking behaviours
- Exposure
- Test (and consequently change) beliefs (by real-life experiences)
Depression
- Tackle rumination and the vicious cycle of reduced activity - do activity scheduling and pace gradually
- Deal with Beck’s cognative triad: -ve views about world, self and future. Encourage degree of hope.
Also good for eating disorders and sexual dysfunction. Also as adjunctive treatement in psychotic symptoms.
Describe systemic and family therapy
These approaches have their roots in anthropology and cybernetics.
They do not view symptoms or insight as an appropriate focus for treatment intervention, but instead target the system that generates the problematic behaviour. This is classically seen in a family unit, where each family member is viewed as a component, and the patient’s problem is generated (and maintained) by the system’s malfunctioning. Aim to facililitate resources within the system as a whole
individuals, couples, families - focus on relational context, address patterns of interaction and meaning
Systemic therapists might use techniques of suggestion, or emphasising the positive value of symptoms for the whole family, as methods of bringing about change to the family system.
Almost exclusively in child psych settings but is also used in eating disorders (particularly with younger anorexic patients) and as an adjunctive treatment in schizophrenia - high expressed emotion families cause relapse
What are the characteristics of psychotherapies in general?
- An intense confiding relationship with a helpful person (the therapeutic alliance or therapeutic relationship lies at the heart of all psychotherapeutic approaches)
- A rationale containing an explanation of the patient’s distress
- The provision of new information about the nature and origins of the patient’s problems and the ways of dealing with them
- The development of hope in the patient that they will be helped
- Opportunities to experience success during treatment, enabling an increased sense of mastery
- The facilitation of emotional arousal
What is somatization and conversion disorder
Somatization – Multiple physical complaints, no medical explanation – Common
8 symptoms: 4 pain, 4 non-pain (GI, sexual, neurological)
Undifferentiated somatoform disorder no longer requires a specific number of somatic symptoms.
- Conversion Disorder – Single physical complaint, a psychological explanation – Rare
- Malingering – Motivation willful.
Basic Therapy
- Therapeutic allience
- Clarify main complaint
- Liaise re normal investigations
- Rationalise extrordinary investigations
- Clarify psychiatric comorbidity
- Clarify external stress
- CBT & behavioural model of coping
- Support groups & peer support
What is interpersonal therapy?
This was also initially formulated as a time-limited weekly therapy for depressed patients.
It uses the link between the onset of depressive symptoms and current interpersonal problems as a focus for treatment.
It does not make assumptions about aetiology and does not dwell upon enduring aspects of the personality, but addresses current relationships. Therapists are active and supportive.
The utilisation of IPT has expanded from depression to other disorders, including eating disorders.
What is the difference between psychotherapy and counselling?
Counselling offers non-judgemental support and encourages the person to clarify and prioritise current problems and to find solutions. It does not usually explore the therapeutic relationship (as in psychodynamic psychotherapy).
Counselling tends to help people overcome immediate crises (for example job losses, bereavement or relationship problems), whereas psychotherapy helps people with more long-standing problems of a serious nature.
Psychotherapists thus require a long and specialised training and continue to receive regular supervision from colleagues about their clinical work.
Who is suitiable for psychotherapy and where can it be delivered?
The presence of a particular disorder does not necessarily mean that an individual will be suitable for therapy. It is better for those who can
- verbalise their problems
- are psychologically minded (i.e. able to see that psychological processes could contribute to their problems)
- and who take some degree of responsibility for the resolution of their difficulties (i.e. are well motivated)
Assessment for suitability can be difficult, but must be carefully considered to avoid doing harm to the patient (for example by stirring up issues in an exploratory therapy that subsequently cannot then be safely or adequately managed).
Patients with psychosis (other than for some specific CBT interventions) and with serious dependence on illegal drugs are usually not viewed as suitable.
Patients with strong suicidal ideation can sometimes benefit from psychotherapy, so long as there is an adequate structure provided to enable them to be safely contained during treatment (e.g. community team, day hospital or other patient support, as appropriate).
CBT and psychodynamic/analytic therapies can be delivered to individuals (i.e. one therapist and one patient) or in groups (usually around 8 patients with one or two therapists).
Some work is most appropriately done with a patient couple (e.g. in marital or psychosexual work).
Systemic therapies ideally work with all those viewed as parts of the system (e.g. an extended family).
Psychotherapeutic work can be undertaken in day centres/hospitals and sometimes in residential settings (e.g. in therapeutic communities).
Why do patients in some forms of therapy often get worse before they get better?
In the course of psychotherapy, the person sees the generality of his problem
As patients see, ‘This problem is more pervasive than I thought,’ they may be disheartened somewhat
.However to the extent that the problem was broader than they thought, the gain is greater when it is resolved.
To begin with patients may feel better being heard and supported.
But future sessions may go into uncomfortable territory and highlight the losses that have been associated with dysfunctional thinking.
It may be necessary to discuss painful events in childhood that made trust very difficult to maintain.
It may also be necessary to face head on that the issues extend to the patient themselves - that the fault does not always lie with others.
Essentially the therapeutic alliance opens several cans of worms and this can lead to a feeling of being overwhelmed.
This is why motivation is important in assessing a patient’s suitability for psychodynamic psychotherapy
