Psychotherapy Flashcards
Spectrum of therapy techniques
Interpretation →
Confrontation →
Clarification →
Encourage to elaborate →
Empathic validation →
Advice/Praise →
Affirmation
bringing the unconscious thoughts to the surface (conscious)
Interpretation
openly addressing suppression through confronting the patient
Confrontation
reformulation, “So do you mean to say….”
Clarification
request more information
Encourage to elaborate
“That must be really hard for you”
Empathic validation
therapist gives concrete advice or direct praise to the patient
Advice/Praise
Affirmation
“uh-huh,” “I see”
Transference
patient’s unconscious redirection of feelings from the past toward therapist.
Unconsciously, “Hey this therapist reminds me of my overbearing mother”
Countertransference
therapist’s unconscious association of feelings from the past directed at the patient.
Unconsciously, “Hey, this patient reminds me of my jerk ex-husband”
Resistance
unconscious and conscious forces within a patient that resist treatment.
Example: patient repeatedly comes to sessions late due to unconsciously resisting treatment
Free Association
undirected expression of conscious thoughts and feelings as an attempt to “tap into” the unconscious.
Basically, say the first thing that comes to your mind, as it may be related to unconscious stuff
Classical Psychotherapy (famous person association)
Freud
Ego psychology (famous person association)
Anna Freud
Objects relations psychotherapy
Melanie Klein (Object relations are related to drives; “ego splitting;” infant-mother relationships; “depressive/paranoid/schizoid positions”) and
Donald Winnicott (transitional object; “good enough mother”)
Self-psychology
Heinz Kohut (“mirroring;” stuff on narcissism)
Transitional object
Winnicott
Depressive/paranoid/schizoid positions
Melanie Klein
Brief psychotherapy (famous people)
Franz Alexander first started to alter traditional psychodynamic therapy by shortening sessions, decreasing frequency, and other measures to develop modern short-term therapy.
Others: Mann, Malan, Sifneos
Essential Features of Brief Therapy
Specific inclusion criteria
- moderate emotional distress
- desire for relief
- a specific problem to work on
- functional, ability to commit to treatment
exclusion criteria
- psychosis
- substance abuse
- risk of self-harm
Limited to 12-20 hour-long sessions, after which therapy is terminated.
Brief therapy - session elements
- Begin with summary of last session
- Restating focus
- Homework is given
- Clarification is important
- Transference must be quickly identified and worked through.
Goals of brief therapy
four common foci
- losses
- being out of step with expected developmental stage
- interpersonal conflicts
- symptom reduction
Phases of Brief Therapy
- Initial phase: (evaluation thru session 3) evaluates the patient, selects focus, and establishes working alliance
- Middle phase: (session 4-9) where patient starts to worry there won’t be enough time in treatment, issues of separation and aloneness, feels worse during this phase
- Termination phase: (sessions 8-16) patient accepts treatment ending, discuss termination of therapy relationship
ITP problem areas
- Unresolved grief: facilitate grieving process
- Social role disputes: make plan of action to solve interpersonal role disputes (conflict with co-worker, spouse, etc)
- Social role transitions: mourn and accept the loss of an old role (demotion in job, children move out of home) and earn self-esteem in mastering a new role
- Interpersonal deficits: learn to establish healthy relationships and decrease social isolation
Types of behavioral therapy
- Systematic desensitization
- flooding
- EMDR
- Positive reinforcement
- DBT
Systematic Desensitization
Wolpe
Counterconditioning to decrease maladaptive anxiety.
Works on decreasing response to anxiety-provoking stimuli.
Treats phobias.
Example: patient is afraid of heights. Make a hierarchy of least feared to most feared. Think about less feared and use relaxation techniques (mental imagery, relaxing muscles and decreasing autonomic responses) to desensitize self to fear/anxiety. Now go up on the hierarchy (increased anxiety-provoking) and repeat the above to desensitize gradually up the hierarchy
Flooding
Similar to systematic desensitization in that a stimulus is presented and the goal is to desensitize oneself to fear/anxiety. However, no hierarchy, no relaxation techniques, and has in-vivo exposure (actually presented with real fear rather than imagining it). Example: patient fear of heights, go to top of highest building and sit there until fear subsides
EMDR
saccadic eye movements used to treat PTSD
Positive reinforcement
using a “token economy” to reward patients for desired behavior. Good use in Schizophrenics. Can also be used in addicts, similar to methadone maintenance, where abstinence from illicit drugs leads to positive reinforcement with methadone
DBT
treats BPD/personality disorders using combination of supportive/cognitive/behavioral techniques.
Works to improve interpersonal skills and decrease self-destructive behaviors.
Addresses ambivalence, increases motivation, seeks to not reinforce maladaptive behaviors, learn new skills, and restructure the patient’s environment. Uses homework, advice, and confrontation
What is biofeedback?
Designed by Miller to assume voluntary control of the autonomic nervous system and other biologic systems using operant conditioning.
Conditions treated by biofeedback
include Reynaud’s, tension HA, migraines, TMJ, epilepsy, asthma, arrhythmias, fecal incontinence, HTN, and many others
Biofeedback methods
uses EMG, skin temperature, BP, and other measurements to monitor physiologic states. The patient uses relaxation techniques to self-modify autonomic functions to produce resolution of multiple symptoms.
CBT Overview
focuses on the interplay of maladaptive thoughts, feelings, and behaviors that cause mental disorders.
Combines cognitive therapy (identifying and challenging underlying cognitive errors) with behavioral therapy (removing unwanted behaviors).
Occurs over the course of 15-20 weeks.
How long does a CBT course run?
average 15-20 weeks
Goal of therapist in CBT
Teach the patient to become their own therapist through a series of assignments, homework, and close interaction between therapist and patient
CBT indications
CBT is proven to help with patients with MDD, BMD, Panic Disorder, Social Anxiety Disorder, GAD, OCD, Phobias, EDO, Psychotic Disorders, and Substance Abuse.
CBT Goals
identify and alter “cognitive distortions” that maintain symptoms. CBT strives to identify negative “automatic thoughts” that are generated by “cognitive distortions.”
Example: patient believes he is too fat to have friends. This is an automatic negative thought that is the result of a maladaptive cognitive distortion/error.
Cognitive triad in CBT
- Negative self -perception
- Patient sees the world as a negative place
- Patient expects failure and hardship.
3 main components of CBT technique
Didactics, cognitive techniques, behavioral techniques
Didactics
teach the patient about their mental disorder, the cognitive triad, their faulty logic, and cognitive distortions
Cognitive techniques
elicit automatic thoughts, test logic of automatic thoughts, identify cognitive distortion, test validity of cognitive distortion. Example: after her boyfriend breaks up with her, a patient believes nobody will ever love her (automatic negative thought). Therapist states this cognitive distortion is an “overgeneralization” and is untrue that NOBODY will ever love the patient. Then the patient works to disprove the distortion (test validity)
Behavioral techniques
various homework with activities to improve self-reliance and find new healthy ways to cope (replacing substances, suicidality, eating disorders with exercise, art, etc.)
CBT for MDD
provides education (informational intervention), activity scheduling (behavioral modification of anhedonia and PMR), cognitive restructuring (challenge negative views of self), and problem solving (assertiveness training)
CBT for BMD
stress management, monitoring mood to detect early destabilization, improving regularity of circadian system through healthy behaviors (exercise, diets, etc), problem-solving skills to improve compliance with care
CBT for panic disorder
education to stop the “fear-of-fear” cycle and stop catastrophic misinterpretations (“I am having a heart attack”), cognitive restructuring (decrease negativity and catastrophizing), interoceptive exposure (exposure to physiologic symptoms of anxiety through running in place or hyperventilating, similar to desensitization), desensitization, relaxation training
CBT for social anxiety disorder
education, cognitive restructuring, monitoring and “catching” thoughts that precipitate anxiety. Example: “All these people think I’m an idiot.” Exposure intervention (desensitization exercises), social skills training, and some interoceptive exposures (as used in panic d/o)
CBT for GAD
education, cognitive interventions (examine cognitive distortions and negativity), imaginal exposure to worries, relaxation techniques
CBT for OCD
education, exposure and response prevention (desensitization and flooding), cognitive interventions to help break intrusive thoughts/ritualistic behaviors
CBT for PTSD
education, cognitive interventions to challenge perpetual fear of danger, imaginal exposure (narrate trauma, extinguish extreme emotional response, learn to feel safe), desensitization in-vivo, relaxation techniques
CBT for Phobias
exposure interventions, participant modeling (therapist exemplifies a behavior [touching a snake] and encourages patient to copy the behavior)
CBT for Bulimia nervosa
education (including health education), self-monitoring and reporting EDO behaviors, stimulus-control (decreasing triggers [Example: don’t eat in mall with all skinny friends]), cognitive restructuring body image and challenging negative thoughts about body, problem-solving (find new ways to cope with stressors rather than binge/purge)
CBT for Anorexia nervosa
positive and negative reinforcement procedures initially to protect health and decrease hospitalization/decompensation. Also use the above techniques for Bulimia
CBT for substance abuse
motivational interviewing, functional analysis (examine function before vs. after substance abuse), self-monitoring, cognitive interventions to challenge “all or nothing” thoughts (“I had one drink, I blew it, I might as well continue”) and other dysfunctional thinking, problem-solving (identify new means of coping with stressors), and contingency management (contracts, positive reinforcement)
CBT for psychotic disorders
education, cognitive interventions to promote medication compliance, social skills training, stress management
CBT for personality disorders
(need longer treatment CBT than Axis I d/o): emotional regulation (identify, tolerate and modify emotions), reduction of therapy-interfering behaviors (resistance), challenge cognitive distortions, stress management and problem-solving (new coping skills rather than unhealthy mechanisms)
Goals of group therapy
Re-establish pre-morbid levels of functioning in people with acute distress, support targeted populations (medical illness like cancer, or mental illness support groups), provide relief for target symptoms (ex: eating disorders), encourage and stimulate character change (helps identify malignant character deficits in a patient through group reflection, and to promote healthy change).
Abreaction
unearth repressed emotions, and relive them to increase insight
Acceptance
feeling of being accepted by the group, absence of censure and difference of opinion is tolerated
Altriusm
one member helps another, helps to establish cohesion
Cohesion
group is working together for a common goal
Contagion
expression of an emotion in one member elicits the expression of emotion in another member
Corrective familial experience
group re-creates family of origin for one member to help them work through original conflict
Empathy
group member can put himself in the psychological framework of another member and understand the thinking, feeling, and behavior
Imitation
emulation or modeling of one’s behavior after another person
Inspiration
imparting a sense of optimism to group members
Reality testing
person’s ability to evaluate the world outside of themselves and perceive reality accurately
Universalization
the idea that an individual is not alone with their problems
Ventilation
expression of suppressed feelings, ideas, or events to group members to ameliorate a sense of shame or guilt (aka self-disclosure)
Supportive (group therapy)
weekly over months, shared universal dilemmas, helps adapt to environment. Universalization and Reality Testing
Psychodynamic (group therapy)
1-3x/week for years, for neurotic disorders, work on present/past life situations, focus on interpret unconscious conflict to challenge defenses and reduce shame. Catharsis, reality testing, examine transference
CBT (group therapy)
weekly up to 6 months, phobias or compulsions treated, works on cognitive distortions to relieve specific psychiatric symptoms. Reinforcement, cohesion, conditioning
Inpatient (group therapy)
daily groups with rapid turnover of patients, heterogeneous groups, emphasis on the “here and now,” problem-solving, education on treatment. Empathy and reality testing
Family therapy
seeks to resolve family conflict, meets family members’ individual needs, establish healthy role relationships, cope with destructive forces inside and outside the family, and integrate the family into society. Occurs weekly for 1-2 hours. Family may present with a single-family member identified as the “problem” but the dynamic is likely much more complex than that.
Family therapy goals
alter interactions and improve functionality of the family as a unit of individuals. Bring to light hidden patterns and understand the purpose of these patterns
Family therapy technique
collect a thorough history, including a family life chronology in the first 2 sessions. Understand how the parents operate from models from their own parents/families. One technique used is “reframing” Example: “This child is impossible,” can be changed to “This child is trying to distract you from an unhappy marriage.
Behavioral/CBT (family therapy)
core concepts are functional analysis, social learning, and communication. Goals are to resolve problems by improving communication and problem-solving skills while balancing change vs. acceptance. This is the #1 empirically supported family/couples therapy
Bowen Family Systems (family therapy)
Core concepts are differentiation of self, triangulation, family emotional system, and sibling order. Goals are to increase family member differentiation, decrease triangulation, and manage anxiety. Uses genograms
Experimental/Humanistic (family therapy)
Core concepts are attachment theory and “psychotherapy of the absurd” (seriously). Goals are creativity, increasing self-esteem and fostering cohesion through wacky activities like family sculpture. May have 2 therapists
Milan System (family therapy)
Core concepts are neutrality, circular interaction between family and therapists, families get stuck in patterns of interaction, solutions reside with the family, not the therapist, “longterm brief therapy” (long session with a month between sessions). Goals are unmasking the “family game,” changing maladaptive patterns. Techniques include therapist team behind a one-way mirror, “hypothesizing,” “counter paradoxical interventions” (intentionally engage in unwanted behaviors to increase insight), and “circular questions” designed to improve empathy (“What do you think concerns your wife most about your illness”). This is super famous family therapy and sometimes gets teste
Narrative (family therapy)
core concepts are narrative stories of the family system designed to make others understand the dynamic, understanding the family system in the context of a narrative story. Goals are creation of newer, more useful life stories, externalize problems rather than blaming single members for problems, enhance communication through therapeutic letters
Psychodynamic (family therapy)
Core concepts are projective identification (projecting your undesirable characteristics onto another person), splitting, scapegoating, and change occurs through conscious insight into unconscious processes. Goals include increasing insight/empathy, disentangle interlocking pathologies, identify transference within the family dynamic, and challenge resistance. Creation of a “holding environment”
Psychoeducational (family therapy)
Core concepts are expressed emotion, engagement with the family, education workshops, and rehabilitation. Goals include improving social skills and communications, problem-solving, relapse prevention. This is the #1 family-based therapy for families with a member with schizophrenia or another major psychiatric disorder
Structural (family therapy)
Core concepts are boundaries, family hierarchy, coalition/alliance, and engagement/enmeshment. Goals are improving flexibility/adaptability, finding a balance between connectedness and differentiation, and homework-based problem solving
Strategic (family therapy)
Core concepts are power/control, family life cycle transitions, role changes, adapting to change. Believe individual cannot change until the system that sustains them changes. Goals are problem-solving with identification of “exception to the rules,” address double binds, disrupting sequences of behavior that perpetuate problems, “paradoxical directives”
Couples therapy
focuses on the pattern of interactions between two people while considering the individual history of each member.
Couples therapy basic principles
monitor for projective identification and re-enactment of childhood attachment issues with spouse. A couple’s relationship has a life cycle context, within the context of changes in the individual and changes in the family. Life cycle implies that transition from one life cycle to another has the highest risk for divorce and conflict (mid-life crisis, aging, etc). Communication skills are essential. Contraindicated in cases of domestic violence, psychosis, or when divorces is actively being sought out.
Couples therapy interview
components should include evaluation of each partner’s motivation to participate in treatment, providing a safe environment in the first session, identifying each member’s view of what the problem is, assessing for infidelity, and identifying the biggest sources of conflict.
Couples therapy goals
alleviate distress, promote well-being as a unit, problem-solving, promote accountability and responsibility
Couples therapy treatment interventions
interpretation of unconscious processes, communication skills training (including learning active listening skills and learning to fight constructively with specific rules), role playing (role reversal to increase empathy), and paradoxical interventions (reverse psychology stuff where a therapist tells member NOT to change, leading to change).
Depressive Position
Schizoid Position
Paranoid position
