Psychotherapy (MRCP) Flashcards
Lisa is a 35-year-old lady, diagnosed with depression. She has been referred
by her psychiatrist for psychodynamic psychotherapy. According to her
therapist, Lisa has the ability to conceive of her own mental state as
explanations of her behaviour. This phenomenon is called
A. Transference
B. Mentalization
C. Counter transference
D. Empathy
E. None of the above
B. The capacity for mentalizing grows out of attachment theory and refers to a person’s
ability to conceive of his or her own and others’ mental states as explanations of behaviour.
Hence, it is related to psychological mindedness. The psychodynamic clinician assesses the
ability of a patient to see that his or her behaviour grows out of a set of beliefs, feelings, and
perspectives that are not necessarily the same as others’. Like empathy, mentalizing requires
a capacity to sense what is going on in another’s mind and respond accordingly. This capacity
to be sensitive to what others are feeling and to know that one’s internal states contribute
to one’s behaviour augurs well for a more exploratory or interpretative approach in dynamic
psychotherapy.
Which of the following suggests suffi cient psychological mindedness in Lisa?
A. She needs a lot of prompts to give her story
B. She fi nds it diffi cult to bring up memories with appropriate affect
C. She is unaware of this unconscious mental life
D. She does not have poor self-esteem
E. She is unable to step back and observe refl ectively
D. According to Nina Coltart, during psychotherapy, a therapist is exercising his/her skills and
psychological mindedness to explore the patient’s psyche. If the patient is also psychologically
minded, the prospects of treatment success are thought to be greatly increased. Whether a
patient is psychologically minded depends on a number of characters. They include:
1. The capacity to give a history that deepens, acquires more coherence, and becomes texturally
more substantial as it goes on.
2. The capacity to give such a history without needing too much prompting, and a history which
gives the listener an increasing awareness that the patient feels currently related in him/herself,
to his/her own story.
3. The capacity to bring up memories with appropriate affects.
4. Some awareness in the patient that he has an unconscious mental life.
5. Some capacity to step back, if only momentarily, from self-experience, and to observe it
refl ectively.
6. The capacity, or more strongly a wish, to accept and handle increased responsibility for the self.
7. The capacity to imagine and dream and use metaphors.
8. Some capacity for achievement, and some realistic self-esteem.
During her fi rst session, Lisa asks her therapist about certain terms she
came across on the internet. “What is transference?”
A. Empathy in relationships
B. Therapist’s response to the patient based on the therapist’s previous relationships
C. Patient’s response to the therapist based on the patient’s previous relationships
D. Transfer of positive thoughts from the therapist to the patient through self-disclosure
E. All of the above
C. Transference is the displacement of feelings and thoughts associated with a fi gure in
the patient’s past onto the therapist. Transference is often unconscious, at least initially, and the
patient is often puzzled by their behaviour towards the therapist because it does not make sense,
based on who the therapist really is. Hence the enactment of missing a session or of coming late
to a session may reveal unconscious transference. The prevailing view about transference is that
the therapist’s actual behaviour always infl uences the patient’s experience of the therapist. Hence
the transference to the therapist is partly based on real characteristics and partly on fi gures
from the patient’s past: a combination of old and new relationships. Many therapists believe
that interpretation of this transference is an essential process of psychodynamic psychotherapy.
Gabbard says that one should postpone the interpretation of transference until it becomes
a resistance and until it is close to the patient’s awareness. In other words, if things are going
reasonably well, it makes no sense to interpret transference. If the patient develops, for example,
erotized or highly negative feelings, which impede the process of the therapy, interpretation may
be essential. Many therapists regard treatment that focuses on transference as more exploratory
than therapy geared to extra-transference relationships. In supportive therapy, interpretation of
the transference may be minimized, although the therapist may silently interpret the transference
as a way of increasing his or her understanding of the patient.
Which of the following correctly describes counter-transference?
A. The analyst’s or psychotherapist’s transference reactions to the patient
B. His or her reactions to the patient’s transferences
C. Any reactions, feelings and attitudes of the analyst or therapist towards the patient,
regardless of their source.
D. All of the above
E. None of the above
D. Freud used the term counter-transference to describe the analyst’s transference
towards the patient. In other words, the patient might remind the therapist of someone
from the therapist’s past, so that the therapist starts to treat the patient as though he or she
were that fi gure. Over time, this view of counter-transference was broadened to include the
total emotional reaction of the therapist to the patient. Today it is recognized that countertransference
is jointly created—it partly involves the therapist’s past relationships, but it also
involves feelings induced in the therapist by the patient’s behaviour. Counter-transference is
variously defi ned as (1) the analyst’s or psychotherapist’s transference reactions to the patient;
(2) his or her reactions to the patient’s transferences; and (3) any reactions, feelings and attitudes
of the analyst or therapist toward the patient, regardless of their source. These responses are
manifestations of the requisite engagement by the therapist or analyst in the emotional process
of treatment. Moreover, these reactions are a rich source of understanding of the patient’s
experience as it touches the therapist affectively.
During the psychotherapy sessions, the therapist notes that Lisa uses a
number of defence mechanisms that are classifi ed as ‘mature defences’
according to Vaillant. Which of the following is a mature defence?
A. Suppression
B. Repression
C. Dissociation
D. Passive aggression
E. Denial
A. George Vaillant classifi ed defences hierarchically according to the relative degree of
maturity associated with them. Narcissistic defences (denial, distortion, and projection) are the
most primitive and appear in children and persons who are psychotically disturbed. Immature
defences (acting out, passive-aggression, blocking, introjection, and regression) are seen in
adolescents and some non-psychotic patients. Neurotic defences (dissociation, displacement,
intellectualization, isolation, reaction formation, and repression) are encountered in obsessive–
compulsive and hysterical patients as well as in adults under stress. Mature defences according
to Vaillant are altruism, anticipation, asceticism, humour, sublimation, and suppression. These
mechanisms often are used in healthy coping mechanisms.
Nearing the end of her therapy session, Lisa blurts out ‘I am abusing my
children’ before quickly shifting the topic to other things. What is the most
immediate appropriate thing for the therapist to do?
A. End the session on time and explore it in the next session
B. Ask her what she meant by ‘abusing’
C. Reassure her that everything said in therapy is confi dential
D. Tell her that you have to report her to the social services
E. Carry out an extensive assessment of risk to the child
B. In the USA, therapists have a legal duty to warn and protect third parties endangered by
their patients. In the UK, there is no binding requirement on clinicians to disclose dangerousness.
The decision to disclose is based on the judgement that the responsibility to protect the public
outweighs the duty to the patient to protect confi dentiality. The clinician has the responsibility
to make a considered decision whether or not to infringe the right to confi dentiality. Statute law
(e.g. notifi cation of diseases) determines when the clinician ‘must’ infringe that right; case law
when he ‘may’ do so. Most psychotherapy falls under the latter. Each case must be considered
on its merits, possibly on the basis of a risk assessment, and where there is a doubt, the clinician
must discuss it with another clinician. In any case, welfare of children is of foremost importance.
In this particular case, Lisa said she was abusing her children. We do not know what she meant
by ‘abuse’. So, as common sense would inform, the fi rst step is for the therapist to confi rm what
she means by ‘abuse’. If there is a need, the next step would be an informed risk assessment.
Confi dentiality and disclosure are usually discussed with the patient before therapy. Since there
is a potential risk to children, ending the session and reassuring Lisa about confi dentiality are
obviously wrong choices. Premature reporting to social services would result in unnecessary
labelling and also possible loss of rapport and therapeutic alliance. Criticizing her would also lead
to a break in the therapeutic relationship and would be against the principles of ‘unconditional
positive regard’. If there is a case for disclosure, the patient herself should be encouraged to
disclose to social services, as this would be in the best interests of the children involved and the
patient. It is generally thought that inexperienced staff and students should not enquire about
abuse or ask known victims about details of their experience, although they may be approached
by patients making tentative attempts at disclosure, the general rule must be that inexperienced
individuals should not invite discussion of a sensitive subject such as sexual abuse unless they are
being supervised and trained to deal with it. In this case, it is thought that the psychotherapist is
being supervised and would do a general risk assessment based on history and mental state.
Which of the following represents the concept of borderline personality
organization?
A. Identity diffusion
B. Utilizing primitive defences
C. Intact reality testing
D. Characteristic splitting in object relations
E. All of the above
E. Otto Kernberg proposed the term ‘borderline personality organization’ (BPO), a broad
concept encompassing all severe personality disorders. BPO is a stable permanent state based
on four criteria: diffuse identity; primitive defences, including splitting, projection, and projective
identifi cation; intact reality testing that is prone to alterations and failures because of aggression;
and object relations characterized by splitting. The term ‘Identity diffusion’ was developed by
Erikson and later used by Kernberg in his concept of BPO. In psychodynamic terms an individual
with identity diffusion has not integrated good self-images with bad, and, instead, has multiple,
contradictory self-images, some good, some bad. These are invoked at different times and in
different situations so that a meaningful, integrated image of the self is never formed. Salman
Akhtar delineates the syndrome of identity diffusion as consisting of six clinical features:
(1) contradictory character traits, (2) temporal discontinuity in the self, (3) lack of authenticity,
(4) feelings of emptiness, (5) gender dysphoria, and (6) inordinate ethnic and moral relativism.
This syndrome implies severe personality pathology. The inner world in BPO according to
Kernberg, is characterized by split objects. Instead of stable and smoothly integrated internal
representations of people and their relationships, the self and others are experienced in
contrasts of either black or white – ‘no grey zones’. These people generally have an intact reality
testing, but are prone to breaks in it, leading to the so-called ‘micropsychotic’ episodes.
In dynamic psychotherapy, the therapist at times uses certain techniques
that represent the ‘supportive’ end of the psychodynamic continuum
rather than the ‘expressive’ end. Which of the following is suggestive of a
‘supportive’ technique?
A. Confrontation
B. Clarifi cation
C. Interpretation
D. Interpretation of transference
E. Giving advice
E. Dynamic (psychoanalytic) psychotherapy is often conceptualised as being on a continuum
of expressive to supportive. Traditionally, psychoanalytic psychotherapy has focused on the
recovery of repressed psychological material. This process has been called ‘expressive’ and is
distinguished from the ‘supportive’ psychotherapies, which concentrate on supporting healthy
defence (coping) mechanisms. The therapist may employ more or less expressive and supportive
interventions, depending on the needs of the patient. Among the given responses in the question,
advice giving leans towards the supportive end of the continuum. In addition to advice giving,
other techniques usually employed that are at the supportive end of the continuum are praise,
suggestions, reassurance, environmental intervention, and manipulation.
The process by which unconscious ideas are repressed and prevented from reaching awareness because they are unacceptable in psychotherapy is called A. Transference B. Counter-transference C. Resistance D. Therapeutic alliance E. Repression
C. Resistance is broadly defined as the conscious or, more often, unconscious force within
the patient opposing the emergence of unconscious material. Resistance is thought of as the
patient’s attempt to protect her or himself by avoiding the anticipated emotional discomfort that
accompanies the emergence of conflictual, dangerous, or painful experiences, feelings, thoughts,
memories, needs, and desires. Resistance occurs through the use of unconscious defence
mechanisms. The recognition, clarification, and interpretation of resistance constitute important
activities of the psychoanalyst and the psychoanalytic psychotherapist, both of whom must
first appreciate how a patient is warding off anxiety before understanding why he or she is so
compelled.
Jack is a 35-year-old man who perceived his parents as overly authoritarian.
His therapist on the other hand, is friendly and non-authoritarian, but at
times fi rm and sets defi nite limits. The attitude of his therapist gave Jack
the opportunity to identify with a new parent fi gure. This is an example of
a process described by Franz Alexander. Which of the following terms best
represents this process?
A. Resistance
B. Counter-transference
C. Corrective emotional experience
D. Therapeutic alliance
E. Childhood neurosis
C. The therapeutic relationship between therapist and patient gives a therapist an
opportunity to display behaviour different from the destructive or unproductive behaviour of a
patient’s parent. At times, such experiences seem to neutralize or reverse some effects of the
parents’ mistakes. If the patient had overly authoritarian parents, the therapist’s friendly, fl exible,
non-judgemental, non-authoritarian, but at times fi rm and limit-setting attitude gives the patient
an opportunity to adjust to, be led by, and identify with a new parent fi gure. Franz Alexander
described this process as a corrective emotional experience. It draws on elements of both
psychoanalysis and psychoanalytic psychotherapy
Nick has been diagnosed with major depression. His GP is considering
referring Nick for psychodynamic psychotherapy. According to the GP,
Nick has certain qualities he thinks are important for a good prognosis
in psychodynamic psychotherapy. Which of the qualities shown by Nick
has been shown NOT to predict good response in psychodynamic
psychotherapy?
A. Psychological mindedness
B. Introspectiveness
C. Acting out affects
D. Reasonable object relationships
E. Intense search for understanding
C. Most psychotherapists consider certain qualities in their patients as prerequisites for
engaging in psychodynamic psychotherapy. These include psychological mindedness: curiosity
about oneself and the capacity for self-scrutiny. Those who are unable to articulate and
comprehend their inner thoughts and feelings cannot negotiate with the fundamental analytical
words and their meanings. The inability to examine one’s own motivations and behaviours
precludes benefi ts from the analytical method. Introspectiveness: the person should be able
to experience and learn from intense affects or confl icts without acting them out. The person
should be able to form reasonable object relationships, usually the capacity to form and maintain,
as well as to detach from, a trusting object relationship is essential. High motivation: the patient
needs a strong motivation to persevere, in light of the rigors of intense and lengthy treatment.
The desire for health and self-understanding must surpass the neurotic need for unhappiness.
The person should be able to tolerate frustration and therapeutic regression.
Brief psychodynamic psychotherapy has been shown NOT to be of benefi t in which of the following conditions? A. Panic disorder B. Severe depression C. Interpersonal diffi culties D. Opiate dependence E. Somatoform disorder
B. Inclusion criteria for brief psychodynamic psychotherapy diagnoses: depression, mild
to moderate; anxiety, post-traumatic stress disorder, social, panic; somatoform disorders; eating
disorders; opiate dependence;. Patient characteristics include good object relationships (has
had at least one relationship); highly motivated, ‘willing’ patient; narrow symptom/problem focus;
interpersonal diffi culties. Exclusion criteria for brief psychodynamic psychotherapy include a
diagnosis of severe depression, bipolar disorder, psychosis, suicidality; obsessive compulsive
disorder (OCD); severe somatizing disorders; severe eating disorders; poor object relationships;
poor motivation; chronic, severe character pathology; diffuse, ill-defi ned symptomatology. Most
of the above criteria are derived from a systematic review of psychodynamic psychotherapies by
Leichsenring in 2005.
Which of the following therapies involve ‘strokes’ that people exchange and ‘games’ that people play? A. Person-centred psychotherapy B. Gestalt therapy C. Transactional analysis D. Existential therapy E. Physiotherapy
C. Transactional analysis developed by Eric Berne in 1960s. According to Berne, transactions
are stimuli presented by one person that evoke a corresponding response in another. Berne
defi ned psychological ‘games’ as stereotyped and predictable transactions that people learn in
childhood and continue to play throughout their lives. Strokes, the basic motivating factors of
human behaviour consist of specifi c rewards such as approval and love. All people have three ego
states that exist within them: the child (the primitive element), the adult (the reality element),
and the parent (an introject of the values of a person’s actual parents). The therapeutic process
helps people to understand whether they are functioning in a child, adult or parent mode when
interacting with others. It is thought that as patients learn to recognize characteristic games being
repeated throughout life, they can ultimately function in the adult mode as much as possible in
interpersonal relationships.
Focusing on a detail out of context while ignoring other, more salient features in the situation is called A. Arbitrary interference B. Selective abstraction C. Overgeneralization D. Dichotomous thinking E. Personalization
B. The statement refers to selective abstraction, one of the cognitive biases seen in
depression. Other cognitive biases include arbitrary inference, drawing a specifi c conclusion in
the absence of evidence or when the evidence is contrary to the conclusion; overgeneralization,
drawing a conclusion on the basis of one or more isolated incidents; dichotomous thinking, the
tendency to classify experience in one of two extreme categories, ignoring more moderate
variations; personalization, the tendency to relate external events to oneself; magnifi cation/
minimization,- exaggerating (i.e. catastrophizing) or belittling the signifi cance or magnitude of an
event.
Global, rigid, absolute, and overgeneralized convictions about the self that
have powerful effects on how we perceive ourselves are called
A. Core beliefs
B. Conditional rules
C. Automatic thoughts
D. Intermediate beliefs
E. None of the above
A. Core beliefs are global, rigid, absolute, and overgeneralized convictions about the self,
others, and the personal world that have powerful effects on how we perceive ourselves and
our context. They often have their root in early childhood development. An example of core
beliefs is ‘I’m incompetent’. These lie dormant until they are activated by certain situations (which
refl ect childhood events that laid down the core belief). At the next level are ‘intermediate
thoughts’, which consist of rules, assumptions, and attitudes that we use to evaluate ourselves
as well as other people and personal experiences. On most occasions, these rules tend to
contradict the core belief (in a way reinforcing them). Examples of intermediary beliefs might be
‘I need to succeed in everything I do, in order for me to be seen as competent’. A special class of
intermediary beliefs is the conditional rule, which takes the form of ‘If … then’ statements (e.g. ‘If
I succeed in everything I do, only then others will consider me competent’). Automatic thoughts
are cognitions that intervene between external events and a person’s emotional reaction to the
event. For example, the belief that people will laugh at me when I don’t get a distinction at the
exam is an automatic thought that occurs to someone who has the aforementioned ‘core belief ’.
Which of the following terms refer to beliefs that thoughts and behaviours have reciprocal and equivalent effects? A. Anxiety sensitivity B. Pathological worry C. Thought–action fusion (TAF) D. Intolerance of uncertainty E. None of the above
C. TAF is a cognitive distortion. It is thought to have two forms: ‘probability TAF’ in which
the intrusive thought is believed to increase the probability that a specifi c negative event will
occur. This is prominent in those with violent obsessions. ‘Morality TAF’ in which experiencing
the intrusive thoughts is morally equivalent to carrying out a prohibited action. This distortion is
especially prominent in obsessions, is closely related to guilt, and is associated with subsequent
attempts at neutralization. A comparable cognitive distortion termed ‘thought–shape fusion’ is
thought to be present in a minority of people with eating problems and occurs when the thought
of eating induces feelings of fatness, moral unacceptability, and weight gain. These cognitive
distortions can be manipulated experimentally and have clinical implications that include
improvement in understanding the nature of the disorder and its treatment.
Which of the following is a technique for automatic thought modifi cation? A. Guided discovery B. Recognizing mood shifts C. Checklists for automatic thoughts D. Imagery E. Examining the evidence
E. Examining the evidence is a technique in which the therapist and patient collaboratively
explore the evidence for and the evidence against a specifi c distorted thought or belief. When
working through the exercise, the therapist asks the patient to write the thought or belief at
the top of a piece of paper and then label two columns with ‘evidence for’ and ‘evidence against’
the thought. The patient is then guided to explore methodically and write down each piece of
evidence. At the end of this procedure, the evidence for and against the cognition is quantifi ed
and estimated. Guided discovery is the most frequently used technique to help patients articulate
automatic thoughts in sessions. The specifi c technique used is called Socratic questioning. One
of the most powerful ways of teaching patients to detect automatic thoughts is to fi nd a real-life
example of how automatic thoughts infl uence their emotional responses. A shift in mood during
the therapy session can be an opportune time for the therapist to facilitate the identifi cation of
automatic thoughts. The Automatic Thoughts Questionnaire devised by Hollon and Kendall is a
comprehensive list of dysfunctional thoughts that has been used primarily in research studies.
Similar lists can be used in clinical settings when patients are having diffi culty detecting their
automatic thoughts. Imagery and role-play are two methods for uncovering cognitions when
direct questions are unsuccessful (or partially successful) in generating suspected automatic
thinking.
A woman comes to your outpatient clinic. She has recurrent thoughts of
contamination with germs and has to wash her hands up to 20 times every
time she touches wooden surfaces. This prevents her from looking after
her 2-year-old child. She is worried that the child may not be gaining the
required weight. She has also started to lose the skin of her palms due to
the excessive washing. The treatment you would recommend would be
A. Cognitive behaviour therapy (CBT)
B. Combination of selective serotonin reuptake inhibitors (SSRIs) and CBT
C. SSRI only
D. Psychodynamic therapy
E. Eye movement desensitization therapy (EMDR)
B. According to NICE guidelines, in the initial treatment of adults with OCD, low-intensity psychological treatments (including exposure and response prevention (ERP)) (up to 10 therapist hours per patient) should be offered if the patient’s degree of functional impairment is mild and/ or the patient expresses a preference for a low-intensity approach. These include brief individual CBT (including ERP) using structured self-help materials; brief individual CBT (including ERP) by telephone; group CBT (including ERP) (note, the patient may receive more than 10 hours of therapy in this format). Those with mild functional impairment who are unable to engage in low intensity CBT (including ERP), or for whom low-intensity treatment has proved to be inadequate, should be offered the choice of either a course of an SSRI or more intensive CBT (including ERP) (more than 10 therapist hours per patient). Adults with OCD with moderate functional impairment should be offered the choice of either a course of an SSRI or more intensive CBT (including ERP) (more than 10 therapist hours per patient). Adults with OCD with severe functional impairment should be offered combined treatment with an SSRI and CBT (including ERP).
Jack has certain core beliefs about being unlovable. He thinks that this
characteristic makes people abandon him. In order to avoid this, he turns
out to be excessively self-sacrifi cing to his family. From a schema-based
therapy point of view, what is the underlying cognitive process that is
maintaining the schema?
A. Schema surrender
B. Schema compensation
C. Schema avoidance
D. Schema utilization
E. None of the above
B. Schema-based approaches in cognitive therapy are based on the original ideas of Beck.
Early life experiences produce a number of thought patterns or schemata. These thought patterns
are like ‘block moulds’ into which thoughts fi t in when evaluating events. They are otherwise
called core beliefs. These result in underlying ‘assumptions’ which reinforce the core beliefs and
from these arise the negative automatic thoughts. Schemata are thought to be dormant, and
get activated during a depressive episode. Schemata are patterns of unconditional beliefs that
are hard to access and are self-maintaining. There are thought to be three main processes that
maintain schemata. Schema surrender is the process where the person seeks evidence that
supports the beliefs and dismisses any evidence to the contrary. Schema compensation refers to
compensating for the core belief by doing the exact opposite, but, ultimately, this action acts as
a reinforcer that maintains the schema, as in the case described in the question. Ultimately, the
person believes that the family loves him only because he is self-sacrifi cing, and if he was not, he
would still remain unlovable. Schema avoidance is a group of blocking behaviours that help avoid
emotional arousal – e.g. comfort eating.
Maria has obsessive thoughts of a violent nature towards her mother. Which
of the following is the least characteristic of dysfunctional assumptions likely
to be seen in Maria?
A. Having a thought about stabbing my mother is like doing it
B. I should exercise control over my thoughts
C. Although I believe that I will not hurt my mother, I am still responsible for this harmful
thought
D. Not neutralizing the thought of stabbing her mother is equivalent to wishing her mother
stabbed
E. If I don’t please everyone, I am a failure
E. Salkovskis described fi ve characteristic dysfunctional assumptions in patients with
obsessive compulsive disorder (OCD). The fi rst option refers to thought–action fusion, i.e.
having a thought equates to performing the action. This is consistent with the thoughts of
patients with OCD, especially those who have ‘violent’ obsessions. The second statement that a
person should (and can) exercise control over one’s thoughts is also consistent with thoughts in
OCD. Responsibility is not attenuated by other factors (e.g. the low probability of occurrence)
is a typical assumption in patients with OCD. The fourth option is also typical of an obsessive
cognition. The fi nal option is an assumption that is not typical of OCD. This is probably more
typical of a depressive assumption that reinforces the core belief ‘I am a failure’. As a corollary,
there may be another secondary assumption – ‘If I please everyone, I am considered successful’.
