Psychotherapy Deanna Mercer MD FRCPC Jan 16 2011 dmercer@toh.on

1. Psychotherapy Deanna Mercer MD FRCPC Jan 16 2011 dmercer@toh.on.ca

2. Objectives • Introduction to psychotherapy • Psychological Defense Mechanisms • Understanding transference, countertransference and therapeutic alliance • Review of common psychotherapies

3. Introduction to psychotherapy

4. Why do psychotherapy?

8. What is Psychotherapy ? “The attempt to relieve suffering and psychological disability by inducing changes in patients’ attitudes and behavior” Frank JD, Frank JB Persuasion and Healing; a comparative study of psychotherapy, 1991

10. Emotion • Emotions move us to action, communicate to others and provide us with important information about ourselves • Emotions result in suffering and psychological disability when they are intense, long lasting or result in behaviours that are contrary to our goals. • Example: test anxiety

11. How Does Psychotherapy Work? • Therapists capitalize on brain plasticity to produce change at the neural level. • Therapists train the brain to develop new neural associative networks that help the individual respond in ways that are more adaptive and healthy.

12. Psychotherapy: Essential Ingredients • Diagnostic assessment: Clarify symptoms and problems. Assess the context (biological, psychological and social) in which symptoms are occurring. • Understanding: Theory underlying the therapy must provide a way to understand why the patient has developed these symptoms now. • Build hope/increase motivation: Alleviate the patient’s sense of powerlessness to change themselves or their environment • Facilitate experiences of success and mastery

13. Objective # 5245 Describe the general psychiatric indications for psychotherapy

14. Psychotherapy Indications • Most axis I and II disorders either as a stand alone treatment or in combination with medications • Alone or in combination with medications • Depression, anxiety disorders, eating disorders, sexual disorders, dissociative disorders, paraphilias, addictions, personality disorders • In combination with medications • Schizophrenia, bipolar disorder • Contraindications: • delirium, dementia, psychopathy

15. Effectiveness of Psychotherapy • Most psychotherapies have RCT’s demonstrating that they are more effective than treatment as usual • Psychotherapy versus no treatment: ES 0.67 – 0.85 • Many psychotherapies have been compared to pharmacotherapies and found to be equal (ST) or superior (LT) to treatment with medications • Many have documented changes in brain function (PET scans)

16. Objective 5246 List the general characteristics that are associated with good outcomes in psychotherapy

17. Effectiveness of psychotherapy • Patient factors 40% : motivation, capacity for relationships • Relationship factors 30% : therapeutic alliance • Technical factors 15%: approach • Placebo, hope, expectations 15%: patient’s expectation that they will receive help or recover Miller 1997

18. Patient factors • Disorder is suitable for psychotherapy • Patient sees the problem in themselves • Patient believes that change is possible and is ready to make changes • Patient is able to participate in treatment • Patient is able to be self-observant • Patient’s environment supports change

19. Therapeutic Alliance Collaborative alliance between patient and therapist, depends on three factors • Patient –therapist agreement on goals • Patient – therapist agreement on tasks that each person is to perform • Strength of attachment

20. Therapeutic Alliance: Empathy Carl Rogers 1980 “Perceiving the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as if one were the person but without ever losing the “as if” condition”

21. Objective #5247 Describe boundary issues that may come up in the course of psychotherapy

22. Boundary Issues: Setting Boundaries • Creating an atmosphere of safety and predictability • 3 tasks: • Establish and maintain a treatment frame • Establish and maintain a professional relationship • responsibility of the clinician to maintain boundaries, even if a patient requests, demands or provokes a boundary violation • Protect patient privacy and confidentiality

23. Boundary Definition • Usually describe boundaries in terms of our roles (behaviour): What is and what isn’t okay to do with a patient. • Boundary violation: A boundary violation occurs when a patient is clearly harmed or feels exploited • Example: sexual relationship with a patient

24. Harm to patients • Doctor-Patient sexual relationships • Similar to incest in nature of relationship and patient response • Shame, guilt, depression, PTSD, suicide, substance and alcohol use disorders, relationship break up, loss of employment, difficulty trusting physicians, future health is compromised

25. Boundary Violation Boundary Crossing Behaviour that is clearly acceptable to everyone Behaviour that is acceptable in some circumstance and not others depends on situation: personal comfort, location, nature of practice: -using first names -attending patient funeral -disclosing personal information -hiring patient to do work on your house -accepting gifts from patients -attending events where patients will be present Behaviour that is harmful or exploitative sexual behaviour with a patient

26. Boundary Crossing in Psychotherapy • Behaviours that do not cause patient harm and are often helpful • Example: in psychotherapy therapists do not usually touch patients. A patient stumbles as she leaves the office, the therapist helps the patient up • Example: therapists do not usually disclose personal information about themselves: patient asks if the therapist has children, the therapist responds that they do and asks” why do you ask?”

27. Preventing Boundary Violations • Recognize and understand the impact on patients of boundary violations • Recognition amongst physicians that we all have potential to do this behaviour when under stress with insufficient emotional support • Teaching physicians to be aware of when boundary crossings are helpful and when they are not • Improve MD access to psychological health and supports

28. Two Main Strategies in Psychotherapy Change Validation/acceptance

29. Change Strategies • 4 potential solutions to problems causing painful emotions • Change the problem • Change how you feel about the problem • Choose to accept both the problem and how you feel about it • Stay miserable

30. In psychotherapy which of the following are true? • Diagnosis is unimportant so you do not have to worry about doing a diagnostic assessment • Theories in psychotherapy provide a way of understanding why a patient has developed these symptoms now. • Patients must be hopeful and motivated prior to entering therapy for therapy to be successful • Since therapy primarily involves talking one does not pay attention to the patient's experiences outside of therapy.

31. Psychotherapy is contraindicated in which of the following disorders? • depression • paranoid personality disorder • psychopathy • schizophrenia

32. The therapeutic alliance depends on the following except: • The patient and therapist agree on goals • The type of psychotherapy being provided • The patient and therapist agree on tasks that each person is to perform • Strength of attachment

33. Setting boundaries refers to all of the following except: • Creating an atmosphere of safety and predictability • Establishing and maintaining a professional relationship • Ensuring the patient is aware of therapist boundaries so that the therapist no longer has to worry about them • Protecting patient privacy and confidentiality

34. Psychodynamic Cognitive Behavioural Therapy Supportive Types of Psychotherapies

35. Objective # 5248 Define the purpose of a psychological defense mechanism and describe: denial, splitting, projection, reaction formation, rationalization, dissociation

36. Objective # 5250 Briefly Describe the following Psychotherapies: Psychodynamic, Cognitive therapy and Supportive therapy

37. Peter Fonagy Psychodynamic Psychotherapy Glenn O Gabbard

38. Psychodynamic Psychotherapy: Principles • Problematic interactions derive from early relationship difficulty • “how to” of relationships is learned in early life, and repeated over and over again throughout life (repetition compulsion)

39. Psychodynamic Psychotherapy • Balance between here and now relationships and early relationships • Once per week • Face to face • 6 months to several years • Anxiety and depression, personality disorders, somatoform disorders, sexual dysfunction

40. Psychodynamic Psychotherapy • 3 areas addressed • Ego psychology: Drive gratification (desire and aggression) Freud • Object relations: How we perceive our relationships Klein, Fairburn, Winnicott • Attachment theory: Basic need for affirmation, safety, reassurance and self esteem Bowlby, Mahler, Fonagy

41. Understanding Psychological Defense mechanisms • Core Concepts: • Conscious, unconscious • Defenses

42. Psychodynamic Psychotherapy Core Concepts Conscious: material that is in our awareness Preconscious: can be aware of this information by shifting attention Unconscious: material that is not brought into awareness easily because it causes distress

43. Is there an Unconscious? Memories are explicit or implicit • Explicit : with conscious awareness • Implicit: without conscious awareness Procedural memory: “how to” /skills Declarative memory: “knowledge of”/facts

44. Structural Model

45. “Drive Theory” • ID (basic drives: “I want what I want!”) • In conflict with • SUPEREGO (society: I want you to do what I want!) • Results in anxiety • Ego produces defenses: a compromise (usually unconscious) between the id and the superego

46. Less Effective (immature) Denial Projection Regression Splitting Reaction Formation Intellectualization Displacement Rationalization Dissociation Healthy Sublimation Religiousness/asceticism Humor Altruism Suppression anticipation Defense Mechanisms

47. Less Effective Defense Mechanisms • Denial: ignoring an undesirable situation or information and believing as though it did not exist • Projection: attributing to others unwanted ideas or feelings that are experienced within oneself • Splitting: seeing things as all good or all bad • Reaction Formation: transforming an unacceptable wish or impulse into it’s opposite • Intellectualization: Using excessive, abstract thinking to avoid painful emotions

48. Less Effective Defense Mechanisms • Rationalization: Justification of unacceptable attitudes, beliefs or behaviours to make them acceptable to oneself • Dissociation: Disrupting one’s sense of continuity in the areas of identity, memory or consciousness.

49. Healthy Defense Mechanisms • Sublimation: Transforming socially or internally objectionable aims into socially acceptable ones. • Asceticism/Religiousness: Attempting to eliminate pleasurable aspects of an experience due to internal conflicts produced by that pleasure • Humor: Finding comic/ironic elements in difficult situations • Altruism: Committing oneself to the needs of others over and above one’s own needs • Suppression: Consciously deciding not to attend to a particular feeling or impulse. • Anticipation: Delaying of immediate gratification by planning and thinking about future accomplishments

50. What makes a defense pathological? • inflexible • may have been adaptive in the past, but is not adaptive in the present • severely distorts understanding of the present situation • causes significant problems in relationships, functioning, and enjoyment of life