Psychotherapy for the
MRCPsych
Dr Susan Mizen
Consultant Psychiatrist in
Psychotherapy
Key Competencies
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General
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Account for clinical phenomena in psychological
terms
Deploy advanced communications skills
Display advanced emotional intelligence (patients,
colleagues and yourself)
Specific
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Refer appropriately for formal psychotherapies
Jointly manage patients receiving psychotherapy
Deliver basic psychotherapeutic treatments and
strategies.
Acquiring competencies
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Routine Clinical Practice
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Formulation, discussion, reflective diary
(Countertransference), personal therapy.
Case Based Discussion Group
Seeing cases minimum of two, a short and long case
in different modalities.
Portfolio/Logbook – ARCP
WPBA
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CBD
SAPE (yr 2) SAPE 2 (yr 3)
Psychotherapy ACE.
The MRCPsych Exam
Paper 2: 40 questions on therapy related
subjects
 Paper 3: 8%
 CASC
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Psychotherapy History
 Case Discussion
 Difficult Communication
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Time table for the day
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10-11 am
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11.15-12.30am
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Formulation
Lunch
1.00-2.00pm
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Indications and contraindications for therapies
The evidence base for psychological therapies
Prescribing for patients in therapy
Case vignettes and Formulation
2.15
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CASC 1 Difficult Communication
CASC 2 Psychotherapy History
Indications and Contraindications
for Psychological Therapies
Psychodynamic
 Short Term Dynamic
 Group Analysis
 CBT
 IPT
 Family Therapy
 Arts Therapies
 Integrative Therapies
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Evidence Base
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CBT
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Psychodynamic
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PD, Panic Disorder, Depression in the elderly
CAT – Anorexia Nervosa
Behavioural treatments
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Depression, OCD, Phobias, Panic Disorder with Agoraphobia,
GAD, Bulimia, BED, Sexual Dysfunction, PTSD.
Anxiety disorders, Substance misuse, Childhood behavioural
disorders, sexual dysfunction.
EMDR – PTSD
DBT-Borderline and emotionally constricted PD
IPT- Depression and Bulimia
Family Couple – SCZ, Type 1 diabetes in children.
Jointly managing patients in
Psychodynamic therapy
Discussing continuing in therapy with the
anxious or ambivalent patient.
 The patient tells you they think their
therapist is useless or abusive.
 The Patient’s disturbance is escalating in
therapy.
 A patient in therapy begins to establish a
psychotherapeutic relationship with you as
their psychiatrist.
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Prescribing for patients in therapy:
CBT
Advantages
Disadvantages
Medication may
- increase the speed and magnitude of
response to psychotherapy
- reduce symptoms and make treatment
more acceptable.
- improve ego function so the patient can
make better use of therapy.
Psychotherapy may
- promote adaptive behaviour and improve
compliance with medication.
- decreases the likelihood of recurrence.
- provides a more comprehensive
understanding of the patient’s difficulties
than medication alone.
Medication may
- suppress feelings and impede progress
in therapy
- convey a message that a patient’s
feelings are too difficult to be dealt with in
therapy.
- patient may believe improvement is due
to medication not their own efforts.
- lead to devaluation of the therapeutic
relationship.
- be disadvantageous in treating PTSD
where exposure to affect is important.
- lead to poorer outcome with CBT for
panic disorder and agoraphobia, (Westra
2002).
The meaning of medication
Transference and countertransference to
the doctor and medication
 The significance of medication
 The importance of therapeutic alliance
 Indications from medication about the
relationship with the doctor.
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Integrated and Combined Practice
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Integrated Practice
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Therapy and medication are managed by the same person.
Principles
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Informed consent.
Formulate treatment goals at the outset.
Focus on alliance not compliance.
Address medication issues at the beginning or end of sessions.
Symptoms increase at the end of therapy.
Combined Practice
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Separate practitioners offering therapy and medication.
Principles
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Good communication
If there is not a joint formulation – mixed messages.
Meet and plan treatment clarify roles and crisis responses
Meet again if tensions arise.
Prescribing in Psychodynamic
therapy
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Depression in Psychotherapy
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Escalations of disturbance in
psychotherapy
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Splitting and destructive enactments.
Formulation
Triangle of person (Malan)
Current
life
situation /
symptom
Transference
Infantile
objectrelations /
history
Formulation
Diagnosis
Defences
Depression
Object losses in remote or recent past
Ambivalence towards lost object
Identification with lost object
Excessive superego activity
Obsessive Compulsive Disorder
Defences of isolation, undoing and reaction formation.
Ambivalence in object relations, anxiety about aggression
Magical thinking
Anxiety Disorder
Anxiety signals an unsuccessful defence
Agoraphobia sometimes fear of abandonment/separation anxiety
Panic disorder- onset often associated with loss
Simple phobia – classically associated with symbolic significance of the phobic
object
Anorexia Nervosa
Difficulty separating from mother
Body unconsciously perceived as occupied by introject of ‘intrusive’ mother hence
starved, need projected into others who are looked after, projective identification in
family relations.
Alcohol Dependency
Associated with harsh punitive superego, alcohol acting as a ‘superego solvent’.
Consider primary and secondary gain.