Psychotherapy
Deanna Mercer MD FRCPC
Jan 16 2011
dmercer@toh.on.ca
Objectives
• Introduction to psychotherapy
• Psychological Defense Mechanisms
• Understanding transference,
countertransference and therapeutic
alliance
• Review of common psychotherapies
INTRODUCTION TO
PSYCHOTHERAPY
Why do psychotherapy?
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
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
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.
Psychotherapy: Essential
Ingredients
1. Diagnostic assessment: Clarify symptoms and
problems. Assess the context (biological,
psychological and social) in which symptoms
are occurring.
2. Understanding: Theory underlying the therapy
must provide a way to understand why the
patient has developed these symptoms now.
3. Build hope/increase motivation: Alleviate the
patient’s sense of powerlessness to change
themselves or their environment
4. Facilitate experiences of success and mastery
Objective # 5245
Describe the general psychiatric
indications for psychotherapy
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
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)
Objective 5246
List the general characteristics
that are associated with good
outcomes in psychotherapy
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
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
Therapeutic Alliance
Collaborative alliance between patient and
therapist, depends on three factors
1.Patient –therapist agreement on goals
2.Patient – therapist agreement on tasks
that each person is to perform
3.Strength of attachment
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”
Objective #5247
Describe boundary issues that
may come up in the course of
psychotherapy
Boundary Issues: Setting
Boundaries
• Creating an atmosphere of safety and
predictability
• 3 tasks:
1.Establish and maintain a treatment frame
2.Establish and maintain a professional
relationship
• responsibility of the clinician to maintain
boundaries, even if a patient requests, demands or
provokes a boundary violation
3.Protect patient privacy and confidentiality
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
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
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
Boundary
Violation
Behaviour
that is
harmful or
exploitative
sexual
behaviour
with a
patient
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?”
Preventing Boundary Violations
1. Recognize and understand the impact on
patients of boundary violations
2. Recognition amongst physicians that we all
have potential to do this behaviour when under
stress with insufficient emotional support
3. Teaching physicians to be aware of when
boundary crossings are helpful and when they
are not
4. Improve MD access to psychological health
and supports
Two Main Strategies in
Psychotherapy
Validation/acceptance
Change
Change Strategies
•
1.
2.
3.
4.
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
In psychotherapy which of the following
are true?
a) Diagnosis is unimportant so you do not have to worry
about doing a diagnostic assessment
b) Theories in psychotherapy provide a way of
understanding why a patient has developed these
symptoms now.
c) Patients must be hopeful and motivated prior to entering
therapy for therapy to be successful
d) Since therapy primarily involves talking one does not
pay attention to the patient's experiences outside of
therapy.
Psychotherapy is contraindicated in
which of the following disorders?
a)
b)
c)
d)
depression
paranoid personality disorder
psychopathy
schizophrenia
The therapeutic alliance depends on
the following except:
a) The patient and therapist agree on goals
b) The type of psychotherapy being
provided
c) The patient and therapist agree on tasks
that each person is to perform
d) Strength of attachment
Setting boundaries refers to all of
the following except:
a) Creating an atmosphere of safety and
predictability
b) Establishing and maintaining a professional
relationship
c) Ensuring the patient is aware of therapist
boundaries so that the therapist no longer has
to worry about them
d) Protecting patient privacy and confidentiality
Psychodynamic
Cognitive Behavioural Therapy
Supportive
TYPES OF
PSYCHOTHERAPIES
Objective # 5248
Define the purpose of a psychological
defense mechanism and describe:
denial, splitting, projection, reaction
formation, rationalization, dissociation
Objective # 5250
Briefly Describe the following
Psychotherapies: Psychodynamic,
Cognitive therapy and Supportive
therapy
Peter Fonagy
Psychodynamic Psychotherapy
Glenn O Gabbard
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)
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
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
Understanding Psychological
Defense mechanisms
• Core Concepts:
– Conscious, unconscious
– Defenses
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
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
Structural Model
“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
Defense Mechanisms
Less Effective (immature)
• Denial
• Projection
• Regression
• Splitting
• Reaction Formation
• Intellectualization
• Displacement
• Rationalization
• Dissociation
•
•
•
•
•
•
Healthy
Sublimation
Religiousness/asceticism
Humor
Altruism
Suppression
anticipation
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
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.
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
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
Objective 5249
Describe what is meant by
transference, countertransference
and therapeutic alliance
Transference
Freud: “stereotype plate”- sexual desires
from childhood are directed at the
therapist
Current view: Patient’s perception of the
therapist is a mixture of the real
characteristics of the therapist and
aspects of figures from the patient’s past
Countertransference
Freud
• therapist unconsciously experiences the patient as
someone from her past.
• interferes with treatment
Current
• Therapists are human beings with conflicts and
emotional struggles of their own
• Therapist’s “total” emotional reaction to the patient
(based on current and past learning)
• Important source of information regarding the patient’s
effects on others, particularly if the therapists responses
are normative
Cognitive Behavioural
Therapy
Cognitive - Behavioural Therapy
Two central premises
1. Thoughts have a controlling influence on
behaviour and emotions
2. How we behave can strongly affect our
thought patterns
CBT
CBT: Social Phobia
Objective # 5251
Describe the important elements
of cognitive therapy
CBT: Cognitive Errors
• Habitual ways of thinking in response to
internal and external events
• influence how we see ourselves, our world
and our future (negative cognitive triad)
• arise in the context of mental illness and
perpetuate the illness
a.Cognitive distortions: “black and white
thinking”
b.Schemas: “I am unlovable”
CBT : Behavioural Methods
• Break patterns of avoidance or
helplessness – behavioural activation
• Gradually face feared situations –
systematic desensitization
• Build coping skills – graded task
assignments
• Reduce painful emotions and physiological
arousal – breathing and relaxation training
Case Study: Gina
• Presents for treatment of anxiety
• Always worried
• Panic attacks, increased since episode of
fainting several months ago
• Panic attacks in crowds, driving, on
elevators, eating in the cafeteria
• Avoiding these activities
CBT
• Length: 5-20 sessions
• Focus is on the here and now
• Primary treatment for depression, anxiety,
eating disorders
• Combined treatment for severe or
treatment resistant depression,
schizophrenia, bipolar disorder
All of the following are true regarding
cognitive behavioral therapy except:
a) The two central premises of CBT are:
1) Thoughts have a controlling influence on behaviour
and emotions
2) How we behave can strongly affect our thought
patterns
b) cognitive errors have a negative influence how we see
ourselves, our world and our future
c) Cognitive errors occur prior to the onset of mental
illness and are responsible for causing mental illness
d) Systematic desensitization refers to gradually facing
feared situations.
Supportive
Psychotherapy
Supportive Psychotherapy
• Reduction in anxiety through empathy,
concern and understanding
• Strengthen “healthy” or effective
mechanisms of coping
• Helpful for most psychiatric disorders
• Often used in conjunction with other
treatments
Psychodynamic Psychotherapy Case Study
ALEX
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
Therapeutic Alliance
Collaborative alliance between patient and
therapist, depends on three factors
1.Patient –therapist agreement on goals
2.Patient – therapist agreement on tasks
that each person is to perform
3.Strength of attachment
Countertransference
Current
• Therapists are human beings with conflicts and
emotional struggles of their own
• Therapist’s “total” emotional reaction to the patient
(current and based on past learning)
• Important source of information regarding the patient’s
effects on others, particularly if the therapists responses
are normative
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
Which is true regarding defences ?
a) Defences are problematic when they are inflexible and
when they severely distort the understanding of the
present situation
b) Defences are thought to be a compromise between the
superego , representing basic drives and desires and
the ego representing societal wishes
c) Maladaptive defences include: denial, splitting, reaction
formation and altruism
d) In psychodynamic psychotherapy defences are
considered unchangeable and are therefore ignored.
References
• Persuasion and Healing, JD Frank and JB Frank
1991
• Long Term Psychodynamic Psychotherapy: A
Basic Text, Glen Gabbard 2004
• Learning Cognitive-Behavior Therapy: An
illustrated guide, Jesse E Wight 2005