Psychological treatments
January 18, 2016
J.Talbot, MD,PHD,FRCP
jtalbot@uottawa.ca
Director psychotherapy training
Department of Psychiatry, University of Ottawa
Learning Objectives
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Describe neural correlates of psychotherapy.
Describe the general psychiatric indications for psychotherapy.
Briefly describe the following psychotherapies: psychodynamic,
cognitive behavioural therapy (dialectical behavioural therapy),
interpersonal therapy.
Describe what is meant by transference, counter‐transference and
therapeutic alliance.
Define the purpose of a psychological defense mechanism and
describe mature and immature mechanisms: denial, splitting,
projection, reaction formation, rationalization, sublimation.
Describe the links between thoughts, feelings and behaviours and
and the rationale for various treatment options
Psychotherapy is a form of learning
Learning changes the brain
Psychotherapy changes the brain
Psychological treatment is a
biological treatment.
Neuroimaging studies
• Over 20 studies have examined brain changes
after psychotherapy.
• Cognitive Behavioral Therapy (CBT)/Dialectic
Behavior Therapy (DBT), psychodynamic
psychotherapy, and interpersonal
psychotherapy alter brain function.
• Psychotherapy and neural plasticity is a
burgeoning field of study.
General indications for psychotherapy
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Anxiety disorders
Depressive disorders (including bipolar disorder)
Schizophrenia
Substance abuse
Insomnia
Eating disorders
Personality disorders
Attention Deficit Hyperactivity Disorder
Chronic pain and persistent pain
Family/marital discord
Gambling
Empirically supported treatments
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Psychoanalysis
Psychodynamic Therapy
Behavioral Activation
Cognitive Behavioural Therapy
• Dialectical Behavioural Therapy
• Acceptance and Commitment Therapy
• Mindfulness Based CBT
• Interpersonal Therapy
• Motivational Interviewing
http://psychologicaltreatments.org
Psychoanalysis (& its offshoot
psychodynamic therapy)
Psychoanalysis and its offshoot
psychodynamic therapy
• Goal: relieve symptoms by developing insight and understanding
the influence of the past on the present.
• The therapeutic relationship is central
– Transference
– Countertransference
• Techniques:
– Interpretation
– Dream analysis
– Attention to parapraxis
• Maladaptive defense mechanisms (resistance) targeted
https://www.youtube.com/watch?v=yFqFuuIDfvI
Transference
• 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
• Interpretation of transference is a source
of understanding and thereby change.
Countertransference
• 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.
Psychoanalysis and its offshoot
psychodynamic therapy
• Indicated for:
– Depression
– Anxiety disorders
– Somatoform disorder
– Anorexia Nervosa
• Not indicated for obsessive compulsive
disorder
Modes of deliver: psychodynamic
tx
– Psychoanalysis
• 4 to 5 sessions/week for 2-7 years
– Long term psychodynamic therapy
• 1 or 2 sessions/week for few months to a few years
– Short term psychodynamic therapy
• 1 or 2 weekly sessions for a total of 12-20 sessions
– Can be delivered in individual or group formats
Psychological defenses
• Are unconscious and automatic ways of
responding to internal and external stress and
emotional conflict.
• Are necessary
• Can be classified as:
– Primitive (immature)
– Neurotic
– Mature
http://psychcentral.com/lib/15-common-defensemechanisms
Primitive Defense Mechanisms
• Denial: The refusal to accept reality or fact, acting as
if a painful event, thought or feeling did not exist.
• Splitting: Preserves good feelings and avoids
bad feelings by separating them into different
people.
• Projection: Perceiving and reacting to
unacceptable inner impulses as though they
were outside self.
Neurotic Defense Mechanisms
• Reaction formation: Converting of unwanted
or dangerous thoughts, feelings or impulses
into their opposites
• Rationalization: Putting something into a
different light or offering a different
explanation for one’s perceptions or behaviors
in the face of a changing reality
Mature defenses
• Sublimation: The channeling of unacceptable
impulses, thoughts and emotions into more
acceptable ones.
• Humor: when used as a defense mechanism,
is the channeling of unacceptable impulses or
thoughts into a light-hearted story or joke.
Cognitive Behavioural Therapy
Empirical support for CBT
Treatment of choice
= as good or better than medications; lower relapse
rate
Major Depressive Disorder (mild to moderate)
Generalized Anxiety Disorder
Post traumatic stress disorder
Acute stress disorder
Panic Disorder (with or without Agoraphobia)
Social and Specific Phobias
Obsessive-Compulsive Disorder
Empirical support for CBT
Efficacy in combined treatments:
Schizophrenia
Bipolar affective disorder
Personality disorders
Eating disorders
Paraphilias
Impulse control disorders
Substance use disorders
Cognitive Behavioural Therapy
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present & future focus
goal-oriented & time-limited
sessions structured
guided discovery
generalization promote with homework
Modes of delivery
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individually with trained specialist (20- 24 sessions)
Group therapy
CBT “lite” in primary care settings
Bibliotherapy
Internet based
Apps
Cognitive Behavioural Therapy
Psychotherapy
(CBT/IPT), E-therapy,
self-help books, APPs
Relaxation
techniques
Yoga
Mindfulness
Antidepressants
Exercise
Stresses of life
J. Talbot (2014)
Behavioral activation
Characteristic thinking/behaviour
• Depression
– Negative view of self, others and the world
– Withdraw
• Anxiety
– Exaggerated risk of danger/underestimation of
capacity to cope
– Avoids
Cognitive distortions contribute to
emotional distress
Examples:
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Filtering
Black/white thinking
Overgeneralizing
Jumping to conclusions
Catastrophizing
Personalizing
Shoulds
Mind reading
http://www.getselfhelp.co.uk/unhelpful.htm
Dialectical Behaviour Therapy
• Is a form of CBT
• Developed by M. Linehan for patients with
borderline personality disorder.
• Combines individual and group therapy
• Specific skills taught:
– Mindfulness
– Emotional regulation
– Interpersonal effectiveness
– Distress tolerance
Interpersonal Therapy
• Focus is on social roles and interpersonal conflict.
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Complicated grief
Interpersonal disputes
Role transitions
Interpersonal deficits
• Indications: depression, post-partum depression,
eating disorders, social phobia
• Modes of delivery:
– 12-16 weekly individual sessions
– Group therapy
https://iptinstitute.com/about-ipt
Summary
• Wide range of indications for psychological
treatments
• Evidence based psychotherapies include:
– Psychodynamic therapy
– Behavioral Therapy
– Cognitive Behavioural Therapy (including DBT)
– Interpersonal Therapy
• There is before and after psychotherapy
functional imaging evidence of neural changes