Overview of Psychotherapy
Back to Basics 2008
Tin Ngo-Minh, MD
PGY2 Psychiatry
University of Ottawa
Objectives
• Overview of psychotherapy
• Review of defense Mechanisms
• MCQ
Common Psychotherapies
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Supportive Psychotherapy
Conginitve behavioral Therapy - CBT
Interpersonal Psychotherapy - IPT
Dynamic Psychotherapy
Other Psychotherapies
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Behavioral Therapy
Mindfulness-Based Cognitive Psychotherapy
Dialectical Behavior Therapy - DBT
Acceptance and Commitment Therapy - ACT
Therapeutic Alliance
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Commitment in therapy
Better to disclose information
Pt feels valued as an individual
Development of a meaningful relationship
• By trying to genuinely understand the
patient, being empathic
Supportive Psychotherapy
• To maintain, restore and improve selfesteem, ego-function and adaptive skills
• Self-esteem: praise, reassurance,
encouragement, normalization
• Ego-function: rationalization/reframing,
advise/teaching, naming the problem,
clarification, confrontation, interpretation
• Adaptive skills: preventing anxiety,
anticipatory guidance, problem solving
Cognitive-Behavioral Therapy
(CBT) (A. Beck)
• People perceptions and automatic thoughts
about situation influences their emotional and
behavioral reactions
• Depression: negatively biased judgements
patient have of themselves (themselves, world
and future – internal-global-stable)
• Educative, collaborative and empirical approach
- examination of distorded cognitions
• Time limited (6-16 sessions)
CBT goal
• Teach patients how to respond to their
dysfunctional thinking. Guide patients in
evaluating the validity of their thoughts,
seeking alternative explanations or
perspectives, decatastrophizing,
examining the utility of their thinking,
getting distance from their thoughts
through reflecting on advice they would
give to others, and planning a course of
action.
CBT Techniques
• Socratic questioning, clarification, exploration,
use of specific examples, « downward arrow »
• Problem solving, relaxation, graded task
assignement, graded exposure, activity
monitoring (M + P), scheduling, behavipral
activation, psychoeducation, guided discovery,
dysfunctiuonal thought record, behavioral
experiements, weighting advantages and
disadvantages, coping cards, imagery work,
response prevention
• Homework, weekly visits (6-12 sessions x 1hr)
CBT – Thought Record
Interpersonal Psychotherapy – IPT
(Sullivan)
• Focus on interpersonal relationship
– Improve maladapted communication skills
– Change expectations in relationship
– Discrepencies between support and its needs during
time of crisis
• Symptom reduction Here and Now
• Based on attachment theory
• Teach skills, problem solving, to continue to
build new relationships and releave the distress
• Indication: anxiety – depression
• Time limited (12-20 sessions)
IPT - Techniques
• Analysis of communication pattern
– Convey their needs more clearly and
effectively
• Ex: explore a conflict: reactions – consequences
– Transference in therapy
– Feedback – role paying
– How ask for help
– Explore the perception of the other
IPT – Area of expertise
• Grief and loss
– Resolution of grief – description (good/bad) of
the lost person
– Facilitate mourning, new or change in
interpersonal relationship, seek support
• Interpersonal dispute
– Better communicate attachment needs
• Role transition
– Give up old role
Dynamic Psychotherapy
• Change ingrained pattern of interpersonal
relatedness and personality style
– Learn a more flexible and independant manner of
interacting
• Object relation theory
– image of self and other evolve out of human
interaction
• Therapist as a participant-obsever
• Transference (repetion of past conflict into
therapeutic relationship)
Dynamic Psychotherapy Assumptions
• Maladaptive relationship patterns are
learned from the past
• Dysfunctional patterns are reenacted in
vivo in the therapy
– Therapist, through a new emotional
experience (experiencial learning) – attempt
to alter the dysfunctional interactive style
– Invitation for metacommunication (what’s
happening between therapist and patient) –
highlight dysfunctional reenactment
• Assessment of maladaptive pattern
– Thoughts, feeling, perception and behaviors
of the patient of an interpersonal nature
– Expectation of other’s reactions
– Behavior of other people and interpretation
– Patient’s behaviours and attitudes toward the
self – how the person treat himself
Other Psychotherapies
Behavioral therapy
(Skinner)
• Little attention in gaining insight
• Time limited therapy
• Anxiety management skills
– Relaxation/breating
– Structured problem solving
– Behavioral rehearsal
• Exposure therapy
– Phobias, OCD, PTSD
Mindfulness-based Cognitive
Therapy (MBCT)
(Kabat-Zinn, Segal)
• Mindfulness is a meditative practice from
Buddhism, which aims to help people identify
their thoughts, moment by moment, but
without passing judgement on the thoughts.
• “We can respond to situations with choice rather
than reacting automatically”
• Little emphasis on changing the content of
thoughts (unlike CBT)
• Body scan - meditation
Dialectical Behavior Therapy (DBT)
(Linehan)
• For borderline patients
• Behavioral principle to promote change and
mindfulness to promote acceptance
• Extreme behaviors and emotions: Learn a
middle ground
• Mix of individual and structured group therapy
– 1) enhance patient motivation
– 2) enhance patient capabilities
– 3) ensure that new capabilities generalize to the
patient’s natural environment
DBT - Goal
The goal is to bring out the opposites, both
in therapy and the client’s life, and to provide
conditions for synthesis. Strategies
include extensive use of stories, metaphor,
and paradox; the therapeutic use of
ambiguity; viewing therapy, and indeed all of
reality, as constant change; cognitive
challenging and restructuring techniques;
and reinforcement for use of intuitive,
nonrational knowledge bases.
Acceptance and
Commitment Therapy (ACT)
(Hayes)
• ACT attempts to teach clients to accept, rather
than control or eliminate, private experiences
(i.e., negative emotions, thoughts, memories)
• "self-as-context“ Here and Now — the you that
is always there observing and experiencing and
yet distinct from one's thoughts, feelings,
sensations, and memories.
• Acceptance, defusion, being present, a
transcendent sense of self, values, and
committed action.
Review of defense
mechanisms
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Denial
Distortion
Delusional Projection
Fantasy
Projection
Somatization
Acting out
Idealization
Displacement
Dissociation
Isolation
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Splitting
Dissociation
Intellectualization
Rationalization
Reaction Formation
Repression
Altruism
Humor
Identification
Introjection
Sublimation
Suppression
MCQs
A 42-year-old man has just been informed that he has
poorly differentiated small cell carcinoma of the lung. When
asked if he understands the serious nature of his illness,
the patient proceeds to tell his physician how excited he is
about renovating his home. This patient is exhibiting
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A. denial
B. displacement
C. projection
D. rationalization
E. reaction formation
F. sublimation
A 55-year-old male begins group therapy. After the first
session, he befriends one of the other clients, and
begins telling her how extraordinarily intelligent and
talented the facilitator is. At the next session, he and the
facilitator disagree. After the session, he tells his fellow
group member that the facilitator is utterly incompetent
and that they should sue for malpractice. This is an
example of
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B.
C.
D.
E.
displacement
fixation
reaction formation
regression
splitting
A 17-year-old girl loses her best friend in an
automobile accident. After the death, she starts
writing for hours daily in her diary. This would most
likely be an example of which of the following
defense mechanisms?
A. Identification
B. Projection
C. Rationalization
D. Regression
E. Sublimation
A 27-year-old swimmer who feels insecure about
her athletic abilities harshly criticizes her
teammates' techniques. Which of the following ego
defense mechanisms is she displaying?
A.
B.
C.
D.
E.
Displacement
Projection
Reaction formation
Repression
Sublimation
There is a classic zoo story about a cage with three
monkeys in it. The largest monkey steals the middle-sized
monkey's banana. The middle-sized monkey then screams
with rage, hits the smallest monkey on the head, and then
steals his banana. The middle-sized monkey is using which
of the following mechanisms of defense?
A. Displacement
B. Projection
C. Reaction formation
D. Regression
E. Repression
Good luck on the Exam!