The Psychotherapies

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The Psychotherapies
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Colleges position

• Mental health strategy justifies it
• MHPs should learn about lived experience of
  consumers and carers
• MHPs gain therapeutic leverage from their
  relationship with consumers and carers
• Psychiatrists should be well versed in CBT
  psychodynamics incl. Long-term therapy
• Psychiatrists are uniquely placed
• Medical training complex, severe, co-morbid
  incl. Physical disorders
• Concurrent pharmacological therapy
• Involuntary treatment
• Biopsychosocial perspective
• Child adolescent training developmental
  perspective

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Psychotherapy in emergencies!

• The META Principles
• Manage own feelings
• Empathic can be the way MHA is invoked!
• Take time true emergencies are rare
• Ally with patient in dealing with 3rd parties
• Suicidal
• Understand accept pain --gt provide hope
• Violent
• Patients often fearful and --gt fear in others
• Remind yourself theyre suffering and need help

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Attachment theory
bond with other that you can contact under
stress Bowlby - evolutionary significance -
systems theory dynamics - elaboration of
increasing relationship with care giver in
development Secure / sense of oneself as
lovable and others as trustworthy Insecure / -ve
effect on ability to develop future
relationships Even insecure attachment figures
satisfy some attachment needs so DON'T TOTALLY
DEMONISE the inconsistent/poor caregiver
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Attachment

• 2. Preferential attachment for human-ness (eg
  faces and voices from 6 weeks)
• 4. Indiscriminate attachment to humans until 7/8
  months
• 1. If attachment insecure, there can be
  indiscriminate attachment and disinhibited
  behaviour

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• 3. Monkey experiments showed that if surrogate
  cloth mothers were rejecting, infant more
  clingy to them
• Abused children can have strong attachment and
  loyalty
• Anxiety can increase attachment, even towards the
  cause of the anxiety

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Long-Term

• 5. Early attachment associated with adult
  relationship styles
• ?early inner working models of relationships act
  as prototypes for later relationships
• 6. Neonatal separation may affect mums bonding,
  rather than childs attachment
• This could affect later attachment
• Cannot say it will cause emotional disorder in
  adulthood

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The big 5 personality dimensions CANEO
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Erikson

• Epigenetic principle Developmental stages occur
  in sequential clearly defined stages that must be
  satisfactorily resolved for developments to
  proceed smoothly
• Personality is developed as the person passes
  through developmental stages, and is continuously
  being modeled and thus is able to be changed.
• Therapy involves past tensions and poor
  resolutions of crises being relived in the
  therapeutic relationship and learning new ways of
  dealing with issues
• Teaching the observed to be self-observant

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Erikson
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Non-specific therapeutic factors

• Good therapeutic relationship
• Opportunity for catharsis and ventilation
• Fostering of insight/learning new ways to cope
• Placebo or hope factor (patients expectation
  that it will help)
• Patients motivation
• Therapists charisma and belief in the
  model/system they are using
• Therapists sanctioned healer role
• Therapists ability to empathise with and
  validate the patient
• Explanatory model (provision of an explanation
  for problems)
• Structure of therapy the ritual, regularity,
  frame or holding aspect of it

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The psychotherapies

• CBT

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Becks thinking errors
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CBT the evidence

• Better than generalist counselling
• Panic disorder and GAD (CBT)
• Phobic disorders (Exposure therapy systematic
  desensitisation)
• OCD (Exposure and response prevention)
• Huge evidence base also for MDD
• But usually compared with antidepressants

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The psychotherapies

• IPT

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IPT miscellany

• Interpersonal inventory is made early
• Who
• How often in contact
• Whats good bad about it
• What does each party expect
• How could it be made better
• Interpersonal disputes are assessed as in
• Renegotiation they are trying to fix it
• Impasse the cold marriage
• Dissolution irretrievably disrupted

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PSYCHODYNAMICS
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Key Psychodynamic ConceptsUnfortunately,
Conscious Things Can Really Obscure Aetiologies

• Unconscious is much of mental life
• The Child is the father of the man
• Transference to the therapist teaches much
• Countertransference mirrors what the patient
  induces in others
• Resistance to therapy is much of what therapy is
  about!
• Overdeterminism of aetiologies and functions of
  symptoms
• Authenticity and uniqueness are what we aim the
  patient to develop a sense of

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Topographical Structural

• Conscious
• Preconscious
• Unconscious
• Primary process thinking
• No place/person/time
• Operates on images and symbols

• Ego Cu
• Id U
• Superego cU
• EgoC Executive
• Ego u Defences
• Id sex aggression
• S.Egoego ideal
• prescribes should
• moral consciounce
• proscribes shouldnt

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Symptoms psychodynamic compromises
Ego ? Id has conflict ? Superego
Signal anxiety
Ego defends
A symptoms is formed as a compromise
Also gratifies Ids wish in a Distorted way
Curbs unbearable expression
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Defences
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Defences
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Defences
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Defences

• Funtions
• Protect against undesirable id wishes e.g. sexual
  or aggressvie
• Self-esteem maintenance e.g. in narcissistic
  threat
• Abandonment protecting against
• External threat e.g. denying illness

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Freuds development
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Object-relations theory

• Melanie Klein Representations of experiences
  with (associated affective states) people
  including the self to whom the infant relates are
  internalised (sometimes inaccurately) as psychic
  objects
• British independent school Fairburn,
  WinnicotPrimary developmental motive is object
  seeking vs drive gratification (cf. Freud)

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Self Psychology KohutDevelopmental perspective
Lack of developmentally appropriate empathy from
mum
Deficit sense that somethings
missing/selfobject functions are lacking
Looking for responses from others to make up for
lacking selfobject functions
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Attachment theory Bowlby
Displaying behaviours to lure mum
Physical closeness to mum
Soothing psychological state
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Dis-attachment
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Dream terminology
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Psychodynamic odds and sods

• Autistic phase/normal autism (M. Mahler)
• First few weeks of life where self/other boundary
  doesnt exist
• Identification against mothers femaleness (N.
  Chodorow)
• Leads to boys sexual identity development
• Mirror transference (H. Kohut)
• Therapist is experienced as being the same as
  patient
• Therapists sole role is seen as being to praise
  or mirror the patient

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Brief dynamic psychotherapy
? The task is to enable the patient to understand
and resolve his internal conflict and its
relationship to the other people in his life,
past and present. ? Malans (1979) 2
triangles -Triangle of conflict- hidden feeling
or impulse / anxiety / defence -Triangle of
person- past relationships, current or recent
relationships, transference relationships. ? Model
extended by Molnos (1984) combined the 2
triangles
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Narrative therapy
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Narrative therapy
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Adherence therapy
Phases A1 Eliciting patients stance or
attitudes to treatment 1 A2 Exploring
ambivalence towards treatment 1 A3 Highlighting
need for maintenance treatment 1 B Key
principles of Adherence therapy B1 Non-blaming
atmosphere 1 B2 Focus on eliciting the
patients concerns 1 B3 Express empathy with
patient 1 B4 Support self-efficacy (knowledge
on which to base choices, autonomy, self-care
etc.) 1 C Key techniques of Adherence therapy
C1 Reflective listening 1 C2 Regular
summarizing 1 C3 Inductive questioning (using
specific examples to help patient grasp overall
principles) 1 C4 Explore ambivalence,
exploration of pros and cons of alternatives 1
C5 Discussion of the discrepancy between present
behaviour and broader goals 1 C6 Use of
normalizing rationales (e.g. Giving examples of
how unusual symptoms can be caused by various
things such as Sleep deprivation, Post-traumatic
stress disorder, Sensory deprivation, Hostage
situations, Sexual abuse, etc. - so as to help
the patient feel more ' normal' and less
alienated by the concept of "schizophrenia", and
to catastrophize less about the term is
combined with sensible, accurate psychoeducation
and explanations of symptoms.) 1 C7 Techniques
drawn from Cognitive Therapy 1 C8 Techniques
drawn from Motivational Interviewing 1 C9
Techniques drawn from Psychoeducation principles