The Psychotherapy of Anxiety Some Practical Questions

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Psychotherapy Some Practical Questions and
Answers1 A Presentation for SOMC Medical
Education
Kendall L. Stewart, M.D. Date
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Why is this important?

• There are a lot of distressed people out there.
• They will benefit from medication and
  counseling.1
• They will be seeing counselors and you need to
  have some idea of what is going on in those
  sessions.
• You will be referring these patients to
  psychotherapists you must be able to discern the
  wheat from the chaff.
• Moreover, physicians are in a position to do a
  lot of good or ill with psychotherapeutic
  techniques during a brief office visit.

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What is psychotherapy?

• Treatment of mental or emotional disorders by
  psychological means
• Helping professional listens to and talks with an
  anxious person with expectation that - as a
  result - this person will feel better1
• There are endless varieties most practitioners
  take an eclectic approach2

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What do the different brands of psychotherapy
have in common?

• An anxious person and a compassionate,
  knowledgeable and ethical helper work together to
  ease suffering
• An emphasis on the therapeutic relationship
• The importance of understanding or insight1
• The necessity for behavioral change
• The expectation that the anxious person will
  improve

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Is the psychotherapy of anxiety effective?

• Sometimes yes, sometimes no
• Manual-based psychotherapies, such as Cognitive
  Behavioral Therapy (CBT) and Interpersonal
  Therapy (IPT), have been shown to be as effective
  as medication
• The relentless demand for counseling documents
  wide-spread desperation if not effectiveness1
• Most consumers report benefit
• Insurers hesitant to pay for extended counseling

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What are some of the characteristics of good
counselors?

• Professionally competent
• Genuine concern for those who seek them out1
• Effective listeners
• Respectful but honest
• Ethical
• Reliable and available
• Focus on patterns of thought, feeling and
  behavior

• Give practical feedback
• Put the sufferers needs first
• Encourage autonomy
• Non judgmental
• Confront respectfully2
• Expert collaborators
• Focus on documented behavioral change
• Know their own limitations

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How does the professional build a therapeutic
relationship?

• A genuine concern for suffering persons is the
  right start.1
• Effective listening including understandable
  feedback is required.
• One must convey hope that the sufferer can and
  will feel better.
• The sufferers feelings must be legitimized.
• The helper must be viewed as trustworthy.
• A reputation for excellence definitely jump
  starts the process.

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How are feelings dealt with in therapy?

• All feelings are OK
• Feelings are just feelings - its what we do with
  them that matters
• All feelings make sense (in the context they
  arose)
• Feelings change

• Unrecognized feelings pose the greatest dangers
• Feelings should be
• identified
• accepted
• expressed
• We must not be held hostage by our feelings

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How do counselors go about figuring out what is
wrong?

• By taking a careful history
• By making a careful diagnosis
• By examining interpersonal conflicts
• By identifying maladaptive attitudes and
  behaviors
• By watching for patterns of thought, feeling and
  behavior that precipitate internal anxiety
• By monitoring ones own feelings
• By watching for the use of psychological defense
  mechanisms
• By confirming ones impressions with the patient

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What is insight and what is its value?

• It is an awareness of those pathologic attitudes
  and behaviors that contribute to the problem.
• It may include an awareness of how those
  attitudes and behaviors developed.
• It gives the sufferer hope that he or she can
  change.
• Insight is not a cure.
• Full insight is not required for significant
  improvement.

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How do maladaptive beliefs and behaviors develop?
Real or Perceived Trauma in Childhood
Irrational Beliefs and Maladaptive Behaviors
Interpersonal Conflicts
Emotional Symptoms
Clinical Syndromes
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What are some of the steps in the anxiety cascade?
Palpitations Indigestion Feared situation Etc.
External or Internal Trigger
Automatic Thought (Cognitive Distortion)
I am helpless
Emotional reasoning Overgeneralization Catastrophi
c thinking Black-or-white thinking Should or
must Negative predictions Mind reading Labeling Pe
rsonalization Negative focus Somatic focus
Cognitive Processing Errors
Unpleasant feelings Anxiety
Amplification Loop
Intense Anxiety or Panic
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How do psychotherapy patients improve?

• Ventilation produces temporary relief.
• Education brings comfort
• Insight gives hope.
• More realistic expectations bring peace.
• Correction of cognitive distortions gives sense
  of control
• Behavioral change precipitates different
  reactions from others.1
• Practice builds confidence.
• Reinforcement increases odds of sustained change.2

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What practical counseling techniques can be used
in primary care practice?

• Progressive muscular relaxation
• Sensory override techniques
• The rubber band technique for excessive
  rumination
• Therapeutic writing
• A blueprint for life
• Behavioral self analysis
• Best option search
• As-if acting
• Playing-the-hand-you-are-dealt strategy

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What are some of the dangers of psychotherapy?

• Unnecessary treatment
• Worsening symptoms
• Excessive dependence on therapist
• Therapy addiction
• Avoidance of more effective treatment
• Boundary violations

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Where can you learn more?

• American Psychiatric Association, Diagnostic and
  Statistical Manual of Mental Disorders, Fourth
  Edition, Text Revision, 2000
• Kaplan HI, Sadock BJ, Synopsis of Psychiatry,
  Ninth Edition, 2003
• Goldman HH, Review of General Psychiatry, Fifth
  Edition, 2000
• Jacobson JL and Jacobson AM, Psychiatric Secrets,
  2001
• Kaplan HI, Sadock BJ, Pocket Handbook of Clinical
  Psychiatry, Second Edition, 1996
• Stahl SM, Essential Psychopharmacology
  Neuroscientific Basis and Practical Applications,
  Second Edition, 2000
• Stewart KL, Dealing With Anxiety A Practical
  Approach to Nervous Patients and an Overview of
  the Objectives in the Anxiety Module in the OUCOM
  Psychiatry Block, 2000

Please visit www.KendallLStewartMD.com to
download related White Papers and presentations.
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How can you contact me?
Kendall L. Stewart, M.D. Chief Medical
Officer Southern Ohio Medical Center President
CEO The SOMC Medical Care Foundation, Inc. 1805
27th Street Portsmouth, Ohio 45662 740.356.8153
stewartk_at_somc.org Webmaster_at_KendallLStewartMD.co
m www.somc.org www.KendallLStewartMD.com
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