Psychotherapy for the MRCPsych

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Psychotherapy for the MRCPsych

• Dr Susan Mizen
• Consultant Psychiatrist in Psychotherapy

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Key Competencies

• General
• Account for clinical phenomena in psychological
  terms
• Deploy advanced communications skills
• Display advanced emotional intelligence
  (patients, colleagues and yourself)
• Specific
• Refer appropriately for formal psychotherapies
• Jointly manage patients receiving psychotherapy
• Deliver basic psychotherapeutic treatments and
  strategies.

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Acquiring competencies

• Routine Clinical Practice
• Formulation, discussion, reflective diary
  (Countertransference), personal therapy.
• Case Based Discussion Group
• Seeing cases minimum of two, a short and long
  case in different modalities.
• Portfolio/Logbook ARCP
• WPBA
• CBD
• SAPE (yr 2) SAPE 2 (yr 3)
• Psychotherapy ACE.

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The MRCPsych Exam

• Paper 2 40 questions on therapy related subjects
• Paper 3 8
• CASC
• Psychotherapy History
• Case Discussion
• Difficult Communication

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Time table for the day

• 10-11 am
• Indications and contraindications for therapies
• The evidence base for psychological therapies
• Prescribing for patients in therapy
• 11.15-12.30am
• Formulation
• Lunch
• 1.00-2.00pm
• Case vignettes and Formulation
• 2.15
• CASC 1 Difficult Communication
• CASC 2 Psychotherapy History

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Indications and Contraindications for
Psychological Therapies

• Psychodynamic
• Short Term Dynamic
• Group Analysis
• CBT
• IPT
• Family Therapy
• Arts Therapies
• Integrative Therapies

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Evidence Base

• CBT
• Depression, OCD, Phobias, Panic Disorder with
  Agoraphobia, GAD, Bulimia, BED, Sexual
  Dysfunction, PTSD.
• Psychodynamic
• PD, Panic Disorder, Depression in the elderly
• CAT Anorexia Nervosa
• Behavioural treatments
• Anxiety disorders, Substance misuse, Childhood
  behavioural disorders, sexual dysfunction.
• EMDR PTSD
• DBT-Borderline and emotionally constricted PD
• IPT- Depression and Bulimia
• Family Couple SCZ, Type 1 diabetes in children.

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Jointly managing patients in Psychodynamic therapy

• Discussing continuing in therapy with the anxious
  or ambivalent patient.
• The patient tells you they think their therapist
  is useless or abusive.
• The Patients disturbance is escalating in
  therapy.
• A patient in therapy begins to establish a
  psychotherapeutic relationship with you as their
  psychiatrist.

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Prescribing for patients in therapy CBT
Advantages Disadvantages
Medication may - increase the speed and magnitude of response to psychotherapy - reduce symptoms and make treatment more acceptable. - improve ego function so the patient can make better use of therapy. Psychotherapy may - promote adaptive behaviour and improve compliance with medication. - decreases the likelihood of recurrence. - provides a more comprehensive understanding of the patients difficulties than medication alone. Medication may - suppress feelings and impede progress in therapy - convey a message that a patients feelings are too difficult to be dealt with in therapy. - patient may believe improvement is due to medication not their own efforts. - lead to devaluation of the therapeutic relationship. - be disadvantageous in treating PTSD where exposure to affect is important. - lead to poorer outcome with CBT for panic disorder and agoraphobia, (Westra 2002).
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The meaning of medication

• Transference and countertransference to the
  doctor and medication
• The significance of medication
• The importance of therapeutic alliance
• Indications from medication about the
  relationship with the doctor.

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Integrated and Combined Practice

• Integrated Practice
• Therapy and medication are managed by the same
  person.
• Principles
• Informed consent.
• Formulate treatment goals at the outset.
• Focus on alliance not compliance.
• Address medication issues at the beginning or end
  of sessions.
• Symptoms increase at the end of therapy.
• Combined Practice
• Separate practitioners offering therapy and
  medication.
• Principles
• Good communication
• If there is not a joint formulation mixed
  messages.
• Meet and plan treatment clarify roles and crisis
  responses
• Meet again if tensions arise.

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Prescribing in Psychodynamic therapy

• Depression in Psychotherapy
• Escalations of disturbance in psychotherapy
• Splitting and destructive enactments.

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Formulation
Triangle of person (Malan)
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Formulation
Diagnosis Defences
Depression Object losses in remote or recent past Ambivalence towards lost object Identification with lost object Excessive superego activity
Obsessive Compulsive Disorder Defences of isolation, undoing and reaction formation. Ambivalence in object relations, anxiety about aggression Magical thinking
Anxiety Disorder Anxiety signals an unsuccessful defence Agoraphobia sometimes fear of abandonment/separation anxiety Panic disorder- onset often associated with loss Simple phobia classically associated with symbolic significance of the phobic object
Anorexia Nervosa Difficulty separating from mother Body unconsciously perceived as occupied by introject of intrusive mother hence starved, need projected into others who are looked after, projective identification in family relations.
Alcohol Dependency Associated with harsh punitive superego, alcohol acting as a superego solvent. Consider primary and secondary gain.