PSYCHOANALYSIS

Is based on theory of sexual repression & traces d unfulfilled infantile libidinal wishes in individuals unconscious memories Psychoanalytic process Bringing to surface repressed memories or feelings by means of scrupulous unraveling of hidden meanings of verbalized material & of d unwitting ways in which d px wards off underlying conflict through defensive forgetting & repetition of d past
recollection
recoil time & event where d core of neurosis formed - reconstuction of event through - reminiscence, associations, autobiographical linking of dvlpmntal events

Contraindications Absence suffering, poor impulse control, inability to tolerate frustration & anxiety motivation to understand Extreme dishonesty Antisocial PD Concrete thinking OR absence of psychological mindns Serious physical illns Age >40 y/o Close r/ship w analyst Stages One Px become familiar w method, routines & requirements of analysis & realistic therapeutic alliance formed btwn analyst & px Px describe prob gains initial relief through catharsis & sense of security b4 delving into sorce of illns motivated by wish to get well Two actual neurosis transference neurosis gradual surfacing unconscious conflict irrational attachment to analyst Repetition of childhood pattern Recall of traumatic memories Three Dissolution of analytical bond as px prepares for leave-taking Transference neurosis subside More mature adaptation to px prob Patient Requisites motivation Ability to form a r/ship Psychological-mindedns & capacity for insight Ego strength

repetition
emotional replay of former interaction w significant individual in px's life

working thought
- previously repressed memories hv been brought into consciousns & px gradually set free (cured of neurosis)

Indications All psychoneuroses : anxiety d/o, obsessional thinking, compulsive behavior, conversion d/o, sexual dysfx, depressive state & many other nonpsychotic state Present of significant suffering so that px > willing to sacrifice time & financial for psychoanalysis Genuine wish to understand Must able to withstand frustration, anxiety & other effect so that px does X acting out their feelings in self-destructive manner Intelligence must be at least average Must hv reasonable, mature superego honest w analyst
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1. 2. 3. 4.

Goals Gradual removal of amnesias rooted in early childhood based on assumption that when all gaps in memory hv been filled co-morbid condition will cease Achieving some measure of self-understanding or insight Major Approach & Techniques 3 features 1. Individual (dyadic) Direct fx of Freudian theory of neurosis as an intrapsychic phenomenon, which takes place w/in d person as instinctual impulses continually seek discharge 2. Tx is frequent Long term interval btwn session is avoided so that d momentum gain in uncovering conflictual material is not lost & confronted defenses do not hv time to strenghten 3. Long term Psychoanalytic settings designed to promote relaxation & regression usually Spartan & sensorially neutral & external stimuli r minimized

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Psychoanalytic psychotherapy
Derived from psychoanalysis ONLY use insight oriented method Strategies Expressive (insight oriented, uncovering, evocative, interpretive) Supportive (r/ship-oriented, suggestive, repressive, suppressive) Supportive psychotherapy Aims at the creation of a therapeutic r/ship as a temporary buttress or bridge for d deficient px. To augment extratherapeutic measures D global perspective is to places major etiological emphasis on external rather than intrapsychic events; especially on stressful environment & interpersonal influences on severely damaged self
Supportive Significant ego defects of a long term nature Severe life crisis

Indications

Expressive Strong motivation to understand Significant suffering Ability to regress in service of the ego Tolerance for frustration Capacity for insight (psychological mindedns) Intact reality testing Meaningful object relations Good impulse control Ability to sustain work Capacity to think in term of analogy & metaphor Reflective response to trial interpretation

Goals

Major approach & tech

Poor frustration tolerance Lack of psychological mindns Poor reality testing Severely impaired objects relations Poor impulse control Low intelligence Little capacity fro self-observations Organically based cognitive dysfx Tenuous ability to form therapeutic alliances px self awarens Support reality testing Improve object r/ship through xploration of current interpersonal event & Provide ego support perceptions Maintain or reestablish usual level of functioning Focused understanding ones prob Major trustdeal with preconscious or conscious derivatives of conflicts as they became manifest in present interactions Clarify recent dynamic patterns & maladaptive behavior in present Establish of a therapeutic alliances Either single or in combination Early recognition & interpretation of ve transference Partial gratification of dpendency need Only limited or controlled regression is encouraged Support in ultimate dvlpmnt of legitimate independence +ve transference manifestation lft unexplored Help in dvlping pleasurable actvt Adequate rest & diversion Removal of xs strain Hospitalization, medication if needed Guidance & advice in dealing w current issues

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BRIEF PSYCHODYNAMIC PSYCHOTHERAPY

Brief Focal P . (Malan & Tavistock Group) Clarify the nature of defense, anxiety & impulse Link the present, the past, & the transference Px able to think in feeling terms High motivation Good response to trial interpretation Time-Limited P. Short-Term Dynamic P. Short-Term Anxiety-Provoking (Mann) (Davanloo) P. Resolution of d present & Resolution of oedipal conflict, loss Resolution of oedipal conflict chronically endured pain & focus, or multiple foci pxs ve self-image High ego strength Able to engage & disengage Therapist quickly able to identify a central issue Exclude MDD, acute psychosis, & borderline PD Psychological mindedns 1 past meaningful r/ship Able to tolerate affect Good response to trial transference interpretation High motivation Flexible defense Lack of projection, splitting & denial 5-40 sessions Longer duration for seriously ill Above-average intelligence 1 past meaningful r/ship High motivation Specific chief complain Able to interact with evaluator Flexible

Goal

Selection criteria

Duration Focus Termination

C/i

Up to 1 year 12 treatment hours Mean session = 20 Internal conflict presence since Present & chronically endured childhood pain Particular image of self Set a definite date at beginning Specific last session set at No specific termination date of tx beginning of tx Px is told that tx will be short Termination a major focus of therapy work Serious suicidal attempt MDD that interfere with tx Substance dependence agreement Chronic alcohol abuse Acute psychotic state Incapacitating chronic Desperate px who need but obsessional symptoms cannot tolerate object relations Incapacitating chronic phobic symptoms Gross destructive or self destructive acting out

A few months Oedipal (triangular) conflict No specific date given

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BIOFEEDBACK
Involve recording & display(auditory or visual) of small changes in the physiological levels of feedback parameter Based on idea that autonomic nervous system (ANS) can come under voluntary control through operant conditioning Can be use by itself or combination with relaxation Used in rehab of neuro d/o 2. Relaxation therapy Relaxation characterized by : i. Immobility of body ii. Control over focus of attention iii. Low muscle tone iv. Cultivation o specific frame of mind, described as contemplative, nonjudgemental, detached or mindful. E:g; Relaxing breathing Px w panic d/o Relaxation serve as occasion setting stimulus Anxiety d/o 1. Later adaptation of progressive muscular relaxation Joseph Wolpe chose progressive relaxation as a response incompatible w anxiety when designing his systemic desensitization 1st session ???? 2nd session px completed work with all principal muscle group in one session Once px mastered all d procedure, these groups r combined into larger group then px can practice relaxation by recall 2. Autogenic training Method of self-suggestion Px directing their attention to specific body area & hearing themselves think certain phrases reflecting a relaxed state 3. Applied tension Used to counteract fainting response Px learn to tense muscle & maintain long wnuf for a sensation of warmth dvlp in face px release d tension repeat several times Augment with BP measurement Adverse effect : h/ache 4. Applied relaxation Eliciting a relaxation response in stressful situation itself For panic d/o & GAD Step :

Theory By Neal Miller : normally involuntary ANS can be operantly conditioned by use of appropriate feedback used of instrument : px acquire in4 about status of involuntary bio. fx

px learn to regulate these bio. state that affect symptoms

Methods 1. Instrumentation Depends on px & specific problem Px r attached to d instrument that measure physiological fx & translate d measurement into an audible or visual signal that px used to gauge their response E:g : Electromyogram (EMG) Measure electrical potential of muscle fibers Electroencephalogram (ECG) Measure -waves that occur in relaxed state Galvanic skin response Show skin conductivity during relaxed state (GSR) gauge Thermistor Measures skin temp (which drops during tension bcoz peripheral vasoconstriction

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Technique Progressive relaxation Release-only relaxation Cue-controlled relaxation Differential relaxation

Step in applied relaxation Instructions Session 1: hands, arms, face, neck, and shoulders Session 2: back, chest, stomach, breathing, hips, legs, and feet As with progressive relaxation, except that the tension phase is omitted; when release-only relaxation is mastered, the patient can relax within 5 to 7 mins A stimulus -the word relax - is presented just before exhalation; patients focus on their breathing while already in a relaxed state; the therapist says the word inhale just before each inhalation and the word relax just before each exhalation; after approximately five cycles, the patient mentally says these words (optionally dropping the inhale) Patients can remain relaxed and move at the same time by differentially keeping muscles unrelated to the movement in a relaxed state; after achieving a relaxed state, patients lift an arm or a leg or look around in the room, while keeping movements and tension in other body parts at a minimum; patients also perform differential relaxation in other settings, including sitting in different chairs, sitting at a desk while writing, talking on the phone, and walking. Patients relax by taking one to three breaths with slow exhalations, thinking the word relax before each exhalation and scanning their bodies for areas of tension; with this practice, relaxation is shortened to 20 to 30 secs; patients are instructed to relax in this manner 15 to 20 times per day at certain predetermined events in their natural environment (e.g., when they look at the watch or make a telephone call. As a reminder, colored dots might be taped on the watch or phone. After some time, the dots are changed to a different color to keep their reminding power fresh).

Rapid relaxation

Application training Patients relax just before entering the target situation; they stay in the situation for 10 to 15 mins, using their relaxation skills as a coping technique; patients may initially be accompanied by the therapist; alternatively, if the patient's problem is panic attacks or generalized anxiety, imagery or physical exercise is used to induce fearful sensations, which then are used for application training

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COGNITIVE THERAPY
Used in : 1. Depression 2. Panic d/o 3. OCD 4. Personality d/o 5. Somatoform d/o Goals : identify & alter cognitive distortion that maintain symptoms Selection criteria : 1. primarily used in dysthymic d/o 2. Nonendogenous depressive d/o 3. Symptoms r not sustained by pathological family Duration : time limited ; usually 15-25 weeks; once weekly meeting Techniques : 1. Collaborative empiricism 2. Structured & directive 3. Assigned readings 4. Homework & behavioural tech 5. Identification of irrational belief & automatic thoughts 6. Identifications of attitude & assumptions underlying vely biased thought Components 1. Didactic aspects Therapists didactic aspect include explaining to px : Cognitive triad Schemas Faulty logic That they (px & therapist) will formulate hypothesis 2gether & test them over course of tx Requires full explanation of r/ship o depression & thinking, affect, & behavior as well as rationale of all tx 2. Cognitive techniques Involve 4 process: a) Eliciting automatic thoughts b) Testing automatic thoughts c) Identifying maladaptive assumptions d) Testing d validity od maladaptive assumptions 3. Behavioural techniques Behavioural & cognitive tech r done together help px understand d inaccuracy of their cognitive assumptions & learn new strategies & ways of dealing with issues E:g : Scheduling activities Mastery & pleasure Graded task assignments Self reliance training Role playing Diversion techniques

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Indications for Cognitive Therapy 1. Criteria that justify the administration of cognitive therapy alone: Failure to respond to adequate trials of two antidepressants Partial response to adequate dosages of antidepressants Failure to respond or only a partial response to other psychotherapies Diagnosis of dysthymic disorder Variable mood reactive to environmental events Variable mood that correlates with negative cognitions Mild somatoform disorders (sleep, appetite, weight, libidinal) Adequate reality testing (i.e., no hallucinations or delusions), span of concentration, and memory function Inability to tolerate medication effects or evidence that excessive risk is associated with pharmacotherapy 2. Features that suggest cognitive therapy alone is not indicated: Evidence of coexisting schizophrenia, dementia, substancerelated d/o, mental retardation Patient has medical illness or is taking medication that is likely to cause depression Obvious memory impairment or poor reality testing (hallucinations, delusions) History of manic episode (bipolar I disorder) History of family member who responded to antidepressant History of family member with bipolar I disorder Absence of precipitating or exacerbating environmental stresses Little evidence of cognitive distortions Presence of severe somatoform disorders (e.g., pain disorder) 3. Indications for combined therapies (medication plus cognitive therapy): Partial or no response to trial of cognitive therapy alone Partial but incomplete response to adequate pharmacotherapy alone Poor compliance with medication regimen Historical evidence of chronic maladaptive functioning with depressive syndrome on intermittent basis Presence of severe somatoform disorders and marked cognitive distortions (e.g.hopelessness) Impaired memory and concentration and marked psychomotor difficulty Major depressive disorder with suicidal danger History of first-degree relative who responded to antidepressants History of manic episode in relative or patient

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DIALECTICAL BEHAVIOURAL THERAPY

Px r seen weekly Goals : improviing interpersonal skills & decreasing self-destructive behavior Technique used : advice metaphor, story telling, confrontation Used for : Borderline PD Substance abuse Eting d/o Schizophrenia PTSD Fx : 1. To enhanced & expand pxs repertoire of skillful behavioural patterns 2. Improve px motivation to change by reducing reinforcement of maladaptive behavior; including dysfx cognition & emotion 3. To ensure that new behavioural pattern generalize from the therapeutic to the natural environment 4. To structure the environment so that effective behaviours, rather than dysfx behavior r reinforced 5. To enhance motivation & capabilities of d therapist so that effective tx is rendered Modes of treatment : Group skills training Individual therapy Telephone consultation Consultation team How DBT works..

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INTERPERSONAL PSYCHOTHERAPY
Goal : to reduce or eliminate psychiatric symptoms by improving d quality of pxs current interpersonal relations & social functioning 3 phase : Initial phase identify the prob areas that will be target for tx Intermediate working on target problems areas Termination phase focused on consolidating gains made during tx & preparing d px for future work on their own Techniques 1. Individual Interpersonal Psychotherapy Phases of Interpersonal Psychotherapy 1. 2. 3. 4. 5. 6. Initial phase: sessions 1 5 Give the syndrome a name; provide information about prevalence and characteristics of the disorder Describe the rationale and nature of interpersonal psychotherapy Conduct the interpersonal inventory to identify the current interpersonal problem area(s) associated with the onset or maintenance of the psychiatric symptoms Review significant relationships, past and present Identify interpersonal precipitants of episodes of psychiatric symptoms Select and reach consensus about the interpersonal psychotherapy problem area(s) and treatment plan with patient 1. 2. 3. 4. 5. Termination phase: sessions 16 20 Discuss termination explicitly Educate patient about the end of treatment as a potential time of grieving; encourage patient to identify associated emotions Review progress to foster feelings of accomplishment and competence Outline goals for remaining work; identify areas and warning signs of anticipated future difficulty Formulate specific plans for continued work after termination of treatment Interpersonal problems areas : description, goals, & strategies
Interpersonal Prob Area Grief Description Goals Strategies Complicated Facilitate the Reconstruct the bereavement after mourning process px's r/ship with d the death of a loved Help deceased patient one reestablish interest Explore ass. in new activities feelings (-ve & and relationships +ve) to substitute for Consider ways of what has been lost becoming reinvolved w others A hx of social Reduce patient's Review past impoverishment, social isolation significant r/ship, inadequate or Enhance quality of including ve & unsustaining +ve aspects any existing interpersonal r/ship relationships Explore repetitive pattern in r/ship Encourage the formation of new Note problematic relationships interpersonal patterns in session & relate them to similar patterns in pxs life

Interpersonal deficits

Intermediate phase: sessions 6 15 1. Implement strategies specific to the identified problem area(s) 2. Encourage and review work on goals specific to the problem area 3. Illuminate connections between symptoms and interpersonal events during the week 4. Work with the patient to identify and manage negative or painful affects associated with his or her interpersonal problem area 5. Relate issues about psychiatric symptoms to the interpersonal problem area
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Interpersonal role disputes

Role transitions

Conflicts with a Identify the nature Determine the significant other - a of the dispute stage of the partner, other family Explore options to dispute: member, coworker, renegotiation resolve the dispute or close friend (calm down Modify participants to expectations and facilitate faulty resolution); communication to impasse ( bring about a disharmony to satisfactory reopen resolution negotiation); If modification is dissolution (assist unworkable, mourning & encourage patient adaptation) to reassess the expectations for Understand how nonreciprocal role the relationship expectations relate and to generate to the dispute options to either Identify available resolve it or resources to bring dissolve it and about change in mourn its loss the r/ship Economic or family Mourn and accept Review ve & +ve change the the loss of the old aspects of old and beginning or end of role new roles a r/ship or career, a Recognize the Explore feelings move, promotion, +ve & -ve aspects about what is lost retirement, of the new role & Encourage graduation, dx of a assets & liabilities development of medical illness of the old role social support Restore selfsystem and new esteem by skills called for in developing a sense new role of mastery regarding the demands of the new role

2. Interpersonal Psychotherapy Delivered in a Group Format Interpersonal Psychotherapy Phases/Tasks Initial: sessions 1-5; identify problem areas Group Stages Engagement: sessions 1-2 Members' Work Therapist Interventions Members look for structure as they grapple with the anxiety of being in a group and sharing their problems. Members work to manage negative feelings over interpersonal differences as they emerge in the group. Members work out differences and strive toward common goals. Establish a structure that encourages appropriate selfdisclosure. Facilitate norms for effective communication. Help members understand their reactions in the context of interpersonal differences in their outside social lives. Facilitate connections among members as they share their work with each other. Encourage practice of newly acquired interpersonal skills in and outside of the group. Help members to consolidate their work and to plan continued work. Assist members in grieving the loss of the group.

Differentiation: sessions 3-5

Middle: sessions 6-15; work on goals

Work: sessions 6-15

Final: sessions 16-20; consolidate treatment

Termination: sessions 1620

Members struggle with how to manage the impending loss of connection with other group members.

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