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Syed Fazri

List the key features common to all types of

Compare and contrast the major types of
Understand the various psychiatric conditions
treated by psychotherapy
Describe factors to consider in determining if
psychotherapy is appropriate for a specific patient
Describe factors to consider in selecting a specific
type of psychotherapy for a specific patient

What is
0 Interpersonal, relational intervention by trained

therapists to aid in life problems

0 Goal: increase sense of well-being, reduce discomfort
0 Employs range of techniques based on relationship
building, dialogue, communication and behavior
change designed to improve the mental of individual
patient or group

What is
0 Some therapies focus on changing current

behavior patterns
0 Others emphasize understanding past issues
0 Some therapies combine changing behaviors with
understanding motivation
0 Can be short-term with few meetings, or with
many sessions over years

What is
0 Can be conducted with individual, couple, family

or group of unrelated members who share

common issues
0 Also known as talk therapy, counseling,
psychosocial therapy or, simply, therapy
0 Can be combined with other types of treatment,
such as medications

What can psychotherapy

0 Learn to identify and change behaviors or

thoughts that adversely affect life

0 Explore and improve relationships
0 Find better ways to cope and solve problems
0 Learn to set realistic goals

All psychotherapies
0 A working alliance between patient and

0 An emotionally safe setting where the
patient can feel accepted, supported, uncriticized
0 A therapeutic approach that may either be
strictly adhered to or modified according to
patient needs
0 Confidentiality as integral to therapeutic
relationship except with safety issues

Who seeks therapy

and why?
0 Children: behavioral, school, family issues
0 Adolescents: as above and issues of

separation and peer relationships

0 Young adults: all of above plus career issues
0 Mature adults: all of above plus issues of
changing relationships, family alignments,
health, work and social status
0 Older adults: all of above plus end of life

Your brain on
0 Psychotherapy-related changes in brain

activity are strikingly similar within patients

who share the same psychiatric diagnosis.
0 Psychotherapy and pharmacotherapy achieve
similar efficacy and are associated with
overlapping but not identical changes in
brain-imaging profiles

Types of psychotherapy

0 Focus on unconscious as it emerges in

treatment relationship
0 Insight by interpretation of unconscious
0 Most rigorous: 3-5 times/week, lasts years,
0 Patient lies on couch, analyst unseen to
eliminate visual cues
0 Must be stable, highly motivated, verbal,
psychologically minded and be able to
tolerate stress without becoming overly
regressed, distraught, impulsive

0 Analyst neutral
0 Goal: structural reorganization of personality
0 Techniques: interpretation, clarification,

working through, dream interpretation

Prominent early psychoanalysts:


Sigmund Freud (1856-1939) Carl Jung (1875-1961)

Psychoanalysis: Terms
0 Transference: unconscious redirection of feelings for

one person to another (including the therapist)

0 Countertransference: redirection of therapists
feelings for the patient
0 Therapeutic alliance: therapist and patient trust
0 Resistance: ideas unacceptable to conscious;
prevents therapy from proceeding
0 Free association: patient says what comes to mind
uncensored. Clues to unconscious

0 Everyone uses them
0 They are usually identified as more mature,

neurotic or less mature

0 Under duress people tend to use less mature
defense mechanisms

Mature defense mechanisms

0 Altrusim: deal with stress or conflict through

dedication to meeting others needs

0 Anticipation: anticipate possible adverse events
and prepare for them
0 Humor: deal with stress by seeing irony
0 Sublimation: channel potentially maladaptive
impulses into socially acceptable behavior
0 Suppression: avoid thinking about stressor
0 Affiliation: turn to others for support

Neurotic defense

0 Displacement: transfer negative feelings about one

object to another
0 Externalization: blame problems on another
0 Intellectualization: rely excessively on details to
maintain distance from painful emotions
0 Repression: expel disturbing thoughts from
0 Reaction formation: do opposite of what you feel

Primitive defense
0 Denial: refuse to acknowledge aspect of reality

0 Autistic fantasy: excessive day-dreaming

0 Passive-aggressive: indirectly express aggressive

feelings towards others

0 Acting out: engage in inappropriate behavior without
consideration of consequences
0 Splitting: compartmentalize opposite affective states
0 Projection: falsely attribute unacceptable feelings to
0 Projective identification: falsely attribute to a second
individual who in turn projects back to patient

This therapy engage in a more supportive

Psychoanalytic therapy is based upon
psychoanalysis but is less intensive
0 (1-3 sessions per week)
It is for individuals who want to understand
more about themselves and those who have
difficulties that affected them
Client will talk about their life and the therapist
will listen, this is known as talk therapy. The
therapist will look for patterns that may have
cause the clients difficulties
Usually face-to-face session

Client are advised not to make radical changes

in their lifestyle as it may disturb the

therapeutic process
Example of radical change :
0 filing a divorce/ quitting their job
0 This therapy also use other techniques
0 (free association, dream analysis)
Termination can take place when both
therapist and client mutually agree that the
client had :
Resolve the problem/core conflict
II. Accepted their remaining emotional problem
III. Understand the root of their difficulties

a mi

A method of therapy derived from theories

and practice of Sigmund Freud

The gradual exploration with the patient on
thoughts and conflicts that are not
previously directly accessible to their
conscious mind
Insight-oriented therapy

0 The goals of psychodynamic therapy are :

0 a clients self-awareness and understanding of
the influence of the past on present behavior
0 enables the client to examine unresolved
conflicts and symptoms that arise from past
dysfunctional relationships and manifest
themselves in their desire

0 When the problem:
0 Can be conceptualize in psychodynamic terms
0 Is emotional and interpersonal
0 Involves low self esteem and recurrent problems in

forming intimate relationship

0 When the person:

0 Has adequate social support
0 Willing to bring about change through their own efforts
0 Can look honestly on their motives
0 Capable of ceasing self-exploration once session ended

0 Effective for:
0 Mood disorders
0 Anxiety disorders
0 Substance abuse disorders
0 Eating disorders
0 Sexual dysfunction
0 Adjustment disorders
0 Personality disorders

0 Obsessional/ hypochondriacal disorders
0 Severe mood disorders
0 Schizophrenia

0 Starting treatment
0 Initial assessment
suitability for brief
treatment, select
problems that are to be
focused on
0 Brief the patient
focus and length of
treatment, possibility of
persisting problems
0 General aim of linking
past and present
behaviour patterns

0 Subsequent sessions
0 Talks about the problem
examples, emotionally
painful subjects, ideas and
0 Identify common themes
in their problems and their
responses, how current
behaviour began
0 Consider alternative ways
of thinking and behaving
0 Try new, more adaptive
ways of behaving and
responding to emotions


0 Behavioral therapy is based on learning

theory, which states that behaviors can

be learned by conditioning and can similarly
be unlearned by deconditioning
0 Short duration therapy 6-8 weeks
0 Cost effective

Classical conditioning:
A stimulus can eventually evoke a conditioned
(Example: Pavlovs dog would salivate when
hearing a bell because the dog had learned that
bells were always followed by food.)
Operant conditioning:
Behaviors can be learned when followed by
positive or negative reinforcement.
(Example: Skinners boxa rat happened upon a
lever and received food; eventually it learned to
press the lever for food [trial-and-error learning].)

1. Systemic desensitization :
Based on the principle of counter conditioning
a person overcomes maladaptive anxiety
elicited by a situation/object by approaching
the feared situation gradually
Consists of three main steps :
1. Relaxation Training
2. Hierachy construction
3. Desensitisation of stimulus

Step 1 :Relaxation

Produces physiological effects opposite to those of

anxiety: slow HR, increase peripheral blood flow &
neuromuscular stability.

Relaxation training, such as meditation, is one type of

coping strategy.

Another means of relaxation is cognitive reappraisal of

imagined outcomes
imagine whats happening when exposed to the
phobic object, allowing them to recognize their
catastrophic visions and contrast them with the actual

Step 2 : Hierachy
Clinicians determine all the conditions that

elicits anxiety then patients create a

hierarchy list of 10 to 12 scenes in order of
increasing anxiety.
E.g. an acrophobic hierarchy may begin with

a patient imagining standing near a window

on the 2nd floor and end with being on the
roof of a 20-story building.

Step 3 : Desensitisation
of stimulus
Patients proceed systematically through the list

from the least to the most anxiety-provoking

scenes while in a deeply relaxed state.

rate of progression through the list

determined by their responses to the stimuli.


When patients can vividly imagine the most-

anxiety provoking scene of the hierarchy with

calmness they experience little anxiety in the
corresponding real-life situation.

2. Flooding and implosion

- Patient is confronted with a real flooding or

imagined anxiety-provoking stimulus and not

allowed withdraw from it until he/she feels calm
and in control.
- Relaxation exercises are used to help the patient
tolerate the stimulus.
- Eg : A patient who has fear of flying is made to fly
in an airplane

0 Phobias
0 Obsessions
0 Compulsions
0 Certain sexual disorders


0 Aims at correcting the maladaptive methods

of thinking, thus providing relief from

consequent symptoms
0 Learns how his behavior is influenced by his
0 Usually brief treatment
0 Lasts 6 weeks 6 months

Cognitive Technique :


Eliciting autonomic thoughts


Testing autonomic thoughts


Identifying maladaptive assumptions


Testing validity of maladaptive


Eliciting autonomic
0 Intervenes between external events and

persons emotional reaction towards it

0 Eg: if I wear this, people will think Im over

the top

Testing autonomic
Goal: encourage patient to reject

inappropriate automatic thoughts

Blame: therapist reviews the situation and

reassigns the blame away from the patient

Alternative: undermining the inaccurate

autonomic thoughts

Identify maladaptive
0 Patterns become apparent after both two are

0 Represent rules/ maladaptive general
0 Eg: in order to be happy, I must be perfect

if nobody likes me, am not lovable

Testing validity
Similar to testing the validity of automatic

Therapist questions their assumptions so
that patient can validate them
Eg :

why is it so important for you to be perfect?

Behavioral technique :
0 Goal: Test and change maladaptive and
inaccurate cognitions
Help patients understand the inaccuracy
and learn new ways of dealing with stress

0 Depression
0 Anxiety Disorder
0 Panic Disorder
0 Phobias
0 Management of psychotic symptoms

( eg : delusion and hallucination )

Therapy (

0 Synthesis of cognitive-behavioral, person

centered, and mindfullness-based therapies.

0 Originally created for Borderline Personality
0 Uses group work, individual therapy, and self
monitoring to change target behaviors

How it is differ from

0 A focus on acceptance and validation of

behavior as it is in the moment

0 An emphasis on treating therapy-interfering
0 An emphasis on the therapeutic relationship
0 A focus on dialectical processes
0 Therapist is required to participate in weekly

0 suicidal and parasuicidal behaviors
0 substance abuse
0 depression in older adults

Other types of

Group Therapy
0 Less time consuming procedure
0 Offers patient and family an opportunity to

realize that many others have and share

problems that are very similar to them
0 Encompasses theoretical spectrum of
therapies: supportive, time-limited, cognitivebehavioral, psychodynamic, interpersonal,
family, client-centered based on
nonjudgmental expression of feelings

Family Therapy
0 Joined by parents and other family members
0 Aimed to help patient by improving family


0 Improved communication, autonomy for each

member, agreement about roles

0 Reduce conflicts and distress

0 Indications young patient living with parents

0 Types
0 Psychodynamic
0 Structural organization of the family
0 Systemic present functioning of family
0 Eclectic

0 About 75% of patient receiving family

therapy had better outcome than those who

0 For children and adolescent, family therapy
appears to be effective in treatment of eating
disorder, substance abuse and conduct

Effectiveness in psychological

Effectiveness of Treatment
Research has shown that many people with

psychological disorders benefit from treatment.

Effectiveness depends on the specific disorder being
treated and the skill of the therapist.
Ways of Assessing Effectiveness:
The effectiveness of a particular therapeutic approach
can be assessed in three ways:

client testimonials,
providers perceptions, and
empirical research.

a. Client Testimonials
0 Clients who get treatment for psychological

problems often testify to their effectiveness.

However, such testimonials can be unreliable
for several reasons:

Regression toward the mean:

People often go into treatment because they are in extreme

distress. When their distress becomes less extreme, they may
attribute this to the treatments effectiveness. But even without
treatment, extreme distress tends to decrease. The tendency
for extreme states to move toward the average when assessed
a second time is called regression toward the mean.
The placebo effect:

People often feel better after being in treatment because of

their expectations that they will improve.
The justification of effort effect:

People may believe that treatment was effective because they

spent time, effort, and money on it. If people work hard to reach
a goal, they are likely to value the goal more. This phenomenon
is called justification of effort

b.Providers Perceptions
Treatment providers can say whether a treatment is effective, but this can

be unreliable for several reasons:

Regression toward the mean affects providers perceptions of success.

They may believe that a client who entered treatment in crisis became
less extremely distressed because of the treatment. However, such an
improvement may have occurred without any intervention.
Providers perceptions may be biased because clients often emphasize

improvements in order to justify discontinuing treatment.

Providers may also have biased perceptions because they continue to

hear from past clients only when those clients were satisfied with
treatment. They dont often hear from clients who found treatment

c.Empirical Research
Another way to assess effectiveness is through careful empirical

research. Research has shown that some treatments are more

effective for a particular problem than a placebo or no treatment.
These treatments are known as empirically validated
treatments. Researchers have to conduct two or more studies in
order to conclude that a specific treatment is effective for a
particular problem.
Research shows that psychotherapy works for many psychological

problems. Although people who do not receive therapy also

sometimes improve with time, people who do receive therapy are
more likely to improve. Research also shows that all approaches to
therapy are about equally effective, though certain kind of
therapies do seem somewhat more effective for specific problems.

Specific disorder

Most effective treatment

Panic disorders

Cognitive therapy

Specific phobias

Systematic desensitization

Obsessive-compulsive disorder

Behavior therapy or medication


Cognitive therapy

Posttraumatic stress disorder

and agoraphobia

Exposure treatment