1. Psychotherapy A Patient-Centered, Evidence-Based Diagnostic and Treatment Process A Presentation for the Students of Ohio University Heritage College of Osteopathic Medicine Kendall L. Stewart, MD, MBA, DFAPA December 2, 2011

2. Why is this important? There are a lot of anxious people. They will be seeing counselors 1 and you need to have some idea of what is going on in those sessions. 2 You will be referring these patients to psychotherapists; you must be able to discern the wheat from the chaff. psychotherapists Physicians are in a position to do a lot of good or ill with psychotherapeutic techniques during a brief office visit. 1 I will use the generic term in this talk. Many different professionals do this work. 2 There are many “brands” of psychotherapy. I will focus on the common ground.

3. 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 better There are endless varieties; most practitioners take an eclectic approach. There is a huge, indiscriminate demand for these services. 1 Insurance payment for these services is carefully managed. 2 There is an increased emphasis on evidence-based psychotherapeutic approaches.evidence-based 1 Consumers overwhelmingly value psychotherapy. Manual-driven psychotherapies are effective—really. 2 I have the unspeakable luxury of treating patients for free, deciding with them what they need.

4. 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 insightinsight The necessity for behavioral change The expectation that the anxious person will improve The realization that the real work is done outside of class 1 1 A nun once asked me whether I was a “Freudian” or a “Jungian.”

5. Is psychotherapy 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 medicationCognitive Behavioral Therapy (CBT)Interpersonal Therapy (IPT) The relentless demand for counseling documents wide- spread desperation if not effectiveness 1,2 Most consumers report benefit Insurers hesitant to pay for extended counseling 1 Therapy is so intellectually stimulating and enjoyable, it can easily become an end in itself. 2 Real life is where it is at—not talking about real life.

6. What are some of the characteristics of good counselors? Professionally competent Genuine concern for those who seek them out 1 Effective listeners Respectful but honest 2 Ethical Reliable and available Focus on patterns of thought, feeling and behavior Give practical feedback Put the sufferer’s needs first Encourage autonomy Non judgmental Expert collaborators Focus on documented behavioral change Know their own limitations 1 I never accept people for therapy I don’t genuinely like. 2 Only when you have solved a real conflict do you have a relationship.

7. 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 sufferer’s feelings must be legitimized. The helper must be viewed as trustworthy. A reputation for excellence definitely jump starts the process. 2reputation for excellence 1 There is no substitute for a servant heart. 2 A passion for excellence is the best vaccine against burnout.

8. How are feelings dealt with in therapy? All feelings are OK Feelings are just feelings - it’s what we do with them that matters All feelings make sense (in the context they arose) Feelings change Unrecognized feelings pose the greatest dangers 1 Feelings should be –identified –accepted –expressedexpressed We should not be held hostage by our feelings 2 1 When you promise what you cannot sustain, your resentment will contaminate your interactions with others. 2 Your feelings will be your greatest challenges in your career—and in life.

9. How do counselors go about figuring out what is wrong? By taking a careful historyhistory 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 one’s own feelings By watching for the use of psychological defense mechanisms By confirming one’s impressions with the patient 1 1 The art of asking respectful, clarifying questions may be the greatest psychotherapeutic skill.

10. 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.Insight is not a cure Full insight is not required for significant improvement. 1 1 Let me explain how insight works. A woman felt insecure. I asked about her first memory of this feeling. She recalled arriving at school late.

11. How do maladaptive beliefs and behaviors develop? Real or Perceived Trauma in Childhood Irrational Beliefs and Maladaptive Behaviors Interpersonal Conflicts Emotional Symptoms Clinical Syndromes

12. What are some of the steps in the anxiety cascade? External or Internal Trigger Automatic Thought (Cognitive Distortion) Cognitive Processing Errors Amplification Loop Intense Anxiety or Panic PalpitationsIndigestion Feared situation Etc. “I am helpless” Emotional reasoning Overgeneralization Catastrophic thinking Black-or-white thinking Should or must Negative predictions Mind reading LabelingPersonalization Negative focus Somatic focus Unpleasant feelings Anxiety

13. 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 controlcognitive distortions Behavioral change precipitates different reactions from others. Practice builds confidence. 1,2 1 Any improvement should be noted. One physician commended anther physician on his efforts to control his temper. 2 That increased the odds that he would keep on trying to improve.

14. What practical counseling techniques can be used in primary care practice? Progressive muscular relaxationProgressive 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

15. 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

16. What is the biological basis of psychotherapy? Some research findings suggest –That the brain responds to environmental influence through the alteration of gene expression, –That psychotherapy has specific measurable effects on the brain, andpsychotherapy –That implicit memory may be modified by psychotherapeutic interventions. 1 1 Gabbard, GO, “A Neurobiologically Informed Perspective on Psychotherapy,” British Journal of Psychiatry, Vol. 177, pp 117-122. 2000

17. Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008Concise Textbook of Clinical Psychiatry, Third Edition Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.here Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007The Massachusetts Handbook of Neurology Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005First Aid© for the Psychiatry Clerkship, Second Edition Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 2009 3Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007Lange Q&A: Psychiatry Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008Spark: The Revolutionary New Science of Exercise and the Brain Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000Dealing With Anxiety: A Practical Approach to Nervous Patients,”

18. Where can you find evidence-based information about mental disorders? Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.here Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.here Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.here Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.here Download this presentation and related presentations and white papers at www.KendallLStewartMD.com. www.KendallLStewartMD.com Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.www.SOMC.org Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.here

19. How can you contact me? 1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center Chairman & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com 1 Speaking and consultation fees benefit the SOMC Endowment Fund.

20.  Safety  Quality  Service  Relationships  Performance   Safety  Quality  Service  Relationships  Performance  Are there other questions? Jeffrey Hill, DO OUCOM 1987 Darren Adams, DO OUCOM 2002