1. Psychological treatments
January 18, 2016
J.Talbot, MD,PHD,FRCP
Director psychotherapy training
Department of Psychiatry, University of Ottawa

2. Learning Objectives Describe neural correlates of psychotherapy.
Describe the general psychiatric indications for psychotherapy.
Briefly describe the following psychotherapies: psychodynamic, cognitive behavioural therapy (dialectical behavioural therapy), interpersonal therapy.
Describe what is meant by transference, counter‐transference and therapeutic alliance.
Define the purpose of a psychological defense mechanism and describe mature and immature mechanisms: denial, splitting, projection, reaction formation, rationalization, sublimation.
Describe the links between thoughts, feelings and behaviours and and the rationale for various treatment options  

3. Psychotherapy is a form of learning Learning changes the brain
Psychotherapy changes the brain

5. Psychological treatment is a biological treatment.

6. Neuroimaging studies
Over 20 studies have examined brain changes after psychotherapy.
Cognitive Behavioral Therapy (CBT)/Dialectic Behavior Therapy (DBT), psychodynamic psychotherapy, and interpersonal psychotherapy alter brain function.
Psychotherapy and neural plasticity is a burgeoning field of study.

7. General indications for psychotherapy
Anxiety disorders
Depressive disorders (including bipolar disorder)
Schizophrenia
Substance abuse
Insomnia
Eating disorders
Personality disorders
Attention Deficit Hyperactivity Disorder
Chronic pain and persistent pain
Family/marital discord
Gambling

8. Empirically supported treatments
Psychoanalysis
Psychodynamic Therapy
Behavioral Activation
Cognitive Behavioural Therapy
Dialectical Behavioural Therapy
Acceptance and Commitment Therapy
Mindfulness Based CBT
Interpersonal Therapy
Motivational Interviewing

9. Psychoanalysis (& its offshoot psychodynamic therapy)

10. Psychoanalysis and its offshoot psychodynamic therapy
Goal: relieve symptoms by developing insight and understanding the influence of the past on the present.
The therapeutic relationship is central
Transference
Countertransference
Techniques:
Interpretation
Dream analysis
Attention to parapraxis
Maladaptive defense mechanisms (resistance) targeted
It started with the discoveries of Sigmund Freud a century ago, but its methods have changed and developed a great deal since then. It’s the most complex of the talking treatments, and has had a significant influence on most other forms of therapy. awareness of feelings and thoughts that were once outside of the person's awareness.
Quality of the client–therapist alliance is a reliable predictor of positive clinical outcome independent of the type of psychotherapy.

11. Transference
Patient’s perception of the therapist is a mixture of the real characteristics of the therapist and aspects of figures from the patient’s past
Interpretation of transference is a source of understanding and thereby change.
is the projection onto another person (e.g., the analyst) of feelings, past associations, or experiences.
This is an important concept in psychoanalysis because it demonstrates that past experiences impact the present.
Interpreting transference in the psychoanalytic setting can shed light on unresolved conflicts.

12. Countertransference
Therapist’s “total” emotional reaction to the patient (based on current and past learning)
Important source of information regarding the patient’s effects on others.
This refers to the analyst’s feelings and attitudes towards the patient: his/her reaction to the patient’s transference, how his/her own experiences impact his/her understanding of the patient, and the analyst’s emotional responses to the patient.

13. Psychoanalysis and its offshoot psychodynamic therapy
Indicated for:
Depression
Anxiety disorders
Somatoform disorder
Anorexia Nervosa
Not indicated for obsessive compulsive disorder
It started with the discoveries of Sigmund Freud a century ago, but its methods have changed and developed a great deal since then. It’s the most complex of the talking treatments, and has had a significant influence on most other forms of therapy. awareness of feelings and thoughts that were once outside of the person's awareness

14. Modes of deliver: psychodynamic tx
Psychoanalysis
4 to 5 sessions/week for 2-7 years
Long term psychodynamic therapy
1 or 2 sessions/week for few months to a few years
Short term psychodynamic therapy
1 or 2 weekly sessions for a total of sessions
Can be delivered in individual or group formats

15. Psychological defenses
Are unconscious and automatic ways of responding to internal and external stress and emotional conflict.
Are necessary
Can be classified as:
Primitive (immature)
Neurotic
Mature

16. Primitive Defense Mechanisms
Denial: The refusal to accept reality or fact, acting as if a painful event, thought or feeling did not exist.
Splitting: Preserves good feelings and avoids bad feelings by separating them into different people.
Projection: Perceiving and reacting to unacceptable inner impulses as though they were outside self.
Example
Splitting: MsA mother never kept food in the house and was critical. Nevertheless, Ms A idealizd her mother and vilifies her father. As an adult Ms. A is unable to seem as having any good qualities despite her desperate wish for a heteroseual relationhsip. Idealizing devaluation.
Projection: protects ego by perceiving unaceptiable thoughts, feelings and fantasies as originating outside of the self. Mr. B GF cheted ont his. He did not expeirence anger but became paranooid that she was spreading rumors about him. Mr. B experiencing the anger as coming from his girlfirnd.
Immature. It is considered one of the most primitive of the defense mechanisms because it is characteristic of early childhood development. Many people use denial in their everyday lives to avoid dealing with painful feelings or areas of their life they don’t wish to admit. For instance, a person who is a functioning alcoholic will often simply deny they have a drinking problem, pointing to how well they function in their job and.

17. Neurotic Defense Mechanisms
Reaction formation: Converting of unwanted or dangerous thoughts, feelings or impulses into their opposites
Rationalization: Putting something into a different light or offering a different explanation for one’s perceptions or behaviors in the face of a changing reality
For instance, a woman who is very angry with her boss and would like to quit her job may instead be overly kind and generous toward her boss and express a desire to keep working there forever. She is incapable of expressing the negative emotions of anger and unhappiness with her job, and instead becomes overly kind to publicly demonstrate her lack of anger and unhappiness. . For instance, a woman who starts dating a man she really, really likes and thinks the world of is suddenly dumped by the man for no reason. She reframes the situation in her mind with, “I suspected he was a loser all along.”Justification of unacceptable attitudes, beliefs, or behaviours to make them tolerable.

18. Mature defenses
Sublimation: The channeling of unacceptable impulses, thoughts and emotions into more acceptable ones.
Humor: when used as a defense mechanism, is the channeling of unacceptable impulses or thoughts into a light-hearted story or joke.
For instance, when a person has sexual impulses they would like not to act upon, they may instead focus on rigorous exercise. Refocusing such unacceptable or harmful impulses into productive use helps a person channel energy that otherwise would be lost or used in a manner that might cause the person more anxiety.
Going for run when angry.
Writing a poem when sad discharges feelings.

19. Cognitive Behavioural Therapy

20. Empirical support for CBT
Treatment of choice
= as good or better than medications; lower relapse rate
Major Depressive Disorder (mild to moderate)
Generalized Anxiety Disorder
Post traumatic stress disorder
Acute stress disorder
Panic Disorder (with or without Agoraphobia)
Social and Specific Phobias
Obsessive-Compulsive Disorder

21. Empirical support for CBT
Efficacy in combined treatments:
Schizophrenia
Bipolar affective disorder
Personality disorders
Eating disorders
Paraphilias
Impulse control disorders
Substance use disorders

22. Cognitive Behavioural Therapy
present & future focus
goal-oriented & time-limited
sessions structured
guided discovery
generalization promote with homework
Modes of delivery
individually with trained specialist ( sessions)
Group therapy
CBT “lite” in primary care settings
Bibliotherapy
Internet based
Apps

23. Cognitive Behavioural Therapy
Psychotherapy (CBT/IPT), E-therapy, self-help books, APPs
Antidepressants
Exercise
Thinking
Mood
Bodily sensations
Behaviour
Relaxation techniques
Yoga
Mindfulness
Stresses of life
Behavioral activation
J. Talbot (2014)

24. Characteristic thinking/behaviour
Depression
Negative view of self, others and the world
Withdraw
Anxiety
Exaggerated risk of danger/underestimation of capacity to cope
Avoids

25. Cognitive distortions contribute to emotional distress
Examples:
Filtering
Black/white thinking
Overgeneralizing
Jumping to conclusions
Catastrophizing
Personalizing
Shoulds
Mind reading

26. Dialectical Behaviour Therapy
Is a form of CBT
Developed by M. Linehan for patients with borderline personality disorder.
Combines individual and group therapy
Specific skills taught:
Mindfulness
Emotional regulation
Interpersonal effectiveness
Distress tolerance

27. Interpersonal Therapy
Focus is on social roles and interpersonal conflict.
Complicated grief
Interpersonal disputes
Role transitions
Interpersonal deficits
Indications: depression, post-partum depression, eating disorders, social phobia
Modes of delivery:
12-16 weekly individual sessions
Group therapy

28. Summary Wide range of indications for psychological treatments
Evidence based psychotherapies include:
Psychodynamic therapy
Behavioral Therapy
Cognitive Behavioural Therapy (including DBT)
Interpersonal Therapy
There is before and after psychotherapy functional imaging evidence of neural changes