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

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  

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

Psychological treatment is a biological treatment.

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.

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

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 http://psychologicaltreatments.org

Psychoanalysis (& its offshoot psychodynamic therapy)

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 https://www.youtube.com/watch?v=yFqFuuIDfvI 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.

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.

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.

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

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 12-20 sessions Can be delivered in individual or group formats

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 http://psychcentral.com/lib/15-common-defense-mechanisms

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.

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.

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.

Cognitive Behavioural Therapy

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

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

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 (20- 24 sessions) Group therapy CBT “lite” in primary care settings Bibliotherapy Internet based Apps

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)

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

Cognitive distortions contribute to emotional distress Examples: Filtering Black/white thinking Overgeneralizing Jumping to conclusions Catastrophizing Personalizing Shoulds Mind reading http://www.getselfhelp.co.uk/unhelpful.htm

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

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 https://iptinstitute.com/about-ipt

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