Psychological Treatments in Psychiatry

PSYCHOLOGICAL TREATMENTS IN
PSYCHIATRY
DR NKPORBU A. K. (MBBS, MS.c Pharmcol, MPH, M.Sc Med Ed, Ph.D,

FWACP, ICAP, LMIH)
Associate Professor of Psychiatry and Mental Health,
Department of Mental Health, University of Port Harcourt.
Consultant Neuropsychiatrist, UPTH.
Learning Objectives
• At the end of this lecture, students should be able to:
• Understand basic historical background of the different counseling
theories.
• Understand the basic principle underling the theory.
• Appreciate the strengths and challenges of the individual theories.
• Apply the principle to the different counseling methods.
Psychoanalysis and psychoanalytic
psychotherapy
• Psychoanalysis
• Psychoanalytic process involves bringing out repressed memories and
feelings.
• Indicated in neurotic and non-psychotic illnesses
• Contraindications in absence of suffering, poor impulse control,
inability to tolerate frustration and low motivation.
• The goal is the gradual removal of amnesias rooted in childhood, so
the patient no longer remain fixated in the past.
Psychoanalytic theory
• Background
• The Psychoanalytic theory was developed by Sigmund Freud (1856 - 1939)
and the therapy based on this theory is referred to as'psychoanalysis'.
• Sigmund Freud is recognised for developing the most comprehensive theory
of personality and this formed the foundation on which many other theories
were developed.
• Though Freud's classical psychoanalysis is not practiced in SUD treatment
settings today, many concepts introduced by Freud are widely used.
• Defense mechanisms, transference and countertransference issues are some
of his contribution's.
Freud’s view of personality and symptom
development
• Freud believed that the person's personality is shaped by unconscious
needs and drives. He believed that the conscious mind is only a small
part and that most of our experiences and memories are in the
unconscious.
• Therapy thus focused on recognising the unconscious influences and
developing new ways to deal with it.
Role of Therapist
• Goal of therapy is to bring the unconscious to the level of the conscious
• This helps strengthen the ego and help develop behavior based on reality
instead of instinct or guilt. . '
• Childhood experiences are discussed, interpreted and analyzed to :
• Experience the feelings related to the memories
• Gain understanding of the reason behind the symptoms (why)
• Identify and understand defense mechanisms and Gain more control over
their lives.
• The therapist maintains a 'blank screen approach' making it easy for the
client to talk without hesitation about whatever comes to his mind (free
association). Dream analysis is another tool used.
Stages of Personality development
• Oral stage: First year of life: Nurturing relationship with the caregiver usually the mother would
develop the ability to love and trust others. If this stage's need is not met, greed, inability to trust
others and difficulty in intimate relationships would follow.
• Anal stage: 1 - 3 years of life: Learns independence and expresses feelings of anger and aggression.
If not, the helplessness interferes with his sense of autonomy and the person is unable to recognise,
express and deal with negative feelings.
• Phallic stage: 3-6 years of age: In this stage sexual attitudes develop based on how the parents and
caregivers respond. The child learns to be comfortable with his sexual identity.
• Freud also described the stage of latency (6 to 12 years) when sexual interests are replaced with
school, sports and other social relationships.
• The rest of the life period was described as the genital stage.
• Freud believed that the personality consists of three psychological structures:
• The Id, Ego and Superego
• These do not operate separately but the personality functions based on these three components.
Psychoanalytic Psychotherapy
• Also derives from fundamental formulations and techniques of
psychoanalysis.
• Is a blend of uncovering and suppressive measures.
• The duration is usually shorter than that of psychoanalysis.
• It can be expressive (insight-oriented, evocative or interpretive).
• Indicated in mild to moderate ego weakening, including neurotic
conflicts, symptom complex, nonpsychotic conditions, narcissistic
behaviours, reactive conditions.
• It can be supportive(relationship-oriented, suggestive, suppressive or
repressive)
Psychoanalytic Psychotherapy
• Supportive psychotherapy is indicated for those who have poor eo
strenght, whose potential for decompensation is high.
Brief psychodynamic psychotherapy (BPP)
• BPP is a time limited treatment(10 to 12 sessions) that is based on
psychoanalysis and psychodynamic theory.
• Used for depression, anxiety, PTSD, among others.
• TYPES
• Brief focal psychotherapy
• Time-limited psychotherapy
• Short-term dynamic psychotherapy
• Short term anxiety psychotherapy
Group Psychotherapy
• Group psychotherapy uses therapeutic forces within the group,
constructive interaction between members, and intervention of a
trained leader to change the maladaptive behaviuor, thought and
feelings of emotionally distressed individuals.
• Applicable to both inpatient and outpatients
• More economical
Principles of Group Psychotherapy
• Psychoanalytic approach
• Transactional approach
• Supportive group therapy
• Behaviour group therapy
• Gestalt group therapy
• Client –centered group therapy
Examples Group Therapy
• Group psychotherapy
• Combined individual and group psychotherapy
• Self-Help group
• psychodrama
Group selection
• Screening interview
• Psychiatric history
• Mental state examination
• Obtain dynamic, behavioural and diagnostic information
Therapist’s basic tasks in Group Therapy
1. Decision to establish a therapy group
•Determine setting and size of the group
•Choose frequency and length of the group sessions
•Decide on open versus close group
•Select a cotherapist for the group
•Formulate policy on group therapy with other therapeutic
modalities
• 2. Act of creating a therapy group
•Formulate appropriate goals
•Select patients who can perform the group tass
•Prepare patients for group therapy
•3. construction and maintenance of a therapeutic
environment
•Build the culture of the group explicitly
•Implicitly identify resolve common problems
•Eg membership turnover and subgrouping conflict
20 therapeutic factors in group
psychotherapy
• Read
Those considered suitable for Group therapy
• Authority Anxiety
Those considered unsuitable for group
therapy
• Those with peer group anxiety eg borderline and schizoid personality
disorders
• Who have destructive relationship with their peer group
• Antisocial personality
• Manic patients
• Severely depressed or suicidal patients
Specialised Group therapy
Self-Help Group
• Persons who are trying to cope with a specific problems of life crisis
• Emphasize cohesion
• Homogeneitry
• Similar problems
• Similar symptoms
• Provide mutual support
Combined Individual and Group Therapy
• A particular treatment modality
• Same therapist most ideally
• Varying or same frequency
• Drop out rate is lower
• Meaningful integration with the group therapy yields therapeutic
experience.
Psychodrama
•A form of group therapy.
•Personality maing up interpersonal relationship conflicts and
emotional problems are explored by means of special dramatic
methods.
•Requires the most participation from the therapist.
ROLES
•Director
•Protagonist
•Auxillary ego
•group
Techniques in Psychodrama
• Area of functioning, a dream, symbolic role, an unconscious ttitude,
an imagined future situation, symptoms can be acted out.
• Employs soliloquy
• Role reversal
• The double
• Multiple double
Ethical and legal issues in group therapy
•Confidentiality
•Violence and aggression
•Sexual intercourse
Family Therapy
• Family therapy can be defined as any psychotherapeutic endeavour
that explicitly focuses on altering the interactions between or among
family members and sees to improve the functioning of the family as
a unit, and/or the functioning of an individual.
• Both family and couples therapy aim at some change n rational
functioning
• Increases family’s goal and coping ability
• Relationship difficulty is the clear indication.
• Also useful in some mental disorders
Techniques
• Initial consultation
• Interview technique
• Frequency and length
Criteria for termination
• When they can complete transaction, check and ask
• When they can interpret hostility
• See how others see them
• See how they see themselves
• One member can tell others how they manifest themselves
• Can disagree
• Can make choices
• Can learn through practice
• Can free themselves from the harmful effects of past models
Modifications
• Family Group Therapy
• Social network Therapy
• Paradoxical Therapy (Paradoxical injuction)
• Reframing (positive connotation))
Goals of Family Therapy
• To resolve or reduce pathogenic conflicts and anxiety
• To enhance the perception and fulfilment of one another’s emotional
needs
• To promote appropriate role relationships between sexes and
generations
• To strengthen the capacity of individual members and the family as a
whole to cope with destructive forces within and without.
• To influence family identity and values towards health and growth.
• To integrate family into the large system of society
Couples (Marital) Therapy
•Is a form of psychotherapy designed to
psychologically modify the interaction of two
persons who are in conflict over one or several
parameters-social, emotional, sexual or
economic.
Types of Couples Therapy
•Individual therapy
•Individual couple therapy
•Cojoint therapy
•Four-way session
•Group psychotherapy
•Combined therapy
Indications
•Individual therapy has failed
•Onset of problems in one or both is clearly
retional
•Problem in communication
Contraindications
•Severe psychosis
•Clear intension to divorce
•Refusal by a partner to participate
Behaviour Therapy
•It involves changing the behaviour of the person
to reduce dysfunction and to improve quality of
life.
•Utilises mainly the learning theory
Behaviour therapy contd
Background
• In this approach the focus is on changing observable behaviour, identifying
current influences on the behaviour and developing an intervention to
promote change.
• Initially, the focus on this group of therapies was only on behaviour and
later on cognition or thinking was also incorporated.
• Initially, behaviour therapy was developed based on principles related to:
• Classical conditioning
• Operant conditioning
• Social learning theory
• Each of these three approaches is discussed below.
Behaviour therapy contd
• These three approaches explained how behaviour was shaped or developed.
However, from the 1970's, the importance of cognition (thoughts and
beliefs) was recognised and cognitive elements were included into therapy.
The distinction between behaviour therapy and cognitive therapy is less in
today's practice and therapy addresses behaviour as well as cognition.
Today, the term 'cognitive-behaviour therapy' has largely replaced
'behaviour therapy' (Corey G, 2009).
• Behaviour therapy is also referred to as behavioural modification. This:
approach believes that behaviour is learnt and therefore can be unlearned or
changed by altering the factors that influence behaviour.
• Classical conditioning was illustrated by Ivan Pavlov through experiments
with a dbg. In Pavlov's experiment, a dog salivated to the smell and sight of
food. The salivation is a natural or unconditioned response to food.
Systematic Desensitization
•Relaxation training
•Hierarchy construction
•Desensitization of the stimulus
•Adjunctive use of drugs
Indications
•Anxiety-provoking stimulus-phobias, OCD

•Certain sexual disorders
Others forms of behaviour therapy
• Therapeutic –Graded Exposure
• Flooding (implosion)
• Participants modeling
• Assertiveness training
• Social Skills Training
• Aversion Therapy
• Positive reinforcement eg token economy
Cognitive Therapy
•Is a short-term, structured therapy that uses
active collaboration between patients and
therapist.
•Aims at identify and alter cognitive distortions
that maintain symptoms.
•Usually 15 to 25 weeks, once a wee session
Cognitive-behaviour therapy
• Cognitive-BehaviourTherapy (CBT) combines cognitive and
behavioural principles.
• CBT has been used in variety of settings and groups and has generated
more amount of research evidence than any other approach.
• The core idea in CBT is that:
• Thought disturbances lead to psychological distress By changing
thought patterns one could change feelings and behaviours.
• The theoretical basis of these approaches is similar. All emphasise:
• Collaborative relationship with the client
Cognitive-behaviour therapy
• Cognitive disturbances are cause of distress and need to be altered to
bring about changes in affect and behavior.
• Time limited and structured approach to therapy.
• Rational Emotive Behaviour Therapy (REBT) developed by Albert
Ellis who is referred to as the 'grandfather of cognitive-behaviour
therapy'.
• Cognitive therapy was developed by Aaron Beck.
• Cognitive-behaviour modification was by Donald Meichenbaum.
• All the therapies focus on the present, are directive, problem oriented,
and make use of homework assignments.
Techniques
•Eliciting automatic thoughts
•Testing automatic thoughts
•Identifying maladaptive assumptions
•Testing the validity of maladaptive assumptions
Indications
• Dysthymia
• Major depressive disorder
• Hypomanic episodes
• Anxiety disorder-GAD, Panic, OCD
• Anorexia nervosa
• Conversion disorder
• Suicidal behaviour
• Paranoid personality disorder
others
•Biofeedback
•Hypnosis
•Thank you

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PSYCHOLOGICAL TREATMENTS IN

DR NKPORBU A. K. (MBBS, MS.c Pharmcol, MPH, M.Sc Med Ed, Ph.D,

•Anxiety-provoking stimulus-phobias, OCD

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