PSYCHOTHERAPY in
PSYCHIATRY:
an INTRODUCTION
Mgr. Veronika Hublová,
PhDr. Hana Přikrylová Kučerová, PhD
Dept. of Psychiatry,
Masaryk University Brno
Psychotherapy on the Road to ... Where?
http://www.nytimes.com/2005/12/27/science/27ther.html?pagewanted=2&_r=0
What is psychotherapy?
 Interpersonal, relational intervention by
trained therapist addressing mental health
concerns
 range of techniques based on relationship
building, dialogue, communication and
behaviour change designed to improve the
mental state of individual patient or group
What can psychotherapy do?
 It can enhance self acceptance, empower
the patient to make life changes and help to
learn how to respond to challenging
situations with healthy coping skills.
 Goal: change = increase sense of wellbeing
= one´s ability to reduce discomfort
Who is a trained professional in
psychotherapy?
In Czech Republic and in terms of the health
care covered by health insurance
companies, psychotherapy can be provided
only by:
medical doctors (usually psychiatrists)
or clinical psychologists
Who is a trained professional in
psychotherapy?
 Training programs in PST or shorter courses
in PST techniques are open also to other than
clinical professionals
 Psychotherapeutical methods are appliccable
in all helping professions
 Psychoterapy as a profession has not been
embedded in Czech law yet and untrained
persons are not tested for the competence
 anyone can call themselves a “therapist!”
Who is a trained professional in
psychotherapy?
 To acquire the certificate means to attend
compulsory self-experience training comprising at
least 500 training hours plus a minimum of 150-200
psychotherapeutical practice under the supervision.
 The PST approach matters, too; all in all, the cost
of the training makes several tens of thousands
Czech crowns, which discourages many who may be
interested
 This condition is one of the reasons for the lack of
qualified professionals.
Ethical code in psychotherapy
• Ethical principles of
psychotherapy are
standardized and are
very similar throughout
the world
 Ethical principles:
1. Responsibility
2. Competence
3. Moral and legal
standards
4. Confidentiality
5. Welfare of the client
6. Assessment techniques
7. Professional
relationships
8. Public statements
9. Research
Psychotherapy competencies required for basic
training in psychiatry in Royal College of
Psychiatrists
GENERAL
 Account for clinical
phenomena in
psychological terms
 Deploy advanced
communication skills
 Display advanced
emotional intelligence in
dealings with patients and
colleagues
SPECIFIC
 Refer appropriately for
formal psychological
therapies
 Jointly manage patients
receiving psychotherapy
 Deliver basic
psychotherapeutic
treatments in at least two
modalities
Most frequent indications for
psychotherapy according to ICD-10
 MENTAL AND BEHAVIOURAL DISORDERS DUE TO
PSYCHACTIVE SUBSTANCE ABUSE (FT10-19)
 SCHIZOPHRENIA, SCHIZOTYPAL AND DELUSIONAL
DISORDERS (F20-29)
 MOOD (AFFECTIVE) DISORDERS (F30-39)
 NEUROTIC, STRESS-RELATED AND SOMATOFORM
DISORDERS (F40-48) AND DISORDERS OF ADULT
PERSONALITY AND BEHAVIOUR (F60-69)
Psychotherapeutical approaches
 Psychodynamic (psychoanalytic,…)
 Behavioral
 Cognitive Behavioural (CBT, DBT,…)
 Eclectic a integrative approach
 Family therapy
 Group therapy
Characteristics common for all
psychotherapies
 based on rationale or conceptual structure
that is used to understand the patient
problem
 use of the specific procedure in the
relationship that is linked to rationale
 structure relationship
 expectation of improvement
Psychoanalysis
 basic concept includes stages of
 psychosexual development (oral, anal, phallic)
 the structures of conscious and uncoscoius
thougts (primary versus secondary process
thinking)
 the structures of drive and motivation (id, ego,
superego)
Psychodynamic psychotherapy
 concepts are embodied in psychoanalytic
theory (it does not involve rigidly defined
techniques that characterized classical
psychoanalysis)
Psychodynamic psychotherapy
 based on the idea of self exploration and self
understanding which open up the possibilities
for change in personality and behaviour
 treatment of: personality disorder, sexual
dysfunction, somatoform , anxiety disorders,
mild depression
Types of psychodynamic
psychotherapy
 supportive psychotherapy - lessening of
anxiety through reassurance, advice,
modifications of social factor (it helps
patients to get through difficult situations), it
is incorporated into any of the other types of
PT
 short term psychotherapy
Psychodynamic approach- core
assumptions
1. Psychological causation
2. Early childhood experiences/early interactions between
children and their parents determine personality
development
3. Conflict between opposing psychological forces is an
inevitable aspect of human development.
4. Motives behind behavior are unconscious/hidden
because our conscious minds find them unacceptable.
We develop different defense mechanisms to keep
them out of consciousness.
Psychodynamic approach- core
assumptions
• 5. Critical feature of effective psychotherapy is
the establishment and development of a
relationship between the patient and therapist.
• 6. Psychological defenses
• 7. Emphasis on the therapeutical relationship
Concepts and techniques
 Transference:
◦ the developing relationship between the patient and
therapist
◦ patient responds to the therapist as he did toward
significant individuals in his childhood (usually his
parents)
◦ primary means for therapeutic change
◦ Developing and working through the transference
relationship is the most basic and important element of
psychoanalytic therapy.
 Countertransference
 Resistence
Concepts and techniques
 Free association
 Interpretation
 Dream interpretation
 Insight
Defense mechanisms
 Everyone uses them
 They are usually identified as more mature,
neurotic or less mature
 Under stress, people tend to use less mature
defense mechanisms
Mature defense mechanisms
 Altruism: deal with stress or conflict through
dedication to meeting other’s needs
 Anticipation: anticipate possible adverse events
and prepare for them
 Humor: deal with stress by seeing irony
 Sublimation: channel potentially maladaptive
impulses into socially acceptable behavior
 Suppression: avoid thinking about stressor
 Affiliation: turn to others for support
Neurotic defense mechanisms
 Displacement: transfer negative feelings
about one object to another
 Externalization: blame problems on
another
 Intellectualization: rely excessively on
details to maintain distance from painful
emotions
 Repression: expel disturbing thoughts from
consciousness
 Reaction formation: do opposite of what
you feel
Primitive defense mechanisms
 Denial: refuse to acknowledge aspect of reality
 Autistic fantasy: excessive day-dreaming
 Passive-aggressive: indirectly express
aggressive feelings towards others
 Acting out: engage in inappropriate behavior
without consideration of consequences
 Splitting: compartmentalize opposite affective
states
 Projection: falsely attribute unacceptable
feelings to another
 Projective identification: falsely attribute to a
second individual who in turn projects back to
patient
Defense and diagnosis - examples
 OCD – isolation, undoing and reaction formation;
ambivalence in relations, anxiety about agression,
magical thinking
 Anxiety disorder – anxiety signals unsuccessful
defense; agoraphobia: fear of abandonment, panic
disorder – often associated with loss
 Alcohol dependency - associated with harsh
punitive superego; alcohol acts as a “superego
solvent”
Cognitive behavioral therapy (CBT)
 Derives from cognitive and behavioral
psychological models of human behavior
including theories of normal and abnormal
development and theories of emotion and
psychopathology.
 Utilizes the cognitive model, operant
conditioning and classical conditioning to
conceptualize and treat a patient’s
problems.
Cognitive behavioral therapy
 successfully established its evidence base
 used in a wide range mental health
problems: depression, anxiety disorders,
bulimia, anger management, adjustment to
physical health problems, phobias, chronic
pain.
Cognitive therapy
 aim : to abolish negative thoughts which allow
symptoms to persist
 our moods and feelings are influenced by our
thoughts and the psychological disturbances are
caused by habitual errors in thinking. By correcting
these distorted ways of thinking, therapist
restructures patients´ views of themselves
Cognitive therapy
 three major cognitive patterns observed in
depression (by Beck)
 - a negative view of oneself
 - a negative interpretation of experience
 - a negative view of future
 the goal : to indentify and restructure those negative
schemas (that shape perception)
Group therapy
 Carefully selected participants meet in group guided by
trained leader
 Participants get immediate feedback
 Patients may also have GT outside individual therapy
 Self-help groups enable members to give up patterns
unwanted behavior
 The most prevalent method with a broad indication
 It is a first choice method in: neurotic and anxious
disorders and personality disorders
 As a supportive method, it is used in: affective disorders,
psychoses and in persons with serious somatic illness
Towards resolving dichotomy
Long/standing dichotomy in psychiatry:
 Psychological x physical approaches to treatment
 Anatomical/objective brain x “subjective”
brain/mind
Recent developments in genetics and especially in neuroscience
allow to evidence neuroscientific/neurobiological basis of
complex mental processes like psychological defences, or the
impact of relational trauma in infancy (Mizen, in Puri,
2010 )
Psychotherapy affects brain activity
 Psychotherapy-related changes in brain activity are
strikingly similar within patients who share the
same psychiatric diagnosis.
 Psychotherapy and pharmacotherapy achieve
similar efficacy and are associated with
overlapping but not identical changes in brainimaging
profiles
Roffman J. et al. Neuroimaging and functional neuroanatomy of
psychotherapy. Psychological med 2005 35:1385-1398
Eric Kandel’s new intelectual framework
for psychiatry
 1. All mental processes derive from the operations of the
brain
 2. Genes and their protein products determine the neuron
network in the brain which then enters into control of
behaviour
 3. Nurture (behavioral and social factors) becomes nature
 4. Learning changes neural connections
 5. Psychotherapy may bring long-term changes in behaviour through
learning, changing gene expression, altering the strength of synaptic
connections and bringing about structural changes. (Mizen, in Puri,
2010)
References
 Collier JAB, Longmore JM, Harvey JH : Oxford handbook of clinical
specialties, Oxford, 1998
 Puri, Basant, K. and Treasaden, I: Psychiatry: an evidence-based text. Hodder
Arnold. London, 2010
 Sadock, Benjamin, J: Kaplan & Sadock’s comprehensive textbook of
psychiatry Volume II, 8th ed.,Lippincott Williams & Wilkins, Philadelphia,
c2005
 Waldinger RJ: Psychiatry for medical student, Washington DC : American
Psychiatric Press, 1997
 EAP - http://www.europsyche.org/contents/13134/statement-of-ethical-
principles
 Royal College of Psychiatrists - http://www.rcpsych.ac.uk/
 Eric Kandel, Big Think, Uncoonscious Decision Making,
http://www.youtube.com/watch?v=ph7LcupAENw