Psychotherapy

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• Principal Methods of Psychological treatment
• AIMST University
• Department of psychiatry
• 20 Apr 2011

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Behaviour therapy

• Based on learning theory
• Skinner
• Symptoms are unwanted conditioned responses which
  can be removed by relearning
• Aimed at modifying overt maladaptive behaviors as
  well as the cognitions, physical changes and
  emotions that accompany overt behavior
• Antecedent
• Event ----? Behavior---?Consequence

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Pavlovs Experiment
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Classical conditioning

• UCS (meat) --? UCR (salivation)
• UCS is paired with CS
• CS-? Cr
• Extinction It occurs when the occurrence of the
  conditioned responses decrease or disappear
• Generalization Tendency for the conditioned
  stimulus to evoke to evoke similar responses
  after the response has been conditioned
• Discrimination the ability to differentiate
  between a conditioned stimulus and other stimuli
  that have not been paired with an unconditioned
  stimulus

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Operant conditioning

• Involves the modification of behavior by using
  rewards
• Rewards are usually praise, tokens, financial
  incentives etc
• The more the behavior is rewarded the more likely
  the patient is to repeat the behavior (positive
  and negative
• reinforcement)
• Punishment reducing a behavior by presenting
  unpleasant stimulus

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reinforcement

• It is a consequence that causes a behavior to
  occur with greater frequency
• Positive reinforcement occurs when a behavior
  (response) is followed by a stimulus (commonly
  seen as pleasant) that increases the frequency of
  the behavior
• Punishment occurs when a behavior is followed by
  the removal of a stimulus commonly seen as
  unpleasant) thereby increasing the behavior
• Contingency management
• Used for modifying problem behaviors in children
  (with ADHD, conduct disorder etc)

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Token economies

• A system for implementing the principles of the
  contingency management after a variety of
  behaviours,based on the premacks principle (High
  frequency behavior is used as a reward for low
  frequency behavior)
• Four elements
• 1)Target behaviors
• 2)Token system
• 3)Back-up reinforcers
• 4)Goverened by rules of exchange

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Relaxation training

• To reduce anxiety by lowereing mucle tone and
  autonomic arousal
• Relaxing musxcle groups one by one
• Abdominal breathing technique
• Jacobsons progressive muscular relaxation

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Desensitisation

• A technique to control anxiety and follow
  classical conditioning
• Based on the principle of reciprocal inhibition
• If a response incompatible is made to occur at
  the same time as the anxiety provoking stimulus
  the anxiety is reduced by reciprocal inhibition

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Three steps of desensitization

• Relaxation
• Hierarchy construction
• Systematic desensitization

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Exposure

• Sometimes combined with desnistisation for the
  treatment of agoraphobia
• It may be done through imagery or exposure to the
  real feared object as in flooding
• Useful in phobias

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Flooding

• It is also called implosive therapy if done in
  imagination
• By exposing the patient to phobic object and
  preventing the usual escape or avoidance, there
  is extinction of usual anxiety response

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Exposure and response prevention

• Encouraged not to to perform the ritual and this
  is usually coupled with modelling
• Eg. obsessive compulsive disorder

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Thought stopping

• To treat obsessional thoughts
• A sudden intrusive stimulus us used to stop the
  thought

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ASSERTIVENESS TRAINING

• Suitable for shy individuals
• Assertiveness and social skills training teach
  people how to respond appropriately in social
  situations, to express their opinions in
  acceptable ways, and to achieve their goals.
• A variety of techniques-including role modeling
  desensitization, and positive reinforcement(
  reward of desired behavior)- are used to increase
  assertiveness
• Useful in social anxiety disorder, anxious
  avoidant personality disorder, depressives and
  schizophrenics

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STRATEGIES USED IN SOCIAL SKILLS TRAINING

• Making requests, refusing requests
• Expressing unpleasant feelings
• Making apologies
• conflict management (skills in negotiation,
  compromising, tactful disagreeing, responding to
  untrue accusations)
• Role plays and rehearsal may help in achieving
  above behaviors

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Aversion therapy

• When a noxious stimulus (punishment) is presented
  immediately after a specific behavioral response,
  theoretically the response is eventually
  inhibited and extinguished( electric shocks,
  substances that induce vomiting ,corporal
  punishment)
• Useful in treatment of alcohol dependence and
  sexual perversions

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Aversion therapy
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Cognitive therapy

• Produce benefit by changing maladaptive ways of
  thinking
• Becks cognitive theory negative view of self,
  environment and future
• Presence of negative automatic thoughts
• Systematic logical errors in the thinking of
  depressed individual
• Presence of depressogenic schemes and core
  beliefs, strongly held long lasting attitudes

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Pathway of depression (cogntive theory)
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Systematic logical errors

• Arbitrary inference ( drawing conclusion without
  sufficient evidence)
• Overgeneralization( forming conclusions based on
  too little experience)
• Selective abstraction (focus on single detail)
• Magnification and minimization (over/undervaluing
  significance of particular event)
• Dichotomous thinking (tendency to place
  experience into all or none categories)

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Negative cognitions

• No one loves me
• I am always a failure
• I can never be perfect
• People praise me out of pity
• Future holds no hope for me

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Cognitive therapy

• To identify thoughts that are unreasonably self
  depreciating
• Challenging and confrontation (Socratic
  reasoning)
• Formulation of more realistic ideas

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Examples

• Nobody likes me-? even people who like me
  occasionaly get mad at me
• I am a moron-? I am smart, even if I do make
  mistakes now and then
• I am worthless? I am a good person
• My jokes are bad? my class has a no sense of
  humor

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Indications of cognitive therapy

• Depressive disorders
• Anxiety disorders
• Eating disorders
• Post traumatic stress disorder
• Hypochondriasis

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Cognitive therapy example

• I called Sally to go out as we talked about ,I
  got her answering machine, I felt a sinking
  sensation.
• Automatic Thoughts
• They have all gone out and forgotten about me
  because I am not important to them
• I am left out again
• I am going to have to spend another Friday night
  alone
• I just dont fit anywhere in this world
• How can you change these irrational thoughts?

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Psychoanalysis

• Developed from psychoanalysis and the theories of
  Freud
• Concept of conflict which arises out of the
  process of repression is the main theme
• Concept of transference-misperception and
  misappraisal of others based on childhood
  experiences
• Identifying resistance and transference are core
  principles
• Classical psychoanalysis involves free
  association( allowing the client to verbalize
  whatever comes to his mind)

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Psychoanalytically oriented psychotherapy

• Direct form of psychoanalysis
• It results in structural reorganization of
  personality, resolution of unconscious conflicts
• Best indicated for borderline PD and those with
  neurotic disorders
• Patient should be psychologically minded and
  should have motivation/ adequate ego strength

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Freud and his famous coach
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Interpersonal therapy

• Developed by Kerman and Weismann
• Here depression is accepted as a medical model
• Problem areas are classified into three groups
• Grief
• Interpersonal role disputes/Inter personal
  deficits
• Role transitions

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Counseling

• Counseling is usually non-directive
• Therapist maintains and unconditional positive
  regard. He must remain non-judgmental
• Suitable for individuals who have their own
  resources to draw upon
• Involves Information sharing, problem-based
  counseling

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Problem-solving

• Four components
• Symptoms are accessed
• Explanation is provided
• Reassurance
• Actual treatment

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Situations considered for problem solving

• Termination of pregnancy
• Seeking divorce
• Grief
• Discovery of terminal illness
• Attempted suicide

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Approach

• Clarification of problem
• Solutions are thought of Choosing the most
  suitable one
• Plan of action
• Review and Evaluation

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Family therapy

• Family Therapy is useful families with children
  and adolescents who have psychiatric problems
• To help the family to recognize maladaptive
  behaviors and help them to develop more fruitful
  ways of interacting with each other

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Group therapy

• Groups provide support and encouragement
• It helps in sharing problems with other fellow
  members
• Clients recognize that they are not alone to have
  such difficulty
• Self help groups have been effective in alcohol
  dependence, opioid abusers, eating disorders

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Biofeedback

• Biofeedback is based on the idea that the
  autonomic arousal system can come under voluntary
  control through operant conditioning
• This is done by hearing or seeing signals from
  instruments that produce information about
  various measures such as muscle tension. This
  feedback of information about the body helps
  people to try change a function, for instance by
  relaxing.

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Involuntary biological functions

• Skin temperature
• Electrodermal responses
• Muscle tension
• Blood pressure
• Heart rate
• Brain wave activity

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Instruments available

• Electromyogram (EMG), which measures the
  electrical potentials of muscle fibers
• Electroencephalogram (EEG) which measures alpha
  waves that occur in relaxed states
• Galvanic skin response gouge(GSR), which shows
  decreased skin conductivity during relaxed
• state

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Clinical Application

• Tension Headaches
• Migraine
• Bruxism
• Enuresis
• Asthma
• Cardiac arrhythmias
• Grandmal Epilepsy
• Idiopathic hypertension

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Couple therapy and Sex Therapy

• Master and Johnsons sex therapy (sensate focus)
• Start and stop technique and squeeze technique
  for premature ejaculation
• Couple therapy involves addressing issues like
  communication between couples, focus on the
  current behavior (reciprocity negotiation) and
  paradoxical intervention