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© Dr Najib Y2K2

Dr. Muhammad Najib Mohamad Alwi

Jabatan Psikiatri, PPSP

USM

http://clik.to/drnajibhttp://clik.to/drnajib

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Talking Therapy?Talking Therapy?

Terms that you’ve probably heard before:Terms that you’ve probably heard before:CounselingCounseling ““Talking Therapy”Talking Therapy” ““Psychoanalysis”Psychoanalysis”Supportive TherapySupportive TherapyPsychotherapyPsychotherapyEtc.Etc.

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Definition of PsychotherapyDefinition of Psychotherapy

Strupp (1978)Strupp (1978)

“ “ An Interpersonal process designed to bring An Interpersonal process designed to bring about modifications of feelings, cognitions, about modifications of feelings, cognitions, attitudes and behaviour which have attitudes and behaviour which have proved troublesome to the person seeking proved troublesome to the person seeking help from a trained professional ”help from a trained professional ”

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Definition of PsychotherapyDefinition of Psychotherapy

Other definitions:Other definitions:The development of a trusting relationship, The development of a trusting relationship,

which allows free communication and leads to which allows free communication and leads to understanding, integration and acceptance of understanding, integration and acceptance of selfself

The treatment of emotional, behavioural or The treatment of emotional, behavioural or personality problems by psychological meanspersonality problems by psychological means

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CHARACTERISTICS OF ALL CHARACTERISTICS OF ALL PSYCHOTHERAPIESPSYCHOTHERAPIES

Intense, emotionally charged, Intense, emotionally charged, confiding r/shipconfiding r/ship with a with a helping personhelping person

A rationale which contains an A rationale which contains an explanationexplanation of the patient’s of the patient’s distress and of the methods for its releasedistress and of the methods for its release

Provision of Provision of new informationnew information about the nature and about the nature and origins of the problems and of ways of dealing with themorigins of the problems and of ways of dealing with them

HopeHope in the patient that he can expect help from the in the patient that he can expect help from the therapytherapy

An opportunity for experiences of success during the An opportunity for experiences of success during the course of therapy and a consequent enhancement of the course of therapy and a consequent enhancement of the sense of masterysense of mastery

The facilitation of The facilitation of emotional arousalemotional arousal in the patient in the patient

(Jerome Frank, 1971)

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BROAD CHARACTERISTICS BROAD CHARACTERISTICS OF PSYCHOTHERAPIES:OF PSYCHOTHERAPIES:

The The presencepresence of a therapist-patient of a therapist-patient relationshiprelationship

The The interpersonalinterpersonal context of the context of the psychotherapiespsychotherapies

Conducted according to a Conducted according to a modelmodel that that guides the therapist’s actionsguides the therapist’s actions

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Counseling and PsychotherapyCounseling and Psychotherapy

Similarities:Similarities:Counseling under broad definition can also Counseling under broad definition can also

be defined as psychotherapybe defined as psychotherapyCounseling uses some form of Counseling uses some form of

psychological model e.g. Roger’s Client psychological model e.g. Roger’s Client Centred TherapyCentred Therapy

Both provide some form of support to the Both provide some form of support to the patientspatients

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Differences: Counseling vs Differences: Counseling vs PsychotherapyPsychotherapy

CounselingCounseling Offers non-judgemental Offers non-judgemental

support, encourages support, encourages clarification of current clarification of current problems & help clients find problems & help clients find solutions. solutions.

Usually short-term (1 – 3 Usually short-term (1 – 3 sessions)sessions)

Counselors are often not Counselors are often not psychotherapeutically psychotherapeutically trained and seldom trained and seldom requires supervisionrequires supervision

Often done at primary care Often done at primary care settings / schools etc.settings / schools etc.

PsychotherapyPsychotherapy Psychotherapy is Psychotherapy is

supportive but may not supportive but may not directly help to solve directly help to solve problems.problems.

Usually longer-term (12 Usually longer-term (12 sessions or more)sessions or more)

Needs to undergo special Needs to undergo special training and supervisiontraining and supervision

Often conducted in Often conducted in secondary or tertiary secondary or tertiary centres onlycentres only

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PsychotherapiesPsychotherapies

Thus, broadly speaking, the broad definition of Thus, broadly speaking, the broad definition of psychotherapy can encompass a large number psychotherapy can encompass a large number of interventionsof interventions

Kazdin (1986) identified > Kazdin (1986) identified > 400400 different therapies different therapies that can be classified as psychotherapythat can be classified as psychotherapy

Differing levels:Differing levels: InformalInformal: between friends, relatives, self-help groups: between friends, relatives, self-help groups FormalFormal: supportive, dynamic, behavioural etc.: supportive, dynamic, behavioural etc.

THE PSYCHOTHERAPY MATRIX

Theory Technique Mode Setting Timing Level

Psychoanalytic Interpretive Individual General practice

Very brief Self-help

Behavioural Directive Group Outpatient Brief Level 1: Counselling

Cognitive Expressive Couple Day hospital Time-limited Level 2: Non-specialist

Systemic Supportive Family Inpatient Indefinite Level 3: Specialist

Humanistic Paradoxical >1/week weekly < 1/week

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Major Classes of Major Classes of PsychotherapiesPsychotherapies

Psychodynamic PsychotherapyPsychodynamic Psychotherapy Behavioural and Cognitive-Behavioural Behavioural and Cognitive-Behavioural

PsychotherapyPsychotherapy Interpersonal PsychotherapyInterpersonal Psychotherapy Supportive and experiential psychotherapiesSupportive and experiential psychotherapies Group therapiesGroup therapies Family therapies: Systemic / Strategic / StructuralFamily therapies: Systemic / Strategic / Structural Existential Psychotherapy etc…..Existential Psychotherapy etc…..

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Aims of PsychotherapyAims of Psychotherapy Psychodynamic Tx: to change habitual patterns Psychodynamic Tx: to change habitual patterns

of thinking, feeling and behaviour which may of thinking, feeling and behaviour which may include specific symptomsinclude specific symptoms

Behaviour Tx: to reduce symptoms by changing Behaviour Tx: to reduce symptoms by changing specific behavioursspecific behaviours

Cognitive Tx: to reduce symptoms by changing Cognitive Tx: to reduce symptoms by changing thoughts which maintain specific symptomsthoughts which maintain specific symptoms

Interpersonal Tx: to help patient identify and find Interpersonal Tx: to help patient identify and find solutions to current life problemssolutions to current life problems

Family Tx: to see if and how the problem of the Family Tx: to see if and how the problem of the identified patient is maintained by the needs of identified patient is maintained by the needs of the familythe family

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Major Classes of Major Classes of PsychotherapiesPsychotherapies

Psychodynamic PsychotherapyPsychodynamic Psychotherapy Behavioural and Cognitive-Behavioural Behavioural and Cognitive-Behavioural

PsychotherapyPsychotherapy Interpersonal PsychotherapyInterpersonal Psychotherapy SupportiveSupportive and experiential psychotherapies and experiential psychotherapies Group therapiesGroup therapies Family therapies: Systemic / Strategic / StructuralFamily therapies: Systemic / Strategic / Structural Existential Psychotherapy etc…..Existential Psychotherapy etc…..

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What Is It?What Is It? (Psycho-)Dynamic Psychotherapy:

– Is concerned with the way in which a person’s mental representation of self and the world may lead to inappropriate behaviour in present personal and working relationships

– This approach seeks a personal meaning for the patient’s symptoms in terms of his or her past and present life

Aim:– To help the patient by increasing understanding of

his thoughts, feelings and behaviour Thus, it is sometimes called ‘exploratory’ or

‘insight directed’ therapy

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Psychodynamic PsychotherapyPsychodynamic Psychotherapy

Main classification:Main classification:Long-term: Long-term:

Frequency: >2 times per weekFrequency: >2 times per weekDuration: 1-5 years (or more!)Duration: 1-5 years (or more!)“psychoanalysis”“psychoanalysis”

““Brief”:Brief”:Frequency: usually 1/weekFrequency: usually 1/weekDuration: around 3-9 monthsDuration: around 3-9 months

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Psychodynamic PsychotherapyPsychodynamic Psychotherapy

““Brief” Dynamic PsychotherapyBrief” Dynamic PsychotherapyUsually up to 20 sessionsUsually up to 20 sessionsSuitable for patients who has had adequate Suitable for patients who has had adequate

psychological health and adjustment, and who psychological health and adjustment, and who has a specific symptom or problem with a has a specific symptom or problem with a definable onset.definable onset.

At least 8 different variantsAt least 8 different variants

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Who Needs It?Who Needs It?

Dynamic Psychotherapy is demanding on patient and not everyone can benefit from it

Diagnostic conditions where dynamic psychotherapy may be sought:– Depression– Anxiety disorder– Personality disorder– Eating disorder

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RRecognizes problem as psychological RResponsible for his own situation CCuriosity or psychological mindedness MMotivation to understand and change

attitudes and behaviour FFlexible and has problem solving ability CCapacity to relate to another person GGood childhood interpersonal

relationship

Suitability for Suitability for therapy:therapy:

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What Happens In Therapy?What Happens In Therapy?

Patient sits facing about 120o away from the therapist

Setting of clear rules and boundaries Average 50 minutes sessions No set agenda Patient talks on what comes through

their mind Therapist would give comments /

interpretations when appropriate Therapeutic alliance / free association /

ending

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Overview of ConceptsOverview of Concepts

Working allianceWorking alliance: agreement between patient : agreement between patient and therapist that they will work together on the and therapist that they will work together on the patient’s emotional or psychological problemspatient’s emotional or psychological problems

TransferenceTransference: transferring of feelings which : transferring of feelings which belong to a relationship from the past into the belong to a relationship from the past into the present relationshippresent relationship

CountertransferenceCountertransference: feelings elicited in the : feelings elicited in the therapist by the patient’s behaviour and therapist by the patient’s behaviour and communications.communications.

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Triangle of FeelingTriangle of Feeling

DEFENCEDEFENCE ANXIETYANXIETY

HIDDEN FEELING / IMPULSEHIDDEN FEELING / IMPULSE

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Triangle of PersonTriangle of Person

OO

Others (current, recent past)

TT

Transference(here and now)

PPParent / sibling(distant past)

O/T linkO/T link

O/P link

O/P link T/P

link

T/P li

nk

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ReferencesReferences

Individual Psychotherapy and the Science Individual Psychotherapy and the Science of Psychodynamics (2of Psychodynamics (2ndnd Edition). David H. Edition). David H. Malan. Butterworth Heinemann, 1999.Malan. Butterworth Heinemann, 1999.

Dynamic Psychotherapy Explained. Dynamic Psychotherapy Explained. Patricia Hughes. Radcliffe Medical Press, Patricia Hughes. Radcliffe Medical Press, 19991999

This presentation is available on my This presentation is available on my website: website: clik.to/drnajibclik.to/drnajib

Come and see me!Come and see me!