Psychotherapy, Cognitive Behavioral, & Group Therapy Lecture Notes PDF

Please log into Socrative.com Classroom: DEMSHOK 01/22/2025 1  Psychotherapy, Cognitive Behavioral, and Group Therapy Human Behavior and Psychiatry PHA 535 Professor Demshok 01/22/2025...

Please log into Socrative.com Classroom: DEMSHOK 01/22/2025 1  Psychotherapy, Cognitive Behavioral, and Group Therapy Human Behavior and Psychiatry PHA 535 Professor Demshok 01/22/2025 Spring 2025 2  Instructional Objectives 1. Compare and contrast multidisciplinary and interdisciplinary care and explain the significance of each in patient outcomes. 2. Distinguish between various techniques from psychoanalytic, humanistic, Jungian, cognitive, and behavioral therapies, as well as mindfulness, hypnosis, biofeedback, neurofeedback, and imagery, and evaluate the indications and disadvantages of each. 3. Define and identify transference, countertransference, and resistance, and demonstrate effective strategies for managing these dynamics in therapeutic settings. 4. Apply practical therapeutic techniques during patient encounters to enhance communication and treatment efficacy. 3  Multidisciplinary Care in Behavioral Health Intentional communication between a variety of healthcare providers to support patient health and safety. Participants include direct care providers and the patient. Sometimes a “case manager” closes the communication loop Most commonly outpatient care 01/22/2025 4  Interdisciplinary Care in in Behavioral Health Intentional care planning by a team of healthcare providers. Can includes psychiatrists, psychologists, mental health counselors, RNs, PAs, ARNPs, vocational rehabilitation counselors, social worker/ case manager and the patient and family in the care of the patient Communication loop is closed through discussion, feedback, and agreement Commonly inpatient/ residential care Generally superior to multidisciplinary care 01/22/2025 5 What would be some goals of therapy/ counseling? Answer in Socrative 01/22/2025 6  Medications and Therapy Medications Therapy Reduce/ resolve symptoms A healing process, usually person to Amplifies the ability for people person, that assists individuals in to benefit from therapy understanding themselves (thoughts, Can be superior to therapy feelings, actions, motivations) and alone others and their participation in the world Provides education, develops skills, and promotes insight and healthy living strategies toward improving patient and family mental health Healthy in/ interdependence Can be superior to medication alone 7  Types of Therapies Numerous! Some are effective, some are not Some may be dangerous/ expensive 01/22/2025 8  Therapeutic Interventions: Evidence- Based Therapy Characteristics 1. Respectful 2. Non-coercive 3. Non-abusive 4. Concerned with the patient/ client’s best interest (s) 01/22/2025 https://www.mentalhealth.va.gov/get-help/treatment/ebt.asp 9 01/22/2025 10  Individual Therapies Focuses on the trusting relationship between a patient/client and a therapist Facilitate the individual to meet their personal mental health/wellness goals and improved sense of well being 01/22/2025 11  Individual Therapy: Psychoanalytic Involves talking about how the past influences the present and the choices patients make. Process is longer than cognitive behavioral therapy (CBT) and problem focused therapies Sessions are usually an hour long 01/22/2025 12  Individual Therapy: Psychoanalytic Advantages Explores early life experiences: childhood, parental relationships, bonding, shaming Acknowledges the role of the unconscious and unresolved conflicts/ repressed memories – Dream analysis – Free association – “Freudian slips” – Rorschach (ink blot) test 01/22/2025 13 01/22/2025 14  What Do You See? 01/22/2025 15  Individual Therapy: Psychoanalytic Disadvantages Inappropriate for: – Actively psychotic patients – Patients with poor insight – Patients with limited finances and insurance benefits Time consuming: takes many months- years May be ineffective despite insight and consciousness 01/22/2025 16  Psychoanalytic Concepts: Transference Patients transfers their feelings of a particular person (or ideal) in their lives to the therapist/ provider – Example: the patient “falls in love” with the caretaker – Feelings may be positive or negative Part of the expected therapeutic process Therapist facilitates patient “working through” unresolved feelings 01/22/2025 17  Psychoanalytic Concepts: Countertransference The therapist develops positive or negative feelings toward the patient Therapist's unconscious feelings are stirred up during therapy which the therapist directs toward the patient – Anger, affection, attraction, repulsion, “parental” Very common: therapist seeks “supervision” to process their feelings and own their feelings and responses 01/22/2025 18  Psychoanalytic Concepts: Resistance A disruptive response by the client to some topic they find sensitive, which is the source of their anxiety – Example: the client might make an off-handed remark or joke, claim they forgot the information, come late/ miss appointments, or pick a fight with the therapist. Gentle confrontation: “I notice that when we talk about this topic, you make jokes or get upset with me. Could it be this is a difficult/ challenging topic for you?” If patient denies, you could ”go with the resistance” for a time, but it needs addressing 01/22/2025 19  Psychoanalytic Concepts: Attachment Theory Quality of a child’s attachment during the formative years, when the brain is developing exponentially, affects the quality of relationships throughout life. As the caregiver affects the child, the child also affects the caregiver. Patient’s therapy can mimic the attachment features of infants, with the analyst representing the caregiver. 01/22/2025 20  Psychoanalytic Concepts: Attachment Theory 1. Proximity Maintenance: wanting to be physically close to the caregiver/ therapist 2. Separation Distress: "separation anxiety" 3. Safe Haven: retreating to the caregiver/ therapist when sensing danger or feels anxious 4. Secure Base: exploration of the world knowing that the caregiver/ therapist will protect them from danger Dependency, then healthy independence, interdependence, and connection 01/22/2025 21  “Therapy You Can Use”: Client Centered Therapy: Unconditional Positive Regard Pioneered by Carl Rogers In a safe environment, the patient intuitively knows how to feel better and what to do Active listening – Paraphrasing: examples Empathetic Supportive, patient centered Genuine Making eye contact Therapeutic touch (with permission) 22  Client Centered Therapy: Unconditional Positive Regard Disadvantages Not always appropriate – Psychosis and paranoia – Particular cultures – History of physical/ sexual abuse – Mania – Need for skills training/ directions – Time consuming – Expensive 01/22/2025 23  What Are Not Feelings “I feel like you don’t care about me” “I feel like I am the only one who does the dishes in the house.” I feel “abandoned.” What Are Feelings? Happy, sad, angry, afraid, jealous Evokes/ elicited from a situation, memory, behavior – Can’t be “made” to feel an emotion 24  “Therapy You Can Use”®: Role Play Practice: – “Patient” states a feeling. When____happens I feel_______. – “PA” paraphrases – Switch – Share: what was that process like for each of you? 01/22/2025 25  “Therapy You Can Use”: Reframing Use alternative ways to remember and think about a problem or event – Example: lost in the woods! 01/22/2025 26  Individual Therapy: Jungian Psychology Explore and integrate the unconscious to become “whole” Integration of “shadow” and projections – Shadow: all aspects of personality, especially socially unacceptable or positive/ celestial – Projection: personality traits ascribed to others (a form of transference): hero worship or “demonizing” – Connection with the numinous, the “Self,” God – Uses ritual and symbolism ritual and symbols express that which cannot be expressed easily through words or an actual action to evoke a state of mind Jungian Psychology Concepts Archetypes: thematic personalities – Hero – Fair maiden/ Amazonian – Mystic – Queen/ King – Trickster – Villain – Warrior – Healer 28 01/22/2025 29 Jungian Personality Theory 30  Disadvantages of Jungian Psychology Same as psychoanalytic 01/22/2025 31  Individual Therapy: Counseling Client encouraged to talk about feelings Counselor is supportive, accepting, non-judgmental Works in emoting and finding solutions Not as “past” based as psychoanalytic May be short or long term A trained, skilled, confidant with “coaching” Example: relationship/ school difficulties 01/22/2025 32  Individual Therapy: Behavior Therapies Change or reducing maladaptive behavior/ actions (vs examining the unconscious conflicts or aspects) Goal: eliminate the behavior, regardless of the feelings about the behavior and the underlying causes Feelings change as behavior changes Maladaptive behavior is learned and can be unlearned. Example: Learned helplessness Example: Behavioral Activation for depression – Focus on pleasurable activities 01/22/2025 33  Behavior Therapy: Positive Reinforcement A pleasant stimulus (reward) increases the frequency of a particular behavior – praise, sex, tangible goods, increase privileges, status and promotion, social media, phone “dings” – Contingency Management in substance abuse: cash, vouchers, prizes for negative urine tests To reinforce behavior, ≥5 positive to 1 negative ratio – Key to happy marriage: John Gottman, PhD 01/22/2025 34  Behavior Therapy: Systematic Desensitization or Exposure Therapy For phobias, fears, and aversions Training to replace the feelings of anxiety with feelings of relaxation with the object, behavior, or situation Conditioning relaxation instead of anxiety OR Conversely, expose someone intensely to what is feared (with the therapist) 35 Example: fear of flying, VR headsets  “Therapy You Can Use” Cognitive Behavioral Therapy (CBT) The present is more important than the past How one thinks of an event/ situation determines how one feels, which influences behavior Feelings do not have to be dictated by the event, but can be changed by the way a person thinks about the situation (reframing) Lasts 12-20 weeks Automatic, strong feelings are made aware Used for a variety of disorders – Anxiety – Insomnia – Depression – Phobias… and more! 36 01/22/2025 01/22/202 5 37 01/22/2025 38 01/22/2025 39 01/22/2025 40 01/22/2025 41 01/22/2025 42  CBT Advantages Effective! Sometimes superior to medication – PET scans/ fMRIs confirms – Research supports efficacy Adjuvant to medication or superior to/ instead of medication Time efficient Promotes patient autonomy Online or in person Apps: cognitive behavior therapy for insomnia (CBT-I) High reimbursement 01/22/2025 43  CBT Disadvantages Sometimes ineffective Does not address deep, unconscious, programed ways of thinking, feeling, and behaving Patient may need more that 12 weeks of therapy 01/22/2025 44  “Therapy You Can Use” Mindfulness Meditation “Mindfulness means paying attention in a particular way; on purpose, in the present moment, and nonjudgmentally.” -Jon Kabat-Zinn Founder of Mindfulness-Based Stress Reduction (MBSR) “Nowhere to go, nowhere to be, nothing to do.” 01/22/2025 45 Regular Practice Cultivates 3 Core Skills  Concentration: The ability to focus and stabilize one’s attention.  Sensory Clarity: The ability to keep track of the components of sensory experience as they arise in various combinations, moment-by-moment.  Equanimity: The ability to ‘be with’ experience with an attitude of gentle matter-of-factness. 46 Impact Of Mindfulness On Regional Brain Gray Matter Density Participation in an 8-week MBSR program associated with changes in brain grey matter concentration, regions involved in learning, memory, and emotional regulation. – PTSD and major depression associated with decreased density or volume of the hippocampus: – MBSR increases hippocampus density 01/22/2025 47  “Therapy You Can Use”: Imagery and Hypnosis “Imagine, if you will….” A suggestion given during a time of receptivity and focused attention – Relaxed, trusting state – Can be used in stressed states Giving injections: “ Now, whatever you do….” Burn patients: Dabney Ewin MD (see article below in notes) Hypnosis can be directed or non-directed – Recovering memories vs “what comes up?” American Medical Association, American Psychiatric Association, and the American Psychological Association all approve of hypnosis 48  Hypnosis Disadvantages Painful, distressing memories and images Some patients need “grounding” and a sense of here and now reality Avoid in: – Actively psychotic patients – Depersonalization, derealization 01/22/2025 49  Spiegel Eye Roll Test: Test for Hypnotic Susceptibility 01/22/2025 50  “Therapy You Can Use”: Metaphors Stories, images, idioms, analogies which describe a person’s feelings or situation “A picture paints a thousand words…” A way for patient to experience and relate A way for practitioner to communicate “Forming a new habit is like carving a path in the jungle. You trod through the undergrowth and take the same route over and over again, until a clear path is formed. Meanwhile, older pathways become overgrown and wild, disappearing from sight with unuse.” 01/22/2025 51  Common Medical Metaphors Agricultural, militaristic, mechanical and sports metaphors – We “wage war on disease” – Patients “suffer attacks of the disease” – S/he/the is/ are a fighter – Body [has a] defense system. – The ravages of disease – Some treatments are “aggressive” – “Fighting” cancer 01/22/2025 52  Healing Metaphors “A habit forms the way water carves a new stream or river.” “You can’t see the grass growing, but after a week or so, you can see that the lawn needs mowing.” “You can’t pour from an empty cup.” “Our emotions are like a thermometer in the window. You can see clouds or rain or sun, but without a thermometer, you won’t know if it’s 90 degrees or 17 below. Emotions impact how you experience the outside world.” “Your life is a book with many chapters and pages. Every day is a new page. You write your own story.” 01/22/2025 53  “Therapy You Can Use”®: Healing Medical Metaphors What you don’t say is as important as what you do say – “Quitting” smoking vs smoking cessation and normal breathing – “You will be better soon.” vs “We’re done.” – “Good” vs “effective, useful, helpful, facilitating, health promoting” – “Bad” vs ineffective, not useful, harmful to you body – Patients in the OR or in a coma can hear you 01/22/2025 54  “Therapy You Can Use”® Biofeedback Behavior therapy involving relaxation and the power of suggestion Uses biometrics (pulse rate, breathing, skin temperature) and patient monitors their progress so they receive reinforcement of effectiveness – Migraines – Asthma – Chronic pain – GI symptoms – Post traumatic stress disorder (PTSD) Neurofeedback: brainwaves – The biometrics are certain relaxing/ healing brain waves 55  Body Therapies "The truth about our childhood (life) is stored up in our body, and although we can repress it, we can never alter it. Our intellect can be deceived, our feelings manipulated, our perceptions confused, and our body tricked with medication. But someday the body will present its bill, for it is as incorruptible as a child who, still whole in spirit, will accept no compromises or excuses, and it will not stop tormenting us until we stop evading the truth.“ Alice Miller PhD, psychoanalyst (1923-2010) 01/22/2025 56 01/22/2025 57  Body Therapies Talk therapy combined with physical activity or sensation: therapeutic touching, massage, movement, emoting Yoga and breathing 01/22/2025 58  Eye Movement Desensitization and Reprocessing (EMDR) Used for trauma/ post traumatic stress disorder(PTSD) Uses eye movements to facilitate brain retraining and reprocessing Relaxation and self calming techniques The vivid visual image related to the memory A negative belief about self Related emotions and body sensations Positive imaging and reframing 01/22/2025 59  “Therapy You Can Use”: Bibliotherapy Literature which explains psychological diagnoses, “issues” and dealing effectively with them – Depression – Anxiety – Personality disorders – Eating disorders – PTSD – Psychosis 01/22/2025  “Therapy You Can Use”: Bibliotherapy Affirms patient and their condition and “normalizes,” decreasing sense of isolation and being “different” Alone or in conjunction with therapy Offers solutions One time cost or library loan 01/22/2025 61  Disadvantage of Bibliotherapy Patient gains information and insight without though or behavior change Deep seated emotional issues never addressed 01/22/2025 62  “Therapy You Can Use”: Language: Listen to Patient Clues “I’m alright, I guess..” “I’m OK” “Things are mostly better….” “I’m pretty good….” “Not really…“ Global negative statements: “Everyone..” “They always…” 01/22/2025 63  Family Therapy Focuses on the family as a unit Systems theory: one person affects the entire system Development of individual insights and the development of skills to promote communication, empathy, responsibilities, and the success of the family Family “roles”, “identified patient” Parenting and couple’s skills Role playing “Assignments” 64 Recognition can facilitate consciousness and more intentional ways of being 01/22/2025 65  Marriage/ Couples/ Relationship Therapy Improve communication Identify shared goals Confront concerns honestly Honor individual needs Develop plans to continue, change, modify, or dissolve the relationship in a respectful manner that reduces harm and collateral damage. 01/22/2025 66  Group Therapy Effective for persons dealing with any of the same issues/ diagnosis Being with others who may better understand the problem (drug abuse, loss of loved one, eating disorder) Peer support Confrontation, recognizes ineffective behavior and practices/ models effective behavior 01/22/2025 67  Group Therapy Employs many techniques May be topic driven, time limited and/ or ongoing Focus on education, skill development, emotional support, interdependence and well being. Selected participants: some are not suitable 01/22/202 68 5  Which of the following therapies should be avoided in psychotic patients? A. CBT B. Hypnotherapy C. Family Therapy D. Group Therapy 01/22/2025 69  Culturally Competent Interventions 01/22/2025 70 Hoshi was born and grew up in Japan. He has been living in the United States for nearly 20 years, going to graduate school and working as a systems analyst, while his family has remained in Japan. Hoshi entered a residential treatment center for alcohol dependence where the treatment program expected every client to notify his or her family members about being in treatment. This had proven to be a positive step for many other clients and their families in this treatment program, where the belief was that contact with family helped clients become honest about their substance abuse, reconnect with possibly estranged relatives, and take responsibility for the decision to seek treatment. 01/22/2025 71 He was reluctant, but staff members persuaded Hoshi to comply with program expectations. He wrote to his family, describing his current life and explaining his need for treatment. It was not until weeks later, after he had been discharged from residential treatment and was participating in the program's continuing care program, that he received a reply. Staff members were shocked to learn that Hoshi's parents had disowned him because he had “shamed” the family by disclosing the details of his life to the program staff, publicly admitting that he had a drinking problem. 01/22/2025 72 Which of the following therapies is based on systems theory? A. Biofeedback B. Cognitive Behavioral Therapy C. Desensitization Therapy D. Family Therapy 01/22/2025 73 Changing one's thoughts and taking different actions are characteristic of which type of therapy? A. Biofeedback B. Cognitive Behavioral Therapy C. Desensitization Therapy D. Jungian Therapy 01/22/2025 74  Which Therapy is the Best? 01/22/2025 75  All Therapies: Have common features Effective in treating a wide variety of psychiatric diagnoses Psychotherapy-related changes in brain activity are strikingly similar in specific psychiatric diagnoses Many schools of thought in psychotherapy and no one “right” approach Consider multiple “patient factors” when recommending psychotherapy Review evidenced based therapy for the specific condition https://www.mentalhealth.va.gov/get-help/treatment/ebt.asp 01/22/2025 76 01/22/2025 77