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Transcript
Jose Pons Madera, Ph.D. Director - Psy.D. Program Ponce School of Medicine Tel 844-5209 Objectives For Conferences I & II • Define psychotherapy and to explore its mechanisms of action. • Identify the main psychotherapeutic approaches • Recognize the conditions for which psychotherapeutic interventions are indicated or appropriate • Explore Short Term techniques especially Crisis Intervention • Familiarize with Psychoanalytically oriented psychotherapies • Understand the components of Cognitive and Cognitive Behavioral Therapies • List some of the psychotherapeutic techniques utilized for a selected group of mental health conditions. Caso # 1 – Tita de CESCO • Quién es el/la paciente • ¿Es esto una intervención psicoterapeútica? • ¿Que se debe hacer con Tita? ¿Con la Mamá? • ¿Quien más debe estar en la intervención si se ofrece alguna? • ¿Que es psicoterapia? DEFINITION A special relationship between two or more persons, one or some of whom (the patient/s) seek help with problems of daily living or with symptoms that interfere with their functioning and quality of life, and the other (the therapist) is a professional that utilizes the relationship between both as well as other specialized psychological techniques, to help him or them confront their difficulties. Analysis of Definition • Persons Involved – – – – Individuals couples families groups • Patient’s difficulties – Symptoms – Diff w/ daily living – Diminished satisfaction w/ self or life The Psychotherapeutic Process 5 X 3 Model • • • • • THE INTERVIEW Introduction Opening Body Closing Termination THE THERAPY PROCESS • Initial Phase • Middle Phase (Working Through) • Termination Types of Psychotherapy Crisis Intervention Short-Term (Focused) Supportive Psychotherapy Long-Term (Reconstructive) Conditions for which Psychotherapy Might be Indicated • • • • • • • • • • Adjustment Disorders: all types DSM-IV V codes Interpersonal Difficulties & Personality Disorders Depresive Disorders Anxiety Disorders: GAD, Panic, OCD, Phobias. PTSD: with or without dissociation Addiction disorders Behavioral Problems w/ children & adolescents Eating and elimination disorders Somatoform Disorders Curative Factors • Primary Curative Factors: Insight, Behavior Change, Relationship • Factor most correlated w/ positive therapy outcome = EXPECTATION • What Patients get from Psychotherapy: – – – – – Emotional Corrective Experiences Improved Self Esteem Higher Sense of Control Better Relationships Higher Levels of Adaptation Main Types of Psychotherapeutic Modalities Main Theoretical Concepts Process & Techniques Case # 2 – Maria From Junior High School • ¿What is happening to María? • ¿Is this a crisis situation? • ¿What kind of intervention is needed to help her? • ¿What goals should the treatment attempt to reach? • ¿What type of techniques should be utilized to help her? CRISIS INTERVENTION • A strong emotional/behavioral reaction to an external situation or to internal conflicts which alters a person’s capacity to cope with life’s circumstances and affects their psychological stability. – Two types of Crisis • Situational • Developmental • Psychological Characteristics of Persons in Crisis – Psychological “Tunnel” vision • diminished range of options – Pesimism with impaired Problem Solving abilities – Lack of energy and of direction – Psychological regression to stages of helplessness CRISIS INTERVENTION • Role of the Therapist – Understanding of where the pt is and what his/her perception of the situation is. Provide support and reassurance – Opening of perceptual focus and of the capacity to generate alternatives – Help pt adapt to unchangable circumstances or to change those circumstances that may by changed. • Goal of Crisis Intervention – Restoration to previous levels of functioning Psychoanalytic Therapies I. Theory: A. View of Mind B. Core Issues: – intrapsychic conflict & psychosexual fixations – focus on past experiences/emotions II. Process: – Therapeutic Alliance – Resistance – Denial & Defense Mech III. Technique: – Free Association, Dream Interpretation, Interpretation, analysis of transference IV. Indications - Neurotic conflicts Cognitive Therapies • Theory: Cognitive Psychology • Precursor: Karen Horney • Pioneers: A.T. Beck, A. Ellis • Process & Techniques – Irrational Beliefs – Thinking Distortions • Initial Use: Depression & Adjustment Problems • Current Use: – Depresion, anxiety and many conditions including Personality Disorders Behavior Modification • Theory: – Learning Theories:Operant,Visceral, and Cognitive (Motor, Visceral, Social). • Process: – Operational Defn of problem – Identification of contingencies • S-R-Rr o R> Rr – Identification of reinforcers – development of treatment process – monitoring of Beh & Conditioning Variables • Techniques: – Contingency Management • Discriminative S & Rr – Time Out, S control, Self Rr – Desensitization – Modeling Techniques Humanistic Approach • Theory: Phenomenology & Existentialism – Rogers: Client Centered – Frankl: Existential • Process – Reliance on Relationship to achieve meaning or congruence – Perception of internal & external world – Self Actualization – Choices & Being in the World Cognitive Behavioral Therapy • • • • • • Integration of Cognitive w/ Beh. Mod Newer forms integrate Humanistic Approaches Most researched apporach - Empirically Validated Tech. Cost-effective and most Managed Care friendly Most Techniques developed Multiple Modalities/Approaches: – Arnold Lazarus: Multimodal Therapy – Michenbaum: Self Verbalization Technique & multiple conditions – Others • Newer CBT Modalities: – Dialectical Behavior Therapy - DBT – Eye Movement Desentization & Reprocessing - EMDR CBT Techniques • • • • • • • All Behavior Modification Techniques All Cognitive Techniques Relaxation Techniques Social Skills Training Problem Solving Imaginary & visualization techniques (including Gestalt) Somatic techniques: exercises & other Wellness approaches. • Clinical Health techniques • Family & couples therapies • Child therapy Other Psychotherapeutic Modalities • Family/Couples Therapy & Systemic Interventions • Group Therapy • Play Therapy • Ecological Therapy • Psychoeducational • Art Therapy • Dance Therapy Empirically Validated Interventions For Frequently Encountered Conditions From Randomized Clinical Trials to Single Case Studies Conditions & Interventions • Depression: CBT & SSRI (T-I) • ADHD: BT (contingency management), Psychoed for family & school, CBT for child, Stimulants. • Addiction Disorders: Detox (First), Residential, family, CBT/Dynamic or AA, NA or other. CBT for social skills and problem solving • Anxiety Disorders - Panic: BM - progressive exposure & development of coping skills W/ CBT for psychoeducation about anxiety & its management • Obsessive Compulsive Disorder: CBT w/ exposure and response-ritual prevention w/ SSRI Conditions & Interventions • Conduct Disorder: Parent Management Training w/ FT, Problem solving w/ other CBT techniques as needed. School consultation. • • • • Trauma & PTSD: supportive, psychodynamic or EMDR. Borderline Personality Disorder: DBT GAD: psychodynamic, CBT w/ benzodiazepines. Personality Disorders: Psychodynamic or CBT