Psychiatrická klinika LFUK a UNB, Bratislava
PSYCHOTHERAPY & PSYCHIATRIC REHABILITATION Psychiatry 1 – Practical # 4
Authors: Mgr. Miroslava Zimányiová, PhD. MUDr. Dana Krajčovičová, PhD. PhDr. Michal Hajdúk, PhD. Supervision: prof. MUDr. Ján Pečeňák, PhD.
Learning objectives:
Overview of non-biological treatment methods
in psychiatry
Focus on:
Psychoeducation
Psychosocial rehabilitation
Therapeutical methods in psychiatry
Biological therapies - Pharmacotherapy - Brain Stimulation Methods - Phototherapy - Sleep Deprivation
Psychotherapy
Psychoeducation
Psychosocial rehabilitation Psychotherapy
Use of psychological methods in treatment
Therapeutical interaction between Psychotherapist and Client/Patient
Could be used in all fields of medicine, most frequently in psychiatry as part of complex treatment (sometimes as a 1st treatment choise)
Example: Depression
BIO - PSYCHO - SOCIAL
MODEL
Biological predisposition (congenital, gained) Psychological factors Social factors
Complex Therapy of Depression
PHARMACOTHERAPY Antidepressants Antipsychotics Anxiolytics, Hypnotics, Sedatives, Thymoprophylactics, Perceptiveness Compliance Augmentative therapy
PSYCHOTHERAPY Supportive + Fototherapy Systematic + ECT + Sleep deprivation + rTMS Basic Aspects of Psychotherapy
More than 400 psychotherapeutical schools Use of various methods and techniques For all applies: Psychotherapeutical relationship Metodology Emotion processing Problem solving
Psychotherapeutical Relationship
The bound between therapist and patient, it si build since first meeting
Basis = feeling save and secure /for patient/
Is the most important variable in psychotherapeutical effect (research: 70% efficiency with no regards of methods and intervention uses)
Earch contact doctor – patient has a therapeutical effect (or anti-therapeutical)
Psychotherapeutical Proces
In the proces of psychotherapy patient experiences strong emotions
Therapy allows new corrective experience
In the proces of therapeutical change patient experience strong feelings towards therapist and he gets insights into his own relationships and life situation
and he practice new attitudes and behavior What we Influence in Psychotherapy– Education about Experience
SITUATION: Thoughts
Thoughts: What I was thinking about?
Emotions Behavior Emotions: What did I feel?
Body reactions: How my body reacted? Body reactions Behaviour: What did I do?
Transference and Countertransference
Transference – the process by which emotions associated with one person (parent) unconsciously shifts to another
Countertransference – a therapist's own repressed feelings in reaction to the emotions, experiences or problems of patient
Psychotherapeutical schools
Psychoanalysis and dynamic therapies
Humanistic therapies
Cognitive-behavioral therapies Dynamic psychotherapies
Influence of past experience Bringing unconscious processes into conscious mind and their impact on actual experience
Sigmund Freud – Psychoanalysis Carl Gustav Jung – Analytical psychology Alfred Adler – Individual psychology
Humanistic psychotherapy
Selfractualisation Development of inner experience Fullfill one´s meaning of life
Frederick Pearls = Gestalt therapy Carls Rogers = PCA (Person centered approach) Viktor Frankl = Logotherapy
Cognitive-behavioral psychotherapy
Learning (conditioning etc.) Training Experiment
Hans J. Eysenck, Albert Ellis, Aaron Beck Training programmes (Aversive therapy, Systematic desenzitisation, ...) Indication for psychotherapy - Adults
Relationships Depression and anxiety Stress and stress inducted disorders Neurotic disorders Psychosomatic disorders Personality disorders Eating disorders Stabilized psychosis (supportive psychotherapy)
Indications for psychotherapy: Children
Anxiety Addaptation problems Neurotic disorders (enuresis, tics, pain - abdomen, head) ADHD, agressive behaviour Teenage age – selfesteeem, problems in relationships, refusal, identitiy problems, anxiety, depression, selfharming, eating disorders
Contraindications of Psychotherapy
Consciousness disorders
Acute states in psychiatry (acute suicidal patient,
acute psychotic state, severe depression with psychotic
signs)
Demencia, severe cognitive deficit Types of psychotherapy – number of members
1. Individual psychotherapy
3. Couple psychotherapy (a couple = client)
Individual psychotherapy
• Session – 1 client and 1 therapist • Place of session (work-room, „safe place“) • Time frame (50 minutes, 1x week) • Aim – to understand themselves, the client´s situation, building resilience for life events, selfacceptation • Payment: client/insurance • Length: short-term – up to 25 session • Long-term – even few years
Group Psychotherapy
Number of members: 2-15 (optimal 5-10 members) Time frame: Max 90 min, optimal 60 min. Frequency: 1-2 x week Total time schedule: 6-8 weeks (in our Day-Care Center), few months Mechanisms: - Group dynamics - Group structure - Group cohesiveness Factors: membership, emotional support, helping others, selfexploration and selfperormance, feedback, insight, corrective experience, new behaviour pattern training, new information, new social skills Group Psychotherapy
• Reaching therapeutical goals using group dynamics = relationships and interactions between group members • Mental health improvement, elimination/decreasing of social functioning malfunction and adaptation improvment
Goals: • Insight into problems of group members and help them to change maladaptive attitudes • Change maladaptive patterns of behaviour • To mediate know-how about interpersonal and group processes • Support of personality maturation • Elimination of pathological symptoms (training, interpersonal conflicts solving)
Group Therapy Principles
1. Honesty 2. Responsibility 3. Confidentiality 4. „STOP“ Right 5. Tolerance 6. Timing /beginning and end/ 7. One-member at a time 8. Group leader intervene only when necessary 9. Questions for all members 10. No gossips /no talking about member who is not present/
Types of groups
According members: homogenous and heterogenous According functioning: Open or closed groups Accordign topic: •Biography •Thematic •Interaction Roles in group: Monopolista, Kvaziterapeut, Agitátor, Moralista, Intelektuál, Kverulant, Agresor, Autista Group leader: aktive leader, coordinator, member of group or facilitator Developmental stages of closed group: 1.Stage of orientation and dependance 2.Stage of conflicts and confrontations 3.Stage of coherence 4.Stage of productivity 5.Final stage Rehabilitation in Psychiatry
Measures with the aim to include patient with mental disease back into everyday life
1.Psychoterapeutical-rehabilitation procedures: Art and creative activities (arttherapy, bibliotherapy, musiktherapy)
2.Rehabilitation procedures: Work and activation therapy (ergotherapy) Self-care skills training
3.Psychoeducation procedures: Psychoeducation program (PRELAPS and various modifications)
4. Other procedures: Physical activity (walks) Sociotherapeutical club Individual work with families
Rehabilitation in Psychiatry
Proces of social functioning restoration and life satisfaction of patients Professionals: • Psychiatrists • Social workers • Psychologists • Nurses and other health professionals Goal: support of symptom recovery or improvement of personal distress • Decreasing of stigmatisation and prejudice effect • Help patient with reintegration into community • Improvement of psychosocial functioning
Day-Care Center at Psychiatry Clinic and LF UNB
Programme • Psychotherapy – individual, group, psychoeducation • Activation therapy • Pharmacotherapy • Leisure-time activities
Time-frame • maximum 3 months – covered by insurance
Indications • Schizophrenia spectrum disorders • Affective disorders Psychotherapeutical approaches used at PK LF UK a UNB
Forms of group therapy:
• Social and cognitive training (Metacognitive training)
• Social skills training (Integrated Psychotherapeutical program IPT)
• Communication and assertiveness training
• Therapeutic community – features of cognitive- behavioral psychotherapy and supportive psychotherapy
• Individual interview with pacient in supportive psychotherapy
• Relaxation and autogene training
Psychoeducation – definition and goals
Education Program = is a kind of psychotherapeutical treatmetn, similar to racional psychotherapy, oriented on the patient and his family.
Psychoeducation goals:
1. To extend knowledge of psychiatric patient about his psychic disorder
2. Better understanding of disease, insight, warning signs of relaps, better compliance on treatment.
3. Important is also education of relatives.
Psychosis treatment must be complex. One part of complex treatment is education programme. Education is not a single procedure, it is a process.
Psychoeducation Effect Mechanisms
• Education mechanism itself
• Improvement of communication and cooperation of pacient (family) on treatment with doctor (medical stuff)
• More active involvement of pacient (family) into treatment
• Decreasing of Expressed Emotions intensity in the family
• Insight creation and maintenance in patient
• Interpersonal learning (pacient, family)
• Emotional support (pacient, family) Psychoeducation Group - Management
1. Skilled and trained trainer (doctor, psychologist, nurse) 2. Information visualisation 3. Appropriate amount of information /not to overwhealm patiensts/ 4. Adujst topics to needs and requirements of patients 5. Allow patients to express their opinions - discusion 6. Evaluation, and support of adaptive attitudes, opinion and behavior 7. Time manatement of discussion 8. Add new knowledge and experience to the programm 9. Regular check if patients understood information 10. Appropriate timing of training for patient (after successful treatment of acute psychotic symptoms)
Psychoeducation program - Topics
Number of sessions: 8 -10 •Psychic hygiene Time: 60 min Frequency: 2 x week • Healthy lifestyle
Topics: •Activity planning and their importance •What is psychosis? in the afternoon and evenings and at the weekends (including particular plans) •Causes, symptoms, forms, course •Treatment: pharmacology, non- pharmacological and therapeutical • Effective Leasure TimeTraining approaches •What are affective disorders? Causes, symptoms, course, dif. Dg., •Social Skills Training (return to treatment school/work, looking for new job, how to talk about feelings, how to react to •Therapeutical approaches in queastions at consultative committee, stabilized phase ....). •Relaps prevention
Metacognitive Training
• Groups • Time frame: 45 – 60 min • Number of therapists – 1 to 2 • Indications: psychotic disorders and depression • Structure – materials availabe in Slovak translation • Focused on cognitive processes and distortions – memory, attention, emotions, social cognition and how these processes influence everyday life • Based on KBT principles • Activisation of patients – tasks at the training, homeworks Social Skills Training
• Basic assertiveness – positive – compliments, affection expression, asking for favor, empatic listening
• Negative assertiveness – refusal, persistence, critics acceptance, constructive critics, conflict solving
• Communication skills – iniciate, lead, conclude
Relaxation, Autogene training, Breathing Exercises • Psychophysiological integrity (body and mind)
• Tension and relaxation in muscles influences psychic – and other way round
• Methods of relaxation, calming down, reduction of anxiet, stress, anger and pain
• Education about hyperventilation
• Slow and calm breathing training
• Autogene training (Schulz)
• Jacobson progressive relaxation (changing muscle tension and relaxation)
Autogene Training
Basic • Weight • Warm • Calm breathing • Warmth in abdomen • Calm breathing • Cold foreheado
Advanced /colour imagination, object imagination, abstrack values, journey on the sea bottom, journey to the mountain top, free imaginations/ Art and Creative Techniques
• Bibliotherapy
• Ergotherapy
• Musiktherapy
• Arttherapy
Work with families
• Improvement of communication between patient and his family • Reduce Expressed emotions in families • Psychoeducation of family (symptoms, disease course, warning signs, medication, communication, regime and structure) • It helps to improve cooperation of family on the treatment • Destigmatisation of family • Emotional support for families • Counselling in problem solving for families
Bibliotherapy
Forms:
• Reading of poetry (well-known authors) • Reading of stories of well – known authors (novels, fairy tales, myths) • Articles in magazines (i.e. Slovak history, ...)
• Patients reproduce the read texts • Patients formulate main idea and topic of the story • Patients finish partly read text • Patients write their own stories and present them Music Therapy
Passive (receptive): • Listening to various music • Theory background of therapist, comments • Emotions facilitation Feelings representation – drawing, movements,... • Abreaction, relaxation or stimulation (according to chosen music) Music: For relaxation (i.e. organ concerts of J.S. Bach,F.J. Haydn, A. Vivaldi, esoteric music, ...) For stumuation (i.e.. Symphonies of W.A. Mozart, J. Brahms, A. Dvořák, P.I. Čajkovskij, F. Chopen, operas of G. Verdi, G. Rossini, G. Puccini, etc.) For fun – country, folk music, ... For physical activation – (Zumba)
Music Therapy
Active: • Feelings expression by playing musical instruments (guitar, harmonica, piano) • Playing musical instruments, improvisation • To create new song, to interpret a known song • Groups, individual work Art Therapy
Receptive art therapy
Goals:
• Perceiving of artworks (painting, sculpture, etc.) – chosen by therapist with a particular purpose or chosen by patients
• Training of sensitivity in perceiving artwork
• Improvement in recognition of other person feelings (artist, other patients)
• Improvement in ability to verbalize own feelings, to formulate own opinions, ability to accept different opinions
• Concentration training
• Inner tension release
• „Tools“ – books with artworks
Art Therapy
Productive Art Therapy
Individual goals: • therapeutical relationsip • to recognize own posibilities, improvement of selfexpression • improvement of own creativeness and spontaneity, activation • „channelling“ of emotions(abreaction) • to work through relevant personal topics, to increase selfawareness • to get recognition, appreciacion, new leisure activities • relaxation
Group goals: • to improve social contact, cooperation and communication • reflexion of own functioning in group • Corrective experience, emotional support • support of responsibility for collective work • New experience with others – that they might have similar experience
Ergo Therapy
= work with paper, wood, fabric, strings, wires, shells, stones, dried flowers, cley, straw, .... Goals:
• To activate • to improve abilities of planning, realisation and organisation of work • To train everyday or specific skills • To obtain new practical skills
• To support concentration and tenacity • To improve communication skills
• To improve selfesteem • To distruct attention from disease Sociotherapeutical Club
• Meetings of present and alumni Day-Care-Center patients • 1x week in Day-Care-Center • program is prepared by patients • Refreshment (small) prepared by present pacients
Goals: • To continue resocialisation program • Emotional support and corrective experience • To share advice and experience (alumni patients) • To decrease risk of social isolation • early revealing of disease relaps in alumni pacients and medication adjustment • New friendships, mutual help, leisure time together, ...
Any Questions?
Examples of patients arts and crafts in Day-Care Center