Psychodynamic Psychotherapy, Interpersonal Psychotherapy, Motivational Interviewing, & Cognitive Behavioral Therapy

Ottawa Review Course January, 2017

Paula Ravitz MD, FRCPC Associate Professor of Psychiatry, University of Toronto Mt. Sinai Hospital, Morgan Firestone Psychotherapy Chair Disclosures & Acknowledgements

• No industry relations • An IPT expert • WW Norton, “Psychotherapy Essentials to Go” (‘13,’15) • CanMAT panel, Psychological Treatments for MDD

With thanks to CanMAT, Carolynne Cooper, Mark Fefergrad, Sophie Grigoriadis, Simon Hatcher, Jon Hunter, Rex Kay, Sid Kennedy, Molyn Leszcz, Robert Maunder, Edward McAnanama, Clare Pain, Sagar Parikh, Peggy Richter, Wayne Skinner, and Priya Watson OBJECTIVES

Describe the evidence for efficacy, indications, goals, and key concepts of – Psychodynamic Psychotherapy – Cognitive Behavior Therapy – Motivational Interviewing – Interpersonal Psychotherapy

List 6 “common” psychotherapy factors that are known to enhance outcomes.

Psychotherapies are, “an integral component of psychiatric care,” and highlighted “the unique contributions psychiatrists can make when they are able to integrate psychological and biological approaches within a treatment plan.”

Chaimowitz, CPA Position Paper: The Role of Psychotherapy in Psychiatry 2004 Psychiatrists’ knowledge and skills in evidence- supported psychotherapies improve our capacities as stewards of the mental health system, medical experts, consultants, leaders of clinical service teams, shared care collaborators, and trainers of future generations of mental health professionals…to provide the best care for the most complex patients.

Psychotherapy in psychiatric care across settings from ER → in-patient med/surg (CL), psych wards → outpatient psych and primary care.

Used alone, sequenced with, or combined w/ Rx, psychotherapies are recommended for most psychiatric DOs.

Psychotherapy Outcomes Changes the mind & brain; Cost-effective

Outcomes of psychotherapy – Symptom reduction (i.e. remission of depression or panic, reduced suicide attempts) – Improved functional status, decrease lost days of disability – Improved quality of life & relationships – Changes in brain functioning • evident in anxiety, personality disorder, PTSD, and depression psychotherapy interventions

The cost of providing psychotherapy is estimated to be repaid up to twice over through reduced healthcare costs, benefits savings, and regained taxes.

Lazar, S.G., 2014; Layard & Clark, 2014: Clark 2011; Kurdyak, Newman & Segal. 2014.

Preferences & Mental Health care (MHC) Needs Counselling & Psychotherapy

Canadians (N= 25,113) ranked Type of MHC need status counselling as lowest met MHC MHC need Unmet Partially Met need in 2012 Canadian Community Mental Health Survey met % Meta-analysis of 34 studies, in Any which patients’ treatment 12.2 21.1 66.7 preferences were identified, Information 24.5 6.3 69.2 found that psychotherapy was preferred 3x > Rx, particularly in Medication 4.2 4.9 90.9 younger patients and women Counselling 19.8 15.7 64.5 Source: 2012 Canadian Community Health Survey—Mental Health Sunderland & Findlay, 2013.; McHugh et al., 2013

Moving Beyond Skepticism: Psychotherapy Works Meta-analytic findings and RCTs have established that psychotherapy works. Effect sizes are in the .70 range based on 300 studies (Roth & Fonagy ’05; Cuijpers et al. 2016)

For many mental disorders (e.g. depression, panic, borderline personality), psychotherapy is as effective as pharmacological treatments and is associated with superior relapse prevention when treatments are discontinued.

What Works for Whom? Empiric Support ►Consensus Treatment Guidelines MDD: CBT, IPT, BA, MBCT for relapse prevention, Psychodynamic, CBASP

Bipolar : combined with mood stabilizer, Family, CBT or IPSRT for relapse prevention

Eating Disorders: CBT & IPT

What Works for Whom? Empiric Support ►Consensus Treatment Guidelines ANXIETY: specific phobias, exposure; social phobia – CBT; GAD – CBT/Psychodynamic ; Panic – applied relaxation, exposure, CBT; OCD – Exposure Response Prevention

PTSD: exposure based treatments (CBT)

SUBSTANCE USE DISORDERS: 12-step Alcoholics Anonymous, & Motivational Interviewing

PERSONALITY DISORDERS: for BPD – DBT, Psychodynamic & Mentalizing Based-Treatment

SCHIZOPHRENIA/PSYCHOSIS: Family interventions, CBT NICE APA CanMAT/Canadian

*Depression √ √ √ CBT, IPT Eating DO’s √ √ - CBT, DBT, IPT Bipolar DO √ √ √ CBT , IPT, Family-focused Anxiety/Panic √ √ √ CBT, Psychodynamic PTSD CBT CBT, Psychodynamic Personality disorders - Psychodynamic, DBT (Comorbid): DBT, CBT (schema- focused), Dynamic (transference- focused), Mentalization-based Schizophrenia √ √ √ CBT, Family –focused

*To prevent depression relapse: MBCT, IPT-M Psychological Treatments for Acute Treatment of MDD (CanMAT 2016)

Psychological Treatment Recommendation Level of Evidence

Cognitive-behavioural therapy (CBT) st Interpersonal therapy (IPT) 1 LINE LEVEL 1 Behavioural activation (BA) Mindfulness-based cognitive therapy (MBCT) Cognitive-behavioural analysis system of psychotherapy (CBASP)

Problem-solving therapy (PST) 2nd LINE LEVEL 2 Short-term psychodynamic psychotherapy (STPP) Telephone-delivered CBT, IPT Internet- and computer-assisted therapy Long-term psychodynamic psychotherapy (PDT) Acceptance and commitment therapy (ACT) 3rd LINE LEVEL 3 Videoconferenced psychotherapy

Motivational interviewing (MI) 3rd LINE LEVEL 4

6. How do you choose a psychological treatment for MDD

Indications for Psychological Treatment

Considerations for psychological treatment include: – Patients’ attitudes and preferences – Quality of evidence – Risk from delay in treatment initiation – Severity of depression

Depression Severity Recommendation Severe, high-risk Start a treatment that is immediately available Consider all treatment modalities Moderate, low-risk Choice between psychological treatment and ADTs depends on patient preferences and availability Women planning May be preferentially considered for psychological pregnancy treatment Psychotic depression Pharmacotherapy with ADTs and AAPs or ECT

ADT, antidepressant; AAP, atypical antipsychotic; ECT, electroconvulsive therapy

1. When is psychological treatment indicated Predictors of Psychological Treatment Response • Equally beneficial in women and men • Suitable for all ages, levels of education and cultural/ethnic backgrounds • Equally effective for all subtypes and severity of depression • Comparable efficacy as antidepressant treatment, but slower time course of improvement • Combination with antidepressants offers more benefit than psychological treatment alone for PDD

Pharmacotherapy may be preferred as the initial treatment in severe and high-risk depression

PDD, persistent depressive disorder

2. Which individuals with depression are most likely to benefit from psychological treatment

The therapy relationship accounts for why clients improve (or fail to improve) as much as the particular treatment method

Improvement in Psychotherapy as Function of Therapeutic Factors

Norcross, 2011 Psychotherapy Relationships That Work

extratherapeutic change (40%) common factors (30%) techniques (15%)

expectancy/placebo (15%) Total Psychotherapy Outcome Variance

Norcross, 2011 Psychotherapy Relationships That Work

unexplained (40%) patient (30%) relationship (12%) method (8%) therapist (7%) Common Factor Elements

Clear differentiating features exist between specific modalities, however common factors are critically important & necessary for good clinical outcomes Therapist Factors That Improve Clinical Outcomes

Therapeutic Relationship Elements Clinical Effectiveness Level of Evidence • Alliance • Demonstrably effective • Empathy • Collecting patient feedback

• Goal consensus • Probably effective • Collaboration Level 3 • Positive regard

• Congruence/genuineness • Promising but insufficient • Repairing alliance ruptures research to judge • Managing counter-transference

Adapted with permission from Norcross (2011).

Psychological therapies for depression should be delivered by trained and proficient therapists (2nd-line recommendation / Level 3 evidence)

5. What are the key therapist factors that improve clinical outcomes Common Factors (Lambert & Oggles 04)

Support Learning Action

-Catharsis -Affective experiencing -Behaviour regulation -Mitigate Isolation -Cognitive learning -Taking risks -Therapeutic alliance -Corrective emotional experience -Mastery efforts -Reassurance -Insight -Practice -Structure -Change expectations of -Reality testing -Active co-participation personal effectiveness -Success experience

The Therapeutic Alliance

1973-2011: >200 studies (N=14,000 patients)

Positive relation between the alliance quality and diverse outcomes for psychotherapies (p<.0001) What matters most is not just how or what the treatment and therapist offers but how it is subjectively experienced by the patient. A negative therapeutic alliance can be repaired.

Horvath et al. ‘11; Safran & Muran 2000

Therapeutic Alliance (Leszcz)

Therapists’ non-defensive responses to patient negativity or hostility are critical to maintain alliance → Develop the ability to neither internalize nor to ignore patients’ negative responses.

Maintaining the alliance is a skill, central to optimize clinical outcomes.

THERAPIST CHARACTERISTICS THAT PROMOTE A STRONG ALLIANCE (NORCROSS ’11; LESZCZ ET AL ‘15)

Availability Rapport

Empathy Positive Regard

Responsiveness Genuineness

Interest Managing Strain Empathy Connected Knowing “the therapists’ sensitive ability and willingness to understand the client’s thoughts, feelings and struggles from the client’s point of view” (Rogers 80)

(from Elliot, Bohart, Watson & Greenberg, In: Psychotherapy Relationships that Work, evidence-based responsiveness. (132-152) J. Norcross. Oxford, 2011) NEUROANATOMICAL CORRELATES OF EMPATHIC PROCESSES

Beyond Macaque Monkeys’ mirror neurons (Gallese 1960)

Emotional simulation – limbic system Perspective taking – medial & ventromedial areas of PFC & temporal cortex Emotion regulation – probably in orbitofrontal, prefrontal and R inferior parietal cortex's

Decety & Icles, 09; Decety & Lamm 09, Goubert et al 09, Shamay-Tsoory 09

Association between empathy & outcomes: a meta-analysis (1961-2008) 57 psychotherapy studies (N=3,599 patients)

0.30, medium effect size, accounting for 9% of variance in therapy outcome

Moderators Therapist: non-verbal behavior, being non-judgmental, attentive, open Patient: ability and receptiveness to feel & take-in empathic expressions

Duan & Hill 96, Watson 01 Psychotherapy in Psychiatry

What therapist behaviors & techniques are effective with which patients to produce which changes?

• Psychodynamic Psychotherapy • Interpersonal Psychotherapy (IPT) • Cognitive Behavioral Therapy (CBT) • Motivational Interviewing (MI) • Multi-person Modalities: Group, Couples & Family • 3rd Wave & Dismantling of Elements: Mindfulness Based Interventions, Dialectical Behavior Therapy, Cognitive Behavioural Analysis System of Psychotherapy, Behavioral Activation, Acceptance & Commitment Therapy, Mentalization Based Treatment

The 30” elevator response: What is….

• CBT? • Psychodynamic Psychotherapy?

[Royal College requires proficiency in these 2 models of psychotherapy….a prize for volunteers willing to step up] PSYCHODYNAMIC PSYCHOTHERAPY Meta-analyses of Short-term Psychodynamic Psychotherapy Leichsenring et al (‘15) – 1970-2004; <40 sessions; treating multiple disorders (MDD, PTSD, BPD, Cluster C, somatoform pain, social phobia) – No difference between STPP & CBT Abbass et al (Cochrane Review ‘14) – 33 RCTs, CMDs, 2173 patients; greater improvement maintained in follow up in tx v. control groups – “aims to improve long- and short-term problems with emotion processing, behaviour and communication [in]relationships.”

Meta-analysis of Long-term (> 1yr) Psychodynamic Psychotherapy Leichsenring and Rabung JAMA (‘08)

23 studies (1984 to 2008) – 11 prospective RCTs and 12 observational studies – N=1053 patients receiving LTPP Large within-group effect size of 0.96 (95% confidence interval, 0.87-1.05) for pre-post- treatment overall outcomes For the 8 studies that included a comparison group, the overall between-group effect size was even larger at 1.8 (95% CI, 0.70-3.4). INDICATIONS FOR PSYCHODYNAMIC PSYCHOTHERAPY

Non-psychotic, complex, long-standing, and ‘treatment resistant’ conditions e.g. GAD, Chronic Depression, unresolved trauma, Personality DOs, multiple comorbidities

NOT the worried well (Kay, Kay & Ravitz; Doidge)

CanMAT guidelines for treatment of depression in adults lists psychodynamic therapy as a third line treatment with level 2 evidence for the treatment of acute MDD Who benefits from Psychodynamic Psychotherapy? cont. (Rex Kay) -Symptomatic, perhaps with multiple symptoms -Not actively suicidal, or with a recent history of strong suicidal ideation -Not exceedingly impulsive -Not self-harming or substance abusing -Reliably able to attend weekly therapy

Psychodynamic Psychotherapy

A therapy that involves attention to the therapist-patient interaction, with carefully timed interpretation of transference and resistance embedded in a sophisticated understanding of the patient and an appreciation of the therapist’s contribution to the two-person field. (Gunderson & Gabbard ‘08)

It is much more important to know what sort of patient has a disease, than what sort of a disease the patient has. William Osler

Theory helps us to know our patients, make sense of experience, and informs understanding, explanatory models and techniques. (Rex Kay)

Since Freud … neuroscience, infant research, philosophy of mind, feminist theory, queer theory, sociology, cognitive psychology, non-linear dynamics, evolutionary biology, political science, anthropology, Buddhism, evolutionary psychology and ethology.

PSYCHODYNAMIC PSYCHOTHERAPY

6 Key Concepts Gabbard (‘10), Shedler (‘10) & Rex Kay (‘12) 1. Much of mental life is unconscious 2. Past influences present: A Developmental View Childhood experiences interact with genetic factors to shape the adult. Trauma and neglect - sources of pathology. 3. Transference & Counter-transference (CT) • Transference to the therapist is a 1◦ source of understanding • CT provides information re: patient’s impact upon others

PSYCHODYNAMIC PSYCHOTHERAPY

Key Concepts cont. Gabbard (‘10) & Kay (‘12) 4. Defenses & Resistance “the mind will devise ways to keep unpleasant or threatening thoughts, memories, feelings desires or perceptions out of awareness…but can emerge & cause symptoms or difficulties.” (Rex Kay) 5. Psychic Determinism – Symptoms & behaviors serve multiple functions & are determined by complex & oft unconscious forces 6. Subjectivity & not really knowing ourselves – A psychodynamic therapist assists the patient through a process of focusing on inner subjective experience to achieve a sense of authenticity & uniqueness Transference & Resistance

Transference : over-reactions based on perceptions of, and responses to, a person in the here and now that reflects past feelings about, or responses to, important people earlier in one’s life, especially parents and siblings. Resistance: “patient’s attempt to protect herself or himself by avoiding the anticipated emotional discomfort that accompanies the emergence of conflictual, dangerous, or painful experiences, feelings, thoughts, memories, needs, and desires.”

COUNTERTRANSFERENCE

Freud conceptualized countertransference as the therapist’s transference. Winnicott and subsequent contemporary psychotherapy researchers (Drew Westen, Betan et al.) broadened our understanding to include appreciating “objective countertransference” – e.g. having strong feelings toward a patient that reflect what the patient may evoke in others, rather than it being a sole product of the therapist’s unconscious conflict.

Hierarchy of Defense Mechanisms (a partial list, Gabbard pgs 34-36) Ego Psychology (Anna Freud) PRIMITIVE NEUROTIC MATURE Splitting Introjection Humor Projective Identification Identification Suppression Denial Displacement Altruism Dissociation Intellectualization Anticipation – delaying Idealization Isolation of affect gratification Acting out Rationalization Somatization

PSYCHODYNAMIC PSYCHOTHERAPY Insight-oriented

• Focus on affect & expression of emotion • Focus on the individual • Boundaries & Frame: a safe & regular space & time • Explore attempts to avoid aspects of experience • Identify recurring themes & patterns • Discuss past experience • Focus on interpersonal relations • Attend to therapeutic relationship, transference/CT • Explore conflicts, wishes, dreams, & fantasies Psychodynamic/analytic Theories of Personality & Psychopathology

2-person psychology: 1-person psychology: Object Relations, Drives, Structural, Ego Self Psychology, Intersubjective, Relational A Brief History of Psychoanalysis

Relational

Attachment Theory

Self-psychology

Object Relations

Defenses/Ego

Classical/Drive A Brief History of Psychotherapy

Psychodynamic Psychotherapy (1950s-present) • aka “Psychoanalytically-oriented therapy” “Insight oriented” “Intensive” “change-oriented” • dynamic = internal conflict

http://3.bp.blogspot.com/-zNueG6dLRy8/UFSohH-jC8I/AAAAAAAACBk/e9QEFKyTl2I/s1600/Internal+Conflict.jpg A Brief History of Psychotherapy

Psychodynamic Psychotherapy (1950s-present) • people wanted shorter and less intense treatment; also psychiatrists were trained by analysts but not all became analysts

• “couch to chair”, face-to-face, 1-2x/week

• using principles from any of the schools of psychoanalysis; treatment focuses on reflecting on how early relationships influence current patterns DEVELOPMENTAL MODELS (a partial list) Freud pleasure-seeking, psychosexual energies & drives Erikson life-long stages Bowlby/Ainsworth patterns of relating, adaptive for survival

Freud’s Developmental Model Pleasure-seeking, psychosexual energies, drives from Kaplan and Sadock’s Synopsis of Psychiatry, 11th Ed. (pgs 813-815) Oral Phase (birth-18 months) Focus: oral zone. Conflict: weaning process. Outcome: trusting dependence on care-providers. Anal Phase (ages 1-3) Focus: control of bladder and bowels. Conflict: toilet training. Outcome: independence. Phallic/Oedipal/Electra Phase (ages 3-6) Focus: genitals. Conflict: boys with father; girls with mother. Outcome: gender identity; identification with parent of same-sex which initiates development of superego. Latency Phase (ages 6-puberty) Focus: Libidinal drives are suppressed during further development of superego and expansion of ego. Development of interests. Outcome: further integration of identity; skill development. Genital Phase (ages puberty-young adulthood) Focus: opposite sex. Conflict: regression to re-resolve conflicts in a more mature manner. Outcome: individuation/independence, sexual relationships.

Attachment: Bowlby

Protest ------> Despair ------> Detachment

Bowlby, J. Grief and Mourning in Infancy and Early Childhood. (1960). Psychoanalytic Study of the Child, 15:9-52. Attachment Patterns of Relating shaped by early life experiences, environment, & genetics, and influence:

• social functioning • expectations in relationships • coping & stress response • psychological well-being • morbidity and health • behavior – especially in relationships C. 2015 Attachment & Adaptation Back Stories: Experiences with 1° Care-providers Secure Good enough, mostly available & responsive Preoccupied Inconsistently available or responsive Dismissing Consistently unavailable & poorly responsive Disorganized Frightening or frightened Classifying Attachment Patterns & Dimensions (Main; Bartholomew; Mikulincer & Shaver; Maunder & Hunter; Ravitz, Maunder et al. ) • Secure • Insecure – Preoccupied, Dismissing, Disorganized/Fearful

+Sense of Self - Sense of Self

- Sense of Other Dismissing Fearful

+ Sense of Other Secure Preoccupied Attachment Avoidance Attachment

Attachment Anxiety

Adaptive, there & then Here & now, responses of others Secure Flexible→ recruits helping responses Preoccupied Dialed up → rescuing…burn out Dismissing Dialed down → ignoring, disinterest Disorganized Unpredictable → discombobulating

Using Attachment in Psychotherapy

Here-and-now clues • Reflective capacity & ability to mentalize • Narrative coherence • Affect regulation/level of arousal or emotional reactivity • Countertransference There-and-then clues • Early life relationships with primary care providers & trauma history There-and-now clues • Current relationship patterns of relating, mentalizing & interpersonal problems

Resist distancing, disempowering pulls, and be alive to transference tests, enactments and countertransference that may lead to inadvertently reinforcing of pathogenic beliefs

Leszcz, Pain, Hunter, Maunder, Ravitz 2015 An expressive-supportive continuum of interventions (Gabbard ’10 p 74; Luborsky)

Encourage to elaborate Interpret Empathically Observe Validate

Expressive……………………………...... Supportive

Confront Psycho-ed Clarify Advise Praise THE EXPRESSIVE-SUPPORTIVE CONTINUUM adapted from Psychodynamic Psychiatry in Clinical Practice, Fourth Edition (page 115) Indication for expressive or supportive emphasis Expressive Supportive Strong motivation to understand Significant ego defects of a chronic nature Significant suffering Severe life crisis Ability to regress in the service of the ego Low anxiety tolerance Tolerance for frustration Poor frustration tolerance Capacity for insight Lack of psychological mindedness Intact reality testing Poor reality testing Meaningful relationships Severely impaired relationships Good impulse control Poor impulse control Ability to maintain a job Low intelligence Capacity to think in terms of analogy and Little capacity for self-observation metaphor Reflective responses to trial interpretations Tenuous ability to form a therapeutic alliance SHORT-TERM DYNAMIC THERAPY (STDP versions by Sifneos, Malan, & Davenloo) from Kaplan and Sadock’s Comprehensive Testbook of Psychiatry, 9th Edition – enhanced activity of the therapist – therapeutic focus – time limits

“corrective emotional experience” (Alexander)

SIFNOES: SHORT-TERM ANXIETY-PROVOKING PSYCHOTHERAPY from Kaplan and Sadock’s Synopsis of Psychiatry, 11th Edition (p855)

Therapy Therapist’s Task Techniques Dose & Indications -use of positive transference -10-20 sessions -build alliance & contract re: -once weekly focus -maintain focus -work through, corrective -disorders of experience -anxiety-provoking depression, some confrontations anxiety, adjustment Malan’s Triangles… of Conflict & of Persons Others Defense (there & now)

Anxiety Impulse Therapist Parents (transference (past, here & now) there & then) DAVANLOO: STDP ‘crack the unconscious’

Therapy Therapist’s Task Techniques

-build a therapeutic alliance Central dynamic sequence -rapidly reduce resistance -access unconscious via rage, -problem inquiry -for: depression, some guilt and other patient -pressure anxiety, somatoform, feelings -challenge hypochondriasis, -increase patient awareness -access unconscious adjustment, cluster C traits -work to change the way -analyze transference & patient relates to others explore conflict -consolidate -termination

INTERPERSONAL PSYCHOTHERAPY Klerman, Weissman, Markowitz Relationships Matter – in health, illness, recovery & resilience

Vicious ‘Depressogenic’ Cycles Bi-directional Impacts

‘Others Depressed patients can Won’t Care’ Rejection from Insecure Attachment Potential unwittingly evoke Caregivers distance that can be disempowering, perpetuating isolation and despair.

Hostile, Critical, or Indirect Communication

Interpersonal Psychotherapy (IPT)

Empirically supported

Theoretically grounded

Clinically resonant, pragmatic, & effective Goals of IPT Alleviate suffering

Remit symptoms & improve functioning

Resolve current interpersonal problems

Improve communication & relationships

Foster Interpersonal Connectedness

Relationships Matter: in sickness/health, development/well-being Link symptoms to interpersonal interactions & life events.

Interpersonal Experiences

Symptoms IPT specifies elements of comprehensive psycho-social care •Clarifies precipitating Why now? problems

•Identifies useful ‘Who’ ?s social supports

Working through •Guides therapeutic problems discussions IPT: Beginning Phase Similar to what we usually do with a new patient

• Alliance & Assessment/need for Rx • Interpersonal Inventory (social history) • Psycho-educate about depression (the “sick role”), treatment goals/process • Instill hope • Collaboratively choose treatment focus

IPT: relationally focused, affectively guided *Social Roles, *Social Supports, *Communication

Grief • Bereavement

Role • Adapting to life changes Transitions

• Improve understanding & Disputes communication

Interpersonal • Decrease social isolation Sensitivity Middle Phase Strategies PAN-FOCAL FOCUS-SPECIFIC

• Recruiting Social • Losses Supports • Changes • Communication • Disagreements Analysis • Interpersonal Sensitivity • Brainstorming (default category; • Role plays insecure attachment & • Decisional Analysis unresolved trauma)

Social Roles & Role Transitions

Multiple social roles are held by us all, that inevitably change over time

Developmental, vocational, social, biological

Planned/wanted or unplanned/unwanted

“What’s changed? What do you miss?”

Validate and explore what the patient misses, or struggles with, in the context of their life change & role transition

Even changes that might be considered positive, can be associated with depression.

Reflecting on challenges & opportunities helps patients to become unstuck.

- Aspects of current role

+ Aspects of old role

… revising sense of future IPT focus on Grief is selected when…

Onset of current symptoms coincides with the death of a significant other

Sustained functional impairment & symptomatic (e.g. neglecting self-care & suicidal) The patient oft displays emotion or narrative incoherence when talking about a lost significant other

Grief

Recall sequence of events & traditional practices of bereavement

 Before, during, after the death

Reconstruct memories & emotions related to the lost other & the relationship

 Positive, idealized and negative

 anger, ambivalence, sadness, guilt, regret Role Disputes

• Non-shared expectations or values • Communication problems • Empathic failures • Differences may or may not be reconcilable

Screen for domestic violence

Disputes

1. Explore the relationship in greater depth 2. Identify core issues, expectation & values that are in disagreement 3. ‘Stage’ the dispute - Impasse, Renegotiation or Dissolution 4. Explore communication to facilitate understanding & clearer expression (?empathy ?appreciating impacts on one another)

Communication Analysis > >fact-finding, helps both mood & relationships

Explore affectively laden interchanges - feelings, expectations, understanding, (unintended) interpersonal impacts & communication (in detail)

Imaginal or real role plays can generate empathy and ideas for alternative interactions with modified understanding & expectations to improve interpersonal outcomes (and mood)

“An opportunity to engage in a healthy separation from a relationship that has usefully served its purpose” Joyce, Piper, Ogrodniczuk & Klein ‘07

TERMINATION PHASE (THE LAST 1-2 SESSIONS)

Tasks of Termination Reflect on goals, changes, and experience of treatment

Emphasize patient’s autonomous competence, their efforts & successes

Highlight social supports & confidantes

Contingency plan in the event of relapse +/- maintenance tx (once monthly)

IPT: relationally focused, affectively guided *Social Roles *Social Supports *Communication

B • The death & Grief relationship with lost e loved one E g n i d Role n • Challenges & Transitions opportunities i n n i g n • The relationship & Disputes ‘issues’ of g disagreement

IPT, CBT & Psychodynamic Psychotherapy are all affectively guided, empirically supported and share goals to reduce suffering & improve functioning. IPT v. Psychodynamic Psychotherapy focus/structure -present >> past -social roles -expectations & behaviours in relationships (such as communication) v. insights -IPT has phase & focus specific guidelines

IPT v. CBT focus/structure -interpersonal relationships v. automatic thoughts, -and CBT is highly structured (e.g. agenda setting, homework).

Motivational Interviewing Miller & Rolnick

Carolynne Cooper, MSW, RSW & Wayne Skinner, MSW, RSW

Working with Ambivalence

What we do in helping is important, but how we do it is as, or more important

Attending to the therapeutic relationship is key when working with people with complex problems

Clients with Concurrent Disorders and Substance Use disorders present for help more frequently, but are less likely to become engaged, less likely to adhere to recommendations, have poorer outcomes, and are ambivalent about making changes Motivational Interviewing

“…a way of being with people…”

“a collaborative, person-centred form of guiding to elicit and strengthen motivation…” • Miller & Rollnick, 2002, 2012 – Person-centred – Therapist –guided – Exploring ambivalence – Enhancing motivation – Working towards specific goals that lead to healthy changes

The Heart of MI

Empathy MI Spirit Partnership Acceptance Compassion Evocation MI Strategies

• Express empathy • Develop discrepancy • Roll with resistance • Support self-efficacy

MI Skills: O-A-R-S

OPEN Questions AFFIRM REFLECT SUMMARIZE COGNITIVE BEHAVIOURAL THERAPY A. BECK NICE APA CanMAT

*Depression √ √ √ CBT, IPT Eating DO’s √ √ - CBT, DBT, IPT Bipolar DO √ √ √ CBT , IPT, Family-focused Anxiety/Panic √ √ √ CBT, Psychodynamic PTSD CBT CBT, Psychodynamic Personality disorders - Psychodynamic, DBT DBT, CBT (schema-focused), Dynamic (transference-focused), Mentalization-based Schizophrenia √ √ √ CBT, Family –focused

*To prevent depression relapse: MBCT, IPT-M The Cognitive Model

Situation Core Belief Thoughts

Feelings Behaviours

From: Modulation of Cortical-Limbic Pathways in Major Depression: Treatment-Specific Effects of Cognitive Behavior Therapy

Arch Gen Psychiatry. 2004;61(1):34-41. doi:10.1001/archpsyc.61.1.34

Changes in regional glucose metabolism(fluorine-18–labeled deoxyglucose positron emission tomography) in cognitive behavior therapy (CBT) responders (top) and paroxetine responders (bottom)following treatment. Metabolic increases are shown in orange and decreases in blue. Frontal and parietal decreases and hippocampal increases are seen with CBT response. The reverse pattern is seen with paroxetine. Common to both treatments are decreases in ventral lateral prefrontal cortex. Additional unique changes are seen with each: increases in anterior cingulate and decreases in medial frontal, orbital frontal, and posterior cingulate with CBT and increases in brainstem and cerebellum and decreases in ventral subgenual cingulate,anterior insula, and thalamus with paroxetine. oF Indicates orbital frontal Brodmann area (BA) 11; vF, ventral prefrontal BA 47; Hc, hippocampus; dF,dorsolateral prefrontal BA 9/46; mF, medial frontal BA 10; pC, posterior cingulate BA 23/31; P, inferior parietal BA 40; T, inferior temporal BA 20; vC, subgenualcingulate BA 25; ins, anterior insula; and Th, thalamus. Slice location is in millimeters relative to anterior commissure. Numbers are BA designations.

Copyright © 2015 American Medical Date of download: 12/7/2015 Association. All rights reserved.

CBT

• Time limited • Collaborative empiricism • Focus on specific problems/goals • Structured, with agenda setting – Automatic Thought Records, BA, Graded Exposure • Homework Domains of Negative Beliefs

Affiliative Achievement “I am unlovable” “I am helpless”

“I am unworthy” “I am powerless”

“I am not good enough” “I am inadequate”

“I am defective” “I am vulnerable” Distilled Essence of CBT Technique Mark Fefergrad What is the patient’s most important problem to work on now? What cognitions and automatic thoughts are interfering with problem solving? What can I do to help the patient see his/her problem in a more functional way and engage in more functional behaviour? Using the Automatic Thought Record (ATR)

Identify problems and automatic thoughts on the ATR; then use: – The Downward Arrow technique – Socratic Questioning – Cognitive restructuring

In CBT for anxiety

TARGET AVOIDANCE WITH EXPOSURE & AFFECT INTOLERANCE WITH BOX BREATHING Interoceptive Exposure , to become less afraid of symptoms Fear Hierarchy, with graded exposure to help patients Box Breathing, to reduce physical symptoms of anxiety

What do you fear will happen? Automatic Thought Record

Evidence That Evidence That Alternative Automatic Supports The Doesn’t Support Balanced Situation Moods Thought Hot Thought The Hot Thought Thought Rate Mood Uncovering Emotionally-Laden Automatic Thoughts

The Downward Arrow Technique: to identify thoughts, enhance understanding

“He’s ignoring me” e.g. AT = If this was true, what would it mean? “He doesn’t like me…I’m not likeable” If this was true, what would it mean? “I’m not lovable” If this was true, what would it mean? “I’ll always be alone” CBT targets different levels of cognition 1. Automatic thoughts • “Here we go again, she is being unreasonable” 2. Assumptions/contingencies • “If I express my feelings then people will withdraw” 3. Core beliefs • “I’m unloveable” Socratic Questioning

In the best cognitive therapy there are no answers, only good questions that guide discovery of a million different individual answers.

Thoughts are not necessarily facts but fleeting ideas. There are questions that assume one truth versus questions that promote true discovery.

Simply disagreeing with a patient or trying to reassure them is unfortunately not helpful.

Cognitive Restructuring

-Operationalize the negative thought (“How do you define …?”) -Evaluate the utility/implications/advantages and disadvantages of the thought or belief -Evaluate the accuracy of the belief (evidence for and against) -Evaluate alternative ways of thinking in this situation (“What would you say to a friend?”) -Label the cognitive error (David Burns list) David Burns List of Cognitive Distortions

• All or nothing • Mental filter (dichotomous/black or • Mind reading white) • Jumping to conclusions • Catastrophizing • Over generalizing • Disqualifying the positive • Should/must statements • Emotional reasoning • Labeling • Magnifying/minimizing Effective CBT Homework

• Provide a rationale • Work collaboratively not prescriptively – Use Socratic questioning to elicit suggestions from the patient • Personalize the homework task to the patient’s abilities, needs, therapy goals, etc. (re-calibrate if necessary) • Start where the patient is not where the patient thinks he/she should be – Be specific and concrete – Where, when, with whom, for how long, etc. Activity Scheduling/Time Management

• Monitor • Deliberately plan ahead • Behavioural experiments – e.g. pleasure predicting • Cognitive rehearsal – successive steps required, anticipate potential problems, generate solutions or contingency plans A tour of evidence-supported common factors and psychotherapy models

PSYCHODYNAMICS MOTIVATIONAL INTERVIEWING

COGNITIVE INTERPERSONAL BEHAVIOR THERAPY PSYCHOTHERAPY Psychiatrists can integrate psychotherapies into mental health care to: -Improve outcomes & patients’ experiences of non-stigmatizing care -Attend to patients’ needs/preferences -Understand and formulate -Enhance repertoire of strategic & effective interventions with intentional use of common factors We shall not cease from exploration And the end of all our exploring Will be to arrive where we started And know the place for the first time…

T.S. Eliot, The Four Quartets, Little Gidding (‘42) A Partial Bibliography

Abbass,A.A., Kisely , S.R., Town, J.M., Leichsenring , F., Driessen, E., De Maat, S., Gerber,A., Dekker, J., Rabung, S., Rusalovska , S., and Crowe, E.. Short-term psychodynamic psychotherapies for common mental disorders . Cochrane Review, 2014.

Cuijpers P, Donker T, Weissman MM, Ravitz P, Cristea IA. Interpersonal psychotherapy for mental health problems: A comprehensive meta-analysis. The American Journal of Psychiatry. 2016;173(7):680-7

Gabbard, G.O. Long-term Psychodynamic Psychotherapy: A Basic Text. Washington, D.C.: APA Press; 2010. Leszcz M, Pain C, Hunter J, Maunder R, Ravitz P. Psychotherapy Essentials to Go: Achieving Psychotherapy Effectiveness. NY: WW Norton; 2015

Norcross, J.C. Ed. Psychotherapy Relationships that Work: Evidence-Based Responsiveness. 2nd Ed. NY: Oxford Press; 2011.

Parikh SV, Quilty LC, Ravitz P, Rosenbluth M, Pavlova B, Grigoriadis S, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: Section 2. Psychological treatments. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie. 2016;61(9):524-39

Sadock, B.J, Sadock, V.A., & Ruiz, P. Kaplan & Sadock’s Synopsis of Psychiatry, 11th Ed. Wolters Kluwer; 2015.

Safran, J.D. & Muran, J.C. Negotiating the Therapeutic Alliance. NY: Guilford Press; 2000.

Shedler, J. The Efficacy of Psychodynamic Psychotherapy. Am. Psychologist 65:2 (98-109) 2010.