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