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Learning About Psychotherapies    

Summary: By the end of your rotation we'll invite you to watch recorded therapy sessions and indicate, with examples, which of the following were being used, so make time to study these as you go.         

And here's another reason to learn about psychotherapy, sorry to report:  the incidence of depression during internship is 25%, according to one study.Sen   So learning about cognitive-behavioral therapy by actually doing it -- online, on your own, during this rotation -- might have some personal as well as academic benefits.


Good GEW: Genuineness, Empathy, and Warmth
Imagine the context: in 1940-1950, when the world of academic psychiatry was dominated by psychoanalytically trained Freudian physicians.  Attention was directed to doing the technique right more than examining patients' outcomes. Enter BF Skinner: forget your theories, he says; you can only measure inputs and outputs, all the rest is a "black box".  With rats and pigeons he shows the value of scientific rigor studying behavior. 

In that context arrives Carl Rogers. This is not a history lesson, mind you. This is to help you appreciate the leap Rogers engineered, which you will see in the following videotape. Dr. Rogers demonstrated, first in his own clinical work and later in multiple research studies (with Charles Truax) the importance of three factors in psychotherapy outcomes: right, good GEW per the acronym above. 

(If for some reason someone wants a reference for Truax's work, it is referenced and reviewed in this summary of the controversy -- now largely over -- about the large body of work produced by Rogers, Truax and their associates). 

Enough. Just watch. The man. http://www.youtube.com/watch?v=m30jsZx_Ngs 

You should see elements of this technique when you watch anyone doing psychotherapy. You will certainly see it when you watch the Health Psychologists interview patients. Many have argued that GEW is the essential ingredient in nearly all forms of psychotherapy.  Think of it as the 80% ingredient you must not ruin as you mix in another 20% of some "technique" such as those listed below. 

Cognitive-Behavioral
The simplest way to learn this one  is to do it. Go to the Australian national program called Mood Gym, and choose either the depression-focused program there or their new anxiety focused program (whichever you think you might be more prone to, for example). The latter, called E-Couch, has an unfortunate name and unfortunate graphics. The program itself is much more sophisticated than  these would suggest. 

Make up a name for your log-in  -- one that you might remember 2 years from now -- and work your way through the program while you're on this rotation. Remember, you'll be asked to view a tape at the end of the rotation and identify these techniques or their absence. 

Motivational Interviewing
How do you help a person who's not interested in changing a health-related behavior?  (e.g. cigarettes, alcohol use, exercise, diet, glucose monitoring) Or who isn't apparently interested in following your recommendations?

A technique for helping move people from "pre-contemplation" to "contemplation" has been very well researched. This "motivational interviewing" relies on two core principles and one maxim:

    A. Assume ambivalence -- almost everyone has at least a sliver of awareness of why it would be a good idea to change (alcohol, cigarettes, food, exercise, etc). That's what you want to elicit.

    B. People learn what they believe by listening to themselves talk.  So if you can elicit "change talk" and reinforce that, you can move them, at least a little bit, out of their ambivalence and toward the behavior you'd like to see them pursue.

    C. The Maxim: "roll with resistance."  Research suggests that it's much more effective to work around resistance you encounter than to "confront it" head on.

Here's a quick webinar on this technique. We strongly recommend (just short of require) reading Motivational Interviewing in Health Care to really get familiar with this technique during this rotation. We have some copies to check out.  

Again, remember that at the end of this rotation you'll watch recorded psychotherapy sessions and will identify whether this technique is in use, or not. 

Behavioral Activation 
BAT is one of the simplest psychotherapies and yet clearly more effective than a waiting list control condition in randomized trials; and one of the key ingredients in primary care psychotherapy. For a simple description and all the relevant handouts you would use to assist in Behavioral Activation, read page 266 and following -- page 12 of this pdf:  http://web.utk.edu/~dhopko/BATDmanual.pdf  

Psychodynamic Psychotherapy

For board study, familiarize yourself with a standard list of "Freudian Defenses" or forms of "Resistance".  ( Some of thes are clinically useful too... ) For example, here's a good one: http://psychcentral.com/lib/15-common-defense-mechanisms/0001251  

But how to really understand psychodynamic therapy? There are so many myths to disassemble. Yet it is one of the most useful tools in our collection. If you're particularly interested in it, talk to your supervisor about how to learn more. 

In general, as one of my teachers taught years ago, psychodynamic approaches look for something in the patient's behaviors or emotions that really stick out beyond the norm: "too much, too little, too early, too late, wrong place, wrong time, wrong person."  Then explore it. The goal is not to directly change it. The goal is to illuminate it.  

It's like turning up the lights in the living room: once you can see the tables and chairs, maybe you don't have to bump straight into them anymore. This is "developing insight". That includes, especially,  insight into the characteristic defenses one uses to avoid dealing with problems. Usually the defenses are causing the problem that brings the patient into treatment in the first place. For example, a patient might have experienced a significant loss as a child, and have barricaded the pain of that loss away using intellectualization: "it's okay, she suffered, it was best that she died quickly" -- said with a notable lack of evidence for actually feeling the pain that one might expect a person to feel in relating such a story.   

The goal in therapy is identify characteristic defenses, then to exploring the basis for needing such defenses in the first place. But defenses are like timbers in the basement, holding up the floor; better have some other means of supporting the structure, like a solid trust in the therapist, before pulling on those timbers. 

One of my favorite books on this is called Understanding Psychotherapy, by Basch. But there are many others.

JP