Day # 29: Psychotherapy for Depression

In our last lesson we covered an overview of talk therapy and its' proven effectiveness. Remember that multiple meta-analyses show psychological therapies to be as effective as antidepressant medications for those with mild or moderate severity of depression. Today we are going to provide an introduction into some of the most commonly used psychotherapies.


This discussion on therapy is not designed to be a comprehensive review of psychotherapy which would take many days to cover. The purpose of this guide is to introduce you to concepts and terms associated with three commonly used therapies for depression: CBT, PDP, and IPT. Other flavors of therapy will be covered in other sections even though many of them also have benefit in depression (example: dialectical behavioral therapy will be discussed in the personality disorder section).


Today's Content Level: Beginner, Intermediate



PSYCHODYNAMIC PSYCHOTHERAPY (PDP)


Introduction

  • Psychodynamic therapy is based on the theories and techniques of Sigmund Freud and his followers.

  • Focuses on making connections between what the patient is currently experiencing and their experiences during childhood. Areas of focus include unconscious conflicts, repressed feelings, family issues from early in life, and difficulty with current relationships.


Psychoanalysis vs Psychodynamic Therapy

  • These terms are often used interchangeably because they are based on the same theories of Freud and his followers, however there are a few practical differences to understand.


Psychoanalysis

  • This is the classic caricature of Freudian psychotherapy.

  • Intensive psychotherapy which involves long-term treatment (typically > 3-5 years) and takes place several times a week.

  • During therapy the patient is on a couch and the therapist is not visible to the patient.

  • Conducted by a therapist who is a certified psychoanalyst.


Psychodynamic therapy

  • Uses the same principles of psychoanalysis and theories of how the mind works but its logistical application in therapy is a little different.

  • Intensive psychotherapy that can be either long-term or brief (as little as 15 sessions). It is most often delivered once per week.

  • Therapy is done face-to-face as opposed to psychoanalysis.

  • Conducted by a therapist who trained in psychoanalysis/psychodynamics but may not be a certified psychoanalyst.


Therapeutic techniques

  • The goal is to experience symptom relief and internal conflict by utilizing "transference"and "countertransference" as a way to interpret unconscious thoughts.

  • Transference = the patient's unconscious redirection of feelings from the past toward the therapist. Example: the patient has unconscious thoughts that his/her therapist has traits that reminds them of their strict and controlling father.

  • Countertransference = the therapist's unconscious association of feelings from the past toward the patient. Example: the therapist has unconscious thoughts that his/her patient reminds them of needy and emotional partner.

  • Free association: this is basically a technique where the patient is encouraged to say whatever the first thing is that comes to their mind in an attempt to "tap into" the unconscious mind.

  • Resistance: unconscious and conscious reasons that the patient is resistant to treatment or unwilling to discuss a particular topic in therapy.


•We will talk more about important features of psychodynamic theory during our psychological theory section. These features will include defense mechanisms, structural theory of the mind, topographical model of the mind, and much more.



COGNITIVE BEHAVIORAL THERAPY (CBT)


Introduction

  • Developed by Aaron Beck.

  • Occurs over the course of 12-20 weeks.

  • The basic idea is that our thoughts (cognitions), behaviors, and emotions are all interrelated, so that if we change one then we change the rest.

  • Evidenced based treatment for a number of disorders including major depression, bipolar depression, panic disorder, social anxiety, generalized anxiety, OCD, phobias, PTSD, eating disorders, psychotic disorders, substance abuse, and personality disorders.


Therapeutic techniques


•CBT combines cognitive therapy with behavioral therapy.


Cognitive

  • Identify and challenge their underlying "cognitive distortions" that are believed to be maintaining their symptoms of depression (or anxiety or panic or substance use etc.).

  • Therapists aim to identify automatic negative thoughts and core beliefs with the use of socratic questioning.

  • The negative thoughts triad includes themes of: 1) negative self-perception, 2) sees the world as a negative place, and 3) expectation of failure and hardship in the future.

  • Treatment involves education about their disorder and cognitive distortions, challenging their thoughts, examining the evidence for a belief, and many other techniques.

  • There are a number of different cognitive distortions and include: jumping to conclusions, overgeneralization, mental filter, discounting the positive, all-or-nothing thinking, magnification, emotional reasoning, labeling, personalization, and blaming. For additional reading on this topic: Cognitive distortions.

  • Example from Ninja PRITE: after her boyfriend breaks up with her, a patient believes nobody will ever love her (automatic negative thought). Therapist states this cognitive distortion is an “overgeneralization” and is untrue that NOBODY will ever love the patient. Then the patient works to disprove the distortion (test validity).


Behavioral

  • Identifying and removing unwanted behaviors.

  • Therapists use various behavioral techniques and "activation" to help improve the patients self-reliance and find new healthy ways to cope.

  • Patients are given homework and assigned activities to achieve goals.

  • Examples include SMART goals, activity scheduling, and graded task assignment.

  • SMART goals: specific, measurable, attainable, relevant, time-based.

  • Activity scheduling: the patient will schedule their day by the hour and they will measure their feeling of accomplishment and pleasure for all activities done during the day.

  • Graded task assignment: breaking large (seemingly overwhelming tasks) into smaller elements.



INTERPERSONAL THERAPY (IPT)


Introduction

  • Developed by Gerald Klerman.

  • Brief therapy that addresses relationships in the "here and now".

  • Typically occurs for 16-20 sessions with monthly maintenance sessions afterward as needed.

  • Primarily used to treat depression.


Therapeutic techniques

  • It is believed that negative interpersonal dynamics contribute to depressive disorders.

  • In general, the overall goal is to improve interpersonal communication, clarify feelings, and provide reassurance.

  • Common areas for intervention include discussing unresolved grief, social role disputes and transitions, and interpersonal deficits.

  • 1) Grief: assist healing from unresolved grief by facilitating the grieving process.

  • 2) Social role disputes: helps identify and make a plan of action to solve interpersonal role disputes such as conflict with family members or coworkers.

  • 3) Social role transitions: be able to mourn and accept the loss of an old role such as job loss, getting married, divorce, children moving out, etc.

  • 4) Interpersonal deficits: learn to establish healthy relationships and decrease social isolation.



CONCLUSION


I hope today's lesson provided a nice overview about different psychotherapeutic options for our patients with depression. Having read this blog post today obviously hasn't given you the tools to start these therapies with your patients but hopefully provided a framework for understanding their theory and applicability. We will discuss other psychotherapeutic techniques in later themes to include supportive psychotherapy, biofeedback, DBT, group therapy and family / couples therapy.


Resources for this post include Mass General Comprehensive Psychiatry and Kaplan and Sadock Synopsis of Psychiatry. I recommend adding at least one of these comprehensive books to your psych library.



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