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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.

Psychiatric Clinic FMCU and UHB, Bratislava

Learning objectives:

Overview of non-biological treatment methods

in psychiatry

Focus on:

Psychotherapy

Psychoeducation

Psychosocial rehabilitation

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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 a part of complex

treatment (sometimes as a 1st treatment choice)

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Necessary qualification

University degree (general medicine, psychology,

social work)

Training in psychotherapy (4-5 years). Methods, own

experience in psychotherapy, skills training, and

supervision

Continuous education and training

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Example: Depression

MODEL

Biological predisposition (congenital, gained)

Psychological factors

Social factors

BIO - PSYCHO - SOCIAL

Complex Therapy of Depression

PHARMACOTHERAPYAntidepressants

Antipsychotics

Anxiolytics, Hypnotics,

Sedatives,

Thymoprophylactics,

Augmentative therapy

PSYCHOTHERAPYSupportive

Systematic

Perceptiveness Compliance

+ Fototherapy

+ ECT

+ Sleep deprivation

+ rTMS

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Goal of psychotherapy

Supportive (basic) psychotherapy = providing

support and reduction of symptoms

Systematic psychotherapy = treatment of disease

and changes of maladaptive attitudes/behavior

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)

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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 insight into his own relationships and life

situation

and he practice new attitudes and behavior

What we Influence in Psychotherapy–

Education about Experience

SITUATION:

Thoughts: What I was thinking about?

Emotions: What did I feel?

Body reactions: How my body reacted?

Behaviour: What did I do?

Thoughts

Behavior

Body reactions

Emotions

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 a

problems of a patient

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Psychotherapy 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

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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

Adaptation problems

Neurotic disorders (enuresis, tics, pain - abdomen, head)

ADHD, agressive behaviour

Teenage age – self-esteeem, problems in relationships,

refusal, identitiy problems, anxiety, depression, self-

harm, eating disorders

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Contraindications of Psychotherapy

Disorders of consciousness

Acute states in psychiatry (acute suicidal patient,

acute psychotic state, severe depression with psychotic

signs)

Dementia, severe cognitive deficit

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Types of psychotherapy – number of

members

1. Individual psychotherapy

2. Group psychotherapy

3. Couple psychotherapy (a couple = client)

4. Family therapy

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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

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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 cohesion

Factors: membership, emotional support, helping others, self-

exploration and self-perormance, feedback, insight, corrective

experience, new behaviour pattern training, new information, new

social skills

Group Psychotherapy

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 improvement

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

• Reduction of psychopathological symptoms (training, interpersonal

conflicts solving)

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/

Group Therapy Principles

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According members: homogenous and heterogenous

According functioning: Open or closed groups

Accordign topic:

•Biography

•Thematic

•Interaction

Group leader: active 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

Types of groups

The aim is to include patient with mental disease back into everyday life

1.Psychoterapeutical-rehabilitation procedures:

Art and creative activities (arttherapy, bibliotherapy, musictherapy)

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

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 prejudices

• Help patient with reintegration back into the community

• Improvement of psychosocial functioning

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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

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Day-Care Center at Psychiatry Clinic and

LF 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

Psychotherapeutical approaches used at PK LF UK a UNB

Psychoeducation – definition and goals

Education Program = is a kind of psychotherapeutical treatment, similar to racional

psychotherapy, oriented on the patient and his family.

Psychoeducation goals:

1. To extend knowledge of psychiatric patient about his disorder

2. Better understanding of disease, insight, warning signs of relaps, better

compliance with 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.

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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 patients/

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 program

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

Time: 60 min

Frequency: 2 x week

Topics:

•What is psychosis?

•Causes, symptoms, forms, course

•Treatment: pharmacology, non-pharmacological and therapeutical approaches

•What are affective disorders?Causes, symptoms, course, dif. Dg., treatment

•Therapeutical approaches in stabilized phase

•Relaps prevention

•Psychic hygiene

• Healthy lifestyle

•Activity planning and their importance in the afternoon and evenings and at the weekends (including particular plans)

• Effective Leasure TimeTraining

•Social Skills Training (return to school/work, looking for new job, how to talk about feelings, how to react to queastions at consultative committee, ....).

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Metacognitive Training

• Group format

• 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 biases – memory,

attention, emotions, social cognition and how these

processes influence everyday life

• Based on CBT 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)

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Autogene Training

Basic• Weight

• Warm

• Calm breathing

• Warmth in abdomen

• Calm breathing

• Cold forehead

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

• Musictherapy

• 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

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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

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

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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

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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 medicationadjustment

• New friendships, mutual help, leisure time together, ...

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Any

Question?

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Examples of patient`s work

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