Guest Lecture at the Institute of Psychiatry

August 2016

The Institute of Psychiatry, Benazir Bhutto Hospital, in continuation of its academic legacy, hosted a seminar on the theme “An Overview of Psychotherapies; Principles of Cognitive-Behavioral Therapies,” in August 2016. Dr. Bashir Ahmad, Assistant Professor of Psychiatry at the Khyber Teaching Hospital conducted the seminar. In attendance were consultants, residents & house officers from psychiatry and neurology, and psychologists.
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Opening Session

Why learning therapies is important?

The proceedings ensued with Prof. Fareed A. Minhas, Professor of Psychiatry and Head of the Institute, introducing the subject and the respected speaker. He said that extending these opportunities to trainees in the Institute was in fulfillment of his responsibilities as the head. However, he added, the burden of trainees all over Pakistan is upon his shoulders as dean of faculty of psychiatry, at CPSP. He expressed his concerns for the dearth of psychiatrists in the country and the need for more trainee induction, enhancing supervisory skills, and improving patient care. I realize, he said, professionals have inadequate knowledge of psychotherapies and we do not appreciate their due importance. This idea struck me, Prof. Fareed said, when I saw my trainees lacking in these areas. In addition, the psychologists that are interns here at the Institute, are also part of the responsibility on my shoulders, he added. 

"I realize professionals have inadequate knowledge of psychotherapies and we do not appreciate their due importance."

Sharing his thoughts, he further said that I envision for my trainees all over Pakistan to be cognizant of the basic nuts and bolts of psychotherapies and beyond that is in the interest of all trainees themselves. Inspired by the principles of task-sharing and task-shifting we realize, he said, that nothing experienced consultants can do that can’t be transferred to the future psychiatrists and psychologists of the country. He informed the audience of the collaborative efforts of the Institute of Psychiatry with the WHO that seeks to extend Problem Management Plus Training throughout the country for disaster-struck areas. He introduced Dr. Bashir and emphasized that people sitting in Punjab can’t comprehend the strength of the trainees and trainers in KPK. He shared his vision of grooming younger supervisors through such sessions.

Host

Professor Farid Aslam Minhas

Professor of Psychiatry, Head, Institute of Psychiatry, Director, WHO Collaborating Centre, Benazir Bhutto Hospital, Murree Road, Rawalpindi, Pakistan. Dean, Faculty of Psychiatry, College of Physicians, and Surgeons Pakistan.
prof-farid-aslam-minhas

Context

Introduction to psychotherapies

Introduction to therapies

Dr. Bashir expressed his gratitude to Prof. Fareed for the opportunity to present the subject before budding mental health professionals. The topic, he said, is beyond one workshop. He informed the audience that the respected host has invited him to orient the trainees around the areas of psychotherapy stipulated in the CPSP syllabus for FCPS training. This presentation, he said, should benefit psychologists in attendance as well.

He began his presentation with the format of his presentation, explaining that he will focus on the basics of psychodynamic psychotherapies and cognitive behavior therapies. He lamented the usual muddled practice of psychotherapists, where the “therapists” are unaware of the foundational concepts. The college requires the FCPS trainees to be aware of psychodynamic, behavioral, and cognitive-behavioral therapies, he said. The syllabus, he commented, covers all the basics that a trainee should know.

Psychotherapy is the development of a trusting relationship leading to free communication and leads to understanding, integration, and acceptance of self. He then described the need for psychotherapies. In some psychiatric ailments like minor depression & phobias, psychotherapies are the first line of treatments. Even in illnesses where pharmacological interventions are primary, psychotherapies help prevent relapse. Psychotherapies, in view of the evidence, combined with pharmacological interventions are much more effective than either medications or psychotherapies alone. There will be 35-40% of depressive patients who will not respond to pharmacological interventions. Some patients will prefer to abstain from pharmacological treatments and choose psychotherapies because of personal reasons.

Psychoanalysis

Founded by Sigmund Freud, the aim of psychoanalysis is to release repressed emotions and experiences and make the unconscious conscious; allowing the patient to deal with the conflicts. The downside of this method is the long duration of sessions: spread across 5 days per week, and the overall therapy may extend over the years. Others have developed various shorter versions, including brief psychoanalysis, and a combination of cognitive and psychoanalytic therapy known as CAT (cognitive analytical therapy). Psychoanalysis uses inkblots, slips of tongues, free associations, dreams interpretations, resistance, and transference and countertransference.

Rorschach inkblot, Dr. Bashir said, is a projective test that is an ambiguous inkblot the interpretation of which depicts the unconscious processes within the interpreter’s mind. Freud would be very particular to what we would consider an accidental slip of the tongue, he considered everything to be determined and thus thought that the unconscious was seeking expression through these slips; they may be unintentional for the conscious mind but are intended by the unconscious mind. Free associations are immediate responses to a list of words leading to an interpretation of the unconscious. The royal road to the unconscious was the dreams of the individual as understood by Freud, dream interpretation is the formal term. 

The royal road to the unconscious was the dreams of the individual as understood by Freud.

Wherever there would be an uncooperative behavior in the patient’s narration of his thoughts, Freud would consider that this is an area of importance that deserves to be stressed and was labeled as resistance. Transference would be feelings, whether positive or negative, that a patient develops towards the therapist, then that would be an opportunity for the therapist to resolve conflicts of childhood that could not be resolved earlier. Countertransference, in which the feelings of the therapist are evoked towards the patient, can also help us understand the behavior and the unconscious processes of the patient and thus to help them better. This triggered a fruitful discussion regarding the implication of these phenomena which Dr. Bashir concluded with the recommendation that in CBT practice focus on these phenomena is not encouraging and that Carl Rogers dismissed countertransference as when it develops it is indicative that the therapist requires more training and supervision. One of the greatest objections to psychoanalysis is the subjectivity in interpreting these phenomena, resulting in people relegating this as an unscientific modality.

Carl Rogers dismissed countertransference as when it develops, it is indicative that the therapist requires more training and supervision.  

Cognitive and Behavior Therapies 

In the 1930s in London, learning principles were first employed for phobias. BF Skinner strongly contributed to Behavior Therapies by elucidating the concept of operant conditioning. Aaron Beck noted recurring themes in the thinking patterns of depressed patients and realized that they need to be changed for any progress in their treatment. This led to the development of a cognitive approach in psychotherapies. Beck developed Rational-Emotive Therapy. Cognitive approaches integrate with behavioral therapies to produce cognitive behavior therapy. CBT has the strongest evidence base of all the psychotherapies. In developed countries, mental health institutes are sure to have cognitive behavior therapy facilities for their patients. Within further types are RCBT, DBT, and mindfulness-based cognitive behavior therapy.

Cognitive approaches integrate with behavioral therapies to produce cognitive behavior therapy. This therapy has the strongest evidence base of all the psychotherapies, further types are RCBT, DBT, and mindfulness-based cognitive behavior therapy.

CBT presupposes that individuals' feel and behave influenced the structure of their experiences. When you talk about CBT, it must be evidence-based and reality-based. We can’t paint an optimistic picture for the patient that contradicts his objective reality. Those thoughts which are assumed and are not based, after a critical incident, we may challenge with reality testing or a behavioral experiment and corrected leading to an improvement in symptoms. If the patient’s assumptions prove true following the reality testing then, therapists prepare the patient for the catastrophic reaction and explore alternative options.

The Six Principles of Cognitive Behavior Therapy

Professor. Bashir enlisted six universally agreed, core principles of cognitive behavior therapy, acknowledging subtle differences among sources.

  • Principle-1: Alliance requiring

    It expects a solid therapeutic alliance with the patient, and so we exclude those who cannot take part in meaningful communication, for example, those in a state of delirium, and severe psychosis.

  • Principle-2: Participation-dependent

    Talk therapy is a misnomer when people use it for cognitive behavior therapy—it works if the patient enacts towards the goals.

  • Principle-3 Goal Oriented

    It is a goal-oriented and problem-focused therapy—we list short-, medium-, and long-term goals at the outset, review progress at set intervals

  • Time-framed, Current

    It focuses on current problems and is time-framed.

  • Principle-5: Evolving

    The cognitive formulation of patients’ problems and an individual formulation of each patient in cognitive terms is ever-evolving.

  • Principle-6: Educative

    The therapy is educative; it teaches the patient to be his own therapist, empowering them to take control over their lives.

Beck's Cognitive Triad

Aron Beck proposed the cognitive triad of depression in 1979, including a negative view of the self, the world, and the future. It leads to cognitive distortions and systemic biases in thinking.

  • The Self

    "Nobody appreciates me,", "I am a failure,", "I am worthless"

  • The World

    "The world is dangerous," "it is indifferent," "it is full of callous," etc.

  • The Future

    "I hope no improvement," "I will always stay sick,", etc.

Cognitive restructuring

He said that the critical incident is written down at the outset. The therapist proposes the patient document the associated emotions with that situation and rates those emotions. We then ask them to write the immediate thoughts related to this situation, and then to elucidate how much the patient believes this to be true. We then ask the patient to write about the evidence to support this thought. Once this is established, we encourage the patient to assume that the original thought is incorrect and open them up to alternative patterns. We then ask them to rate these alternative thoughts and alternative evidence thereof. We then make them compare the two lists and now produce a more neutral or balanced thought. This is followed by them rating their emotions again. This 5–10-minute exercise engages them in critical thinking; you can see the significant changes in their level of distress, he said.

Closing the Session

With that Dr. Bashir concluded his presentation with an announcement that Group CBT service is being offered in Khyber Teaching Hospital psychiatry and that an accredited 6-month CBT certification will start from Jan 1st, 2017 affiliated with Khyber Medical University. 

Prof. Fareed concluded with a review of the importance of the psychotherapies and yet the lack of understanding among the mental health professionals. He thanked Dr. Bashir and invited everyone for tea. 

Report by: Dr. Yousaf Raza, Post-Graduate Resident, Institute of Psychiatry, BBH. I have reviewed and enhanced the above lesson for reading enhancement. 

Guest Scholar

Institute of psychiatry and World Health Organization Collaboration Center

Professor

Bashir Ahmad

MBBS, FCPS (Psych) Chair, Psychiatry Department & CBT Program Director, Khyber Teaching Hospital Peshawar. Vice-President, Pakistan Psychiatric Society.

Certificate Course in CBT

Applications are open for the certificate course in CBT

Applications are invited for the third batch of certificate course in cognitive behavior therapy from Khyber Medical University with Prof. Bashir Ahmad.
Learn more