List the Practical Arrangements in psychotherapy.

Practical arrangements in psychotherapy refer to the logistical and organizational aspects that help create a structured and effective therapeutic environment. These arrangements are crucial to setting clear boundaries and expectations for both the therapist and the client. Key elements include:

Scheduling: The frequency and duration of sessions are established, typically 50-60 minutes for individual therapy, and agreed upon to ensure consistency.

Location: Sessions may be conducted in a therapist's office, via teletherapy, or in some cases, home visits. The setting should ensure privacy and confidentiality.

Fees and Payment: The cost of therapy is discussed upfront, including payment methods, any insurance coverage, and cancellation policies. Sliding scales may be offered based on a client's financial situation.

Confidentiality: The therapist explains confidentiality rules, including limits where disclosure might be legally required (e.g., harm to self or others).

Record-Keeping: Therapists maintain records of sessions, treatment plans, and progress, often with the client’s consent.

Duration of Therapy: Goals and the anticipated length of therapy are discussed, particularly for brief therapy models like cognitive-behavioral therapy (CBT), which is typically short-term and goal-oriented.

Boundaries: Professional boundaries regarding contact outside of sessions, such as via phone or email, are clarified.

1. List the Practical Arrangements and Important Don'ts's in Psychotherapy and Counselling Presented By- Vismaya Sajeevan (R3)

2. The Initial Interview: Making Practical Arrangements for Psychotherapy. Choose therapist: Select an appropriate therapist. Type of therapy: Decide on the suitable type of therapy. Frequency of visits: Determine how often sessions will be. Duration of therapy: Estimate how long therapy will take. Arrange fee: Agree on the cost of therapy. Handle delays: Plan for any delays before starting treatment. Finalize details: Make final arrangements or refer to another therapist if needed.

3. Choice of Therapist . 1. Therapist's evaluation and compatibility - Assess if the therapist can handle the patient's problem based on training, skills, and emotional response. - Consider interest in the problem and ability to make time and financial arrangements. - Take into account the patient’s wishes. 2. Therapist’s training and skills - Transfer the patient if the therapist is not trained in the needed therapeutic approach (e.g., psychoanalysis, ECT, hypnotherapy). 3. Therapist's preferences: - Some therapists prefer not to handle certain types of patients (e.g., adolescents, borderline cases, addicts).

4. Choice of Therapist 4. Therapist’s sex and age - Therapist’s personality and skill are more important than sex. - Patient’s past experiences with parental figures can influence the preferred sex of the therapist. - Some patients prefer older therapists for perceived greater experience.

5. Choice of Treatment Method and (Treatment Planning). 1. Treatment planning involves considering: - Immediate and ultimate goals - Patient's motivations - Patient's intellectual and personality assets - Existing diagnosis - Therapist’s flexibility, sophistication, and theoretical biases 3. Patient’s desire for quick relief 4. Therapist’s responsibility 5. Types of therapy based on patient history

6. Choosing the Proper Therapeutic Approach.

7. Choice of Categories of Therapy

8. Supportive Therapy Those who would benefit most from supportive therapy fall into seven categories: 1. Patients in states of acute anxiety or depression or with severe disabling psychosomatic symptoms. 2. Schizophrenics showing disintegrative tendencies. 3. Patients with good ego strength who have recently become ill, aiming for restoration to previous adaptive level. 4. Patients with problems where a perverse environmental disturbance is the main stress source. 5. Patients with severe character problems, including obstinate dependency and immaturity. 6. Patients with severe obsessive-compulsive reactions. 7. Patients with especially obdurate habit disorders, alcoholism, and drug addiction.

9. Reeducative Therapy - Benefits patients with personality problems affecting work, educational, marital, interpersonal, and social adjustment. - Particularly effective for patients with fairly good ego strength. Reconstructive Therapy - Suitable for problems caused by severe distortions in past relationships with parents and significant others. - Effective for difficulties where repression is the main defense. Applicable to anxiety disorders, phobic disorders, conversion disorders, some obsessive-compulsive disorders, some personality disorders, and certain somatoform disorders in individuals with good ego strength. Shifting therapy

10. Therapeutic Approaches in Different Syndromes. - Systems Approach: - Considers interrelated units (biochemical, neurophysiological, developmental, conditioned, interpersonal, social, intrapsychic, and philosophical-spiritual). - Effective help involves diagnosing implicated links and targeting treatment toward them. Motivation and Therapeutic Focus: - Assess which link systems the patient is ready to address and which can be changed. - Some systems may be harder to alter and require more extensive therapy. - Choose a link that is more amenable to influence, and work on motivating the patient to address the most significant link involved in their illness.

11. Syndrome Therapeutic Approaches Affective Disorders Major Depressive Disorder: Tricyclic antidepressants, Electroconvulsive Therapy (ECT) Atypical Depression: Monoamine Oxidase (MAO) inhibitors Bipolar Disorder: Lithium Dysthymic Disorder: Psychosocial therapy, MAO inhibitors, Xanax (alprazolam) Alcoholism Inspirational groups (Alcoholics Anonymous), Antabuse Anxiety Disorder Anxiolytics (Valium, Xanax) Attention Deficit Disorder Stimulants (Ritalin, Dexedrine) Conduct Disorder in Children Family therapy, Behavior therapy Dissociative Disorder Hypnosis, Psychoanalytic therapy Educational Problems Counseling , Guidance Enuresis Behavior therapy (reconditioning) Family Problems Family therapy, Group approaches, Hypnosis, Behavior therapy Habit Disorders Group therapy, Behavioral therapy, Hypnotic therapy

12. Marital Problems Couples therapy, Marital therapy Obsessive-Compulsive Disorder Behavior therapy, Antidepressants (Clomipramine) Opiate Addiction Methadone, Inspirational groups (Narcotics Anonymous) Panic Disorder Antidepressants, Behavior therapy Personality Disorder Psychoanalytic therapy, Group therapy, Cognitive therapy Phobic Disorder Behavior therapy—In-vivo desensitization (flooding) Psychosexual Dysfunctions Sex therapy Schizophrenic Disorder Neuroleptics, Rehabilitative therapy, Day hospital care Sleep Walking Hypnosis, Psychoanalytic therapy Somatoform (Psychosomatic) Disorder Relaxation therapy (biofeedback, relaxation hypnosis, meditation) Speech Disorders Speech therapy, Behavior therapy Substance Abuse Inspirational groups (e.g., Narcotics Anonymous) Tension States Relaxation therapy (hypnosis, biofeedback, meditation) Vocational Problems Counseling , Guidance

13. Therapeutic Approach .

14. Therapeutic Approach Description Guidance Educational and vocational problems when treatment goals are abbreviated. Environmental manipulation Financial, housing, recreational, marital, and family problems when goals are abbreviated. Externalization of interests Detached and introspective patients when goals are abbreviated. Reassurance Patients who require rectification primarily of misconceptions related to heredity, physical illness, sexual functions, mental illness. Prestige suggestion and prestige hypnosis Habit disorders such as nail-biting, insomnia, overeating, inordinate smoking; hysterical paralysis, aphonia, and sensory disorders when symptom removal is the only goal in therapy. Pressure and coercion Patients who act out or endanger themselves or others in situations when the treatment goal is limited.

15. Persuasion Obsessive-compulsive personalities when no extensive treatment goal is intended. Emotional catharsis and desensitization Patients who have gone through traumatic experiences that have caused them guilt, fear, or suffering and who have not allowed themselves to emote sufficiently. Muscular relaxation (biofeedback, autogenic training, meditation) Tension states and psychosomatic muscular conditions when an adjunctive palliative approach is indicated. Convulsive therapy Major and bipolar depressions; insulin shock in early schizophrenia; subcoma insulin treatment in severe acute anxiety states, toxic confusional conditions, and delirium tremens. Drug therapy Used in schizophrenia (neuroleptics); depression, bulimia, panic states (antidepressants); anxiety (anti-anxiety agents); tension and insomnia (benzodiazepine hypnotics); alcoholism (Antabuse); and attention deficit disorders (energizing agents).

16. Brain surgery Restricted to patients with severe disabling schizophrenia, chronic disabling obsessive-compulsive neurosis, and hypochondriasis who have not responded to any drug therapy, psychotherapy, or convulsive therapy. Inspirational group therapy Dependent and immature personalities, drug addicts, and chronic alcoholics who need social contacts and benevolent parental figures to help them function. “Relationship therapy” Personality disorders in which distorted attitudes and values are prominent. “Attitude therapy” Personality disorders in which there are cognitive distortions. Interview psychotherapy Various syndromes. Nondirective or “client- centered " therapy Patients with relatively sound personality structures who require help in clarifying their ideas about a current life difficulty or situational impasse. Directive counseling Patients with personality problems who require a forceful parental figure to goad them to activity. Behavior therapy Phobias, habit disorders, obsessive-compulsive disorders; conduct disorders; lack of assertiveness. Semantic therapy Personality problems in patients whose difficulties in communication constitute a primary focus. Reeducative group therapy Patients with some degree of insight into their problems who need emotional catharsis and the experience of interacting with others while learning

17. Freudian psychoanalysis Personality disorders, anxiety disorders, phobic disorders, conversion disorders, obsessive-compulsive disorders, and some somatoform disorders (psychophysiologic reactions) in patients who have good ego strength, are motivated, reach for reconstructive objectives, and are able to establish and tolerate a transference neurosis. Non-Freudian psychoanalysis Personality problems are particularly helped, but other syndromes may be treatable. Psychoanalytically oriented psychotherapy and transactional analysis Various syndromes. Hypnosis Stress disorders, anxiety disorders, phobic disorders, conversion disorders, habit disorders, some types of alcoholism, antisocial personality, and somatoform disorders (psychophysiologic reactions). Narcotherapy Severe stress disorders, anxiety disorders, phobic disorders, and some somatoform disorders and conversion disorders. Sex therapy Sexual disorders.

18. Art therapy As an adjunct in reconstructive therapy when the patient is capable of symbolizing problems in art productions. Play therapy As an adjunct in reconstructive therapy with children. Group therapy Personality problems, preferably in conjunction with individual therapy. Couples therapy Marital problems. Cognitive therapy Depressions, some obsessive-compulsive disorders, adjustment problems brought about by faulty self-statements, values, and beliefs.

19. Treatment Manuals Treatment manuals have been created to standardize psychotherapy, especially for research. Notable examples include Beck et al. (1978) on cognitive behavior therapy, Klerman et al. (1982) on short-term interpersonal psychotherapy, and Strupp & Binder (1984) on time-limited dynamic psychotherapy. These manuals help ensure therapists follow prescribed treatments and allow for better observation of therapeutic practices

20. Challenges 1. Therapists may not always do what they say they do, and their actual practices can deviate from the prescribed treatment. 2. Treatment manuals can be used against therapists in lawsuits, highlighting any deviations from the prescribed methods. 3. No two therapists are exactly alike, even if trained in the same way. Psychotherapy is an art, and therapists' personalities and styles affect their practice. 4. Strict adherence to a manual can limit a therapist's spontaneity and effectiveness, potentially hindering the therapy process.

21. Frequency of Visits The frequency of therapy sessions depends on the patient's needs, practical considerations, and their response to therapy.

22. Rules for the frequency of sessions. Rules for Frequency of Sessions: 1) 1-2 Sessions Weekly: Suitable for most supportive and reeducative therapy. Applicable in many forms of psychoanalytically oriented psychotherapy. Recommended for dependent, infantile patients to prevent hostile, dependent relationships. Advisable when avoiding a transference neurosis. For patients who substitute transference reactions for real-life experiences. For patients who are not severely disturbed and can manage responsibilities and interpersonal relationships. 2)Three to Five Times Weekly: Common in formal Freudian psychoanalysis, with five visits weekly being the norm. This frequency helps establish a transference neurosis, which is crucial for therapy.

23. 2) 3-5 Sessions Weekly: Necessary for Freudian and non-Freudian psychoanalysis, especially when a transference neurosis is desired. Indicated for patients experiencing severe adaptational collapse, such as acute anxiety, depression, psychosomatic symptoms, and ego disintegration. Required for patients with rigid character structures needing a concentrated attack on their defenses. Needed for patients with low motivation for psychotherapy, requiring consistent demonstration of therapy's value. For patients who are intensely hostile or have a weak superego, requiring constant authority to check impulses.

24. Estimating the duration of therapy.

25. General Guidelines for the duration of Therapy. Short-Term Therapy: Effective when the patient has a history of good adjustment prior to the current issue and if the problem is relatively recent. Short-term therapy is often sufficient for symptom relief. Long-Term Therapy: Necessary for patients with a long history of maladjustment or complex conditions, such as borderline schizophrenia or dependent personality disorders. Therapy for these patients may extend to five years or more.Some individuals may need a supportive therapeutic relationship for life.

26. Arranging the Fee Discuss Finances Early Assess Financial Capability Sliding Scale Fees Broken sessions Missed Sessions

27. Delays in starting therapy Lack of Time: Postpone therapy if there’s no immediate need and no available time for the therapist. Urgent Situations: Start therapy immediately if urgent, or refer the patient to a therapist with availability. Avoid Blind Referrals: Ensure the patient isn’t left searching for other therapists without guidance.

28. Final Arrangements Appointment Details: Sessions start and end on time, typically last 45 minutes. Billing is monthly; fees are communicated in advance. Missed Appointments: Notify at least 24 hours in advance to avoid charges. Some therapists charge for missed sessions without notice, while others are more flexible. Payment Policies: Explain fee policies clearly to avoid misunderstandings. Payment can be per visit or monthly. Session Length: Average duration is 45 minutes to 1 hour

29. Referring the Patient

30. Reasons for Referral: No available time or scheduling conflicts. Therapist feels they cannot work effectively with the patient. Patient needs a different type of therapy or a different therapist based on sex, age, race, or orientation. Patient cannot afford the fee. Therapist’s Fit: The therapist may not be suited for the patient’s specific problems or therapy needs. Referrals are made when another therapist’s expertise is better suited. Communicating the Referral: Explain the referral positively, ensuring it’s not perceived as rejection. Highlight the benefits of the new therapist’s expertise.

31. Handling Immediate Needs: If the therapist is unavailable, suggest immediate referrals to other professionals. Financial Considerations: Refer to low-cost clinics or psychotherapeutic centers if finances are an issue. Patient's Comfort: Emphasize the importance of a good therapeutic relationship. Encourage open communication about feelings towards the new therapist. Offer to help find another therapist if needed.

32. Anticipating Emergencies and other difficulties.

33. Advance Planning: Prepare for potential emergencies based on the patient's condition. Common Emergencies: Alcoholics may require hospitalization. Drug addicts need observation for relapse. Psychopathic personalities may face legal issues. Seriously depressed patients are suicide risks. Patients with previous psychotic breaks may relapse. Patients with sexual perversions may face legal and interpersonal conflicts Predicting Symptom Relapses: Patients with anxiety, phobic, or obsessional reactions may experience bouts of anxious emotions. Psychosomatic patients may have recurring symptoms. Patient Preparation: Inform patients early in therapy about the possibility of symptom relapse to mitigate its impact on their faith in therapy. .

34. Essential Correspondence

35. Referral Letter: Write a brief, courteous letter to the individual or agency that referred the patient. Avoid discussing too many case details or tentative dynamics. Mention the disposition of the patient. Include a diagnosis only if the referral source is a physician. Example: To a social agency. Dear [Name], I have seen Mr. [Name], whom you referred to me for consultation, and find him to be suffering from an emotional problem for which psychotherapy is indicated. I believe he would do best with an analytically trained therapist and consequently have referred Mr. [Name] to Dr. [Name], who has been able to make time available for him at a fee satisfactory to Mr. [Name]. Mr. [Name] responded well to the consultation, and there was no reluctance in accepting the referral to Dr. [Name]. I should like to thank you for sending Mr. [Name] to me. Sincerely yours,

36. Sample letter to a physician. Dear Dr. [Name], I have seen Mr. [Name] in consultation and agree with you that a strong emotional element is involved in his present somatic complaint. I believe psychotherapy is definitely indicated; however, I am not, at the present time, able to prognosticate the outcome due to the incomplete motivation that exists for treatment. Mr. [Name] responded satisfactorily to the interview and expressed a willingness to start therapy with me. I should like to thank you for the referral. Sincerely yours,

37. Requesting Additional Information: Correspondence may be required to obtain further information about the patient from former therapists, clinical psychologists, physicians, or institutions where the patient was hospitalized. A "release" form signed by the patient is usually required when requesting such information.

38. ( Wolberg , 2013)

39. The Initial Interview: Important "Don'ts" during the Initial Interview

40. 1) Do not argue with, minimize, or challenge the patient. “Understandably you may feel this way, but there may also be other ways of looking at this situation.” “I do not yet know enough about the problem to make positive statements.”

41. 2) Do not praise the patient or give false reassurance

42. 3)Do not make false promises.

43. 4)Do not interpret or speculate on the dynamics of the patient’s problem. “It will be necessary to find out more about the problem before I can offer you a really valid opinion of it.”

44. 5)Do not offer a diagnosis even if the patient insists on it.

45. 6) Do not question the patient on sensitive areas of life

46. 7) Do not put the patient on a couch for the initial interview

47. 8)Do not try to “sell” the patient on accepting treatment.

48. 9) Do not join in attacks the patient launches on parents, mate, friends, or associates. “A remark like that would be disturbing to you,” or “This situation must have upset you,” or “Actions of this sort can be disturbing to a person.”

49. 10)Do not participate in criticism of another therapist

50. MCQ What should be explained to the patient during the initial interview? A) The history of psychotherapy B) The therapist's personal life C) The problem and potential benefits of therapy D) The cost of therapy

51. MCQ What should be explained to the patient during the initial interview? A) The history of psychotherapy B) The therapist's personal life C) The problem and potential benefits of therapy D) The cost of therapy

52. When choosing a therapist, which factor is NOT considered essential? A) Therapist's training and skills B) Therapist's ability to make time and financial arrangements C) Therapist's favorite hobbies D) Patient's wishes and compatibility with the therapist

53. When choosing a therapist, which factor is NOT considered essential? A) Therapist's training and skills B) Therapist's ability to make time and financial arrangements C) Therapist's favorite hobbies D) Patient's wishes and compatibility with the therapist

54. What is a crucial aspect of patient-therapist compatibility? A) Similar hobbies B) Emotional response between the patient and therapist C) The same age D) Matching educational backgrounds

55. What is a crucial aspect of patient-therapist compatibility? A) Similar hobbies B) Emotional response between the patient and therapis t C) The same age D) Matching educational backgrounds

56. Which type of therapy is suggested for patients seeking quick relief from symptoms? A) Psychoanalysis B) Supportive therapy C) Reconstructive therapy D) Group therapy

57. Which type of therapy is suggested for patients seeking quick relief from symptoms? A) Psychoanalysis B) Supportive therapy C) Reconstructive therapy D) Group therapy

58. THANK YOU!