Indications and Contraindications of Psychotherapy, Selection and

Acceptance of clients for Psychotherapy

What is Psychotherapy?
 “Psychotherapy is an interpersonal process designed to bring about
modifications of feelings, cognitions, attitudes, and behavior which
have proven troublesome to the person seeking help from a trained
professional.”
 Psychotherapy is a “process recurring between two (or more)
individuals in which one (the therapist), by virtue of his position and
training, seeks systematically to apply psychological knowledge and
interventions in an attempt to understand, influence, and ultimately
modify the psychic experience, mental function and behavior of the
other (the patient).”
Indications and Contraindications
1. Psychoanalytic Therapy
2. Supportive Therapy
3. Group Therapy
4. Cognitive Behavioral Therapy
5. Marital Therapy
6. Existential Psychotherapy
7. Family Therapy
Psychoanalytic Psychotherapy
 Psychoanalysis is a theory of human emotional development-based
observations and treatment for emotional illness. Psychoanalysis and
psychoanalytic therapy are talking treatments in which a person’s
psychology is explored in order to help the person master emotional
conflicts.
 Psychoanalysis is based on the concept of unconscious mental
representations that are built up from childhood. These mental
representations of self and others include intense and conflicted emotions.
 The goal is the relief of mental symptoms and life stalemates through
understanding the contributing conflicted emotional forces involved.
The objective is a shift in the compromises of those forces so that
 symptoms ease, psychological development renews, and life growth
progresses.
Indications
 Psychoanalysis is particularly indicated for personality disorders
because the illness affects almost all areas of interpersonal functioning
and requires a model relationship to use as an example. The doctor–
patient relationship in the psychoanalytic setting becomes that model.
 Patients with neurotic symptoms and personality problems have their
cognitive and emotional control functions intact. They are therefore able
to understand and use a psychological treatment to gain conscious insight
into the emotional forces at work in their problems.
Contraindications
 The major contraindications for psychoanalytic treatment are, therefore,
patients who have severe cognitive–integrative function disorders,
patients who have extreme emotional control disorders, and patients
whose reality testing is gone or severely limited.
 Of particular concern are those with emotional discontrol problems
because they respond to intense emotion with disruptive actions or
worsening emotional states
 Relative contraindications are those patients who are not psychologically
minded, or cannot use metaphor and meaning to generalize and
apply to specific symptoms and concrete behavioral actions.
2. Supportive Therapy
 The objective in supportive therapy is to bring the patient to an emotional
equilibrium as rapidly as possible, with amelioration of symptoms, so that
the patient can function at approximately his or her norm.
 An effort is made to strengthen existing defenses as well as to elaborate
better “mechanisms of control.”
Indications
 These indications for supportive psychotherapy conceptually fall into two
groups, which are not really discrete: 1) crisis, which includes acute
illnesses that emerge with the overwhelming of the patient’s defenses in
the context of intense physical or psychological stress; and 2) chronic
 illness with concomitant impairment of adaptive skills and psychological
functions.
 Persons in whom crisis is an indication for supportive psychotherapy are
relatively well-functioning and well-adapted individuals who have
become symptomatic in the context of acute, overwhelming, or unusual
stress
 these individuals have good reality testing, a capacity to tolerate and
contain affects and impulses, good object relations, a capacity to form
a working alliance, and some capacity for introspection.
 Compared with individuals in crisis, individuals who must cope with
chronic mental illness are more traditionally associated with supportive
psychotherapy and are more likely to entail longer-term therapy.
 patients who have moderate to severe personality disorders and whose
idiosyncratic interpersonal style, adaptive skills, and ego deficits are
chronic, pervasive, and maladaptive
Contraindications
 supportive psychotherapy is unlikely to be effective in delirium states,
other organic mental disorders, drug intoxication, and later stages of
dementia.
 Help-rejecting complainers, because they are wedded to the victim role
and are not invested in becoming more adaptive, do not make good use of
supportive interventions but rather become worse as they confirm that the
goodwill and concrete advice of the therapist are not useful.
 Con artists and others who lie or malinger as a matter of course do as
poorly in this treatment.
 Psychopathic individuals, who establish a pattern of pseudo mutuality in
the therapeutic relationship, either quickly understand the lack of
opportunity for real gratification and so drop out of treatment, or become
focused on attempting to use the relationship to inappropriately gratify
real or imagined needs.
3. Group Therapy
 Group psychotherapy is widely used as an intensive treatment modality to
address psychological issues especially those involving unsatisfactory
interpersonal patterns. Group therapy is also used in a more structured
manner to address negative cognitions, to learn skills such as
 assertiveness, and for psycho educational purposes. This wide range of
group applications involves the use of groups that are conducted in quite
different ways.
Indications
 Group psychotherapy is most beneficial for persons having narcissistic
personality features
 And/or lacking in social skills, as well as for adolescents.
Contraindications
 Persons presenting with marked depression, strong suicidal potential,
or acute crisis situations are not considered suitable group members.
 Those having strong paranoid propensities and low tolerance for
anxiety and frustration are also considered inappropriate.
4. Cognitive Behavioural Therapy
 Cognitive behavior therapy (CBT) incorporates principles associated
with information-processing and learning theories.
 A basic assumption of CBT is the recognition that there is a reciprocal
relationship between clients’ cognitive processes (what they think) and
their affect (emotional experience), physiology, and behavior.
 Emphasize the importance of changing cognitions and behaviors as a way
of reducing symptoms and improving the functioning of the affected
person.
Indications
 Clients who are ready to work collaboratively, to actively seek out new
experiences and learn to look at the world in new ways.
 Clients must be willing to commit time and effort to their treatment
 expected to work on their own in between sessions (e.g. Homework)
Contraindications
• CBT is generally not indicated for people with thought disorders
• CBT is also not indicated for people with organic brain disorders or for
people who do not have a good grasp of the language in which
therapy is being conducted
 • clients who are very wedded to a particular theoretical or therapeutic
approach and who are not willing to consider alternative perspectives
might not do well in CBT
• clients who are so impaired that they are unable to actively engage in
treatment might not be good candidates for CBT until they experience
some symptom relief from other approaches (e.g., medication).
5. Marital Therapy
 Marital therapy is a well-known and empirically validated psycho
educational approach to the assessment and treatment of marital distress.
 Various types of Marital therapy are- behavioral marital therapy, insight
focused marital therapy, emotion focused marital therapy.
Indications
 It is most appropriately considered when couple distress is the primary
problem or when certain non relationship factors have caused
significant relationship distress, and the couple, as a unit, needs
therapeutic attention.
 When the partners possess the abilities to collaborate toward mutual
objectives of change, to offer support and accommodation to one another
while addressing the problems at hand, and, when necessary, to
compromise with one another in resolving their defined problems.
Contraindications
 When the couple’s level of relationship distress is very high, one or
both partners’ commitment to the marriage is low, the issues in conflict
are unlikely to change, the couple is invested in maintaining
traditional sex roles, or the couple is unable or unwilling to
collaborate, accommodate, or compromise with one another.
 In these cases, while couple therapy may be indicated, an approach less
focused on behavior change probably would be more effective (e.g.,
integrative behavioral couple therapy, emotion-focused couple therapy,
insight-oriented couple therapy).
 If either partner’s level of individual psychopathology is too severe to be
managed or treated in conjoint therapy, alternative treatments should be
considered (e.g., hospital inpatient milieu, individual or group
psychotherapy, and/or pharmacotherapy).
  Cases featuring domestic violence and including individuals with ASPD
often are not appropriate.
 active psychoses, disabling disorders of depression, anxiety, or
substance abuse.
6. Existential Psychotherapy
 Martin Heidegger, provided alternative formulations of the nature of man
which seemed to provide what was missing in psychoanalysis, namely, an
approach and set of concepts for thinking about clinical work which
allowed therapists to understand therapeutic processes more immediately
and accurately, and to relate to patients as they really were.
 4 important concepts:
Being-in-the-world
Existence
Being-with
Authenticity and falling
Indications
 Historically, existential therapy was developed in work with psychotic
patients. Binswanger, Minkowski, and Boss, in their seminal
descriptions of existential work, presented patients who suffered from
persistent and very troubling delusions and hallucinations.
 Yalom wide variety of patients who were not psychotic, but who suffered
from severe feelings of isolation, loss of meaning, impairments of the
will, or confrontation with death.
Contraindications
 Patients who may be unable to tolerate strong feelings toward the
therapist—for example, individuals who tend to escalate their hopes and
expectations for help and care from the therapist, or who become
excessively angry when such expectations are disappointed— may find
existential approaches counter therapeutic.
7. Family Therapy
 Family therapy is a perspective of interpreting and modifying behavior.
 Although implementation varies, the multiple methods of doing family
therapy derive from a single assumption: Presenting problems originate
from inadequate, inappropriate, or dysfunctional interpersonal
 relationships, and therefore should be subsequently altered using
techniques that in some manner modify interpersonal relationships.
Indications
 Family therapy does not attempt to modify a person but rather the
behaviors exhibited by a system, it is generally applicable to most of
the problems seen by mental health practitioners. With children and
adolescents, it has been applied to problems ranging from conduct
disorder to anxiety and depression.
 In adults, it has been applied to relationship problems, as an adjunct to
the treatment for schizophrenia, depression and anxiety, modifying
family reactions to medical illness, and drug and alcohol abuse.
Contraindications
 Severe psychosis or intense individual psychopathology of one of the
family members.
Selecting and Acceptance of clients for Psychotherapy
 Planning and assigning a patient to a treatment that optimizes gains and
fits the patient’s needs is a shared objective among clinicians.
 Three types of psychotherapies:
a. Supportive Psychotherapy
b. Reeducative Psychotherapy
c. Reconstructive Psychotherapy
1. Supportive Psychotherapy
 Supportive measures may be utilized as the principal treatment or as
adjuncts to Reeducative or reconstructive psychotherapy. They are
employed as:
 1. A short-term exigency or expedient for basically sound personality
structures, momentarily submerged by transient pressures that the
individual cannot handle.
 2. A primary long-term means of keeping chronically sick patients in
homeostasis. 3. A way of “ego building” to encourage a dedication to
more reintegrative psychotherapeutic tasks.
  4. A temporary expedient during insight therapy when anxiety becomes
too strong for existing coping capacities.
 Supportive therapy does not work in many cases where the problems with
authority are so severe that the patient automatically goes into
competition with the helping individual, depreciating, seeking to control,
acting aggressive and hostile, detaching himself or herself, or becoming
inordinately helpless. These reactions, appearing during therapy, may act
as insurmountable resistances to the acceptance of even supportive help.
 Therapies with designations of “palliative psychotherapy,” “social
therapy,” “situational therapy,” and “milieu therapy” fall into the
supportive category.
 Among procedures employed in supportive therapy are guidance, tension
control and release, environmental manipulation, externalization of
interests, reassurance, prestige suggestion, pressure and coercion,
persuasion, and inspirational group therapy.
2. Reeducative Psychotherapy
 The relationship between patient and therapist in reeducative therapy has
as its object the achievement of more extensive goals than in supportive
therapy.
 There is less emphasis on searching for causes than on promoting new
and better forms of behavior. It is posited that individuals with help from
a therapist have within themselves the ability to reorganize their values
and behavioral patterns.
 The objective in reeducative therapy, thus, is the modification of behavior
directly through positive and negative reinforcers, and/or interpersonal
relationships, with deliberate efforts at environmental readjustment, goal
modification, liberation of existing creative potentialities, and, it is hoped,
promotion of greater self-growth. No deliberate attempt is made to probe
for unconscious conflict.
 A fundamental assumption in reeducative therapy is that if one succeeds
in altering a significant pattern in one’s life, the restored sense of mastery
will generalize over a broad spectrum of behavior.
 Among reeducative therapeutic measures are “behavior therapy,”
therapeutic counseling, directive psychotherapy, casework therapy,
“relationship therapy,” “attitude therapy,” distributive analysis and
 synthesis, interview psychotherapy, semantic therapy, reeducative group
therapy, and certain philosophical approaches.
3. Reconstructive Psychotherapy
 An ultimate goal of psychotherapy is to reduce the force of irrational
impulses and strivings and bring them under control, to increase the
repertoire of defenses and make them more flexible, and to lessen the
severity of the conscience, altering value systems so as to enable the
patients to adapt to reality and their inner need.
 There are four main “types” of insight therapy with reconstructive goals:
(1) “Freudian psychoanalysis,” (2) “ego analysis,” (3) “non-Freudian” or
“neo-Freudian psychoanalysis,” and (4) “psychoanalytically oriented
psychotherapy.
Selecting and Acceptance of clients for Psychotherapy
 There are other different ways to identify and select a particular treatment
course.
 Rational approaches rely on the particular formulations of each clinician
and are largely based on theoretical posture and personal experience.
 Alternatively, empirically supported treatments favor diagnosis-
specific interventions, chosen from a selection of name-brand approaches
that have been proven to be more effective than no- or usual treatment in
at least two randomized studies.
 This approach falls prey to a tendency to ignore both individual patient
variations and the importance of contextual and participant factors
beyond therapy brand and patient diagnosis.
 A third method, Systematic Treatment Selection (STS), articulates
treatment selection as a process that focuses on the identification and
application of guiding principles, as opposed to broad theoretical models,
that have been found to be related to the efficacy of each unique patient-
therapist dyad.
 These principles are drawn from research findings on the roles of
treatment contexts, interventions, and participant factors, and incorporate
contributors to an optimal ‘‘fit’’ beyond those found in the brand of
treatment and the diagnosis of the patient. The contemporary approach
that best represents this method of assigning treatment is Systematic
Treatment Selection.
  In other words, STS provides the clinician with a set of empirically
informed guidelines about using different psychotherapeutic strategies
depending on a patient’s proclivities, needs, and overall profile
characteristics.
 The principles that constitute STS are themselves drawn from research on
three domains or classes of variables that mediate or moderate change:
participant factors, interventions, and relationship qualities.
STS
 Systematic Treatment Selection (STS) is an example of an EST.
 STS research rejects the categorization of participants based on diagnosis;
instead favoring a formulation that emphasizes the fit of the patient and
the treatment within the context of individual factors that impact the
efficacy of psychotherapy.
 The methodology of STS was developed by the application of Aptitude
Treatment Interaction (ATI) research designs which center on identifying
client variables that mediate (i.e., facilitate) and moderate (i.e.,
differentially facilitate) the effects of interventions.
 The STS principles which are encompassed in identifying the optimal
‘‘FIT’’ of treatment for a particular patient, is highly dependent upon
having a reliable and valid measure of: a) the patient’s standing on the
critical dimensions that mediate or moderate treatment, b) the active
ingredients of the treatment as it is applied, and 3) outcome.
 Achieving the measurement tools required, proceeded in four steps, each
one of which was linked closely to the derivation of factors that constitute
Optimal Fit and Meaningful Change.
Step #1: Identifying patient factors that mediate change
 The first step in deriving measures was to identify client factors that
predict change (Mediators).
 Beutler consolidated the research findings into four major clusters of
clients’ traits which correlated with change: 1) functional impairment
(i.e., co-morbidity, chronicity, social support, and symptom intensity); 2)
coping styles-preferred response to change/stress (i.e., externalizing
patterns and internalizing patterns); 3) trait-like resistance from
avoidance to reactance; and 4) subjective distress.
  Castonguay , added four more client factors from extant research. These
included stage of readiness for change, preferences for ‘‘type’’ of
therapist, demographic variables (e.g., age, education, culture, gender
etc), and symptom groupings (i.e., dysphoria, anxiety, substance use and
personality).
Step #2: Identifying corresponding treatment factors
 The second step in the process of developing the STS system was to
identify common and specific characteristics of treatment whose effects
are moderated by patient qualities.
 The initial research identified six major dimensions which comprised the
profiles or patterns by which treatments could be identified. These
dimensions included: 1) intensity (duration, frequency); 2) format
(multi-person vs individual); 3) treatment mode (pharmacology,
psychosocial, community); 4) focus (insight/awareness vs symptom-
oriented); 5) therapist directiveness (directive vs evocative); and6)
means of affective regulation (affect control vs affect
discharge/cathartic).
Step#3: Finalization of clinically useful measures
 1) therapist style (from directive to evocative);
 2) facilitating change through insight/awareness,
 3) facilitating direct symptom change;
 4) therapist skillfulness; and
 5) inducing emotional arousal to support.
Step #4: Validation of treatment predictors using converging methods
 In order to achieve the aim of identifying particular patient factors that
predict change, STS researchers have conducted multiple comprehensive
reviews of outcome literature on Major Depression, Anxiety Disorder,
and Chemical Abuse, with the hope of finding cross-theory and cross-
population predictors of change.
 Many new variables have been incorporated into the algorithms that
comprise the STS assessment and treatment planning system.
 The inclusive nature of the STS system ensures that it remains up to date.
  The core or original concepts of matching and the principles deriving
from these concepts have been widely supported in individual studies
(Castonguay & Beutler, 2006) as well as meta-analyses (Norcross, 2011).
 Researchers have also conducted a series of independent studies,
constituting over 100 research papers and books, using a variety of
different methodologies.
References
 Wolberg L.R., 2013. Techniques of Psychotherapy (4th edition).
 Michel Hersen & William Sledge. Encyclopaedia of Psychotherapy.
 Larry E. Beutler ∗, Kathleen Someah, Satoko Kimpara, Kimberley Miller,
2015. Selecting the most appropriate treatment for each patient. Palo Alto
University, USA.
 Horwitz, L. (1976). Indications and contraindications for group
psychotherapy. Bulletin of the Menninger Clinic, 40 (5), 505- 507
 Winston Arnold et al.2004. Introduction to supportive psychotherapy.