COUNSELING TYPES

William T. Garrison,PhD
BASICS
DESCRIPTION
• Psychotherapeutic and counseling interventions play
an important role in the
management of chronic and acute-onset diseases and
disorders. They are
typically the primary initial mode of evaluation and/or
treatment for most mild
to moderate psychiatric disorders that reach criteria using
the DSM-5 (1) or
ICD-10 (2) diagnostic classification systems. It shouldbe
noted that the DSM
system has recently been revised with significantchanges
in several disorder
categories and their criteria. Treatment and successful
control of either
medical or psychological conditions require some form of
professional
counseling experience. Best outcomes occur when they are
employed by a
skilled practitioner. However, psychotherapy differs from generic
counseling,
which can take many forms and is delivered commonly in
nonmedical
settings, with mixed results.
• Counseling approaches areusually tailored to the
specific presenting problem
or issue and serve educational and emotional support
functions. Typically,
such counseling in medical settings willbe time-limited and
problem-focused
and often not intended to lead to major medical symptom
relief or major
behavioral changes.
• The goals of psychotherapy range from increasing
individual psychological
insightand motivation for change to reduction of
interpersonal conflict in the
marriage or family, reduction of chronic or acute emotional
suffering, and
reversal of dysfunctional or habitual behaviors. There are
several general
types of psychotherapy, starting with individual,marital, or
family
approaches. In addition, a number of psychological theories
guide various
methods and treatment philosophies. The following is a brief
overview of
commonly used psychotherapeutic and counseling
methods.
• Psychodynamic therapy: Unconscious conflict manifests
as patient’s
symptoms/problem behaviors:
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– Short-term (4 to 6 months) and long-term (=1year)
– Focus is on increasing insightof underlying conflict
or processes to initiate
symptomatic change.
– Therapist actively helps patient identify patterns of
behavior stemming
from existence of an unconscious conflict or motivations that
may not be
accurately perceived.
• Cognitive-behavioral therapy (CBT):Patterns of thoughts
and behaviors can
lead to development and/or maintenance of symptoms. Thought
patterns may
not accurately reflect reality and may lead to psychological
distress:
– Therapy aims at modifying thought patterns by
increasing cognitive
flexibility and changing dysfunctional behavioral patterns.
– Encourages patient self-monitoring of symptoms and
the precursors or
resultsof maladaptive behavior
– Uses therapist-assisted challenges to patient’s basic
beliefs/assumptions
– May use exposure, a procedure derived from basic
learning theories, which
encourages gradual steps toward change.
– Can be offered in group or individual formats
– Therapist’s role is suggestive and supportive.
• Dialectical behavior therapy (DBT):Techniques such
as social skills training,
mindfulness, and problem solving areused to modulate
impulse control and
affect management:
– Derivativeof CBT
– Originally used in treatment of patients with self-
destructive behaviors
(e.g., cutting, suicide attempts)
– Seeks to change rigid patterns of cognitions and
behaviors that have been
maladaptive
– Uses both individual and group treatment modalities
– Therapist takes an active role in interpretation and
support.
• Interpersonal psychotherapy: Interpersonal relationships in a
patient’s life are
linked to symptoms. Therapy seeks to alleviate symptoms
and improve social
adjustment through exploration of patient’s relationships and
experiences.
Focus is on one of four potential problem areas:
– Grief
– Interpersonal role disputes
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– Role transitions
– Interpersonal deficits: Therapist works with the patient in
resolving the
problematic interpersonal issues to facilitate change in
symptoms.
• Familytherapy: focuses on the family as a unit of
intervention
– Uses psychoeducation to increase patient’s and
family’s insight
– Teaches communication and problem-solving skills
• Motivational interviewing: focuses on motivation as a
key to successful
change process
– Short-term and problem-focused
– Focuses on identifying discrepancies between goals
and behavior
– “5 A’s” model is a brief counseling framework
developed specifically for
physicians to effect behavioral change in patients:
Assess for a problem.
Advise making a change.
Agree on action to be taken.
Assist with self-care support to make the change.
Arrange follow-up to support the change.
• Counseling (heterogeneous treatment)
– Often focuses on situational factors maintaining
symptoms
– Often encourages the use of community resources
• Behavioral therapy: relatively nontheoretical approach to
behavioral change or
symptom reduction/eradication through application of
principles of stimulus
and response
Pediatric Considerations
• Important distinctions aremade between psychotherapy
and counseling for
children/teens comparedto adults/couples.
• The focus of evaluation must include attention to
parent and family processes
and factors. Interventions typically include interactions and
sessions with
parents as well as collateral work with teachers and other
school personnel.
• Younger children willoften be evaluated and diagnosed
through behavioral
descriptions provided by parents and other adults who know
them well as well
as through direct observation and/or play techniques. Children
of all ages
shouldbe screened using behavioral checklists that arenorm-
referenced for
age.
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• Any child or teenager who requests counseling
shouldbe interviewed initially
by the primary care provider and referred appropriately.
Most referrals willbe
in response to parental request, however.
• Psychotherapeutic interventions with the strongest
empirical basis with
children include behavior therapy/modification, CBT, and
family/parenting
therapy. Play therapy has the least empirical support, and
insight-oriented
therapies appear to be more effective with older children
(>11 years).
• There is controversy regarding the efficacy of
psychopharmacologic treatment
in preadolescents, although clear benefits have been
demonstrated in some
studies. Treatment guidelines for mild to moderate
depressed mood and/or
anxiety disorders typically recommend pediatric CBT initially,
and studies
have typically supportedthis approach in preteen and
milder cases.
EPIDEMIOLOGY
• ~18.8 million adults suffer from clinical depression, and
20 million suffer
from a diagnosable anxiety disorder.
• One in four Americans report seeking some form of
mental health treatment in
their adult life. This includes generic counseling in
nonmedical settings such
as work, clergy,or school settings and also includes visits to
primary care
providers. It is estimated that between 3.5% and 5%of
adults in the United
States actually participate in formal mental health
psychotherapy annually.
• Public health experts report that the majority of those
adults with diagnosable
psychiatric disorders, however, do not receive professional
mental health
services. This is due to multiple factors, including failure to
identify,
noncompliance with psychiatric referral, regional shortages of
providers,
economic barriers, and excessive time duration from referral
to available
service.
• A large study conducted between 1987 and 1997
concluded that the
percentage of adults in psychotherapy remained relatively
stable over that
decade, the use of psychopharmacology doubled, and older
adults (aged 55 to
64 years) increasingly sought psychotherapy services. In that
same study, it
was found that psychotherapy duration (number of
sessions) decreased
substantially and about 1/3 of psychotherapy patients only
attended one or two
sessions.
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RISKFACTORS
The need for psychotherapy or counseling services is
directly and indirectly
associated with a host of socioeconomic and biogenetic
factors, including the
general effectsof poverty, family or marital dysfunction; life
stressors; medical
diseases or conditions; and individual biologic predisposition
to mental health
disorders.
GENERALPREVENTION
It is generally assumed that early identification and
intervention of child and
adolescent psychopathology increases the likelihood of reducing
the risk for
adult psychopathology, but this has not been sufficiently
validated in all
categories of psychological disorders. Data support such
claims in disorders such
as childhood ADHD, anxiety disorders, and habit disorders of
childhood,
however.
TREATMENT
GENERALMEASURES
There is evidence of a “dose effect” in psychotherapy
outcomes research, with
some investigators suggesting that 6 to 8 sessions are
necessary to yield positive
initial effectsand upward of 15 to 20 sessions for longer term,
sustainable
therapeutic effects. This dose effect may not be applicable
to counseling services
with primarily informational or emotional/supportive functions.
Also, long-term
therapy shouldbe evaluated at 6- to 12-month intervals to
determineefficacy.
MEDICATION
• Psychotherapy is most likely to be accompaniedby use
of pharmaceutical
adjuncts in moderate to severe cases of psychological
dysfunction that do not
respond to other therapies or in cases of extremely poor
qualityof life or high
risk. The most common examples arein cases of clinical
depression or anxiety
that clearly incapacitates the patient or significantly reduces
his or herquality
of life. Patients at risk for suicide or who represent a
danger to others arealso
candidates for acute psychopharmacotherapy. Studies suggest
that verbal and
behaviorally oriented therapies can add efficacy to
medication treatment in
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both depression and anxiety.
• There is controversy in the research field regarding the
efficacy of medication
alone versuspsychotherapy alone versuscombined treatments.
The most
recent consensus has been that combined treatments in
moderate to severe
psychological dysfunction aremost likely to render positive
short-term results
and increase the likelihood that such effectscan be
sustained over time.
ADDITIONALTHERAPIES
• Anxiety disorders
– Panic disorder with and without agoraphobia: CBT,
psychodynamic therapy
– Generalized anxiety disorder: CBT
– Obsessive-compulsive disorder: CBT
– Posttraumatic stress disorder: CBT
– Specific phobia: CBT
– Social phobia: CBT
• Mood disorders
– Unipolar depression: CBT, interpersonal therapy,
psychodynamic therapy
– Bipolar disorder: family therapy, interpersonal therapy,
CBT
– Schizophrenia: psychodynamic therapy, family therapy,
CBT
• Eating disorders
– Binge eating disorder: CBT, interpersonal therapy
– Bulimia nervosa: CBT, interpersonal therapy
• Personality disorders
– Borderline: DBT, CBT
• Substance-use disorders
– Alcohol: counseling, CBT, motivational interviewing
– Cocaine: CBT, counseling
– Heroin: CBT, counseling
– Smoking: 5 A’s
• Somatoform disorders:
– Hypochondriasis: CBT
– Body dysmorphic disorder: CBT
COMPLEMENTARY & ALTERNATIVE MEDICINE
A host of nonempirically based psychological and
nutritional therapies can be
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found outside of mainstream medicine and psychological
science. Very little or
no evidence exists to support such experimental therapies, but
all have the
considerable power of the placebo effect fuelingtheir anecdotal
supports or
claims. Placebo effectsarealso thought to be powerfully
enhanced by the use of
ingested or applied substances that create real physiologic,
although not
therapeutic, changes in the patient. If it makesthem feel
different, they aremore
likely to believe it helps.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
There is evidence of a “dose effect” in psychotherapy
outcomes research, with
some investigators suggesting that 6 to 8 sessions are
necessary to yield positive
initial effectsand upward of 15 to 20 sessions for longer term,
sustainable
therapeutic effects. This dose effect may not be applicable
to counseling services
with primarily informational or emotional/supportive functions.
Because many
patients cease attendance to psychotherapy sessions after
one or a few sessions,
most interventions of this type cannot be accurately
evaluated by the referring
provider. Long-term therapy shouldalso be evaluated for
effectiveness at regular
periods.
REFERENCES
1. American Psychiatric Association. Diagnostic and
Statistical Manual of
Mental Disorders. 5th ed. Arlington, VA: American Psychiatric
Association;
2013.
2. World Health Organization.The ICD-10 Classification of
Mental and
Behavioural Disorders: Clinical Descriptions and Diagnostic
Guidelines.
Geneva, Switzerland: World Health Organization;1992.
ADDITIONAL READING
• Bortolotti B, Menchetti M, Bellini F, et al. Psychological
interventions for
major depression in primary care: a meta-analyticreview of
randomized
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controlled trials. Gen Hosp Psychiatry. 2008;30(4):293–302.
• Eddy KT, Dutra L, Bradley R, et al. A
multidimensionalmeta-analysis of
psychotherapy and pharmacotherapy for obsessive-compulsive
disorder. Clin
Psychol Rev. 2004;24(8):1011–1030.
• Furukawa TA, Watanabe N, Churchill R. Combined
psychotherapy plus
antidepressants for panic disorder with or without
agoraphobia. Cochrane
Database Syst Rev. 2007;(1):CD004364.
• Hunot V, Churchill R, Silva de Lima M, et al.
Psychological therapies for
generalised anxiety disorder. Cochrane Database Syst Rev.
2007;
(1):CD001848.
 CODES
ICD10
• Z71.9 Counseling, unspecified
• Z71.89 Other specified counseling
• Z63.9 Problem related to primary support group,
unspecified
CLINICAL PEARLS
• Combined medication and psychotherapeutic
treatments in moderate to severe
psychological dysfunction aremost likely to render positive
short-term results
and increase the likelihood such effectscan be sustained over
time.
• Relapse is common over time and/or as treatments
arediscontinued.
• Children <10 years may benefit significantly from
counseling or
psychotherapy alone for symptom relief.
• Older children and those with more severe
symptoms typically require
psychopharmacologic options in concert with counseling
or verbal therapy
approaches