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Counseling Types

Basics

  • Psychotherapy and counseling are key in managing psychiatric and some medical conditions.
  • Psychotherapy differs from general counseling, often more structured and medical.
  • Counseling in medical settings is usually time-limited, problem-focused, and aims to improve coping.
  • Goals vary from insight, motivation, behavior change, to interpersonal conflict resolution.

Common Psychotherapy Approaches

Psychodynamic Therapy

  • Focus: unconscious conflicts causing symptoms.
  • Duration: short-term (4-6 months) or long-term (≥1 year).
  • Therapist helps patient identify behavior patterns linked to unconscious beliefs.

Cognitive-Behavioral Therapy (CBT)

  • Targets dysfunctional thoughts and behaviors maintaining symptoms.
  • Enhances cognitive flexibility and behavior change.
  • Uses self-monitoring, therapist-assisted challenges, and graded exposure.
  • Delivered individually or in groups; adults or children.

Dialectical Behavior Therapy (DBT)

  • Developed from CBT with focus on emotional regulation and impulse control.
  • Effective in self-destructive behaviors (cutting, suicide attempts).
  • Combines individual and group therapy.
  • Therapist actively interprets and supports.

Interpersonal Psychotherapy

  • Focuses on interpersonal relationships linked to symptoms.
  • Targets grief/loss, role disputes, transitions, interpersonal deficits.
  • Aims to improve social adjustment and reduce symptoms.

Family Therapy

  • Family unit is the treatment focus.
  • Uses psychoeducation, communication, and problem-solving skills training.

Motivational Interviewing (MI)

  • Short-term, problem-focused counseling to enhance motivation for change.
  • Used often before other therapies.
  • Uses "5 A’s" model: Assess, Advise, Agree, Assist, Arrange follow-up.

Supportive and Informational Counseling

  • Addresses situational factors maintaining symptoms.
  • Encourages use of community resources.

Behavioral Therapy

  • Applies stimulus-response principles to reduce symptoms.
  • Often preceded by motivational interviewing in behavioral/parenting therapy.

Pediatric Considerations

  • Evaluation includes parent/family processes and school personnel input.
  • Behavioral checklists norm-referenced for age/gender recommended.
  • Behavior therapy, CBT, family/parenting therapy have strongest evidence.
  • Play therapy useful for rapport and trauma in younger children.
  • Insight-oriented therapies more effective in children ≥10 years.
  • Psychopharmacology reserved for more severe cases or poor functioning.

Epidemiology

  • 19 million US adults suffer clinical depression; >20 million have anxiety disorders.
  • 1 in 4 Americans seek some mental health treatment in lifetime.
  • Only 3.5-5% receive formal psychotherapy annually; COVID-19 increased rates recently.
  • Many adults with diagnosable psychiatric disorders do not receive professional care.

Risk Factors

  • Socioeconomic stressors, family dysfunction, medical illnesses, biologic predisposition.

Prevention

  • Early identification/intervention in children/adolescents may reduce adult psychopathology risk (evidence stronger for ADHD, anxiety, habit disorders).

Treatment

General Measures

  • "Dose effect": 6-8 sessions needed for initial benefit; 15-20 sessions for sustainable change.
  • Counseling with mostly informational focus may need fewer sessions.
  • Regular evaluation for efficacy recommended.

Medication

  • Adjunctive in moderate/severe psychiatric dysfunction or suicide risk.
  • Combined psychotherapy and pharmacotherapy yields better outcomes than either alone.
  • Many patients require psychotherapy without medications.

Additional Therapies by Condition

  • Anxiety Disorders: CBT, psychodynamic therapy.
  • Panic Disorder: CBT, psychodynamic therapy.
  • Generalized Anxiety Disorder: CBT.
  • OCD: CBT.
  • PTSD: CBT, play therapy in children.
  • Phobias: CBT.
  • Mood Disorders: CBT, interpersonal therapy, psychodynamic therapy.
  • Bipolar Disorder: family therapy, interpersonal therapy, CBT/DBT.
  • Schizophrenia: psychodynamic therapy, family therapy, CBT/DBT.
  • Eating Disorders: CBT/DBT, interpersonal therapy, behavior modification.
  • Personality Disorders: DBT, CBT.
  • Substance Use Disorders: counseling, CBT, motivational interviewing.

Complementary & Alternative Medicine

  • Many nonempiric therapies exist; placebo effects significant.
  • Nutritional and psychological experimental therapies lack strong evidence.

Ongoing Care

  • Monitor attendance and effectiveness regularly.
  • Suicidal or high-risk patients require more frequent monitoring.

References

  • American Psychiatric Association. DSM-5. 5th ed. 2013.
  • Meta-analyses on psychotherapy and pharmacotherapy efficacy for depression, OCD, anxiety disorders.

ICD10: - Z71.9 Counseling, unspecified - Z71.89 Other specified counseling - Z63.9 Problem related to primary support group, unspecified

Clinical Pearls: - Combined medication and psychotherapy improves outcomes and sustainability. - Relapse common without ongoing treatment or reassessment. - Children <10 years often benefit from counseling/behavior therapy alone. - Older children and severe cases may need combined pharmacologic and psychotherapeutic approaches.