Psychotherapy
- Essential ingredient in a good patient therapist relationship is built on genuine trust & interest
- Hundreds of types of psychotherapy; all have different theories to how changes in pt occur
I. Psychoanalysis
The classical long-term insight oriented therapy
Goal = identifying major personality changes by identifying and “working through” unconscious conflicts by free association, analysis of the transferance and resistences, and dream interpretation
It takes several hundred hours
Selection criteria for patients for psychoanalysis
- Primary oedipal conflict
- Internal conflict
- The ability to symptom relief through understanding
- Have to be psychologically minded
- Able to experience and observe strong effects without acting out
- Have supportive relationships available in both past and present
Topographical Model of the Mind- Freud- includes:
- Conscious (awareness)
- Preconcious (readily available to conscious)
- Unconcious- thoughts and feelings that can’t be conscious without overcoming strong resistances; gives rise to
Dreams
Paraprexes (Freudian slips)
Psychological symptoms
Symptoms of psychological illness = conflicts b/t unconscious drives and moral judgements you make; repressed in an effort to avoid the actual conflict
Structual Theory of the Mind
- Id – reservoir of unorganized, instinctual drives
- Ego- “executive organ”; the seat of logic and abstract thinking; mediator b/t the id and the superego, and the actual reality based environment
- Superego- conscience controlled of ideals internalized from parental figures
The role of the therapist in psychoanalysis is limited to timely interpretation of the patients assns; not as active as other types of therapy
Transferance- the patients feelings and behavior toward the analyst that are based on infantile wishes the patient has towards parents/parental figures
Countertransferance- the analysts reaction to the patient, based on his or her past experienced
Dream interpretation- the manifest content is what the dreamer reports; the latent contnet is the unconscious meaning of the dream after condensations, substitutions, and symbols have been analyzed
Psychanalysis is usually used in pt termed “neurotic” or pts with personality disorders
Relative contraindications for this type of therapy include an older age, low IQ, if their life situation cannot be modified, antisocial personality disorders (have to be able to relate to someone), if there are time constraints, psychotic disorders
An analyst should not treat friends/relatives b/c this interferes with interpretation
II. Psychotherapy
- Supportive Psychotherapy- the goal is to evaluate the pts current lifesituation and his/her strengths or weaknesses, and help the patient make whatever realistic changes that will allow him/her to be more functional
- Usually weekly for several wks or months
- Works very little with the unconscious and doesn’t attempt major personality changes
- Techniques used:
Reassurance
Suggestion
Ventilation
Abreaction
Environmental manipulation
- Good candidates for this therapy are pts with coping problems or serioous psychiatric illnesses like schizophrenia and bipolar
- Abreaction- the process in which a memory of a traumatic experience is released from repression and brought into consciousness-when able to express the affect associated with memory, the affect is discharged and the symptoms associated with it disappear
- Brief Psychotherapy- short-term therapies that are based on psychoanalytic concepts; more practical today in managed-care environment; pt must be motivated for change; there has to be circumscribed focus that is agreed upon and a termination date usually set in advance
- Usually about 20 sessions
- Interpersonal Psychotherapy- goal is to improve current interpersonal skills; selection critertia include outpatient, nonbipolar, nonpsychotic depressive disorders
- Usually lasts 12-16 wks, once a week
- Techniques include:
Reassurance
Clarification of felling states
Improvement on interpersonal communication
Testing perceptions
- Crisis intervention- deals with persons in the midst of crisis – rapidity is of the essence; there must be a joint understanding of the psychodynamics of the situation and an awareness of how they are responsible for the crisis; goal is to understand maladaptive rxns the pt uses to deal with crisis and how to avoid this in the future
- Group Psychotherapy- treatment in which carefully selected emotionally ill people are placed in a group guided by a trained therapist to help one another effect personality change; two main strengths when compared to individual therapy include opportunity for immediate feedback from patients peers and the opportunity for both the pt and the therapist to observe the pts psychological, emotional, and behavioral responses to a variety of persons, eliciting a variety of transferances
- Goal is to aleviate symptoms, to change the interpersonal relations, and to alter specific family-couple dynamics
- Selection varies based on type of group:
Homogenous groups tend to target specific disorders
Adolescents and pts with personality disorders may especially benefit
- Contraindications include substantial suicide risk, sadomasachist acting out
- Different types include:
Directive-supportive
Psychodynamic-interpersonal
Family and couple
- Duration can be weeks to year; time-limited to open ended
- Therapists role is primarily a fascilitative one; ideally ythe group members themselves are the source of cure and change
- Self-help groups are composed of persons who want to cope with a specific problem or life crisis; members provide education, suppoprt, and alleviate a sense of alienation that the other members may be feeling
- The groups emphasize cohesion
- Psychodrama- a method of group psychotherapy in which personality makeup, interpersonal relationships, conflict, and emotional problems are explored by means of special dramatic methods; include the protagonist, auxillary egos, and the director
- Family Therapy
- Family Systems Theory- a family behaves as if it were a unit with a particular homeostasis of relating that is maintained regardless of how maladaptive it is
- The goals of therapy are to recognize and acknowledge the often covert pattern of maintaining balance within a family and to help them understand the pattern’s meaning
- Family therapists generally believe that one member of the family has been labeled the “identified patient”; the goal of the therapist is to help the family understand that the identified pts symptoms are serving a crucial function in maintaining the families homeostasis
- Several types
Family Systems Therapy- functioning in families is impaired by relationships with family of origin; poor differentiation, anxiety, family projection process, and family triangulation; goal is differentiation of family members and modification of relationships by detriangulation and repairing cut-offs
Structural Theory- symptoms result from current structural family imbalance; malfunctioning hierarchical arrangement; boundaries; goals of therapy are to reorganize family structure; shift members relative positions to disrupt malfunctioning pattern and strengthen parental hierarchy
- Marital Therapy- form of psychotherapy designed to psychologically modify the interaction of 2 people who are in conflict with each other over one parameter or many parameters – social, emotional, sexual, economic
- Problems in communication are a prime indications for therapy- need to see each other realistically
- Contraindications include patients with severe forms of psychosis, one or both of the partners really want a divorce, or one spouse refuses to participate out of anxiety or fear
- Goals to alleviate emotional stress and disability while promoting the well-being of partners together and individually
- Biofeedback- provides information to a person regarding 1 or more physiological processes in an effort to enable the person to gain some voluntary control over bodily functions that normally operate outside of consciousness— headaches, pain, tachycardia, asthma, bruxism to name a few
- Can cause EMG, EEG, GSR
- Behavior Therapy- goal is to modify learned maladaptive behavior patterns that lead to pathological symptoms; the emphasis is on removing overt symptoms, without regard for the patients private experiences or inner conflicts
- Selection requirements = specific, well delineated, easily identifiable maladaptive behaviors (phobias, overeating, sexual dysfunction); psychophysiological disorder in which symptoms are affected by stress (asthma, pain)
- Duration- generally time-limited, specific behavior
- Techniques based on Learning Theory (operant and classical conditioning)
Relaxation training
Reinforcements (Positive) – If behavioral response is followed by a rewarding event, it tends to be strengthened and to occur more frequently than before the reward
Aversive Therapy- pt is given an unpleasant, aversive stimulus when behavior is undesirable. Used for alcohol abuse, paraphilias, impulsive behaviors
Flooding- based on the premise that escaping from an anxiety provoking environment experience reinforces anxiety through conditioning; keeping the person in the anxiety-provoking situation will cause the fear to subside
Participant modeling
Token economies
Systematic desensitization- based on the behavioral principle of counterconditioning, which states that a person can overcome maladaptive anxiety elicited by a situation or object by approaching the feared situation gradually and in a psychophysiological state that inhibits anxiety
The pt attains a state of complete relaxation and is then exposed to the stimulus that elicits the anxiety
The negative reaction of anxiety is then inhibited by the relaxed state, a process that is called reciprocal inhibition
This process consists of 3 steps:
1. Relaxation training
2. Hierarchy construction
3. Desensitization of the stimulus
Example of a hierarchy for dog phobia
Looking at a picture of a dog in a childs book
Cuddling a childs stuffed dog
Seeing a dog on a leash at 10 yds, 5 yds, passing by
Touching a dog behind a fence in a store
Looking at the neighbors spaniel in the arms of the owner
Touch it when it is quiet and held by the owner
Stroking it
Looking at an Alaskan dog
Watching span. jump on road when pt is indoors/windows closed
Watching the spaniel walk around the room
Feeding the spaniel a biscuit
The spaniel being held by the owner and then jumping on the ground etc. etc. etc. ending in…
Dogs fighting
Desensitization is done systematically by having the pet proceed through the list while in a deeply relaxed state from the least anxiety provoking to the most anxiety provoking
- Graded exposure is similar to systemic desensitization, except that relaxation is not involved and treatment is usually carried out in real life situations
- Implosion therapy- pt with situation-caused anxiety is directly exposed for a length of time to that situation (flooding) or in imagination (implosion)
- Operant Conditioning- subject is active and behaves in a way that produces a reward-learning occurs as a consequence of action
- Classical Conditioning- (Pavlov)- new behavioral patterns can be developed when a given stimulus known to generate a response is paired with a second stimulus (conditioned response); Food + Bell = salivation; Bell = Salivation
Involves…..
- UCR- unconditioned resp
- UCS- unconditioned stim
- CR- Conditioned response
- CS – Conditioned Stimulus
- Cognitive Therapy
- The goal is to identify and alter cognitive distortions that maintain symptoms; used primarily for dysthymic disorder, nonendogenous depressive disorders, anxiety disorders
- Time Limited to 15-25 sessions
- Technique includes 4 main processes:
1. Eliciting automatic thoughts (cognitive distortions)
2. Testing automatic thoughts
3. Identifying maladaptive assumptions
4. Testing the validity of maladaptive assumptions
- In Depressive Disorder, for example, pts have a negative view of self, experience, and future
- Patients with Panic Disorder have a catastrophic misinterpretation of bodily and mental experiences
- Hypnosis
- Defined as, “the state or condition in which a person responds to appropriate suggestions by experiencing alterations of perceptions, memory, or mood; essential feature is the subjective experiential change
- Indicated in treatment of obesity, substance abuse related disorders, and anxiety
- Contraindicated in psychotic pts, OCD pts, and pts who have difficulty when they feel out of control
Tags: Countertransferance, Dream interpretation, ego, Group Psychotherapy, neurotic, oedipal conflict, Paraprexes, Psychoanalysis, superego, Transferance
