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Psychotherapies

H.M.Zainie Hassan.A.R.dr.SpKJ(K)


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Psychoanalysis and Psychoanalytic

Psychotherapy

Two kinds problems take people to psychiatristfor treatment: their origins largely in the remotepast of lives and those that from currentstresses/pressures.

When patients problem stems mainly from thepast with relatively little contribution from thepresent,psychoanalysis may well be thetreatment of choice.

Psychoanalytic therapy uses the theoreticalframework provided by psychoanalysis,but itstherapeutic goals less extensive.


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Psychoanalysis

In 1881 Anna O,neurotic young womantreated by Josep Breuer, that patientssymptoms disappeared when she expressedthem verbally while hypnotied. Freud use

the technique with Breuer in 1895 in studieson Hysterya.

Freud eventually gave up placing hispatients in hypnotic trance, instead them torecline on a couch, concentrate with their

eye closed on past memories related theirsymptoms. That concentration methodeeventually became the technique of freeassociation is one of hallmark s ofPsychoanalysis .


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Psychoanalysis

Psychoanalytic Process

involves bringing to the surface repressed memories andfeelings by means of a scrupulous unraveling of hidden

meanings of verbalized material and of the unwitting ways inwhich the patient wards off underlying conflicts throughdefensive forgetting and repetition of the past.

The overall process of analysis is one in which unconsciousneurotic conflicts are recovered from memory and verbally

expressed, reexperienced in the transference,reconstructed bythe analyst, and, ultimately, resolved through understanding.

Freud referred to these processes as recollection, repetition,and working through,which make up the totality ofremembering, reliving, and gaining insight.


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Model Struktural Freud(topographical

model of the mind)

Psychoanalysis

emphasizes the conflict

between unconscious

drives and moraljudgments, that conflict

account for the

phenomenon of

repression which isregarded as

pathological.


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Indications and Contraindications

In general, all of the so-calledpsychoneuroses aresuitable for psychoanalysis. These include anxietydisorders, obsessional thinking, compulsive behavior,conversion disorder, sexual dysfunction, depressive

states, and many other nonpsychotic conditions, suchas personality disorders.

Many contraindications for psychoanalysis are the flipside of the indications. The absence of suffering, poorimpulse control, inability to tolerate frustration and

anxiety, and low motivation to understand are allcontraindications.Age, Intelligence,lifecircumstances,antisocial personality disorder must beconsidered before embarking on a course of treatment.


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Psychoanalytic Psychotherapy

which is based on fundamental dynamicformulations and techniques that derive frompsychoanalysis, is designed to broaden itsscope.

Its focus the patient current conflicts andcurrent dynamic patterns

The strategies of psychoanalytic psychotherapycurrently range from expressive (insight-oriented, uncovering, evocative, or interpretive)techniques to supportive (relationship-oriented,suggestive, suppressive, or repressive)techniques.

psychoanalytic psychotherapy rarely uses the

couch; patient and therapist sit face to face.


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Brief Psychodynamic

Psychotherapy Brief psychodynamic psychotherapy is a time-

limited treatment (10 to 12 sessions) that is basedon psychoanalysis and psychodynamic theory.

It is used to help persons with depression, anxiety,and posttraumatic stress disorder, among others.

Brief psychodynamic psychotherapy has gainedwidespread popularity, partly because of the greatpressure on health care professionals to containtreatment costs.

It is also easier to evaluate treatment efficacy bycomparing groups of persons who have had short-term therapy for mental illness with control groupsthan it is to measure the results of long-termpsychotherapy


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Group Psychotherapy, Combined

Individual and Group

Psychotherapy, and Psychodrama

A widely accepted psychiatric treatment modality, group psychotherapy usestherapeutic forces within the group, constructive interactions between members,and interventions of a trained leader to change the maladaptive behavior,

thoughts, and feelings of emotionally distressed individuals. In an era ofincreasingly stringent financial constraints, decreasing emphasis on individualpsychotherapies, and expanding use of psychopharmacological approaches, morepatients have been treated with group psychotherapy than with any other form ofverbal therapy. Group therapy is applicable to inpatient and outpatient settings,institutional work, partial hospitalization units, halfway houses, communitysettings, and private practice. Group psychotherapy is also widely used by thosewho are not mental health professionals in the adjuvant treatment of physicaldisorders. The principles of group psychotherapy have also been applied withsuccess in the fields of business and education in the form of training, sensitivity,and role-playing.

Group psychotherapy is a treatment in which carefully selected persons who areemotionally ill meet in a group guided by a trained therapist and help one anothereffect personality change. By using a variety of technical maneuvers andtheoretical constructs, the leader directs group members' interactions to bring

about changes.


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Family Therapy and Couples

Therapy

Family therapy can be defined as any psychotherapeutic endeavor that explicitlyfocuses on altering the interactions between or among family members andseeks to improve the functioning of the family as a unit, or its subsystems, and/orthe functioning of individual members of the family. Both family and coupletherapy aim at some change in relational functioning. In most cases, they also

aim at some other change, typically in the functioning of specific individuals inthe family. Family therapy meant to heal a rift between parents and their adultchildren is an example of the use of family therapy centered on relationshipgoals. Family therapy aimed at increasing the family's coping with schizophreniaand at reducing the family's expressed emotion is an example of family therapyaimed at individual goals (in this case, the functioning of the person with

schizophrenia), as well as family goals. In the early years of family therapy,change in the family system was seen as being sufficient to produce individualchange. More recent treatments aimed at change in individuals, as well as in thefamily system, tend to supplement the interventions that focus on interpersonalrelationships with specific strategies that focus on individual behavior.


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Dialectical Behavior

Therapy

Dialectical behavior therapy (DBT) is a type of psychotherapy that was originallydeveloped for chronically self-injurious patients with borderline personalitydisorder and parasuicidal behavior. In recent years, its use has extended to otherforms of mental illness. The method is eclectic, drawing on concepts derived from

supportive, cognitive, and behavioral therapies. Some elements can be traced toFranz Alexander's view of therapy as a corrective emotional experience, and otherelements from certain Eastern philosophical schools (e.g., Zen).

Patients are seen weekly, with the goal of improving interpersonal skills anddecreasing self-destructive behavior using techniques involving advice, metaphor,storytelling, and confrontation, among others. Patients with borderline personality

disorder especially are helped to deal with the ambivalent feelings that arecharacteristic of the disorder. Marsha Linehan, Ph.D., developed the treatmentmethod, based on her theory that such patients cannot identify emotionalexperiences and cannot tolerate frustration or rejection. As with other behavioralapproaches, DBT assumes all behavior (including thoughts and feelings) is learnedand that patients with borderline personality disorder behave in ways thatreinforce or even reward their behavior, regardless of how maladaptive it is.


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Genetic Counseling

Genetic counseling is a process thatprovides information (medical, technical,

and probabilistic) to the patient (andfamily) at risk for developing a specificdisorder. The provision of informationoccurs in conjunction with helping themadapt emotionally and psychologically to

the diagnosis (or threat of it), thusfacilitating informed decision making. Theprocess aims to minimize distress, toincrease one's feeling of personal control,and to facilitate informed decision making.


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Biofeedback

Biofeedback involves the recording anddisplay of small changes in the physiologicallevels of the feedback parameter. The displaycan be visual, such as a big meter or a bar oflights, or auditory. Patients are instructed to

change the levels of the parameter, using thefeedback from the display as a guide.Biofeedback is based on the idea that theautonomic nervous system can come undervoluntary control through operantconditioning. Biofeedback can be used by

itself or in combination with relaxation. Forexample, patients with urinary incontinenceuse biofeedback alone to regain control overthe pelvic musculature. Biofeedback is alsoused in the rehabilitation of neurologicaldisorders. The benefits of biofeedback may

be augmented by the relaxation thatpatients are trained to facilitate.


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Behavior Therapy

The term behavior in behavior therapy refers to a person's observable actionsand responses. Behavior therapy involves changing the behavior of patients toreduce dysfunction and to improve quality of life. Behavior therapy includes amethodology, referred to as behavior analysis, for the strategic selection ofbehaviors to change, and a technology to bring about behavior change, such asmodifying antecedents or consequences or giving instructions. Behaviortherapy has not only influenced mental health care, but, under the rubric ofbehavioral medicine, it has also made inroads into other medical specialties.

Behavior therapy represents clinical applications of the principles developed inlearning theory. Behavioral psychology, or behaviorism, arose in the early 20thcentury in reaction to the method of introspection that dominated psychologyat the time. John B. Watson, the father of behaviorism, had initially studiedanimal psychology. This background made it a small conceptual leap to arguethat psychology should concern itself only with publicly observablephenomena (i.e., overt behavior). According to behavioristic thinking, becausemental content is not publicly observable, it cannot be subjected to rigorousscientific inquiry. Consequently, behaviorists developed a focus on overt

behaviors and their environmental influences. Today, different behavioral schools continue to share a focus on verifiable

behavior. Behavioral views differ from cognitive views in holding that physical,rather than mental, events control behavior. According to behaviorism, mentalphenomena or speculations about them are of little or no scientific interest.


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Cognitive Therapy

Cognitive therapy is a short-term, structured therapy that uses active collaborationbetween patient and therapist to achieve its therapeutic goals, which are orientedtoward current problems and their resolution. Cognitive therapy is used withdepression, panic disorder, obsessive-compulsive disorder, personality disorders, andsomatoform disorders. Therapy is usually conducted on an individual basis, althoughgroup methods are sometimes helpful. A therapist may also prescribe drugs inconjunction with therapy.

The treatment of depression can serve as a paradigm of the cognitive approach.

Cognitive therapy assumes that perception and experiencing, in general, are activeprocesses that involve both inspective and introspective data. The patient'scognitions represent a synthesis of internal and external stimuli. The way personsappraise a situation is generally evident in their cognitions (thoughts and visualimages).

Those cognitions constitute their stream of consciousness or phenomenal field,which reflects their configuration of themselves, their world, their past, and their

future.

Alterations in the content of their underlying cognitive structures affect theiraffective state and behavioral pattern. Through psychological therapy, patients canbecome aware of their cognitive distortions. Correction of faulty dysfunctionalconstructs can lead to clinical improvement.


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What is Cognitive Behavioural Therapy?

CBT is a form of psychotherapy that is hereand now focused and will look at how you

think about yourself, the world and other

people; this can be used as a method which

can help to teach the relationship between

thoughts, feelings & behaviour.


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Hypnosis

Hypnosis, in contemporary lay thought, is oftensteeped in mystery and its powers believed toborder on magic. In reality, hypnosis is apowerful means of directing innate capabilities

of imagination, imagery, and attention. Duringthe hypnotic trace, focal attention andimagination are enhanced and simultaneouslyperipheral awareness is decreased. This trancemay be induced by a hypnotist through

formalized induction procedures, but it can alsooccur spontaneously. The capacity to behypnotized and, relatedly, the occurrence ofspontaneous trance states is a trait that variesbetween individuals, but is relatively stable

throughout a person's life cycle.


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Interpersonal Therapy

Interpersonal psychotherapy (ITP), a time-limited treatment formajor depressive disorder, was developed in the 1970s, definedin a manual, and tested in randomized clinical trials by Gerald L.Klerman and Myrna Weissman. ITP was initially formulated asan attempt to represent the current practice of psychotherapyfor depression. It assumes that the development andmaintenance of some psychiatric illnesses occur in a social and

interpersonal context and that the onset, response totreatment, and outcomes are influenced by the interpersonalrelations between the patient and significant others. The overallgoal of ITP is to reduce or eliminate psychiatric symptoms byimproving the quality of the patient's current interpersonalrelations and social functioning.

The typical course of ITP lasts 12 to 20 sessions over a 4- to 5-month period. ITP moves through three defined phases: (1) Theinitial phase is dedicated to identifying the problem area thatwill be the target for treatment; (2) the intermediate phase isdevoted to working on the target problem area(s); and (3) thetermination phase is focused on consolidating gains madeduring treatment and preparing the patients for future work on

their own (Table 35.11-1).


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Psychiatric Rehabilitation

Psychiatric rehabilitation denotes a wide rangeof interventions designed to help people withdisabilities caused by mental illness improvetheir functioning and quality of life by enablingthem to acquire the skills and supports needed

to be successful in usual adult roles and in theenvironments of their choice. Normative adultroles include living independently, attendingschool, working in competitive jobs, relating tofamily, having friends, and having intimate

relationships. Psychiatric rehabilitationemphasizes independence rather than relianceon professionals, community integration ratherthan isolation in segregated settings for personswith disabilities, and patient preferences rather

than professional goals.


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Combined Psychotherapy

and Pharmacology The use of psychotropic drugs in combination with

psychotherapy has become widespread. In fact, it hasbecome the standard of care for many patients seen bypsychiatrists. In this therapeutic approach, psychotherapyis augmented by the use of pharmacological agents. Itshould not be a system in which the therapist meets withthe patient on an occasional or irregular basis to monitorthe effects of medication or to make notations on a ratingscale to assess progress or side effects; rather, it shouldbe a system in which both therapies are integrated andsynergistic. In many cases, it has been demonstrated thatthe results of combined therapy are superior to eithertype of therapy used alone. The term pharmacotherapy-oriented psychotherapy is used by some practitioners torefer to the combined approach. The methods ofpsychotherapy used can vary immensely and all can becombined with pharmacotherapy.


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Reference

Sadock, Benjamin James; Sadock, Virginia

Alcott: Kaplan & Sadock's Synopsis of

Psychiatry: Behavioral Sciences/Clinical

Psychiatry, 10th Edition

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