Psychotherapies

Overview

Psychotherapy is the use of communication and language to help patients understand their thoughts, feelings, and actions to bring about positive change. It is based on the communication between a therapist (psychologist or psychiatrist) and a patient.

• Absolute contraindications to psychotherapy
  • Coma/stupor
• Relative contraindications to psychotherapy as the only mode of treatment
  • Acute psychosis
  • Severe Major Depressive Disorder
  • Suicide risk
  • Dementia

Historical Psychotherapies

Modern Psychotherapies

It appears the trend of modern psychotherapies is for each psychotherapy to have its own abbreviation. CBT is the most commonly used psychotherapy in clinical practice. Psychodynamic psychotherapy (adapted from psychoanalytic principles) continued to be used, but to a lesser extent, particularly for borderline personality disorder.

Psychoanalytical Therapies (Explorative Psychotherapy)

Psychoanalysis is derived from Sigmund Freud’s psychoanalytic theories of the mind, where he proposes that behaviors and symptoms result from unconscious mental processes. These unconscious processes include defense mechanisms and conflicts between one’s ego, id, superego, and external reality. Other psychoanalytical theories have been developed by Melanie Klein, Heinz Kohut, Michael Balint, Margaret Mahler, and others.

• Examples of psychoanalytic therapies
  • Psychoanalysis
  • Psychoanalytically oriented psychotherapy
  • Brief dynamic therapy
  • Interpersonal therapy

Psychoanalysis

The goal of psychoanalysis is to bring repressed feelings into conscious awareness so the patient may deal with them. Psychoanalysis is therefore considered “insight-oriented” because its core aim is to help individuals gain a deeper understanding (insight = understanding) of their unconscious motivations, thoughts, and feelings. Insight-based psychotherapies are more common nowadays than Freud’s psychoanalysis or Freud’s pure psychoanalysis

Important concepts in psychoanalysis

• Clinical practice
  • Patients should not be psychotic, be intelligent, and stable in relationships and daily living
  • 3 – 5 days per week
  • Lasts many years
  • The therapist sits out of view and is usually passive
• Indications for psychoanalysis
  • Cluster B and Cluster C personality disorders
  • Anxiety disorders
  • Problems coping with life events
  • Sexual disorders
  • Persistent depressive disorder
• Contraindications
  • Patients who have problems with reality testing, e.g., active psychosis or active mania

Insight-oriented psychotherapy (Expressive Psychotherapy)

Insight-oriented psychotherapy helps the patient understand their psychological functioning and personalities, i.e., gain new insight into current dynamics of their feelings, response to issues, behaviors in different situations, and relationships with other persons

Supportive psychotherapy

In supportive psychotherapy, the therapist offers the patient support during periods of illness or temporary decompensation with the goal of restoring and strengthening the patient’s defences. The treatment is not insight-oriented but focuses on empathy, understanding, and education. It provides a period of dependence for patients in need of help in dealing with guilt, shame, anxiety, and meeting the frustrations of external pressure that may be too great to handle. There is a risk that the patient may regress and become too dependent.

Brief Interpersonal Therapy

Interpersonal therapy helps the patient gain insight into the roots of problems by focusing on CURRENT relationships and building relationship skills, e.g., with spouse, family, work, and friends. The sessions focus on reassurance, clarification of emotions, improving interpersonal communications, and testing perceptions. Key contributions to Interpersonal therapy are from Harry Sullivan, Klerman, and Weissman.

• Clinical practice
  • Brief course (6-12 weeks)
  • Patients explore current problems
  • Teaches skills and approaches to current problems, e.g., how to approach new people for anxiety

Behavioral Therapy

Behavioral therapy identifies maladaptive behaviors (e.g., phobias and compulsions) that contribute to the patient’s symptoms and helps the patient change these behaviors by replacing them with healthy alternatives. It is usually combined with CBT. Behavioral therapy was pioneered by B.F Skinner and is based on learning theory (behaviors can be learned by conditioning and unlearned by deconditioning)

Conditioning techniques for learning behavior

Deconditioning techniques for unlearning behavior

Cognitive Therapy

Aaron Beck, a professor of psychiatry, is considered the pioneer of cognitive therapy. He developed cognitive therapy to treat depression. It aims to identify negative faulty assumptions, automatic thoughts, and core beliefs, and replace them with positive ones. Cognitive therapy can be just as effective as medication.

Examples of faulty assumptions and negative thoughts

• Indications for cognitive therapy
  • Depression
  • Anxiety
  • Paranoid personality disorder
  • Obsessive-compulsive disorder
  • Somatic symptom disorder
  • Eating disorder

Cognitive Behavioral Therapy (CBT)

Cognitive therapy was expanded to include behavioral components and became Cognitive Behavioral Therapy. Since then, CBT has been successfully used to treat a range of disorders either on its own or with medication. The basic rationale behind CBT is that how one thinks (cognition) and how one acts (behavior) affect how one feels (mood). Negative cognitions and maladaptive behaviors can cause one to have a low mood. By identifying and correcting negative cognitions and maladaptive behavior, mood can be improved. The focus of CBT is on the ‘here and now’ and not on the origin of the problems. The main objective is to help the patient use practical cognitive and behavioral strategies to overcome the problem(s).

• Indications for CBT
  • Depression
  • Anxiety
  • Schizophrenia
  • Substance use disorder
• Clinical practice
  • Time-limited therapy: 12 – 16 sessions
  • Sessions once a week
  • Each session lasts for about 50 minutes
  • The goals of treatment are clearly identified at the beginning of therapy
  • Progress is regularly monitored during therapy
  • The patient is an active participant during therapy
  • The patient is given ‘homework’ tasks to complete between sessions
  • Rating scales are used at the beginning and at the end of therapy to assess the effectiveness

CBT vs Explorative Psychotherapy

Dialectical Behavioral Therapy (DBT)

Dialectical behavioral therapy was pioneered by Marsha Linehan. It is a type of CBT that is useful in reducing self-destructive behaviors and hospitalization in patients with borderline personality disorder. It incorporates cognitive and supportive techniques, along with ‘mindfulness’ derived from traditional Buddhist practices.

Group Psychotherapy

Group therapy gained momentum during World War II when neuroses in the military were treated in a group setting. It was pioneered by Wilfred Bion and Siegfried Foulkes, among others. Group therapy is useful in treating substance use disorder, adjustment disorder, and personality disorders. Therapeutic communities are useful in the management of patients with severe borderline personality disorders.

• Clinical practice
  • The size of the group may vary from small (6 – 8) to large (20 – 50, i.e., therapeutic communities).
  • Can be peer-led with no therapist present to facilitate the group, e.g., Alcoholics Anonymous
• Types of therapy administered
  • Psychoanalytical
  • Cognitive
  • Behavioral
  • Supportive
• 4 important features of therapeutic communities (by Rapoport)
  • Communalism
  • Democratisation
  • Permissiveness
  • Reality confrontation

Family Psychotherapy

Family therapy refers to the application of psychotherapeutic techniques to the family unit as a whole (even if a child is the one who has been referred). It started in the 1950s following the work of Ackerman in America (’Psychodynamics in family life’). It was also developed by Skynner in Britain, who applied Kleinian analytic principles to families. Family therapy is based on the assumption that a child’s problems are a reflection of the problems in the family. It is commonly used as an adjunctive treatment in many psychiatric conditions. There are several types of family therapy, with considerable overlap between the different types in clinical practice. It is especially useful in treating schizophrenia and anorexia.

• Three main types of family therapy
  • Systemic
  • Structural
  • Strategic

Couples Therapy

Couples therapy is used to treat conflicts, sexual problems, and communication problems within the context of an intimate relationship.

Types of couples therapy

• Relative contraindications to couples therapy
  • Lack of motivation from one or both spouses
  • Severe illness in one of the spouses, e.g., schizophrenia