Psychological Therapies



Psychological Therapies





Psychological therapy or psychotherapy describes any interaction between a patient (often referred to as a “client” in psychotherapy) and a trained individual in which specific techniques are used to help the patient overcome psychological problems such as depression, adjust to life situations like divorce, increase individual development (e.g., achieve career success), or improve compliance with clinical recommendations (McDonald et al., 2002).

The most familiar models of psychotherapy are the psychoanalytic and behavioral models. In psychoanalysis and related therapies, treatment focuses on understanding the underlying, intrapsychic, and unconscious reasons for a person’s problematic emotions and behavior. The expectation of this type of therapy is that once the person understands the basis of the feelings and behavior, he will be able to change them. In behavioral therapy, the actions of the person are the focus of treatment. The expectation of behavioral therapy is that by learning adaptive behavior and unlearning maladaptive behavior, a person can change his or her problematic behavior. In a related way, cognitive-behavioral therapy attempts to identify and then change problematic cognitions; that is, ideas patients have about themselves that ultimately affect their behavior. These ideas include erroneous interpretations of life events and unrealistic expectations of themselves. These and other commonly used types of psychotherapy are summarized in Table 11-1 and are discussed later in this chapter.


• PSYCHOANALYSIS AND RELATED THERAPIES

Psychoanalysis and related therapies are based on Freud’s psychodynamic concepts of the unconscious mind, transference reactions, and defense mechanisms (see Chapter 8). These therapies are insight-oriented. They aim to understand the underlying, unconscious basis of current conflicts and behaviors by recovering repressed experiences and integrating them into the patient’s personality. Techniques that are used include free association, dream interpretation, analysis of transference reactions, and analysis of resistance (Table 11-2). These techniques can be useful not only in insight-oriented therapies but also to enhance physician-patient relationships in primary care settings (Goldberg, 2000).


Types of therapy

The central strategy of classic psychoanalysis is to slowly uncover experiences that are repressed in the unconscious mind. To accomplish this goal, psychoanalytic patients receive extended treatment, often four to five sessions weekly over 3 to 6 years. Typically, the patient reclines on a couch facing away from the therapist during treatment.

In contrast to psychoanalysis, psychoanalytically oriented psychotherapy has the patient sitting in a chair and facing the therapist. Moreover, psychoanalytically oriented psychotherapy is briefer and more direct.

Brief or short-term dynamic psychotherapy is designed to help people deal with current life problems or crises. It includes a lengthy first interview in which the patient is helped to quickly unlock the unconscious mind and focus on the present problem. Subsequently, the patient is confronted with his or her transference reactions and use of defense mechanisms during 12 to 40 weekly sessions.

Interpersonal therapy is based on the notion that psychiatric problems, specifically depression, result from difficulties in dealing with other people. In 12 to 16 structured weekly sessions, patients gain insight into how their interpersonal interactions and patterns of behavior lead to self-isolation. Positive transference (see below) with a consistently empathic and supportive therapist is facilitated; however, unlike psychoanalysis, interpersonal therapy focuses on present rather than past experiences.


Appropriate patients for psychoanalysis and related therapies

Certain patients are better suited to psychoanalysis and related therapies than others. The most
appropriate patient for these therapies is intelligent, flexible, and not psychotic. He or she is also able to tolerate the negative emotions, such as anger and guilt, that can surface during this type of treatment. The patient must also be able to maintain an ongoing relationship with a therapist and, importantly, desire not only to relieve psychological symptoms but also to gain insight into and understanding of the problem. Additional characteristics are desirable for traditional psychoanalytic patients. Namely, they should be young (usually age < 40 years) and not be dishonest or have an antisocial personality disorder. In addition, patients should have a stable life situation and, perhaps most significantly and practically, have the time and money to spend on this time-consuming and expensive form of treatment.








table 11.1 MODELS OF PSYCHOTHERAPY AND MAJOR USES



























































MODEL

TYPE

MAJOR USES


Psychoanalytical

Psychoanalysis and psychoanalytically oriented psychotherapy

To treat emotional problems (e.g., conversion disorder, obsessive-compulsive disorder, moderate to severe personality disorders, dysthymic disorder) resulting primarily from childhood conflict

Brief dynamic therapy

To improve coping with current life stressors

Interpersonal therapy

To gain insight into the causes of one’s difficulties with others


Behavioral

Systemic desensitization


Aversive conditioning

To treat phobias


To treat addictions (e.g., smoking), paraphilias (e.g., pedophilia), and maladaptive habits (e.g., nail biting)

Flooding and implosion

To treat phobias

Token economy

To increase positive behavior in autistic or intellectually disabled persons

Biofeedback

To treat chronic physical disorders

Cognitive-behavioral therapy

To treat mild to moderate, unipolar, nonpsychotic depression


Other

Group therapy

To improve interpersonal relationships and treat personality disorders

Leaderless group therapy

To provide support during stressful life experiences (e.g., cancer survivors’ or ostomy groups) and to deal with addictions (e.g., alcoholics anonymous)

Family therapy


Marital/couples therapy


Sex therapy

To treat family, relationship, or sexual problems

Supportive therapy

To sustain people during stressful life experiences or chronic mental illness

Stress management

To help people deal with chronic emotional stress



• BEHAVIORAL AND COGNITIVE-BEHAVIORAL THERAPIES

Behavioral and cognitive-behavioral therapies are based on learning theory, including both classical and operant conditioning (see Chapter 9). In contrast to psychoanalysis and related therapies, the person’s history and unconscious conflicts are considered irrelevant in these therapies and thus are not examined. Rather, the aim of these therapies is to relieve the person’s symptoms by unlearning maladaptive behavior and altering negative thinking patterns. Therapies based on classical conditioning include systematic desensitization and aversive conditioning. Those based on operant conditioning include flooding and implosion, token economy, and biofeedback.


Systematic desensitization

Systematic desensitization is a technique used primarily in the treatment of phobias (i.e., irrational fears) (see Chapter 15). The theory behind this treatment is that in the past, through the process of classical conditioning, the phobic person associated an innocuous stimulus with a fear-provoking stimulus. Eventually, the innocuous stimulus became frightening. The treatment involves exposure
to increasing doses of the fear-provoking stimulus while pairing it with a relaxing stimulus to induce a relaxation response. Because one cannot simultaneously be fearful and relaxed (reciprocal inhibition), the person shows less anxiety when exposed to the fear-provoking stimulus in the future. Case 11-1 demonstrates the use of systematic desensitization in the treatment of a phobia.








table 11.2 TECHNIQUES USED IN PSYCHOANALYSIS























TECHNIQUE

DESCRIPTION

USE IN TREATMENT


Free association

The patient says whatever comes to mind.

Layer by layer, unconscious memories are revealed and interpreted by the therapist; to do this, the patient must be as honest as possible with the therapist.


Interpretation of dreams

The patient reports her unedited dreams to the therapist.

The therapist interprets the dreams to examine the patient’s unconscious conflicts and impulses.


Analysis of transference reactions

The patient’s unconscious feelings (e.g., anger, disappointment) stirred up by physical or behavioral characteristics of the therapist are expressed toward the therapist.

These expressions are used by the therapist to understand the significance of the patient’s important past relationships (see Chapter 8).


Analysis of resistance

The patient blocks unconscious thoughts from consciousness (resistance) because he or she finds them uncomfortable or unacceptable.

The therapist evaluates this unconscious editing of thoughts to identify the patient’s painful or conflicted ideas, memories, or wishes.



Aversive conditioning

Aversive conditioning is used mainly in the treatment of unwanted behavior such as paraphilias or addictions. Here, using classical conditioning, a personally pleasurable but maladaptive behavior like smoking or sexual interest in children is paired with an aversive or painful stimulus like an electric shock, so that the two become associated. Subsequently, the person stops engaging in the maladaptive behavior because it automatically provokes an unpleasant response. For example, a 35-year-old smoker is given an electric shock each time he is shown a videotape of a group of people smoking. Later he feels uncomfortable when he sees a package of cigarettes and avoids smoking.


Flooding and implosion

Flooding and implosion are operant conditioning techniques used also to treat phobias. The strategy of these techniques involves direct exposure (without the possibility of avoidance or escape) to the actual (flooding) or imagined (implosion) feared stimulus. For example, a woman who is afraid of riding in cars takes a long road trip (flooding) or imagines being in a car (implosion) on a long road trip. The theoretical basis of flooding and implosion is that by preventing avoidant/escape behavior, the conditioned response (avoidance of the feared stimulus) becomes extinct. Clearly, this dramatic form of treatment is best handled by a therapist well trained in these techniques.


Token economy

Token economy is a strategy used to increase positive behavior in persons who are severely disorganized (e.g., psychotic), autistic, or intellectually disabled. Through the process of operant conditioning, desirable behavior (e.g., tooth brushing and hair combing) is reinforced by a reward or positive reinforcement (a token). Subsequently, the person increases the desirable behavior to gain the reward. For example, a 24-year-old poorly groomed female inpatient with disorganized schizophrenia is given a token when she takes a shower. She can exchange the tokens for privileges like visiting the snack bar or watching a movie. She then takes a shower every day.

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Jun 16, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Psychological Therapies

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