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01 - Chapter 17 Psychotherapies

Chapter 17 Psychotherapies

Psychoanalysis and Related Therapies....................................................................................184 Freud’s Theories of the Mind...................................................................................................184 Topographic Theory...........................................................................................................184 Structural Theory...............................................................................................................184 Defense Mechanisms..............................................................................................................184 Mature Defenses................................................................................................................185 Neurotic Defenses..............................................................................................................185 Immature Defenses...........................................................................................................186 Other Defense Mechanisms...............................................................................................186 Psychoanalysis........................................................................................................................186 Important Concepts and Techniques Used in Psychoanalysis.............................................187 Psychoanalysis-Related Therapies.....................................................................................187 Behavioral Therapy.................................................................................................................187 Learning Theory.................................................................................................................187 Conditioning......................................................................................................................188 Behavioral Therapy Techniques (Deconditioning)..............................................................188 Cognitive Therapy...................................................................................................................188 Clinical Example of the Cognitive Theory of Depression.....................................................189 Cognitive-Behavioral Therapy (CBT)........................................................................................189 Dialectical Behavioral Therapy (DBT)......................................................................................190 Group Therapy........................................................................................................................190 Family Therapy........................................................................................................................190 Couples Therapy......................................................................................................................191 PSYCHOTHERAPIES CHAPTER 17

184 PSYCHOTHERAPIES  KEY FACT Normal development: Id is present at birth, ego develops after birth, and superego development is traditionally considered to be completed by age 6. ■ Psychoanalysis. ■ Psychoanalytically oriented psychotherapy. ■ Brief dynamic therapy. KEY FACT ■ Interpersonal therapy. According to Freud, the superego is the aspect of one’s psyche that represents “morality, society, and parental teaching.” TOPOGRAPHIC THEORY KEY FACT The Freudian superego represents internalization of cultural rules. STRUCTURAL THEORY Defense Mechanisms It is common to combine psychotherapy with medications. Split treatment describes the arrangement where a physician prescribes medication and someone else provides therapy. In these cases, the physician and therapist should ­regularly communicate regarding the patient’s treatment. Psychoanalysis and Related Therapies Psychoanalysis and its related therapies are derived from Sigmund Freud’s psychoanalytic theories of the mind. Freud proposed that behaviors, or symptoms, result from unconscious mental processes, including defense mechanisms and conflicts between one’s ego, id, superego, and external reality. Since the time of Freud, many other psychoanalytic theories have been developed. Influential theorists have included Melanie Klein, Heinz Kohut, Michael Balint, Margaret Mahler, and others. Examples of psychoanalytic therapies include the following: Freud’s Theories of the Mind

  1. Unconscious: Includes repressed thoughts that are out of one’s awareness; involves primary process thinking (primitive, pleasure-seeking urges with no regard to logic or time, prominent in children and psychosis). Thoughts and ideas may be repressed into the unconscious because they are embarrassing, shameful, or otherwise too painful.
  2. Preconscious: Contains memories that are easy to bring into awareness, but not unless consciously retrieved.
  3. Conscious: Involves current thoughts and secondary process thinking (logical, organized, mature, and can delay gratification).
  4. Id: Unconscious; involves instinctual sexual/aggressive urges and primary process thinking.
  5. Superego: Moral conscience and ego ideal (inner image of oneself that one wants to become).
  6. Ego: Serves as a mediator between the id, superego, and external environment, and seeks to develop satisfying interpersonal relationships; uses defense mechanisms (see below) to control instinctual urges and distinguishes fantasy from reality using reality testing. Problems with reality testing occur in psychotic individuals. Defense mechanisms are used by the ego to protect oneself and relieve anxiety by keeping conflicts out of awareness. They are (mostly) unconscious processes that are normal and healthy if they are mature and used in moderation (i.e.,

adaptive). They may be unhealthy if immature (i.e., maladaptive). Immature defense mechanisms can be used excessively as seen in some psychiatric disorders. Defense mechanisms are often classified hierarchically. Mature defense mechanisms are healthy and adaptive, and they are seen in high-functioning and healthy adults. Neurotic defenses are encountered in obsessive-compulsive patients, patients with other anxiety disorders, and adults under stress. Immature defenses are seen in children, adolescents, psychotic patients, and some nonpsychotic patients, such as those with severe personality disorders. They are the most primitive defense mechanisms. MATURE DEFENSES Mature ego defenses are commonly found in healthy, high-functioning adults. These defenses often help people integrate conflicting emotions and thoughts.

  1. Altruism: Performing acts that benefit others so as to vicariously experience pleasure. (Clinical example: A patient’s child recently died from ovarian cancer. As part of the grieving process, the patient donates money to help raise community awareness about the symptoms of ovarian cancer so other patients could potentially benefit from early intervention.)
  2. Humor: Expressing (usually) unpleasant or uncomfortable feelings without causing discomfort to self or others. (Clinical Example: When talking about lifestyle modifications, a diabetic patient jokingly reports that they are exercising their arm muscles when they eat.)
  3. Sublimation: Satisfying socially objectionable impulses in an acceptable manner (thus channeling them rather than preventing them). (Clinical ­example: Person with unconscious urges to physically control others ­becomes a prison guard.)
  4. Suppression: Purposely ignoring an unacceptable impulse or emotion so as to diminish discomfort and accomplish a task. (Clinical example: Nurse who feels nauseated by an infected wound puts aside feelings of disgust to clean wound and provides necessary patient care.) NEUROTIC DEFENSES
  5. Displacement: Shifting emotions from an undesirable situation to one that is personally tolerable. (Clinical example: Student who is angry with their mother talks back to their teacher the next day and refuses to obey ­instructions.)
  6. Intellectualization: Avoiding negative feelings by excessive use of intellectual functions and by focusing on irrelevant details. (Clinical example: Physician dying from colon cancer describes the pathophysiology of the disease in detail to their 12-year-old child.)
  7. Isolation of affect: Unconsciously limiting the experience of feelings or emotions associated with a stressful life event so as to avoid anxiety. (Clinical example: Patient describes the recent death of their beloved spouse without emotion.)
  8. Rationalization: Explanations of an event to justify outcomes or behaviors and to make them acceptable. (Clinical example: “My boss fired me today because they aren’t meeting their quotas, not because I haven’t done a good job.”)
  9. Reaction formation: Doing the opposite of an unacceptable impulse. (Clinical example: Patient who is attracted to their married coworker insults them.) PSYCHOTHERAPIES  KEY FACT Suppression, as a defense mechanism, is a conscious process that involves avoiding paying attention to a particular emotion. WARDS QUESTION Q: A former gang member becomes a police officer working in the intercity to prevent gang violence. What is the defense mechanism? A: Sublimation—The channeling of destructive impulses to create something constructive.

186 PSYCHOTHERAPIES  KEY FACT Intellectualization is a defense mechanism where reasoning is used to block confrontation with an unconscious conflict or undesirable thought or feeling. IMMATURE DEFENSES WARDS QUESTION Q: An individual buys an unreasonably expensive new watch and tells their friends that they needed it because their old one was not reliable enough and they have to make sure to get to appointments on time. What is the defense mechanism? A: Rationalization—Attempting to justify behavior to make it ­acceptable. OTHER DEFENSE MECHANISMS WARDS QUESTION Psychoanalysis Q: A person accuses their partner of cheating when they themselves are involved in numerous affairs. What is the defense mechanism? A: Projection—Ascribing one’s objectional qualities onto others. KEY FACT Remember for individuals with borderline personality disorder, splitting is their major defense mechanism. ■ Clusters B and C personality disorders. ■ Anxiety disorders. ■ Problems coping with life events. ■ Sexual disorders. ■ Persistent depressive disorder. 6. Repression: Preventing a thought or feeling from entering consciousness. (Repression is unconscious, whereas suppression is a conscious act.) (­Clinical Example: A sexual assault victim tries hard but cannot recall details of the crime when questioned by police.)

  1. Acting out: Giving in to an impulse, even if socially inappropriate, so as to avoid the anxiety of suppressing that impulse. (Clinical example: Patient who has been told their therapist is going on vacation “forgets” their last appointment and skips it.)
  2. Denial: Not accepting reality that is too painful. (Clinical example: Woman who has been scheduled for a breast mass biopsy cancels her appointment because she believes she is healthy.)
  3. Regression: Performing behaviors from an earlier stage of development so as to avoid tension associated with current phase of development. (Clinical example: Patient brings their childhood teddy bear to the hospital when they have to spend the night.)
  4. Projection: Attributing objectionable thoughts, qualities, or emotions to others. (Clinical example: An individual who is attracted to others believes their partner is having an affair.)
  5. Splitting: Labeling people as all good or all bad; often seen in borderline personality disorder. (Clinical example: Patient who tells their doctor, “You and the nurses are the only people who understand me; all the other doctors are mean and impatient.”)
  6. Undoing: Attempting to reverse a situation by adopting a new behavior. (Clinical example: An individual who has had a brief fantasy of killing their spouse by sabotaging their car, takes the car in for a complete checkup.) The goal of psychoanalysis is to resolve unconscious conflicts by bringing repressed experiences and feelings into awareness and integrating them into the patient’s conscious experience. Psychoanalysis is therefore considered insight oriented. Patients best suited for psychoanalysis have the following characteristics: not psychotic, intelligent, and stable in relationships and daily living. Treatment is usually 3–5 days per week for many years. During therapy sessions, the patient usually lies on a couch with the therapist seated out of view. To become an analyst, professionals (MDs, PhDs, PsyDs, and MSWs) must complete training at a psychoanalytic institute. In addition to attending seminars and treating patients under supervision, the training requires that they receive their own analysis. Psychoanalysis can be useful in the treatment of the following:

IMPORTANT CONCEPTS AND TECHNIQUES USED IN PSYCHOANALYSIS ■ Free association: The patient is asked to say whatever comes into their mind during therapy sessions. The purpose is to bring forth thoughts and feelings from the unconscious so that the therapist may interpret them. ■ Dream interpretation: Dreams are seen to represent conflict between urges and fears. Interpretation of dreams by the psychoanalyst is used to help achieve therapeutic goals. ■ Therapeutic alliance: This is the bond between the therapist and the patient, who work together toward a therapeutic goal. ■ Transference: Projection of unconscious feelings regarding important figures in the patient’s life onto the therapist. Interpretation of transference is used to help the patient gain insight and resolve unconscious conflict. ■ Countertransference: Projection of unconscious feelings about important figures in the therapist’s life onto the patient. The therapist must remain aware of countertransference issues, as they may interfere with their objectivity. PSYCHOANALYSIS-RELATED THERAPIES Examples of psychoanalysis-related therapies include:

  1. Psychoanalytically oriented psychotherapy and brief dynamic psychotherapy: These employ similar techniques and theories as psychoanalysis, but they are less frequent, less intense, usually briefer (weekly sessions for 6 months to several years), and involve face-to-face sessions between the therapist and patient (no couch).
  2. Interpersonal therapy: Attachment-focused psychotherapy that centers on the development of skills to treat certain psychiatric disorders. Treatment is brief (once-weekly sessions for 3–4 months). The idea is to improve interpersonal relations. Sessions focus on reassurance, clarification of emotions, improving interpersonal communication, and testing perceptions. It has demonstrated efficacy in the treatment of depression and has been modified for use in adolescents.
  3. Supportive psychotherapy: Purpose is to help patient feel safe during a difficult time and help to build up the patient’s healthy defenses. Treatment is not insight oriented but instead focuses on empathy, understanding, and education. Supportive therapy is commonly used as adjunctive treatment in even the most severe mental disorders. Behavioral Therapy Behavioral therapy, pioneered by B. F. Skinner, seeks to treat psychiatric disorders by helping patients change behaviors that contribute to their symptoms. It can be used to extinguish maladaptive behaviors (such as phobic avoidance, compulsions, etc.) by replacing them with healthy alternatives. The time course is usually brief, and it is almost always combined with cognitive therapy as CBT. LEARNING THEORY Behavioral therapy is based on learning theory, which states that behaviors are learned by conditioning and can similarly be unlearned by deconditioning. PSYCHOTHERAPIES  WARDS TIP Psychoanalysis is not indicated for people who have problems with reality testing, such as actively psychotic or manic patients. KEY FACT An example of transference would be when a patient who has repressed feelings of abandonment by their parent becomes angry when their therapist is late for the appointment.

188 PSYCHOTHERAPIES  CONDITIONING KEY FACT Positive reinforcement: Giving a reward for a desired behavior. KEY FACT Negative reinforcement: Encouraging a behavior by removing an aversive stimulus. (Example: Putting on the seatbelt in the car to stop the beeping.) Punishment, in contrast, is an aversive response to a behavior. Punishment is not negative reinforcement. KEY FACT Biofeedback is used to treat a wide scope of clinical conditions including agoraphobia, fecal incontinence, tension headache, and hypertension. Cognitive Therapy ■ Classical conditioning: A neutral stimulus can evoke a conditioned response. (Example: Pavlov’s dog would salivate when hearing a bell because the dog had learned that bells were always followed by food.) ■ Operant conditioning: Behaviors can be learned when followed by positive or negative reinforcement. (Example: Skinner box—a rat presses a lever by accident and receives food; eventually, it learns to press the lever for food [trial-and-error learning].) BEHAVIORAL THERAPY TECHNIQUES (DECONDITIONING) ■ Systematic desensitization: The patient performs relaxation techniques while being exposed to increasing doses of an anxiety-provoking stimulus. Gradually, they learn to use relaxation skills to tolerate and cope with the anxiety-provoking stimulus. Commonly used to treat phobic disorders. (Example: A patient who has a fear of spiders is first shown a photograph of a spider, followed by exposure to a stuffed toy spider, then a videotape of a spider, and finally a live spider. At each step, the patient learns to relax while exposed to an increasing dose of the phobia.) ■ Flooding and implosion: Through habituation, the patient is confronted with a real (flooding) or imagined (implosion) anxiety-provoking stimulus and not allowed to withdraw from it until they feel calm and in control. Relaxation exercises are used to help the patient tolerate the stimulus. Less commonly used than systematic desensitization to treat phobic disorders. (Example: A patient who has a fear of flying is made to fly in an airplane [flooding] or imagine flying [implosion].) ■ Aversion therapy: A negative stimulus (such as an electric shock) is repeatedly paired with a specific behavior to create an unpleasant response. Used to treat addictions or paraphilic disorders. (Example: An alcoholic patient is prescribed Antabuse (disulfiram), which makes them ill every time they drink alcohol.) ■ Token economy: Rewards are given after specific behaviors to positively reinforce them. Commonly used to encourage showering, shaving, and other positive behaviors in disorganized patients. Also frequently used in treatment of substance use disorders on rehabilitation units as part of a contingency management program where abstinence is reinforced with material rewards or privileges. ■ Biofeedback: Physiological data (such as heart rate and blood pressure measurements) are given to patients as they try to mentally control physiological states. Can be used to treat anxiety disorders, migraines, hypertension, chronic pain, asthma, and incontinence. (Example: A patient is given their heart rate and blood pressure measurements during a migraine while being instructed to mentally control visceral changes that affect the pain.) Cognitive therapy, pioneered by Aaron T. Beck, seeks to correct faulty assumptions and negative feelings that exacerbate psychiatric symptoms. The patient is taught to identify maladaptive thoughts and replace them with positive ones. It is most commonly used to treat depressive and anxiety disorders, and is usually combined with behavioral therapy in CBT. It may also be used for paranoid personality disorder, obsessive-compulsive disorder, somatic symptom

­disorders, and eating disorders. Cognitive therapy can be as effective as medication for some disorders. CLINICAL EXAMPLE OF THE COGNITIVE THEORY OF DEPRESSION ■ Cognitive distortions, also known as faulty assumptions or automatic thoughts. (Example: If I were smart, I would do well on tests. I must not be smart since I received average grades this semester.) ■ Negative thoughts. (Example: I am stupid. I will never amount to anything worthwhile. Nobody likes a worthless person.) Cognitive-Behavioral Therapy (CBT) CBT combines theories and approaches from cognitive therapy and behavior therapy. Treatment follows a protocol or manual with homework assignments between therapy sessions. During therapy sessions, the patient and therapist set an agenda, review homework, and challenge cognitive distortions. The patients learn how their feelings and behavior are influenced by their thoughts. Treatment is usually brief and may last from 6 weeks to 6 months. Research has shown that CBT is effective for many psychiatric illnesses, including depression, anxiety disorders, schizophrenia, and substance use disorders. Mrs. R is a 22-year-old college student who is hospitalized after she tried to kill herself by taking an overdose of fluoxetine. This is her fifth overdose, and all have been in response to perceived rejections. She often feels “empty inside” and reports that she has had many intense relationships that have ended abruptly. She reports that she has been married for 1 year but fights constantly with her husband because of suspicions that he is unfaithful. Her husband denies these allegations and reports that he is tired of her outbursts, explaining that she yells at him and has become physically abusive. He has threatened to divorce her if these behaviors continue. During your evaluation, you notice multiple healed scars over her forearms, and she admits to self-harm behavior by cutting and burning herself because, “When I get angry, it helps me feel better.” During her hospitalization, you notice that her mood has improved and that she has become close to other patients. She says, “They are like family.” Although you have seen her only twice, she thinks you are “a great doctor,” unlike the psychiatrists who have treated her in the past, who have all been “idiots.” You call her outpatient therapist, who confirms that she has been diagnosed with borderline personality disorder. What are the recommended psychotherapeutic modalities for this patient? Dialectical behavioral therapy (DBT) and psychoanalytic/psychodynamic therapy have shown to be effective treatments in randomized controlled ­trials for borderline personality disorder. DBT is a form of cognitivebehavioral therapy that is effective in reducing the urges to ­engage in self-harm behavior and leads to fewer hospital days. Although the efficacy of couples therapy in borderline patients has been debated, it might be ­considered in this case. What special considerations should be taken into account when engaging in psychotherapy? The psychotherapist should always be aware of positive or negative ­countertransference developed toward the patient. Frequent discussion and PSYCHOTHERAPIES  WARDS TIP CBT focuses on a patient’s current symptoms and problems by examining the connection between thoughts, feelings, and behaviors.

190 PSYCHOTHERAPIES  Group Therapy WARDS QUESTION Q: What is the primary treatment for borderline personality disorder? A: Dialectical behavioral therapy (DBT). Family Therapy counseling with colleagues is useful. Patients with borderline personality disorder are challenging to treat due to their intense emotions, impulsivity, and anger. What particular defense mechanism is exhibited by Mrs. R? She exhibits splitting as evidenced by her extreme dichotomous thinking in expressing that you are a “great” psychiatrist, whereas other psychiatrists who have treated her in the past are “idiots.” Dialectical Behavioral Therapy (DBT) DBT was developed by Marsha Linehan, and its effectiveness has been demonstrated in research trials. Once-weekly individual and group treatment can effectively diminish the self-destructive behaviors and hospitalizations of patients with borderline personality disorder. It incorporates cognitive and supportive techniques, along with “mindfulness” derived from traditional ­Buddhist practice. DBT has demonstrated effectiveness in patients with borderline ­personality disorders and eating disorders. ■ Three or more patients with a similar problem or pathology meet together with a therapist for group sessions. Many of the psychotherapeutic techniques already reviewed are used, including behavioral, cognitive, and supportive. ■ Certain groups are peer led (including 12-step groups like Alcoholics Anonymous) and do not have a therapist present to facilitate the group. These groups meet to discuss problems, share feelings, and provide support to each other. ■ Group therapy is especially useful in the treatment of substance use disorders, adjustment disorders, and personality disorders. Advantages of group therapy over individual therapy include: • Patients get immediate feedback and support from their peers. • Patients gain insight into their own condition by listening to others with similar problems. • If a therapist is present, there is an opportunity to observe interactions between others who may be eliciting a variety of transferences. Family therapy is useful as an adjunctive treatment in many psychiatric ­conditions because:

  1. An individual’s problems usually affect the entire family. They may be viewed differently and treated differently after the development of psychopathology, and new tensions and conflicts within the family may arise.
  2. Psychopathology may arise or worsen due to dysfunction within the family unit. These conditions are most effectively treated with the entire family present. Evidence demonstrates that high expressed emotion (critical and

emotionally over-involved attitudes toward a family member) negatively impacts mental health in psychiatric patients. The goals of family therapy are to reduce conflict, help members understand each other’s needs (mutual accommodation), and help the family unit cope with internally destructive forces. Boundaries between family members may be too rigid or too permeable, and “triangles” may result when two family members form an alliance against a third member. The therapist may assist in correcting these problems. (Example of boundaries that may be too permeable: A parent and child smoke marijuana together and share intimate details about their sexual activities.) Family therapy is especially useful in treating schizophrenia and anorexia in adolescents. Couples Therapy Couples therapy is useful in the treatment of conflicts, sexual problems, and communication problems within the context of an intimate relationship. The therapist sees the couple together (conjoint therapy), but they may also be seen separately (concurrent therapy). In addition, each person may have a separate therapist and be seen individually (collaborative therapy). In the treatment of sexual problems, two therapists may see the couple together (four-way therapy). Relative contraindications include lack of motivation by one or both spouses and severe illness in one of the spouses (e.g., schizophrenia). PSYCHOTHERAPIES 

192 PSYCHOTHERAPIES  NOTES

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