Definition and types
Psychotherapy is interpersonal treatment rooted in psychological principles and mechanisms of mental disease.
Psychotherapy helps patients identify and diminish adverse feelings and thoughts and develop health-promoting behaviors.
Types of psychotherapy:
- Cognitive and behavioral therapy
- Psychoanalysis or psychodynamic psychotherapy
- Interpersonal therapy
- Motivational interviewing
- Dialectical behavioral therapy
- Supportive psychotherapy
- Group and family therapy
Features of psychotherapy
- Systemic interaction:
- The therapist uses a structured interview with the patient.
- The structure is based on the therapist’s understanding of the psychological basis of disease.
- Psychological principles of mental disorders:
- Mental health and disease are affected by psychological mechanisms.
- This phenomenon is seen in inhibited memory of severe psychological trauma contributing to mental disorders—that is, dissociative disorders.
- Targeted domain: In order for psychotherapy to be effective, a defined goal must be set.
- Shared features among psychotherapies:
- All types of psychotherapy are unique, but all also share common features.
- Psychotherapy involves verbal interchanges between the patient and therapist.
- Nonverbal cues are also seen in “talking therapies,” which are important to the therapist regardless of the method used.
- Psychodynamic therapy is based on the principle of psychoanalysis (that most mental disorders are caused by deep unconscious conflicts):
- Previous childhood experiences and relationships contribute to the person’s current situation and behavior.
- The goal of this method is to help the patient gain insight into and resolve their past experiences.
- Psychoanalysis requires long-term treatment (frequent visits for years).
- Psychodynamic therapy is more brief (about once a week, but can go for months).
- This method is best suited for young, intelligent adults with no psychosis.
Concepts in psychodynamic therapy
- Classical psychotherapy: Unresolved conflicts lead to psychopathology (i.e., depression).
- Ego psychology:
- Originated from Sigmund Freud’s id-ego-superego model
- Takes defense mechanisms into consideration (conflicts are explored, as well as the defensive attempts made by the patient)
- Object relations:
- A child’s relation to an object develops the psyche and shapes future relationships.
- Objects are persons, usually a mother.
- Understanding the patient from within their subjective experience
- Achieved by:
- Empathy: Positive experience with the therapist helps form a therapeutic alliance.
- Mirroring: using positive responses of others to see the positive in oneself
- Idealizing: having another individual or an external other who is calm to provide comfort when one is having conflict
- Psychoeducation serves as the foundation for other forms of psychotherapy.
- Provide the patients with information about the diagnosis that is necessary to help them accept their condition
- Discusses treatment options, thus empowering the patient to anticipate problems and become proactive in the management of their condition
- Components of psychoeducation include:
- Review of diagnosis
- Course and prognosis of disorder
- Outline of different treatment options
- Discussion of common comorbidities
- Identification of warning signs and a plan to prevent relapse
- Useful in a wide variety of settings for many diagnoses (e.g., bipolar disorder)
- Supportive therapy is a type of therapy used in many settings and is usually brief.
- The therapy emphasizes empathy and aims to reduce the subjective distress of the patient.
- Helps patient(s) cope with illness
- Helps patient(s) handle a crisis and maintain optimism
- The therapist listens to patient’s concerns, with a focus on encouragement and patient’s strengths, thus enabling a decrease in negative thinking.
- One of the most widely used and most effective methods of therapy
- Dr. Aaron Beck is credited with the creation of this method, which is based on the theory that thoughts, behaviors, and emotions are all linked.
- Combination of cognitive therapy and behavioral therapy (CBT):
- Cognitive therapy:
- The perception of things affects our behavior, thus psychological problems arise from distorted thinking.
- Determines and corrects the thinking (maladaptive beliefs and faulty assumptions) that exacerbates the psychopathology
- Behavioral therapy:
- Manipulates the physiologic and external environment
- Uses thought exercises and experiences to reduce symptoms (relaxation, reinforcement, and graduated exposure to stimuli)
- The goal is to replace maladaptive behaviors with healthier alternatives.
- Cognitive therapy:
- A structured, interactive, and present-oriented approach
- Patients are generally highly motivated.
- Ranges from 5 to 20 sessions
The following are techniques:
- Classic conditioning:
- A stimulus can evoke a conditioned response.
- Seen in the Pavlov’s dog experiment, in which a bell was run when the dog was fed, so over time, whenever a bell was rung, the dog salivated.
- Operant conditioning: Instrumental learning (as seen in Skinner’s box) has behavioral consequences.
- Positive reinforcement:
- Something is added to increase the behavior.
- Adding a rewarding experience → ↑ behavior
- Rat presses on lever and gets food → ↑ rate of pressing
- Negative reinforcement:
- Something is removed to increase the behavior.
- Removal of adverse stimulus → ↑ behavior
- Rat presses on lever and noise stops→ ↑ rate of pressing
- Positive punishment:
- Something is added to decrease the behavior.
- Adding an aversive stimulus to an undesired behavior → ↓ behavior
- A fine is given for speeding → ↓ speeding
- Negative punishment:
- Something is removed to decrease the behavior.
- Removal of stimulus after an undesired behavior → ↓ behavior
- A toy is taken from a child when they throws a tantrum → ↓ tantrums
- Extinction: weakening and loss of the conditioned response when reward or reinforcement is discontinued
- Positive reinforcement:
- Systematic desensitization:
- This technique is based on the principle that phobias are a learned behavior that can be modified.
- The patient performs relaxation techniques while an anxiety-provoking stimulus is being presented in gradually increasing doses.
- For example, for a patient who is afraid of dogs: pictures of dogs are shown, then a stuffed animal, then a more realistic exposure
- Degree of “imagined” stimuli is increased and the patient is instructed to remain relaxed.
- Involves intensive recollection of anxiety-provoking situations
- The patient who is afraid of dogs is asked to imagine going to a dog park.
- Patient is immersed in the actual stimulus.
- The patient who is afraid of dogs goes to a dog park.
- Aversion therapy:
- A negative stimulus is repeatedly paired with a specific behavior to create an unpleasant response, leading to a behavioral change.
- Example: alcoholic patients are given disulfiram so when they drink alcohol, they will get violently sick.
- Token economy:
- If a patient shows certain behaviors, they get a reward for positive reinforcement.
- Children with conduct disorders can be treated with this technique.
- Physiologic data (i.e., HR and BP measurements) are given to patients during times of distress.
- This feedback allows the patients to make changes in their body (e.g., relax).
- Example: A patient with migraines is encouraged to visualize the dilation of her arteries whenever experiencing pain (to mentally control the physiologic state).
- Systematic desensitization:
- Fundamentals of cognitive therapy:
- Coping skills training
- Stress management
- Assertiveness training
- Some of the techniques:
- Journaling: allows self-reflection by identifying thought patterns and related emotions
- Cognitive restructuring:
- Process of challenging and reframing negative thoughts and looking at a situation from a different perspective
- Can be achieved by guided questioning by the therapist
- Interpersonal therapy focuses on interpersonal difficulties resulting in psychological problems:
- Grief over loss
- Interpersonal skill deficits
- Role transitions
- This therapy is based on the theory that relationships are the most important aspect leading to psychological disorders.
- The patient’s social experiences should be addressed (e.g., relationship distress leads to a higher rate of depression).
- This form of therapy is opposed to the psychoanalytical theory that it is intrapsychic conflict that leads to psychological problems.
- Motivational interviewing is a counseling approach that aims to change behaviors (e.g., substance abuse disorders).
- The therapist understands the patient’s perspectives and the problematic behaviors and tries to match strategies to promote change depending on the patient’s readiness.
- Key elements:
- Expressing empathy: engage the patient without judgment and assess patient’s readiness to change
- Identifying discrepancies between the behaviors and personal values:
- Obtain patient’s thoughts on what is hoped for, the current behavior, and how these match up.
- In the process, the behavior-change goal or target is focused on and motivation can be built on this.
- Expecting resistance and accepting it: Avoid arguments or confrontation.
- Support self-efficacy:
- Belief that the patient can achieve a specific behavior
- It is the patient who decides to change, makes the plans, and implements the plans to reach the goal.
- The clinician’s role is guidance and encouragement.
Dialectical Behavioral Therapy
- Dialectical behavior therapy is a variation of CBT developed by Dr. Marsha Linehan for borderline personality disorder (BPD).
- Involves managing treatment targets with the aim of reducing suicidal or dangerous behavior, treatment-interfering behavior, and quality of life-interfering behavior, among others
- Primary focuses:
- Interpersonal effectiveness
- Emotion regulation
- Distress tolerance
- Group therapy is an approach involving discussion, sharing of feelings, and peer support.
- Develops a support system of people with similar difficulties
- The patient(s) get immediate feedback from peers.
- Listening to others going through the same problems may help the patient gain insight into their condition.
- The therapist is also able observe patient interactions.
- An example of this is Alcoholic Anonymous.
- Useful in grief or bereavement, substance abuse, adjustment disorders, and personality disorders.
Family Therapy and Marital Therapy
- Treatment in which the family system is the focus
- The entire family is seen together, facilitating group understanding of individual psychopathology and how it affects the family unit.
- Impaired communications and relationships are addressed to help the patient with psychiatric illness and the rest of the family.
- Helps identify conflicts that may arise and means to resolve these issues
- Couples therapy is used in marital conflicts, communication issues, sexual problems,
- The therapist helps identify each individual’s needs and the obstacles to achieving these.
- Sessions are usually conjoint, with each one also seeing a separate therapist.
Summary of Types of Psychotherapy
|Psychoanalysis and psychodynamic therapy||
|Psychoeducation (and family therapy)||
|Cognitive-behavioral therapy (CBT)||
|Group psychotherapy||Patients who share a diagnosis guide each other through recovery through discussions, sharing of feelings, and peer support.||
||Substance use disorders|
|Dialectical behavioral therapy||
||Borderline personality disorder|
|Marital therapy||Couples go to a therapist who identifies individual needs along with the obstacles in meeting those needs.||Marital and sexual conflicts|
- Gabbard, G., DeJean, V. (2021) Unipolar depression: psychodynamic therapy. UpToDate. Retrieved July 12, 2021, from https://www.uptodate.com/contents/unipolar-depression-in-adults-psychodynamic-psychotherapy
- Ingersoll, K. (2021) Motivational interviewing for substance use disorders. UpToDate. Retrieved July 12, 2021, from https://www.uptodate.com/contents/motivational-interviewing-for-substance-use-disorders
- Lebow, J. (2021) Overview of psychotherapies. UpToDate. Retrieved July 11, 2021, from https://www.uptodate.com/contents/overview-of-psychotherapies
- Lomax J.W., Ivan M (2019). Psychodynamic psychotherapy and the therapeutic relationship. Chapter 11 of Ebert M.H., Leckman J.F., Petrakis I.L.(Eds.), Current Diagnosis & Treatment: Psychiatry, 3rd ed. McGraw-Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=2509§ionid=200802805
- McLean J. (2007). Psychotherapy with a narcissistic patient using Kohut’s self psychology model. Psychiatry (Edgmont) 4(10):40–47.
- Novotney, A. (2017, December). Psychoanalysis vs. psychodynamic therapy. Monitor on Psychology 48(11). http://www.apa.org/monitor/2017/12/psychoanalysis-psychodynamic
- Salomon, R.M. (2019). Adjustment disorders. Chapter 28 of Ebert, M.H., Leckman, J.F., Petrakis, I.L. (Eds.), Current Diagnosis & Treatment: Psychiatry, 3rd ed. McGraw-Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=2509§ionid=200806502
- Skodol, A. (2021) Psychotherapy for borderline personality disorder. UpToDate. Retrieved July 12, 2021, from https://www.uptodate.com/contents/psychotherapy-for-borderline-personality-disorder
- Swartz, H. (2021) Interpersonal therapy (IPT) for depressed adults: indications, theoretical foundations, general concepts and efficacy. UpToDate. Retrieved July 12, 2021, from https://www.uptodate.com/contents/interpersonal-psychotherapy-ipt-for-depressed-adults-indications-theoretical-foundation-general-concepts-and-efficacy