Psychotherapy

Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychodynamic therapy seeks to bring forward unconscious or repressed thoughts to help address the current behavior. Cognitive-behavioral therapy corrects faulty assumptions and tries to replace maladaptive behavior with healthier alternatives. Psychoeducation provides patients with information about the disorder, including anticipated problems and treatment so that they are able to manage. Other forms include supportive therapy (short-term therapy to help through a life crisis), motivational interviewing (changing maladaptive behaviors by guiding the patient to be the agent of change for themself), interpersonal therapy (focusing on the relationships rather than repressed thoughts), and dialectical behavioral therapy (using a hierarchy of treatment targets, like reduction of suicidal and dangerous behavior). Treatment is offered in different formats (individual, family, couple, or group). The goals vary and can include changing the individual’s behaviors and thoughts, improving relationships, reducing psychiatric symptoms as well as functional impairment, and involving the family to enhance treatment.

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Overview

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
  • Psychoeducation
  • 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

Description

  • 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

Table: Important processes related to psychodynamic therapy
Concept Description
Unconscious
  • Thoughts repressed/ideas blocked because of the conflict they create
  • Psychotherapy tries to bring out the unconscious for analysis.
Free association
  • The patient is instructed to talk freely about ideas that come to mind, even if they seem to be loosely related.
  • A means by which the therapist accesses the unconscious process by linking topics and identifying areas of resistance and patterns of thinking.
  • These methods help to define unconscious conflicts that might have led to the patient’s current problem.
Dream analysis
  • Dreams are seen to represent conflict between urges and fears.
  • One of the best ways to understand the unconscious mind is to interpret the individual’s dreams.
  • Helps determine therapeutic goals
Transference
  • Unconscious redirection of feelings and desires about important people in the patient’s life onto the therapist
  • Example: seen in a patient with repressed feelings of abandonment who becomes irate when the therapist is late
Countertransference
  • Unconscious redirection of feelings about important figures in the therapist’s life onto the patient
  • Can interfere with objectivity (requires awareness on the part of the therapist)
  • Example: patient reminds physician/therapist of their younger sibling
Defense mechanism
  • Means unconsciously used by the patient to cope with conflicts and sustain interactions with people important to the patient
  • Can be:
    • Immature or primitive (denial, splitting, projection)
    • Higher-level (humor, repression, rationalization)
Resistance
  • Conscious and unconscious forces within the patient that oppose the purpose of the patient’s evaluation and the goals of the treatment
  • Patient misses or is late to appointments or refuses to open up regarding an issue.

Types

  • Classical psychotherapy: Unresolved conflicts lead to psychopathology (i.e., depression).
  • Ego psychology:
    • Originated from Sigmund Freud’s id-ego-superego model
    • Takes defense mechanisms Defense mechanisms Defense mechanisms are normal subconscious means of resolving inner conflicts between an individual's subjective moral sense and their thoughts, feelings, or actions. Defense mechanisms serve to protect the self from unpleasant feelings (anxiety, shame, and/or guilt) and are divided into pathologic, immature, mature, neurotic, and other types. 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.
  • Self-psychology:
    • 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

  • 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 Bipolar disorder Bipolar disorder is a highly recurrent psychiatric illness characterized by periods of manic/hypomanic features (distractibility, impulsivity, increased activity, decreased sleep, talkativeness, grandiosity, flight of ideas) with or without depressive symptoms. Bipolar Disorder)

Supportive Therapy

  • 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.

Cognitive-Behavioral Therapy

Description

  • 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.
  • A structured, interactive, and present-oriented approach  
  • Patients are generally highly motivated.
  • Ranges from 5 to 20 sessions

Behavioral therapy

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
  • Deconditioning:
    • 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
    • Implosion:
      • 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.
    • Flooding:
      • 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.
    • Biofeedback:
      • 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 Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries whenever experiencing pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain (to mentally control the physiologic state).

Cognitive therapy

  • Fundamentals of cognitive therapy:
    • Education
    • Relaxation
    • 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

  • Interpersonal therapy focuses on interpersonal difficulties resulting in psychological problems:
    • Grief over loss
    • Interpersonal skill deficits
    • Disputes
    • 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

  • 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:
    • Mindfulness
    • Interpersonal effectiveness
    • Emotion regulation
    • Distress tolerance

Group Therapy

  • 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

Family 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

Marital therapy

  • 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

Table: Summary of the most important types of psychotherapy and their best indications
Type Description Indications
Psychoanalysis and psychodynamic therapy
  • Psychoanalysis: frequently per week, several years
  • Psychodynamic therapy: once a week, for months to years
  • Reveals unconscious aspects of a patient’s life
  • Identifies repressed experiences and feelings that are causing psychological problems
  • Personality disorders
  • Depression
  • Anxiety disorders
  • Indicated for higher-functioning patients (not used in psychotic patients)
Psychoeducation (and family therapy)
  • Educates the patient and family with necessary information about the disease
  • Enables the patient to learn to anticipate and manage problems
  • Schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia (reduce relapses)
  • Bipolar disorder
Supportive psychotherapy
  • Focuses on helping the patient deal with a life crisis and cope with illness
  • More indicated for shorter-term use
  • Grief
  • Substance abuse
  • Depression
  • Anxiety
Cognitive-behavioral therapy (CBT)
  • Identifies irrational thoughts and assumptions leading to psychopathology
  • Replaces maladaptive behaviors with healthier alternatives
  • Depression
  • Anxiety disorders
  • Eating disorders
  • Impulse control disorders ( OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD), hoarding disorder, etc.)
  • PTSD PTSD Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Posttraumatic Stress Disorder (PTSD) (trauma-focused CBT)
  • Phobic disorders (CBT with exposure)
  • Medical conditions ( insomnia Insomnia Insomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking. Insomnia, smoking, low back pain Back pain Back pain is a common complaint among the general population and is mostly self-limiting. Back pain can be classified as acute, subacute, or chronic depending on the duration of symptoms. The wide variety of potential etiologies include degenerative, mechanical, malignant, infectious, rheumatologic, and extraspinal causes. Back Pain)
Interpersonal therapy
  • Short-term treatment focusing on loss, role, and transitions in life
  • Addresses interpersonal difficulties that lead to psychological problems
Depression
Group psychotherapy Patients who share a diagnosis guide each other through recovery through discussions, sharing of feelings, and peer support.
  • Substance use disorders
  • Eating disorders
  • PTSD PTSD Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Posttraumatic Stress Disorder (PTSD)
  • Alcohol abuse
Motivational interviewing
  • An approach to help patients change maladaptive behaviors
  • The patient makes the decision to change and tries reach a target behavior.
  • The therapist offers guidance.
Substance use disorders
Dialectical behavioral therapy
  • Provides lessons on mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance
  • Helps reduce injurious behavior and number of hospitalizations
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

References

  1. 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
  2. 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
  3. Lebow, J. (2021) Overview of psychotherapies. UpToDate. Retrieved July 11, 2021, from https://www.uptodate.com/contents/overview-of-psychotherapies
  4. 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&sectionid=200802805
  5. McLean J. (2007). Psychotherapy with a narcissistic patient using Kohut’s self psychology model. Psychiatry (Edgmont) 4(10):40–47.
  6. Novotney, A. (2017, December). Psychoanalysis vs. psychodynamic therapy. Monitor on Psychology 48(11). http://www.apa.org/monitor/2017/12/psychoanalysis-psychodynamic
  7. 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&sectionid=200806502
  8. Skodol, A. (2021) Psychotherapy for borderline personality disorder. UpToDate. Retrieved July 12, 2021, from https://www.uptodate.com/contents/psychotherapy-for-borderline-personality-disorder
  9. 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

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