Psychotherapy

September 23, 2011

Psychotherapy can be defined as “the treatment of mental or emotional disorders, or of related bodily ills by psychological means.” Another source defines it as “the art of alleviating personal difficulties through the agency of words and a personal, professional relationship.” There are many different types of psychotherapy, each of which has its own premise for success, utility, and sometimes inherent limitations. Following are the most widely used and accepted psychotherapeutic modalities, with an overview of each.

PSYCHOANALYSIS

Psychoanalysis is typically reserved for patients whose emotional difficulties arise solely from the past. The therapeutic relationship focuses on bringing forth repressed material that has encumbered a patient’s ability to optimally manage life’s provocations. Repression is a defense mechanism characterized by withholding a feeling or idea from conscious awareness.

The process of psychoanalysis utilizes the concepts of transference, countertransference, interpretation, therapeutic alliance, and resistance. Transference refers to unconscious feelings the patient has toward the analyst (positive or negative), typically founded upon the patient’s relationships/conflicts with parental figures. Countertransference refers to the analyst’s responses to the patient, also typically based in the unconscious. Interpretation is the analyst’s understanding and explanation of psychologically based events. Therapeutic alliance refers to the relationship between analyst and patient, based upon trust and cooperation. Resistance implies a patient’s withholding of information from the analyst, either conscious (lengthy silences) or unconscious (repressed feelings, desires).

Psychoanalysis is a longstanding process, usually comprising 3-6 years, or longer; individual sessions occur four or more times a week, the patient typically assuming the recumbent position on a couch, with the analyst seated out of view. This is said to foster the therapeutic process of regression and obtaining necessary repressed material. Disorders most effectively treated with psychoanalysis are usually limited to anxiety disorders (phobias, obsessive-compulsive disorders), dysthymia (mild depression), and some sexual, personality, and impulse control disorders.

PSYCHOANALYTIC PSYCHOTHERAPY

Although based on psychoanalytic concepts, this modality focuses on a patient’s current conflicts and behaviors, and how this affects one’s self-perception and relationships with others. There are two basic types of psychoanalytic psychotherapy: (a) supportive or relationship-oriented and (b) expressive or insightoriented.

Supportive therapy is typically used when a patient has encountered a time-limited crisis situation, or decompensation, and lacks the ego strength to manage the challenge entirely independently. Expressive therapy, on the other hand, is not problem focused, but instead allows the patient to acquire new insights into one’s behaviors and interactions with others, assuming rather intact ego strength.

The therapy is also one-on-one, but a couch is not used in the process, treatment can be short lived (a few sessions for a particular problem) or comprise several years (1-3 sessions/week), and there is much less emphasis, if any, on the concepts of regression and transference. Unlike psychoanalysis, psychoanalytic psychotherapy is used to treat most psychiatric disorders.

BRIEF PSYCHOTHERAPY

Also utilizing psychodynamic concepts, this type of therapy is appealing because of its shorter duration. Conflict resolution, transference, interpretation, and resistance are all central elements of the brief psychotherapies, of which there are several. Examples include brief focal psychotherapy, time-limited psychotherapy, short-term dynamic psychotherapy, and short-term anxiety-provoking psychotherapy. The duration of therapy may be up to 1 year, but typically averages a few months.

CRISIS INTERVENTION

Seemingly obvious, this therapy is very timelimited, brief, and serves to resolve a crisis situation that has caused a person to manifest psychiatric symptoms. It is typically used for individuals who have developed maladaptive coping mechanisms to crisisoriented situations, which when repeated over time produce greater and more intense difficulties in managing such experiences. The patient eventually develops psychiatric symptoms that further interfere with optimal functioning.

The goal of therapy is to facilitate learning new and adaptive coping skills by using reassurance, environmental manipulation, and suggestion, ultimately reducing the patient’s anxiety. Duration of treatment is anywhere from 1-2 sessions to 1-2 months, with the hope that what is learned in therapy is used in future crises to prevent regression back to unhealthy or maladaptive responses.

GROUP PSYCHOTHERAPY

There are a variety of group therapy approaches, all of which utilize the “group experience” to render individual personality change.

Supportive group therapy, for example, encourages reality testing by group members and focuses on present environmental change and adaptation. Psychoanalytic group therapy, conversely, emphasizes the role of past life experiences and restructuring personality dynamics. Transactional group therapy iterates the importance of “here-and-now” patterns of behavior, while behavioral group therapy uses conditioning methods to effect change for persons with phobias and other dysfunctional learned behaviors. Self-help groups are a type of group therapy characterized by their homogeneity and “sameness” of individual members. The goal for each person is typically to relinquish very similar unwanted behaviors.

Those appropriate for group therapy would be motivated to create/accept change and would be capable of performing the group task. Those who cannot tolerate a group setting or who have markedly unacceptable behaviors for the group milieu would obviously be inappropriate candidates for this type of therapy.

FAMILY THERAPY

Used typically to treat families in conflict, this therapy modality can be very complex and versatile. The family is viewed as a unit, which is determined by the behaviors of its individual related members. One’s symptoms are not so much the focus of treatment as are family dynamics and interactions. Directive control of the sessions by the therapist is imperative, so as to limit further deterioration (during the session) of already dysfunctional relationships.

Frequency of treatment is typically once a week, and duration can be weeks to years. Main goals are improved interpersonal and generational relationships, and overall conflict reduction/resolution.

MARITAL THERAPY

This type of psychotherapy addresses issues of conflict in the context of a couple’s relationship. Reasons for seeking treatment can be emotional, economic, sexual, social, parental, interpersonal, etc. The goal is to facilitate change within the relationship, by modifying unhealthy behaviors, and working toward improving interpersonal development.

Marital therapy can be an option when individual therapy has failed to improve marital conflict, or when marital issues are the source of conflict. It should be noted that for a chance at successful outcomes, both partners must be involved and motivated for treatment.

BIOFEEDBACK

This is a rather unique type of psychotherapy in which a person changes maladaptive, involuntary, physiologic responses oneself, by means of conscious mental control. Feedback instruments relay personal data to the patient (e.g., heart rate, muscle tension), which can then be modified by that person using conscious mental regulation.

Equipment most often used are the electromyogram (EMG—measures muscle movement), electroencephalogram (EEG—measures brain waves), galvanic skin response (GSR—measures skin temperature), and thermistor (measures skin temperature). Conditions that may respond to biofeedback are migraine and tension headaches, cardiac arrhythmias, asthma, enuresis, fecal incontinence, Raynaud’s syndrome, temporomandibular joint (TMJ) pain, blood pressure irregularities, and hyperactivity.

BEHAVIOR THERAPY

Behavior therapy focuses on specific problems, using learning theory and emphasizing standard conditioning techniques. There are various types of therapies used to target identified behaviors (rather than entire areas of dysfunction), and unlike other psychotherapies they do not require one to have insight into the source of the distress. Also, it is usually shorter in duration than the other psychotherapies.

Systematic desensitization, one type of behavior therapy, exposes the patient to increasing levels of anxiety while visualizing feared situations. Steps involved are relaxation training (imagery and muscle relaxation), hierarchy construction (a list of anxiety-provoking scenes increasing in severity), and desensitization of the stimulus (scenes are imagined while in a relaxed state, from least to most anxiety producing).

Graded exposure, another behavioral therapy, uses the same premise as systematic desensitization, but without relaxation training and the patient is exposed to real-life anxiety-provoking situations.

Flooding, often used for specific phobias, requires the patient to repeatedly confront the feared event, without escape, which over time, reduces anxiety and allows the patient to gain a sense of control. No relaxation training is used.

Participant modeling emphasizes patient observation, and eventual mimicking of others who confront the feared or anxiety-provoking event. An example of this would be the therapist who gradually leads the person with agoraphobia into a dreaded situation.

Aversion therapy, another less often utilized behavioral therapy, is used for impulse control problems such as paraphilias and addictions. This is facilitated by presenting the patient with a noxious stimulus after engaging in the undesirable behavior. Examples of such include social disapproval, medications that induce vomiting, and electrical stimuli, to name a few.

HYPNOSIS

The hypnotic state is one which resembles sleep, but is characterized by heightened focal concentration and receptivity to the suggestion of another person (Kaplan & Sadock, 1991). It is a type of therapy often used to uncover repressed memories, to change unwanted behaviors/habits (smoking, overeating, etc.), to treat chronic pain, and to induce anesthesia.

Persons undergoing hypnosis are put into a “trance” state that has varied levels: light, medium, or heavy. Posthypnotic suggestions are typically made during deep trance states. Because hypnotic induction is based upon trust, paranoid patients and those with very rigid, controlling personality structure are not appropriate candidates for this type of therapy.

COGNITIVE THERAPY

This type of psychotherapy is often used to treat depressive conditions. It is based on the premise that cognitive distortions (negative thought patterns) are the basis for causing depressive symptoms (anhedonia, apathy, low motivation, etc.). The goal of treatment is to change one’s thinking, by first identifying cognitive distortions, then finding alternatives to the thought patterns, and finally putting them into practice (mentally and behaviorally). It is believed that this in turn can alleviate depressive symptoms.

Cognitive therapy is of short duration (4-6 months of weekly sessions) and requires commitment and motivation of the patient given there is an established agenda at the outset, interspersed with homework assignments between sessions. In addition to depression, cognitive therapy has been applied to panic and somatoform disorders, paranoid syndromes, impulsive behaviors, and obsessive-compulsive disorders.

SEE ALSO: Cognitive-behavioral therapy, Psychoanalysis, Psychologists

Suggested Reading

  • Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press.
  • Kaplan, H. I., & Sadock, B. J. (1991). Synopsis of psychiatry (6th ed.). Baltimore: Williams & Williams.
  • Manning, D. W., & Frances, A. J. (1990). Combined pharmacotherapy and psychotherapy for depression. Washington, DC: American Psychiatric Press.
  • Storr, A. (1990). The art of psychotherapy (2nd ed.). New York: Routledge.
  • Weinberg, G. (1984). The heart of psychotherapy. New York: St. Martin’s Press.

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