Psychotherapy

1
Psychotherapy

• Developed from psychoanalysis
• Sigmund Freud (1856 - 1939)
• Basic Concepts
• Unconsious
• Psychic Energy
• Repression
• Transference
• Developmental

2
Unconscious

• Dynamic - system of wishes, impulses and memories
  which actively influence thoughts, actions,
  symptoms, dreams, mistakes, accidents and
  emotions
• Id, Ego and Superego
• Unconscious derived from
• - innate drives
• - repressed material
• Defies time and logic
• Not constrained by reality

3
Psychic energy

• Mind fuelled by psychic energy (libido) derived
  from the life preserving drives.Later added
  life-destroying drives. Psychic energy can never
  be created or destroyed but only changed in form.
  Severe psychological disorders e.g. anxiety,
  depression, result from blocking of sexual energy.

4
Repression

• Conscious or unconscious avoidance of painful or
  unwanted information.Early work with Breuer -
  anxiety consequence of repressed energyLater
  proposed anxiety a warning state of the ego
  that signals necessity for repression to defend
  the ego from internal danger arising from
  forbidden impulses and wishes.Extended to
  include reaction formation, sublimation and
  projection.

5
Transference

• Feelings of patient for therapist.
• Initially seen as a nuisance, but later
  encouraged as a re-enactment of earlier
  significant relationships.Exploration of
  transference used as therapeutic tool.Counter
  transference reactions of therapist to patient.

6
Developmental stages

• Oral Anal Phallic Latency GenitalFixation
  can occur at any stage of development and is
  apparent as personality traits or revealed at
  times of stress.Extended by Erikson (1963).

7
Mary - Background

• 50 year Irish Catholic Caucasian woman
• Lives with husband
• Mother of 3 adult children
• Never worked outside home
• Significantly overweight
• Following death of father from a cardiac arrest
  when she was 5 she was raised by a single mother
• Mother suffered from panic attacks.
• Mother was eldest of 2 children having a brother
  2 years her junior

8
Mary Presenting Problem

• Frequent and severe panic attacks involving
  symptoms of rapid breathing, trembling, faintness
  and intense fear
• Episodes only occur outside her home
• Fears she will die of a heart attack
• Symptoms have confined her to home and othe
  safe locations, such as church and her
  daughters house
• Expressing marital conflict, centreing round her
  perceived inability to work despite a recent
  financial setback in the home.

9
Techniques

• Free association
• Insight
• Working through
• Dream analysis
• Analysis of transference

10
Mary - Techniques

• Free association
• Mary encouraged to say whatever is on her mind no
  matter how silly or embarrassing
• Insight
• Mary learns she really hates her mother and her
  panic is partially a guilt reaction to her wish
  that her mother had died when she experienced
  episodes of panic
• Working through
• Learns to accept and cope with her insight
  concerning the hate she experienced towards her
  mother
• Dream analysis
• Reports dream that came to therapy session and
  the therapist was not there to see her. In
  discussing dream reports fears of being abandoned
  by her therapist as well as other important
  figures in her life
• Analysis of transference
• Marys feelings of love and longing for her
  father are projected on to her male therapist

11
Ego Defense Mechanisms

• 1) Repression2) Denial3) Reaction
  formation4) Projection5) Sublimation6) Displace
  ment

12
Mary - Ego Defense Mechanisms

• Repression
• Hate of her mother is so anxiety and guilt
  provoking that she does not allow these to become
  conscious, keeping them repressed in her
  unconscious
• Denial
• Denies having hateful feelings towards her
  mother
• Reaction formation
• Hateful feelings are so powerful that she
  behaves in a very loving way. She expresses a
  great deal of affection and has difficulty not
  being in close contact with her
• Projection
• Dislike of mother is projected onto female
  therapist who she feels is cold, aloof and
  uncaring
• Sublimation
• Hate of mother has led her to channel her
  feelings into charities which prevent child abuse
• Displacement
• Hate toward mother cannot be channelled to her
  for fear of retaliation along with anxiety and
  guilt. Instead she becomes very irritable and
  critical of her husband for no apparent reason

13
Neofreudians

• Jung - 1875 - 1965 rejected emphasis on sexuality
• Erikson - 1909 - 1993 lifespan development
• Adler - 1870 - 1937 compensation for feelings of
  inferiority important

14
Contemporary Approaches

• Kleinke 1994 - Therapeutic goals
• overcoming demoralisation and aging hope
• enhancing mastery and self-efficiency
• overcoming avoidance
• becoming aware of ones misconceptions
• accepting lifes realities
• achieving insight

15
Depression

• Develops
• Experience disappointment e.g. loss of loved one
• Loved one cannot be abandoned and affection
  transferred to someone else
• Person identifies with the other and internalises
  him/her
• Attacks on self are seen as attacks against loss
  or disappointing person

16
Key Features

• Depressed individuals have difficulty giving up
  what they have lostRepressed hostilityInner
  conflictDepression emotional expression of a
  state of powerlessness of the self to achieve and
  live up to strongly held wishes.

17
Anxiety

• Anxious feelings arise from internal conflicts or
  impulses of which individual is not aware. Early
  loss or separation may lead to anxiety in adult.
• Aim to trace feelings back to origins in
  childhood by making interpretation.

18
OCD

• Linked to anal-sadistic stage of development
• Toilet training important
• Association anger and aggression
• Those who do not successfully negotiate this
  stage of development vulnerable to OCD

19
Humanistic Approaches

• Key self actualizing
• Carl Rogers (1902-1987) Person centred therapy
• Therapist
• - passive role
• - few interpretations
• - give individual chance to develop
• Unconditional positive regard. Empathy
• Relationships single most positive influence in
  facilitating human growth

20
Interpersonal Therapy

• Klerman et al 1994
• IPT for depression based on model of Sullivan.
  Brief, time limited, individual therapy.
• Therapists use
• Non-directive exploration
• encourage expression of affect
• teach more effective interpersonal communication
• alter behaviours through insight, information and
  role play

21
Evaluation

• Smith Glass 1977 375 studiesMeta-analysis and
  effect-sizeTreated patients did better than
  untreatedNo difference between types of
  psychotherapy
• e.g. behavioural vs psychodynamic
• Follow up analyses support finding that treatment
  helps.Psychodynamic vs cognitive behavioural
  treatmentsuse treatment manuals/protocolstherap
  ist confined to specific approach

22
Norcross et al 1995

• Different types of therapy - different effects
• General cognitive/behavioural - more positive
  outcomes than psychodynamic or verbal treatment
  orientations

23
NIMH study - Depression Elkin et al 1989

• Cognitive Behavioural
• Interpersonal - psychodynamic and humanistic
• Medication
• Drug placebo
• 250 patients
• All treatments ? improvement
• Minimal differences between CBT and interpersonal
  therapy
• No one approach better for all disorders but
  differences according to specific problems
• Insight oriented dynamic therapy appropriate for
  depression and mental discord

24
Frank et al 1990

• Maintenance of gains following medication
• Monthly IPT vs Monthly IPT medication vs IPT
  placebo vs placebo alone
• Relapse rate lowest in IPT medication
• Monthly IPT patients stayed well twice as long as
  placebo

25
Factors associated with positive outcome

• Weinberger 1995
• - therapeutic relationship
• - expectation of success
• - providing experience of mastery or control
  over problem
• - confronting a problem
• - an attribution of success or failure

26
Change is difficult

• Behaviour and thinking patterns difficult to
  change
• Proshcaska 1984 - process of change
• - 5 stages
• - 5 levels
• - 10 processes

27
Poor Outcome

• Characteristics of patient
• -Little motivation for change
• -Low tolerance of anxiety
• -History of inability to maintain satisfying
  interpersonal relationships
• Characteristics of therapist
• -Lack of empathy
• -Impatient
• -Authoritarian
• Interaction or fit between patient and therapist