The psychotherapies

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CHAPTER 14 The psychotherapies

David J. Castle, Darryl Bassett

Psychotherapy is a broad term that encompasses anything from support of the individual through a time of personal turmoil to daily psychoanalysis conducted over years. Indeed, the term is probably so broad that it has become rather un-useful, and requires a descriptor to specify what is meant. Box 14.1 outlines the major types of psychotherapy.

BOX 14.1 Types of psychotherapy

Types of psychotherapy include:

• supportive psychotherapy
• psychoeducation
• behavioural therapy
• cognitive therapy
• cognitive behaviour therapy
• interpersonal psychotherapy
• dialectic behaviour therapy
• brief psychodynamic psychotherapy, and
• long-term psychodynamic psychotherapy (e.g. psychoanalysis).

Supportive psychotherapy

This term is applied to the most basic form of psychotherapy, which should form part of any therapeutic relationship. Arguably, other more specific forms of psychotherapy build onto a supportive framework. Supportive psychotherapy entails:

image the provision of a supportive, caring and listening environment for the patient
image giving the patient an opportunity to ventilate their feelings (catharsis)
image discussion of the patient’s strengths, vulnerabilities and current life stressors
image enhancement of the patient’s coping skills to assist them deal with life stressors, and
image provision of a framework for monitoring clinical progress.

Psychoeducation

Broadly, psychoeducation refers to the provision by the therapist of general information to the patient (and their family and significant others, as indicated) regarding the nature of their mental illness and the potential therapeutic interventions available. There is also a more specific component, where the therapist addresses how this general knowledge applies to the particular individual. This process can also be an entry into a discussion about the impact of the illness on significant others, and can lead to an understanding about how the patient can monitor their mental state and the specific steps they can take to help themselves get better.

For example, the patient with depression and alcohol abuse can be provided with information about the interaction between these, and a discussion can begin about how each set of problems can be addressed.

There are many useful resources that can assist in the process of psychoeducation. These include books, pamphlets, videos, DVDs and myriad websites. It is best for the therapist to review such material before directing the patient to it. Also, some patients try to seek so much information that it becomes confusing and counterproductive. Thus, it is best to have a few good quality resources one can recommend.

Behavioural therapy

Behavioural therapy essentially encompasses techniques where a feared object or situation is faced rather than avoided. This can be done in vivo (i.e. in real life), or imaginally (i.e. the person summonses the image into their mind): the former is usually preferred, as it is easier to do and seems more powerful. Sometimes, the feared situation is such that it is impossible to reenact in vivo (e.g. post-traumatic stress disorder after a horrific fire). In such cases, imaginal exposure can be effective.

Behavioural therapy is usually undertaken in a step-wise manner, such that the patient constructs a hierarchy of fears and works at each step in an ongoing manner, akin to a runner getting fit according to a stepped exercise regime. The ‘least feared’ object or situation is tackled first, consolidated, and then the next task on the hierarchy is attempted. The therapist acts much like a sports coach—guiding, supporting and encouraging the individual to take the next step, and providing useful tips about how to motivate oneself and overcome the barriers to ‘getting fit’ again. The actual ‘work’ has to be performed by the patient, and they need to ‘stay with’ the anxiety aroused by the situation or feared object until their anxiety abates to a substantial degree. This is done repeatedly until that fear step is conquered, and the next step can be taken. The process is also referred to as exposure and response prevention (EX/RP), in that the patient ‘exposes’ themself to the feared situation, and does not give in to the urge to perform the usual ‘response’ (e.g. running away).

It can be useful to help the patient manage their overall anxiety, such that they employ, for example, slow-breathing techniques and positive self-talk to help them through the tasks. However, they do need to experience some degree of discomfort and anxiety at each step; otherwise, the step is not therapeutically useful. Some people employ techniques such as emotional withdrawal, ask others for reassurance, or resort to alcohol or benzodiazepines to deal with

CASE EXAMPLE: behavioural therapy

A 35-year-old woman had severe agoraphobia with avoidance of any crowded situations. A major impediment to living her life to the full was her total avoidance of shops: this led to conflict with her husband because he had to do all the family shopping and had come to resent this. The patient constructed a hierarchy, with the most difficult task being supermarket shopping on a busy Saturday morning by herself. She was encouraged to start with small steps, including going to the local corner store with her husband during a time when no one else was around. Once she had conquered this, she was encouraged to go to the same store by herself, then to try it at busier times of the day. She was also taught about how she could reduce her anxiety and attenuate panic attacks, through slow-breathing techniques. After some months of concerted work, she felt able to tackle supermarket shopping: again, she first went with her husband, moving on to going by herself.

anxiogenic situations: these can interfere with the therapeutic effect of behavioural therapy.

Occasionally, instead of a step-wise approach, the patient can be exposed in a single session to their most feared situation (e.g. the spider phobic allowing a tarantula to crawl on them). This is known as flooding.

Behavioural therapy is also the primary therapeutic modality in obsessive-compulsive disorder. Here the individual ‘faces’, again in a hierarchical manner, the fear associated with an obsessional thought. For example, the patient who repeatedly checks electrical appliances is tasked with switching the toaster on, then off, and checking just thrice rather than 30 times, and ‘stays with’ the anxiety this arouses, until it subsides. Again, this task is repeated until conquered, whereafter the next step is embraced (e.g. check just twice, and then only once). The patient must be reminded not to seek reassurance from others, and their family members should be coached as supportive co-therapists, rather than giving in to the reassurance-seeking of the patient, such as, for example, going and checking the toaster for them.

Cognitive therapy

The notion that un-useful cognitions drive depression and anxiety symptoms might seem obvious, but the utility of cognitive challenge in a therapeutic sense gained ascendancy only in the 1960s, with the work of, among others, Aaron T Beck. Beck postulated that people who are prone to depression (his initial focus) tend to see themselves, the world around them, and their future, in a negative way, and that they tend to have negative automatic thoughts in response to events in their world. He also identified a number of thinking traps people with depression tend to fall into (see Box 14.2).

BOX 14.2 Cognitive ‘thinking traps’

Cognitive ‘thinking traps’ include the following:

• dichotomous thinking: seeing things as ‘black-or-white’; all-or-nothing thinking (e.g. ‘If I don’t come first in the race, then I am useless at running and might as well just give it up’; ‘If I don’t do it perfectly, then it will be no good at all’)
• overgeneralisation: concluding that if one thing goes wrong, then everything is going to go wrong (e.g. ‘I didn’t answer that interview question very well; I am sure they will think I am a moron and I won’t get the job’)
• personalisation: jumping to an immediate conclusion that an event relates (usually negatively) to oneself (e.g. ‘My colleague seemed grumpy in the morning staff meeting; I must have done something to offend him’)
• arbitrary inference: jumping to conclusions without weighing the evidence (e.g. ‘I didn’t manage to complete my homework properly; I will never get the hang of this therapy’), and
• selective attention: the tendency to ‘filter in’ only negatives, rather than giving equal weight to all sources (e.g. ‘One person rated my lecture badly; I am a useless lecturer’).

Cognitive therapy involves helping individuals identify and challenge negative automatic thoughts. They are also taught to recognise their own thinking traps, and use this knowledge to assist them to face the world in a more positive manner. The patient is encouraged to keep a diary of negative thoughts, including rating to what extent they believe them (usually as a percentage). They then try to challenge these, and then rate whether the intensity of the belief has been eroded, and to what extent. This is done in an iterative way, and therapy sessions include looking over the diaries with the therapist, and working through examples together. A further technique is the so-called downward arrow, which seeks to explore the underlying schemas the individual holds.

CASE EXAMPLE: cognitive therapy

A 41-year-old woman presented with a recurrence of depression. She saw everything in a negative way, and talked about herself in a denigratory manner. Upon reflection, she reported that her childhood had been dominated by highly critical and emotionally distant parents, who never saw anything worthwhile in her activities and were constantly finding fault. She had come to perceive herself as worthless and incapable of doing anything productive. The therapist challenged some of her underlying assumptions, including her lack of self-worth and her perceptions of incompetence by encouraging her to identify her avoidance of anything good in herself and the achievements and abilities she had already demonstrated.

Cognitive behaviour therapy (CBT)

Cognitive behaviour therapy (CBT) has become a ubiquitous approach to the management of many mental disorders. It integrates both behavioural and cognitive therapeutic techniques, and has shown proven benefit for milder forms of depression, and many of the anxiety disorders. It has also been applied to bipolar disorder and to persistent delusions and hallucinations in people with schizophrenia.

CASE EXAMPLE: cognitive behaviour therapy

A 20-year-old student sought help because he was socially isolated and feared social situations. He wanted to socialise, but was terrified other people would think he was an ‘idiot’ and would make fun of him. The therapist set, with the patient, social interaction homework tasks, starting with going out to a restaurant with his sister. Incrementally, he was encouraged to place himself in more challenging social situations. The therapist also modelled

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