CHAPTER 14 The psychotherapies
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.
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.
anxiogenic situations: these can interfere with the therapeutic effect of behavioural therapy.
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:
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.
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.
Interpersonal psychotherapy
IPT is a ‘here and now’ therapy, and addresses issues such as grief (e.g. loss events), role transitions (e.g. retirement), role disputes (e.g. conflictual relationships) and interpersonal deficits (e.g. social isolation) on current psychopathology. The idea is that identification and resolution of interpersonal problems current at the time of onset of symptoms will lead to improved life circumstances and thus improved symptomatology. Initially used for depression, IPT has been modified for use in a range of circumstances, including depression associated with HIV, depression in pregnancy and, in conjunction with social rhythm therapy (SRT), for bipolar disorder.
Dialectic behaviour therapy
DBT aims to address four specific goals:
Individual therapy is provided in parallel to the group process, with an aim to reinforce group-therapy-derived skills and awareness, with greater focus upon individual needs. Intersession telephone contact is agreed upon as a strategy for contact between therapy sessions and is established with clear but strict boundaries. The contact focuses upon crisis intervention and the application of the above skills to coping ‘in the moment’. The patient is encouraged to tolerate the distress and to address this further in the next available therapy session.
Psychodynamic psychotherapy
This form of therapy owes much to Sigmund Freud, but subsequent workers refined, expanded upon and/or challenged his original views, as outlined in Box 14.3.
BOX 14.3 Freud and the post-Freudians
Freud’s original technique (psychoanalysis) involved asking the patient to ‘free-associate’, bringing to the session whatever came into their mind at the time. The therapist sat behind the patient, intervening only rarely and usually to suggest interpretations of what the patient had said. Freud also emphasised the importance of dreams, referring to them as ‘the royal road to the unconscious’, and offering interpretations thereof. Freud emphasised how the patient’s interaction with the therapist was a recapitulation of earlier life interactions (the transference), and that the therapist also reacted to the patient according to the therapist’s own earlier relationship experiences (the countertransference). A particular task of the therapist was to explore resistance on the part of the patient, to accepting the interpretations of the therapist.
Psychodynamic techniques are generally employed where the intent is to create lasting and profound change for the individual in terms of the way they see themselves. The patient needs to
show some degree of psychological mindedness, a commitment to attending sessions regularly and the resilience (ego strength) to tolerate the feelings evoked through exploration of unconscious issues. It is not appropriate in the face of severe depression or psychosis.
Group therapy
Group therapy can utilise any of the therapeutic techniques outlined above, but with variations respectful of the group situation. The advantages of group therapy are shown in Box 14.4. Potential disadvantages include the logistics of bringing people together regularly, confidentiality issues, and the propensity for some members of the group to be (or perceive themselves as being) ostracised by the others (the skilled therapist can use this therapeutically, but it can be very difficult for the individual concerned).
BOX 14.4 Advantages of group psychotherapy
Groups can be either open, where members can start and exit at pretty much any stage, or closed, where there is a set group of participants who make a commitment to the group, and no further members are allowed to join.
Family therapy
There are a number of forms of family therapy which draw on different approaches. Generally, family therapists tend to use a combination of all of these models in different combinations for particular families. In some instances there will be an attempt to disrupt the structures which exist between individuals, with alterations in family alliances and activities together. Alternatively, it is sometimes very helpful to disrupt the family with a strategy which causes a substantial reorganisation of the family’s approach to life activities and problems.
Couple therapy
CASE EXAMPLE: how different psychological approaches may be applied (supplied by Dr Ed Harari (‘EH’), St Vincent’s Hospital, Melbourne)
A 40-year-old, hitherto successful professional man (‘John’), presented with a 6-month history of increasingly severe clinical features of depression, precipitated by his wife’s discovery of his marital infidelities and the subsequent breakdown of his marriage. The latter had recently culminated in John being forcibly evicted from the family home by a court order sought by his wife. He rented a small flat, where he sat alone most nights, drinking heavily and refusing to answer telephone calls from concerned family and friends. While he reluctantly went to work most days, he knew that his work performance was deteriorating. When interviewed, he denied suicidal intent, but through tears and exclamations of distress he insisted that he had irreparably destroyed his wife’s life, that he was condemned to be a social outcast and that his life was a failure.
EH: We will need to talk about your mum and how you lost her, and other things, including how you might have lost your wife. (allusion to a repetitive pattern in his life) But I wonder if you are expecting me to criticise you when I ask you about your pain, the same way you’ve taken on your father’s judgments and criticise yourself? (interpretation of possible negative paternal transference to EH as well as alluding to John identifying with his critical father)
If John’s depression was judged to be severe enough to prevent him from genuine participation in psychotherapy, or if his condition deteriorated further, antidepressant medication would be indicated and hospitalisation considered. Therapy could resume when the depression had improved. If these measures did not reduce his misuse of alcohol, participation in an alcohol detoxification program could be advised.
References and further reading
Bloch S., editor. An introduction to the psychotherapies, 4th edn, Oxford: Oxford University Press, 2006.
Brown D., Pedder J. Introduction to psychotherapy. London: Routledge; 1989.
Brown J.A.C. Freud and the post-Freudians. Middlesex: Penguin Books; 1987.
Gabbard G.O. Psychodynamic psychiatry in clinical practice, 3rd edn. Washington DC: American Psychiatric Publishing; 2000.
Hawton K., Salkovskis P.M., Kirk J., Clark D.M. Cognitive behaviour therapy for psychiatric problems: a practical guide. Oxford: Oxford Medical Publishing; 1989.
Swales M., Heard H., Williams M. Linehan’s dialectical behaviour therapy (DBT) for borderline personality disorder: overview and adaptation. Journal of Mental Health. 2002;9:121-127.
