Overview

Definition and types

Psychotherapy is interpersonal treatment rooted in psychological principles and mechanisms of mental disease.

Psychotherapy helpspatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship identify and diminish adverse feelings and thoughts and develop health-promoting behaviors.

Types of psychotherapy:

• Psychoanalysis or psychodynamic psychotherapy
• Psychoeducation
• Supportive psychotherapy
• Cognitive behavioral therapy
• Interpersonal therapy
• Motivational interviewing
• Dialectical behavioral therapy
• Group therapy
• Family therapy and marital 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 inhibitedmemoryMemoryComplex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory.Psychiatric Assessment 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 cuesNonverbal cuesTransmission of emotions, ideas, and attitudes between individuals in ways other than the spoken language.Clinician–Patient Relationship 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 gaininsightInsightPsychiatric Assessment 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

Types

• Classical psychotherapy: Unresolved conflicts lead to psychopathology (i.e., depression).
• Ego psychology:
  • Originated from Sigmund Freud’s id-ego-superego model
  • Takesdefense mechanismsDefense mechanismsDefense 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

• Psychoeducationserves as the foundation for other forms of psychotherapy.
  • Provide thepatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship 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 andprognosisPrognosisA prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations.Non-Hodgkin Lymphomas of disorder 
  • Outline of different treatment options 
  • Discussion of commoncomorbiditiesComorbiditiesThe presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival.St. Louis Encephalitis Virus 
  • IdentificationIdentificationDefense Mechanisms of warning signs and a plan to preventrelapseRelapseRelapsing Fever 
• Useful in a wide variety of settings for many diagnoses (e.g.,bipolarBipolarNervous System: Histology 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:
    • TheperceptionPerceptionThe process by which the nature and meaning of sensory stimuli are recognized and interpreted.Psychiatric Assessment 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  
• PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship 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 anaversive 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 thatphobiasPhobiasNeurological Examination 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:alcoholicAlcoholicPersons who have a history of physical or psychological dependence on ethanol.Mallory-Weiss Syndrome (Mallory-Weiss Tear)patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship 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 topatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship during times of distress.
    • This feedback allows thepatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship to make changes in their body (e.g., relax).
    • Example: A patient with migraines is encouraged to visualize the dilation of herarteriesArteriesArteries 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: Histology whenever experiencingpainPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways (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 use 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 withoutjudgmentJudgmentThe process of discovering or asserting an objective or intrinsic relation between two objects or concepts; a faculty or power that enables a person to make judgments; the process of bringing to light and asserting the implicit meaning of a concept; a critical evaluation of a person or situation.Psychiatric Assessment 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.
  • ExpectingresistanceResistancePhysiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow.Ventilation: Mechanics of Breathing 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.
    • TheclinicianClinicianA physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients.Clinician–Patient Relationship’s role is guidance and encouragement.

Dialectical Behavioral Therapy

• Dialectical behavior therapy is a variation of CBT developed by Dr. Marsha Linehan forborderline personality disorderBorderline Personality DisorderA personality disorder marked by a pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts.Cluster B Personality Disorders (BPD).
• Involves managing treatment targets with the aim of reducing suicidal or dangerous behavior, treatment-interfering behavior, andqualityQualityActivities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps.Quality Measurement and Improvement of life-interfering behavior, among others
• Primary focuses:
  • Mindfulness
  • Interpersonal effectiveness
  • Emotion regulation
  • DistresstoleranceTolerancePharmacokinetics and Pharmacodynamics

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 gaininsightInsightPsychiatric Assessment into their condition.
  • The therapist is also able observe patient interactions.
• An example of this isAlcoholicAlcoholicPersons who have a history of physical or psychological dependence on ethanol.Mallory-Weiss Syndrome (Mallory-Weiss Tear) Anonymous.
• Useful in grief or bereavement, substance use disorder,adjustment disordersAdjustment DisordersMaladaptive reactions to identifiable psychosocial stressors occurring within a short time after onset of the stressor. They are manifested by either impairment in social or occupational functioning or by symptoms (depression, anxiety, etc.) that are in excess of a normal and expected reaction to the stressor.Adjustment Disorder, andpersonality disordersPersonality DisordersA major deviation from normal patterns of behavior.Cluster A 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,communicationCommunicationThe exchange or transmission of ideas, attitudes, or beliefs between individuals or groups.Decision-making Capacity and Legal Competence 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

References

1. Gabbard, G., DeJean, V. (2021). Unipolar depression: psychodynamic therapy. UpToDate. Retrieved July 12, 2021, fromhttps://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, fromhttps://www.uptodate.com/contents/motivational-interviewing-for-substance-use-disorders
3. Lebow, J. (2021). Overview of psychotherapies. UpToDate. Retrieved July 11, 2021, fromhttps://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). 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, fromhttps://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, fromhttps://www.uptodate.com/contents/interpersonal-psychotherapy-ipt-for-depressed-adults-indications-theoretical-foundation-general-concepts-and-efficacy