VI.

Therapeutic Approaches in Psychiatry

40. PSYCHOANALYTICALLY ORIENTED PSYCHOTHERAPIES

James L. jaco6son, M.D., and Alan M.laco6son, M.D
1. Describe psychoanalyticallyoriented psychotherapy. Psychoanalytically oriented psychotherapy (sometimes called psychodynamic psychotherapy) encompasses a group of psychotherapeutic approaches founded on the discoveries of Sigmund Freud and later refined and expanded by a number of other researchers, clinicians, and theoreticians. This group of approaches is based on the belief that current behavior, emotions, capacities for functioning, and patterns of relationship are deeply influenced by ones experiences early in life.

2. How might early life experiences affect the present?

Psychoanalytically oriented therapists believe that early developmental experiences influence later behavior and that such influences often are outside of normal awareness. The early experiences are retained in the unconscious mind as expectations about relationships,beliefs about ourselves and the world around us, and mechanisms to control uncomfortable feelings and thoughts and prevent them from coming into the conscious mind. These unconscious processes determine present feelings and actions. Thus, the past shapes the present through forces that are sometimes known and sometimes unknown. For example, a person may maintain a haughty, aloof attitude toward others that results in a painful lack of emotional closeness. In the course of therapy, it is discovered that this way of relating was developed to protect the person earlier in life against a hostile relationship with a demeaning caregiver. Hence, the person developed false superiority to protect from internal feelings of inadequacy, and aloofness to maintain distance from relationships that may be perceived as threatening to self-esteem.

3. How is psychoanalytic therapy conducted?

Psychoanalytic therapy comprises verbal interaction between patient and therapist in an effort to elucidate unconscious past forces that affect current emotions and actions. Intensive therapy often is paced at 1-2 sessions per week over several weeks to years. In psychoanalysis, the most involving approach based on psychodynamic principles, the course of treatment often is longer, with more frequent meetings (up to 4-5 times per week). This process allows the patient to reexperience with the analyst, in a deeply felt way, earlier emotional involvements. The bringing forward of past experiences and reexperiencing them in the present is called transference. Most people are unaware of transference, although it frequently shapes the way in which they relate to other people. Such unawareness is maintained by unconscious mental processes known as defense mechanisms. Although defense mechanisms vary widely (e.g., repression of memory, denial, disconnection of emotion from event [isolation], externalization of blame, internalization, sublimation), their common purpose is to keep potentially anxiety-provoking events and feelings out of awareness. In psychoanalysis and in some forms of psychodynamic therapy, the therapist or analyst interprets (i.e., comments on) defensive maneuvers to gradually uncover their origins by expanding the patients awareness of current events (defensive maneuvers) and historical events (origins). This process stirs uncomfortable feelings and seemingly unacceptable thoughts, and defense mechanisms may be activated in the
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relationship with the therapist. They may present as apparent resistances, such as reactions to the therapist that lead to breaks in the free flow of discussion. In such cases, the therapist offers further commentary on the nature of the resistance, which may lead to further understanding of the difficulties in the interpersonal relationship.

4. What are the benefits to the patient? Through repeated, successive interpretation and intense experience of the connection between current personal involvement (with both the therapist and other people) and past events, the patient learns about the forces directing his or her own behavior. As unconscious sources of difficulty gradually emerge in the therapeutic relationship, the therapist or analyst explains them to the patient over and over again in an effort to expand understanding. Unconscious forces are demonstrated in daily life, in work, in dreams, and in every human endeavor. The patient, in an intimate, evolving relationship with the therapist or analyst, experiences increasingly deep emotional and intellectual understanding of these forces and how they shape attitudes and relationships. Moreover, he or she can compare previously unconscious perceptions to current experiences with the therapist. This comparison provides an opportunity to gain control over the previously unknown impulses and defensive reactions, leading to changed feelings about self and improved relationships with others. The result is greater freedom to make choices in work and in establishing loving relationships. Often, new developmental processes or the reestablishment of normal development ensues. 5. Define transference and countertransference. In its broadest form, transjerence is bringing into a current life experience, such as a relationship, the beliefs, expectations, and perceptions from previous relationships. In analytic therapy transference often refers to relationships from particular stages of development. For example, a patient may experience his wife in the same way that he experienced one of his parents in childhood. Although there may be some similarity to the way his wife behaves, the total perception is colored by the early experience; hence, this is a transference relationship. Countertransference is a specific reaction of the therapist to the patients transference. Examples include feelings, thoughts, and attitudes that are reactions to specific events in therapy. The therapist may experience such a reaction or feeling as being unlike him- or herself; this is often a hint to the presence of a countertransference reaction. For example, the therapist may be unusually silent, angry, or affectionate. Both transference and countertransference can be elucidated to increase understanding of behavior and to assist in the progress of therapy. If not addressed and discussed, such reactions may stall the therapeutic endeavor or lead to negative reactions and cessation of treatment.
6. How are dreams used in psychodynamicpsychotherapy and analysis? Dreams were initially seen by Freud as the royal road to the unconscious. They were thought to contain a direct view into the unconscious life of the individual. Thus, dream interpretation was once considered the central method for understanding unconscious phenomena. Dream elements are symbolic representations of current life events as well as earlier life experiences and conflicts. Although dreams still play an important role in psychodynamic psychotherapy, they now are seen as one of many sources of information about hidden wishes and fears that are relevant to both current and past functioning. The therapist or analyst may focus on current concerns manifested by the content of the dream or on representations of the past. He or she may ask a patient to associate (i.e., let the mind wander and freely react to different thoughts and feelings) to the dream as a whole or the different elements of the dream to unmask and elaborate what the symbols in the dream represent. Such associations are termed the latent content. Current analytic thought places equal (or perhaps more) emphasis on transference as the royal road to the unconscious. Other phenomena that help to elucidate unconscious processes include slips of the tongue (known as parapraxis), fantasies, daydreams, resistance, and virtually any recurrent way of relating in life.

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7. What are defense mechanisms? Defense mechanisms are the methods by which individuals seek to regulate basic instincts. Instincts may be thought of primarily as aggressive and sexual. Defense mechanisms are conceptualized as part of a process called the ego or the I. Freuds initial theory of personality highlighted a conflict between the desire for gratification of basic instincts and the need to control unwanted or dangerous pressure for gratification. He conceptualized repression as the egos central mechanism of defense, but various defense mechanisms are now recognized. Repression refers to the mechanism by which internal urges, thoughts, and feelings and memory of events are forgotten. They are contained in unconscious (or repressed) memory. The repressed is not recognized, but the effects of what has been repressed tend to remain. For example, a person may forget or repress a traumatic event, yet retain an emotion that he or she cannot connect to a particular situation. Inexplicable sadness unattached to a memory, but present in response to certain interpersonal cues, likely results from repression. Other mechanisms of defense include denial, altruism, intellectualization, projection, internalization, and sublimation. Each mechanism represents a somewhat different method of dealing with unacceptable thoughts, feelings, wishes, or events. Although such defensive operations occur largely outside the individuals awareness, they become manifest as types of behavior in all relationships, including the therapeutic relationship. The therapist helps the patient to understand defensive maneuvers and become more aware of their influence on everyday functioning. With the therapists help, the patient can change behavioral patterns.

8. Who is treatable with psychoanalysisor psychoanalyticpsychotherapy?

The clinician must assess the patients relative strengths and capabilities as well as relative weaknesses and difficulties. Psychoanalysis and psychoanalytic psychotherapy are not specifically indicated or contraindicated by particular disorders. The individual who is likely to benefit from psychoanalytic psychotherapy suffers long-standing symptoms such as depressed mood, anxiety, and repetitive patterns of behavior that result in a sense of limited choices and enjoyment. The persons capacities may be thwarted by his or her own actions; there may be a sense of falling short or disappointment with the outcome of behavior and ways of relating. The person may have difficulty being spontaneous or feeling close to others. There also may be a sense of inordinate suffering. Concurrently, there must be adequate psychological and emotional strength to endure the explorations of psychoanalytically oriented therapy. For example, the person must have demonstrated some capacity to achieve, such as a history of satisfaction in relationships with friends or work. The capacities to form relationships, self-observe, and contain strong feelings adequately also are strengths that may aid in the psychotherapeutic process. The psychoanalyst or therapist assesses specific patterns of defensive functioning and the nature of relationships to evaluate to the required sturdiness and motivation. Exploratory and exposing approaches demand considerable patient resilience-as well as support from the clinician.

9. Are risks associated with exploratory psychoanalytic psychotherapy or analysis? Yes. As with any treatment, risks are involved. Dynamic analytic therapy often is anxiety-provoking because of its attempt to pierce the comforting defensive operations used by the patient to cope with unwanted feelings. Ideally, these unwanted feelings gradually emerge into awareness. The therapist must first determine whether the patient is prone to impulsive actions, which may be dangerous if anxiety-provoking feelings and instincts become more accessible (sometimes called acting out). The therapist must assist in managing the expression of such impulses. The goal is a balance between uncovering unconscious elements and maintaining current emotional stability. Psychoanalytically oriented psychotherapy is designed to promote a transitory regression in which the patient experiences earlier ways of relating to people. Regression by definition means returning to a former state. Earlier states of development can be painful to experience and lead to behavior that is no longer appropriate. The result may be transient functioning that is less adaptive. For example, a patient may reexperience the full force of a humiliating experience with his or her father and hence be left more vulnerable. A criticism from a supervisor at work may feel humiliating, and an

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over-reaction can lead to an angry response or even quitting the job. Furthermore, such regression may persist and lead to chronic over-dependence on the therapist. 10. Differentiate exploratory and ego-supportive approaches. The psychodynamic framework includes exploratory therapies that uncover unconscious motives and experiences, thereby weakening defenses. The use of psychoanalytic understanding to strengthen rather than diminish defenses is called ego-supportive psychotherapy. Some of the techniques of supportive psychotherapy are similar to those used in cognitive and behavioral therapies (see chapters 41 and 42). One particularly well-defined method, based in part on psychodynamic principles and developed by Klerman and Weissman, has been termed interpersonal psychotherapy. It is a commonly used short-term, dynamic psychotherapy that contains supportive therapy principles.

11. Describe interpersonal psychotherapy. Interpersonal psychotherapy was designed as a short-term treatment model for patients with depression. It has been empirically evaluated in a series of studies. A manual describes the methods and techniques for therapeutic intervention in a consistent, reproducible fashion. Interpersonal therapy focuses primarily on the social roles and interpersonal interactions in the patients past and current life experiences. Although the entire life-span is covered, the interpersonal therapist places a clew emphasis on current factors, especially a patients disappointment in personal role expectations as well as disputes and problems in relationships. The interpersonal therapist directs the patient to one or two problem areas in current functioning, which then become the primary focus of the therapy. Examples include grief over a loss; disputes in mamage, family, and work; role transitions such as retirement or job demotion; and loss through divorce. Although the interpersonal therapist recognizes the importance of defense mechanisms, he or she does not attempt to address internal conflict as a source of current problems. Instead, behaviors and emotions are examined as they relate to current interpersonal problems.
12. Differentiate interpersonal psychotherapy and uncovering approaches. Interpersonal therapy, as a supportive approach, helps to build on current capacities to function rather than uncover inner conflict. The primary focus is not enduring personality and character problems or earlier life experiences, although they may play a role in depression. The twin goals are: (1) relieve symptoms through reduction of grief, and (2) help the patient develop better strategies for dealing with current problems associated with the onset of depressive symptoms.
Interpersonal Psychotherapy Uncovering Analytic Psychotherapies

What has contributed to the patients current depression? What are the current stresses? Who are the key persons involved in the current stress? What are the current disputes and disappointments? Is the patient learning how to cope with the problem? What are the patients assets? How can 1 help the patient to ventilate painful emotions and talk about situations that evoke guilt, shame, resentment? How can I help the patient clarify his or her wishes and have more satisfying relationships with others? How can I correct misinformation and suggest alternatives?

Why did the patient become what he or she is and/or where is the patient going? What was the patients childhood like? What is the patients character?
Is the patient cured?

What are the patients defenses? How can I find out why this patient feels guilty, ashamed, or resentful? How can I understand the patients fantasy life and help him or her to gain insight into the origins of present behavior? How can I help the patient discover false or incorrect ideas?

Adapted from Klerman G, Weissman M, Rovsanville B, Cherron E: Interpersonal Psychotherapy of Depression. New York, Basic Books, 1984.

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13. How long do psychoanalyticallyoriented therapies take?

Therapeutic approaches range from short-term, well-defined therapies with specific focus, which may require only 2-8 sessions, to psychoanalysis, which may require 4 or 5 sessions per week for many years. Brief forms of treatment focus on specific current problems that result in an outbreak of particular symptoms, such as anxiety or depressed mood. The long-term foims address the source of current difficulty, but also attempt to understand and change basic, long-held patterns of relating to others as well as feelings about self that have developed over a lifetime. Hence, the goals of each particular form of therapy are directly related to the length of treatment. The longer forms of treatment involve the development of an intense interpersonal relationship, the elucidation of of multiple aspects of that relationship, and the development of the personal strength and ability to move beyond it. This relationship may be viewed similarly to other important interpersonal relationships that enhance development, such as with a parent, sibling, friend, grandparent, or mentor. The length of treatment is influenced, therefore, by the goals of therapy and the degree to which the primary focus is on the relationship between patient and therapist. Supportive psychotherapies also vary greatly in duration. Support can last through a specific life event (job change, divorce, grief over the death of a parent), or it may be a long-standing therapeutic relationship that helps fragile patients sufficiently to allow them to function at work and avoid suicide attempts and costly hospitalizations.

14. Differentiate dynamic analytic and behavior therapies. In simple terms, behavior therapies attempt to modify observable behavior through various reinforcement strategies. For example, if an individual is afraid of snakes, behavioral therapy may desensitize the patient to this fear by having him or her learn a specific method of attaining a relaxed state, and then, during relaxation, introducing the idea of a common earthworm. Subsequently, a picture of an earthworm is introduced, followed by the idea of a common, nonthreatening snake. After a picture of a snake, gradual steps may lead to viewing a snake in a contained environment such as a zoo. There is no focus on the origin or symbolic representation of the fear. In psychodynamic psychotherapy, the therapist focuses on both the origin and the object of the fear. Behavior therapy offers a strategy of managing a symptom without the necessity of understanding its meaning or origin. In psychodynamic psychotherapy, management strategies are developed secondarily.

15. Are there uses of psychoanalyticprinciples other than for psychotherapy? The psychoanalytic method in which the patient says everything that comes to mind in the context of an interpersonal relationship is both a method of psychotherapy and a tool for learning about human mental functioning. Based on such information, various theories of human mental functioning and normal development from infancy to old age have evolved. Hence, these principles also provide a tool for investigating inner life, a theoretical framework for human development, and a mechanism of viewing the functioning of the human mind. From a more practical viewpoint, psychoanalytic principles can be used to understand patients reactions to medical illness, compliance and adherence problems in outpatient medical and psychiatric practice, and the complexities of human behavior as manifest in any form of clinical practice. It may well be that the psychodynamic perspective has its broadest application in understanding doctor-patient interchange rather than as a specific method for therapy. Indeed, clinicians using psychopharmacologic, behavioral, and other techniques can use this approach to enrich their understanding of the patient.
BIBLIOGRAPHY
1. B a h t M, B a h t E: Psychotherapeutic Techniques in Medicine. London, J.B. Lippincott, 1961. 2. Binder JL: Research findings on short-term psychodynamic therapy techniques. In The Hatherleigh Guides Series. New York, Hatherleigh Press, 1996, pp 79-97, 3. Greenson RR: The Technique and Practice of Psychoanalysis, vol. 1. New York, International University Press. 1967.

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4. Jacobson AM, Parmelee DX: Psychoanalysis: Critical Explorations in Contemporary Theory and Practice. New York, BrunnerMazel, 1982. 5 . Klerman G, Weissman M, Rovsanville B, Chevron E: Interpersonal Psychotherapy of Depression. New York, Basic Books, 1984. 6. Luborsky L: Theories of cure in psychoanalytic psychotherapies and the evidence for them. Psychoanalytic Inquiry 16(2):257-264, 1996. 7. Mann J: Time-Limited Psychotherapy. Cambridge, MA, Harvard University Press, 1973. 8. Sloane RB, Staples FR, Cristol AH, et al: Psychotherapy Versus Behavior Therapy. Cambridge, MA, Harvard University Press, 1975. 9. Wachtel PL: Psychoanalysis and Behavior Therapy. New York, Basic Books, 1977. 10. Stem DN: The Interpersonal World of the Infant. New York, Basic Books, 1985. I I . Rothstein A: Models of the Mind. New York, International Universities Press, 1985. 12. Vaillant GE (ed): Ego Mechanisms of Defense: A Guide for Clinicians and Researchers. Washington, DC, American Psychiatric Press, 1992.

4 1. COGNITIVE-BEHAVIORAL THERAPY
Jacquehe A.Samson, Ph.D
1. What is cognitive-behavioral therapy? Cognitive-behavioral therapy (CBT) combines treatment approaches of both cognitive and behavioral therapy. The principles were first outlined in a treatment manual specifically targeted to depression by Beck et aL3 The basis of cognitive therapy is the observation that negative feelings result from faulty cognitive processing. Incoming information is selectively filtered so that perceptions are distorted toward negative conclusions. Faulty processing is identified by examining a patients spontaneous thoughts occurring throughout the day or after specific events. These automatic thoughts are key to understanding a patients core system of assumptions and beliefs about the self and the world. CBT treatments first help a patient become aware of automatic thoughts and underlying assumptions and beliefs. The patient is then encouraged to seek evidence by which to support or refute the assumptions, and to modify beliefs based on a more balanced view of all available information. Behavioral techniques are integrated throughout CBT treatment to facilitate change. Specific exercises for thought stopping, relaxation, and impulse control may be combined with monitoring and adjusting daily activities to increase mastery and pleasure experiences. Graded task assignments and systematic graded exposures also may be used.
2. Give an example of cognitive distortion. A depressed patient reported to her cognitive therapist that she felt sad over the weekend. In reconstructing the events of the weekend, she noted that the sadness began during a telephone call on Saturday morning from an old friend. The therapist then encouraged her to remember the conversation and the point at which she first felt sadness. She remembered that her friend Sarah was discussing her plans to take a vacation but did not invite the patient to come along. Her first automatic thought was: Sarah doesnt want me along because Im no fun. Her next thought was, Nobody wants to be with me. I have no friends. She then thought, 1 will be alone for the rest of my life. Gloomy thoughts indeed! The patients faulty processing began with her first reaction to the news of Sarahs vacation. When the therapist asked the patient to examine the evidence for her assumption that Sarah did not want to be in her company, she had to say that there was no evidence; the fact that Sarah called indicated that Sarah enjoyed her company. Once the distortion i n the automatic thought was worked through, the patient felt more hopeful about the future and was able to say that she might ask Sarah if they could plan to do something together soon.