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 daughter’s 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 Mary’s 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) Displacement

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 one’s misconceptions accepting life’s 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/protocolstherapist 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