Download Techniques of Psychoanalytic Psychotherapy

Chapter 15
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Psychotherapy can be
defined as a process in
which a trained
professional uses
psychological methods to
help a person with
psychological problems.
Psychological methods
can refer to almost any
kind of human interaction
that is based on a
psychological theory. It
does not include medical
treatment methods.
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Because a therapist is
in a position of power
relative to a client, it is
essential that the
highest ethical
standards are
followed in the
practice of
psychotherapy.
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Psychotherapy is considered
ethical under the following
circumstances:
The goals of treatment are
carefully considered with
the client. Goals should be
in the best interest of the
client.
 Choices for alternative
treatment options are
carefully considered.
 The therapist only treats
problems that he or she is
qualified to treat.
 The effectiveness of
treatment must be
evaluated in some way.
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Psychotherapy is considered
ethical under the following
circumstances:
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The rules and laws regarding
the confidentiality of
information obtained during
treatment is fully explained to
the client.
The therapist must not use his
or her power in the
relationship to exploit the
client in sexual or other ways.
The therapist must treatment
human beings with dignity
and must respect differences
based on gender, culture, and
so forth.
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Psychoanalysis is the
approach to
psychotherapy founded
by Sigmund Freud.
Psychoanalysis is based
on Freud’s belief that
the root of
psychological problems
is unconscious conflicts
among the id, ego, and
superego.
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Psychological problems
occur when the competing
forces of the id, ego, and
superego get out of
balance and create
conflict.
This unconscious conflict
must be brought to a
conscious level.
The job of the
psychoanalyst is to help
bring unconscious
conflicts to a conscious
level by helping id
conflicts get past the
censorship of the ego.
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Modern techniques
(based on revisions of
Jung, Adler, and
Horney) include:
Free Association
 Dream Interpretation
 Interpretation of
Resistance
 Interpretation of
Transference
 Catharsis
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Free Association:
The individual is
encouraged to talk
about whatever
comes to mind.
 No thought or feeling
is withheld.
 The goal is to “turn
off” the intellectual
control of the ego and
allow glimpses into
the unconscious.
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Dream Interpretation:
The obvious, or
manifest, content of
dreams is believed by
psychoanalysts to
symbolically mask the
true, or latent, content
of dreams.
 By asking patients to
recall dreams, Freud
believed the
information provided
another path to the
unconscious.
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Interpretation of
Resistance:
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Resistance in therapy is
any form of opposition of
the patient to
psychoanalysis.
Two forms of resistance
include vague forms (e.g.,
missing an appointment)
and specific forms (e.g.,
resistance to a therapists
interpretation).
Resistance suggested a
conflict within the patient.
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Interpretation of
Transference:
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The intensity of the
relationship between the
patient and therapist
reveals information about
the patient’s relationship
to other authorities
figures in his or her life.
The behavior of a client
toward the therapist is a
reflection of the client’s
behavior toward parents,
employers, and other
adults.
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Catharsis:
The release of some emotion that is pent up with
unconscious conflicts.
 Catharsis is important to the overall success of
psychotherapy.
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Interpersonal psychotherapy –
came about from neo-Freudian
theories that emphasize the
importance of interpersonal
relationships in our lives more
than unconscious sexual
motivation. Interpersonal
therapy is often referred to as
IPT, which is different from
classical Freudian
psychoanalysis. It ignores
unconscious motivation,
minimizes discussion of the
past, and does not involve
interpretation of the
individual’s relationship with
the therapist. This therapy
focuses on the here and now.
This therapy is completed in 1216 weeks.
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Interpersonal therapists
believe that depression
comes from how we relate
and communicate with the
people in our lives. They
believe there are four kinds
of problems that cause
depression:
1) Grief from the breakup of
a relationship.
2) Conflicts with people who
are significant to us.
3) Life events that are
stressful or that create
threats to our self-esteem.
4) Lack of social skills for
establishing healthy
interpersonal relationships.
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IPT therapists have 7 goals to treat depression:
1) Help the person to feel that the therapist
understands them and that their feelings are
important.
2) Help the person understand his or her
feelings as they relate to what is going on in
their lives, particularly in their current
relationships. They allow discussion of past
relationships to understand the “emotional
baggage” of the past.
3) Help the person learn to express his or her
feelings in constructive ways.
4) Identify relationships that are too unhealthy
to fix, help end them, on move on to healthier
relationships.
5) Help the person to feel a new mastery over
their new roles (maybe dating again).
6) Improve the skills for creating healthy
relationships and maintaining them.
7) Helps the individual to develop an optimistic
focus on current opportunities for change
instead of on the past.
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The therapist must keep
the individual on focus
concerning their feelings,
his or her life
circumstances, and
current options to change.
This therapy has been
quite effective for
depression either by itself
or combined with
medication. This therapy
has also been used with
personality disorders and
eating disorders.
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The Humanistic therapy
believes that the primary
goal is to bring feelings of
which the individual is
unaware into conscious
awareness.
Rogers did not believe in
an unconscious. He just
believed that we denied
certain desires and that
these would cause us
anxiety until they were
brought to the forefront
and dealt with.
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In this therapy, the client is the center of the
process of psychotherapy. More recently, the
term person-centered therapy has come into
use.
The focus is on the client’s ability to help
themselves. The therapist’s role is to create an
environment that is so emotionally safe that
clients will feel free to completely express
themselves and the feelings that they have
denied awareness.
With this type of therapy, the therapist:
1) must be warm
2) must genuinely like the clients and
unconditionally accept everything they think,
feel, or do without criticism
3) must have empathy – an accurate
understanding and sharing of the emotions of
the client.
Reflection – a technique in humanistic
psychotherapy in which the therapist reflects
the emotions of the client to help clients clarify
their feelings.
Client-centered therapists will say very little in
therapy. They avoid giving advice to their
clients. They may ask questions. This is so the
client can learn to solve their own problems
after they gain awareness.
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Humanistic psychologist Fritz Perls
named his approach to therapy,
Gestalt therapy.
In this therapy, therapists want to
help their clients see themselves in
the “whole” or complete way.
The goal of this therapy is the same
as client-centered therapy, creating
an environment where the client
will achieve greater client-centered
awareness.
These therapists are actively
involved in the conversations of
therapy sessions. They point out
inconsistencies of the person’s
thinking. They also challenge their
client’s thinking.
Sometimes, these therapists can deal
with their clients in a
confrontational manner. This
therapy is referred to as “safe
emergency” therapy. This is to
shake loose feelings that have been
denied awareness. In most cases,
this therapy seems to be effective.
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This therapy is often referred
to as CBT. The belief is that
abnormal behavior is learned
from inappropriate
experiences of classical
conditioning, operant
conditioning, and modeling.
These therapists see the
process of learning as central
to the process of therapy as
well. The behaviorist
therapist plays a role as a
teacher who helps the client
unlearn abnormal ways of
behaving and learn more
adaptive ways to take their
place.
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Several CBT methods are used to
treat phobias by extinguishing the
fear response. The first CBT
methods had the person imagining
being the presence of whatever
caused the fear (the phobic
situation).
It is now clear that extinction is
more effective when conducted in
real life settings, a technique
known as graded exposure.
In graded exposure, the therapist
accompanies the patient through a
series of gradually increasingly
fearful situations, beginning with
mildly fearful ones.
Technology has helped greatly
with providing safe, but highly
realistic frightening situations in
the therapists using computergenerated virtual reality
techniques.
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The goal of CBT is to teach
the client adaptive skills that
lead to a more enjoyable life
using methods.
Behavioral activation – the
therapist begins activities
that have naturally “antidepressant” qualities. These
depend upon the
individual’s needs and
preferences and include
possibly a new job,
volunteering, to resuming
piano lessons. They also try
to introduce regular physical
exercise.
Behavioral activation
therapy is the treatment of
depression is very effective.
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Some people (like those with severe mental
disorders) have trouble in social situations and
making friends.
In the CBT technique of social skills training,
the therapist uses shaping and positive
reinforcement to teach persons with these
social deficiencies to speak more often in social
situations, to speak in a voice that is loud
enough to be heard, to make appropriate eye
contact, and to make fewer odd comments.
This is usually accompanied by role playing –
whereas the therapist acts with the client as if
they are in social problematic situations.
Many people have a tough time talking about
their true feelings, asking questions,
disagreeing, and standing up for their rights.
Sometimes, they will keep their feelings in and
people will take advantage of them. People that
keep their feelings in tend to blow up and
angry outbursts.
A goal of social skills training is often to teach
assertive rather than angry ways of expressing
feelings to others. This is usually done by role
playing.
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Cognitive restructuring is an
important CBT method that
rests on the assumption that
faulty cognitions – maladaptive
beliefs, expectations, and ways
of thinking – are the cause of
abnormal behavior.
A great deal of carefully
designed research has
supported the effectiveness of
cognitive therapy for anxiety
and depression, it has become
one of the most widely used
therapy approaches.
Cognitive-behavior therapists
believe that problems do not
always stem from
inappropriate overt actions.
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Psychologist Albert Ellis and psychiatrist
Aaron T. Beck have described a number
of patterns of cognition that they believe
contribute to emotional distress and
inappropriate behavior. Many people
think that depression is caused by
erroneous patterns of thinking.
1) Selective abstration - basing your
thinking on a small detail taken out of
context and given an incorrect meaning.
2) Overgeneralization – the process of
reaching a general conclusion based on a
few specific bits of evidence.
3) Arbitrary inference – these people
conclude that people are asking for
something because something bad is
going to happen.
4) Magnification/Minimization –
minimizing compliments or exaggerating
something someone says to you is part of
this.
5) Personalization – reasoning that
external events are related to you when
there is no logical reason for doing so.
6) Absolutistic Thinking – people that
think in all-or-nothing terms is erroneous
and maladaptive.
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Therapy is not always conducted on
an individual basis. Some methods
of therapy are carried out with
groups or entire families.
Group therapy – psychotherapy
conducted in groups, typically of
four to eight clients at a time.
1 or 2 therapists work with 4-8
clients at a time. Group therapy is
cost-effective and is believed to offer
therapeutic experiences that cannot
be obtained in individual therapy.
Clients can:
1) Receive encouragement from
other group members.
2) Learning that one is not alone in
one’s problems.
3) Learning from the advice alone in
one’s problems.
4) Learning new ways to interact
with others.
Providing therapy in a group can
sometimes make more use of the
therapist’s time.
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Psychoanalysts play the role of
interpreter in groups. They avoid
becoming part of the interactions of
the group members, except to offer
interpretations of what these
interactions reveal.
Therapists will also use group
therapy to help individuals
develop more accurate selfperceptions through actions and
reactions of others.
Cognitive-behavior therapists use
groups to facilitate the teaching of
adaptive behavior and cognitions.
Individuals with complex
problems that require the full
attention of the therapist, or who
do not wish to discuss their
personal problems in front of
others, will benefit from individual
psychotherapy.
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Family therapy – an approach to psychotherapy
that emphasizes an understanding of the roles of
each of the members of the family system,
usually conducted with all members of the
family present.
The approach most used for family therapy is the
family systems approach created by Jay Haley.
The problem of the individual is often caused by
problems within the family.
The individual’s problems may serve a function
in the family system.
The family therapist attempts to solve the
problems of all the family members by
improving the functioning of the family system
as a whole. They try to reach this goal in four
different ways:
1) to give the family members insight into the
workings of the family systems in general and to
correct any dysfunctions of the family, 2) to
increase the amount of warmth and intimacy
among family members, 3) to improve
communications among family members, and 4)
to help family members establish a reasonable set
of rules for the regulation of the family.
The family should be a system that provides each
member with an accurate view of themselves, a
positive opinion of self, and a sense of belonging.
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Medical therapies – are
generally designed to
directly change brain
functioning to treat a
psychological disorder.
There are four types of
medical therapies used
today: drug therapy,
electroconvulsive
therapy, trans-cranial
magnetic stimulation,
and psychosurgery.
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The most widely used medical treatment for
abnormal behavior is drug therapy, in which
medications are used to treat abnormal behavior.
The widespread use of psychiatric drugs has
come about only in the past 40 years. The era of
modern drug therapy began in 1954 with the
introduction of drugs such as Thorazine for the
treatment of schizophrenia. This was the first
drug to really help people with schizophrenia.
Other drugs have been introduced soon after that
are also effective in the treatment of depression
(anti-depressants) and anxiety (tranquilizers).
Psychiatric medications are designed to improve
psychological functioning by influencing a
specific neurotransmitter in the brain.
Selective serotonin reuptake inhibitors (SSRI’s)
cause axons that secrete serotonin to reabsorb the
serotonin more slowly. This keeps the serotonin
active in the synapse longer, giving it more time
to stimulate the dendrite of the next neuron.
These medications often help “normalize”
serotonin transmission in the brain.
There are side effects with these medications,
though. Weight gain or impaired control the
body’s muscles if not carefully monitored. Some
also cause dry mouth and weight loss. Heart
problems, diabetes, or complications with
pregnancies can also take place.
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The best evidence that
improved nutrition can lead
to better mental health
comes from studies of
omega-3 fatty acids. These
are essential to the normal
functioning of the brain and
circulatory system, but they
are not manufactured in the
body.
Humans need a regular
supply of omega-3 fatty
acids from our diets. This is
generally found in fish.
People that are low in
omega-3 fatty acids are more
apt to have depression.
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The idea that people can be
“shocked” out of their
psychological problems has
been around in one form or
another for 2,400 years.
Hippocrates recommended the
use of the herb hellebore to
induce seizures that supposedly
restored balance to the body’s
humors.
Several different kinds of
“shock” treatments were
popular in mental institutions
during the 1800’s. Patients were
thrown in tubs full of eels, spun
in giant centrifuges, and nearly
drowned by being dropped into
lakes through trapdoors in
bridges, a treatment known as
“surprise baths”.
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Other forms of shock therapy have been used,
one in which seizures are intentionally induced.
In the 1930’s, it was noticed that people with
epilepsy rarely ever experienced schizophrenia.
Several psychiatrists experimented with
chemicals that caused seizures to see if they
would cure schizophrenia, but camphor,
insulin, and other chemicals were found to be
ineffective.
Italian doctors first used the method of passing
an electric current through two metal plates
held to the sides of the head to induce
convulsive brain seizures. This method is
known as electroconvulsive therapy (ECT).
This method seems to be very effective with
severely depressed patients. ECT is believed to
alter the same neurotransmitters as those
affected by anti-depressants. No one really
knows how this method really works.
ECT has been used effectively for 50 years. In
the past, the shocks were given without
anesthesia, and the seizures were so violent that
broken bones were not uncommon.
Today, the use of anesthesia and muscle
relaxants makes ECT a far less unpleasant
experience, but mild temporary or permanent
loss may occur. It can also be effective at
treating Bipolar disorder.
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This is similar to ECT, but does
not cause full seizures. A strong
magnetic field is passed
through part of the frontal
cortex. This causes the neurons
to fire in mass and is believed
to alter the sensitivity of the
neurons.
This treatment is repeated over
several weeks. There is
evidence that trans-cranial
stimulation is more effective
than placebo in the treatment of
depression, PTSD, and some
symptoms of schizophrenia.
This treatment is generally used
with severely depressed
patients that have not
responded to other forms of
treatment.
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The most controversial treatment
for abnormal behavior is
psychosurgery. This is a therapy in
which the brain is operated on to
try to alleviate the behavior.
Surgical operations of the brain to
treat psychological disorders came
into vogue in the 1940’s and 1950’s.
The prefrontal lobotomy, a doubleedged, butter-knife-shaped
instrument was inserted through
holes drilled in the temple region of
the skull. Neural fibers that connect
the frontal region of the cerebral
cortex with the limbic system were
cut.
They thought the operation would
prevent disturbing thoughts and
perceptions from reaching the
subcortical brain structures, where
they would be translated into
emotional outbursts.
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Prefrontal lobotomies were not successful
and a loss of intellectual functioning and
seizures were common side effects. The
use of surgeries have declined
considerably since drug therapy has
proven more useful.
The development of more precise
methods of operation on the brain with
needle-thin electrical instruments has
revived psychosurgery. Lobotomies are
now being performed under the name of
capsulotomy, which still cause serious
side effects such as apathy and
difficulties in planning.
Another type of psychosurgery is known
as cingulotomy. In this surgery, the part
of the limbic system called the cingulate
cortex is partially destroyed by electrical
probes. Such operations are performed
infrequently and are used only as a last
resort.