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Psychotherapy

 This chapter provides an overview of common psychotherapeutic approaches, covering a broad spectrum of therapy modalities.

PSYCHOANALYSIS AND PSYCHOANALYTIC PSYCHOTHERAPY

As broadly practiced today, psychoanalytic treatment encompasses a wide range of uncovering strategies used in varying degrees and blends. Despite the inevitable blurring of boundaries in actual application, we describe the original modality of classic psychoanalysis and major modes of psychoanalytic psychotherapy (expressive and supportive) separately here (Table 23-1). Analytical practice, in all its complexity, resides on a continuum. The individual technique is always a matter of emphasis, as the therapist titrates the treatment according to the needs and capacities of the patient at every moment.

Psychoanalysis is virtually synonymous with the renowned name of its founding father, Sigmund Freud. It is also referred to as “classic” or “orthodox” psychoanalysis to distinguish it from more recent variations known as psychoanalytic psychotherapy.

Psychoanalysis is based on the theory of sexual repression and traces the unfulfilled infantile libidinal wishes in the individual’s unconscious memories. It remains unsurpassed as a method to discover the meaning and motivation of behavior, especially the unconscious elements that inform thoughts and feelings.

Psychoanalysis

Psychoanalytic Process. The psychoanalytic process involves bringing to the surface repressed memories and feelings through a scrupulous unraveling of hidden meanings of verbalized material and of the unwitting ways in which the patient wards off underlying conflicts through defensive forgetting and repetition of the past.

The overall process of analysis is one in which unconscious neurotic conflicts are recovered from memory and verbally expressed, reexperienced in the transference, reconstructed by the analyst, and, ultimately, resolved through understanding. Freud referred to these processes as recollection, repetition, and working through, which make up the totality of remembering, reliving, and gaining insight. Recollection entails the extension of memory back to early childhood events, a time in the distant past when the core of neurosis developed. The actual reconstruction of these events comes through reminiscence, associations, and autobiographical linking of developmental events. Repetition involves more than mere mental recall; it is an emotional replay of former interactions with significant individuals in the patient’s life. The replay occurs within the unique context of the analyst as a projected parent, a fantasized object from the patient’s past with whom the latter unwittingly reproduces forgotten, unresolved feelings and experiences from childhood. Finally, working through is both an affective and cognitive integration of previously repressed memories that are brought into consciousness and through which the patient is gradually set free (cured of neurosis). The analytical course includes three major stages (Table 23-2).

Indications and Contraindications. In general, all of the so-called psychoneuroses are suitable for psychoanalysis. These include anxiety disorders, obsessional thinking, compulsive behavior, conversion disorder, sexual dysfunction, depressive states, and many other nonpsychotic conditions, such as personality disorders. Significant suffering must be present so that patients are motivated to make the sacrifices of time and financial resources required for psychoanalysis. Patients who enter analysis must have a genuine wish to understand themselves, not a desperate hunger for symptomatic relief. They must be able to withstand frustration, anxiety, and other strong affects that emerge in the analysis without fleeing or acting out their feelings in a self-destructive manner. They must also have a reasonable, mature superego that allows them to be honest with the analyst.

Intelligence must be at least average, and above all, they must be psychologically minded in the sense that they can think abstractly and symbolically about the unconscious meanings of their behavior.

Many contraindications for psychoanalysis are the flip side of the indications. The absence of suffering, poor impulse control, inability to tolerate frustration and anxiety, and low motivation to understand are all contraindications. The presence of extreme dishonesty or antisocial personality disorder contraindicates analytic treatment. Concrete thinking or the absence of psychological mindedness is another contraindication. Some patients who might ordinarily be psychologically minded are not suitable for analysis because they are in the midst of a major upheaval or life crisis, such as a job loss or a divorce. Serious physical illness can also interfere with a person’s ability to invest in a long-term treatment process. Patients of low intelligence generally do not understand the procedure or cooperate in the process. An age older than 40 years was once considered a contraindication, but today analysts recognize that patients are malleable and analyzable in their 60s or 70s. One final contraindication is a close relationship with the analyst. Analysts should avoid analyzing friends, relatives, or persons with whom they have other involvements.

Patient Requisites. Table 23-3 lists the most important patient requisites for psychoanalysis.

Ms. M, a 29-year-old unmarried woman who worked in a low-level capacity for a magazine, presented for consultation with the chief complaints of considerable sadness and distress over her parent’s reaction when they found that she had had a homosexual relationship. She also realized that she had been working far below her potential. She had never sought any treatment before. She was clearly intelligent, sensitive, self-reflective, and insightful. When she learned about the possibility of psychoanalysis as a treatment option, she worried that meant she was “sicker.” Ms. M, however, began reading Freud, realized that analysis was actually recommended for those who are higher functioning, and became intrigued by the idea. She agreed to come 4 days a week for 50-minute sessions.

She was the oldest of three children and the only girl. Ms. M’s father, a successful professional, was described as very demanding and intrusive; someone who never thought anything was good enough. He had always expected his children to do the “extra credit” assignments as part of their regular work. Ms. M, however, was very proud of her father’s accomplishments. She spoke of her mother in conflicting terms as well: she was a homemaker, weak, and sometimes acquiescent to the powerful father but also an individual in her own right who was involved in community volunteer work and could be a powerful public speaker.

Just before beginning her analysis, Ms. M had had her wallet stolen. In her first analytic session, she spoke of losing all of her identification cards, and to her, it seemed as if she were starting analysis “with a completely new identity.” Initially, she was somewhat hesitant to use the couch because she wanted to see her analyst’s reactions, but Ms. M quickly appreciated that she could associate more easily without seeing the analyst.

As her analysis proceeded, through dreams and free associations, Ms. M became quite focused on the analyst. She became extremely curious about the analyst’s life. What emerged from her associations to seeing the analyst’s appointment book on the desk was that she felt “slotted in.” Whenever Ms. M saw other patients, she felt the office was “like an assembly line.” Further associations led to her feeling slotted in by her parents as they ran from one activity to another. Her resistance manifested itself in Ms. M, often coming as much or more than 15 minutes late to her sessions. Her associations led to her admitting that she did not want her analyst to think that she was “too eager.” Ms. M was able to see that she needed to devalue her analyst and her importance to Ms. M as a defense against an overwhelmingly positive and even erotic transference toward her.

For example, Ms. M wanted to improve her appearance so that the therapist, whom she called a “role model,” would find her more attractive. Her negative transference, however, was never far from the surface, and she denigrated the analyst by wondering if the analyst were a “clotheshorse” who was financing her wardrobe with the patient’s payments.

Her conflicts about her sexual orientation were a central preoccupation in the course of her analysis, particularly because her father was homophobic. Early on, Ms. M felt awkward and uncomfortable when she went to a lesbian bar, and when asked if she qualified for the “lesbian discount,” she said she did not. At one point, she began seeing several men, including a male psychologist. The analyst made the transference interpretation, which Ms. M accepted, that a date with this man seemed as if it were a date with the analyst, and sleeping with him would be equivalent to sleeping with the analyst. Ms. M was also able to see that her transient choice of dating a male therapist was a defensive compromise. Although her homosexual object choice was multidetermined, Ms. M came to appreciate, through her work in analysis, that at least a part of her conflicts about homosexuality stemmed from her relationship with her father. It was a means of securing his attention as well as infuriating him.

Over 4 years, Ms. M performed considerably better at work and earned a promotion to a job commensurate with her potential. She was also able to deal better with both her parents and particularly her father, regarding her sexual orientation. She became much more comfortable with her “new identity” and became involved in a relationship with a professional woman. At the end of therapy, Ms. M and this woman were committed to each other and considering adopting a child. (Courtesy of T. Byram Karasu, M.D. and S. R. Karasu, M.D.)

Goals. In developmental terms, psychoanalysis aims at the gradual removal of amnesias rooted in early childhood based on the assumption that filling all gaps in memory will lead to cessation of the morbid condition because the patient no longer needs to repeat or remain fixated to the past. The patient should be better able to relinquish former regressive patterns and to develop new, more adaptive ones, particularly as he or she learns the reasons for his or her behavior. A related goal of psychoanalysis is for the patient to achieve some measure of self-understanding or insight.

Courtesy of T. Byram Karasu, M.D.

Psychoanalytic goals often seem formidable (e.g., a total personality change), involving the radical reorganization of old developmental patterns based on earlier affects and the entrenched defenses built up against them. Goals may also be elusive, framed as they are in theoretical intrapsychic terms (e.g., greater ego strength) or conceptually ambiguous ones (resolution of the transference neurosis). Criteria for successful psychoanalysis may be largely intangible and subjective, and it is best to view them as conceptual endpoints of treatment that the therapist must translate into more realistic and practical terms.

In practice, the goals of psychoanalysis for any patient naturally vary, as do the many manifestations of neuroses. The form that the neurosis takes—unsatisfactory sexual or object relationships, inability to enjoy life, underachievement, and fear of work or academic success, or excessive anxiety, guilt, or depressive ideation—determines the focus of attention and the general direction of treatment, as well as the specific goals. Such goals may change at any time during analysis, especially as many years of treatment may be involved.

Major Approach and Techniques. Structurally, psychoanalysis usually refers to individual (dyadic) treatment that is frequent (four or five times per week) and long term (several years). All three features take their precedent from Freud himself.

The dyadic arrangement is a direct function of the Freudian theory of neurosis as an intrapsychic phenomenon, which takes place within the person

as instinctual impulses continually seek discharge. Because it is crucial to resolve dynamic conflicts internally if structural personality reorganization is to take place, the individual’s memory and perceptions of the repressed past are pivotal.

Freud initially saw patients 6 days a week for 1 hour each day, a routine now reduced to four or five sessions per week of the classic 50-minute hour, which leaves time for the analyst to take notes and organize relevant thoughts before the next patient. Therapists should avoid long intervals between sessions so that the momentum gained in uncovering conflictual material is not lost, and confronted defenses do not have time to restrengthen.

Freud’s belief that successful psychoanalysis always takes a long time because profound changes in the mind occur slowly still holds. The process is similar to the fluid sense of time that is characteristic of our unconscious processes. Moreover, because psychoanalysis involves a detailed recapitulation of present and past events, any compromise in time presents the risk of losing pace with the patient’s mental life.

PSYCHOANALYTIC SETTING. As with other forms of psychotherapy, psychoanalysis takes place in a professional setting, apart from the realities of everyday life, in which the therapist offers the patient a temporary sanctuary in which to ease psychic pain and reveal intimate thoughts to an accepting expert. The design of the psychoanalytic environment promotes relaxation and regression. The setting is usually spartan and sensorially neutral and minimizes external stimuli.

Use of the Couch. The couch has several clinical advantages that are both real and symbolic: (1) the reclining position is relaxing because it is associated with sleep and so eases the patient’s conscious control of thoughts; (2) it minimizes the intrusive influence of the analyst, thus curbing unnecessary cues; (3) it permits the analyst to make observations of the patient without interruption; and (4) it holds a symbolic value for both parties, a tangible reminder of the Freudian legacy that gives credibility to the analyst’s professional identity, allegiance, and expertise. The reclining position of the patient with analyst nearby can also generate threat and discomfort, however, as it recalls anxieties derived from the earlier parent–child configuration that it physically resembles. It may also have personal meanings—for some, a portent of dangerous impulses or submission to an authority figure; for others, relief from confrontation by the analyst (e.g., fear of the use of the couch and over-eagerness to lie down may reflect resistance and, thus, need to be analyzed). Although the use of the couch is requisite to the analytical technique, it is not applied automatically; the therapist introduces it gradually and may suspend its use whenever additional regression is unnecessary or countertherapeutic.

Fundamental Rule. The fundamental rule of free association requires patients to tell the analyst everything that comes into their heads—however disagreeable, unimportant, or nonsensical—and to let themselves go as they would in a conversation that leads from “cabbages to kings.” It differs decidedly from ordinary conversation—instead of connecting personal remarks with a rational thread, the therapist asks the patient to reveal those very thoughts and events that are objectionable precisely because of being averse to doing so.

This directive represents an ideal because free association does not arise freely but is guided and inhibited by a variety of conscious and unconscious forces. The analyst must not only encourage free association through the physical setting and a nonjudgmental attitude toward the patient’s verbalizations but also examine those very instances when the flow of associations is diminished or comes to a halt—they are as important analytically as the content of the associations. The analyst should also be alert to how individual patients use or misuse the fundamental rule.

Aside from its primary purpose of eliciting recall of deeply hidden early memories, the fundamental rule reflects the analytical priority placed on verbalization, which translates the patient’s thoughts into words, so the patient does not channel them physically or behaviorally. As a direct concomitant of the fundamental rule, which prohibits action in favor of verbal expression, patients should postpone making significant alterations in their lives, such as marrying or changing careers, until they discuss and analyze them within the context of treatment.

Principle of Evenly Suspended Attention. As a reciprocal corollary to the rule that patients communicate everything that occurs to them without criticism or selection, the principle of evenly suspended attention requires the analyst to suspend judgment and to give impartial attention to every detail equally. The method consists simply of making no effort to concentrate on anything specific while maintaining a neutral, quiet attentiveness to all that the patient says.

Analyst as Mirror. A second principle is the recommendation that the analyst is impenetrable to the patient and, like a mirror, only reflect what the patient shows. Analysts should be neutral blank screens and not bring their personalities into treatment. They are not to bring their values or attitudes into the discussion or to share personal reactions or mutual conflicts with their patients, although they may sometimes feel the temptation to do so. The bringing in of reality and external influences can interrupt or bias the patient’s unconscious projections. Neutrality also allows the analyst to accept without censure all forbidden or objectionable responses.

Rule of Abstinence. The fundamental rule of abstinence does not mean corporal or sexual abstinence but refers to the frustration of emotional needs and wishes that the patient may have toward the analyst or part of the transference. It allows the patient’s longings to persist and serve as driving forces for analytical work and motivation to change. Freud advised that the analyst proceeds through the analytical treatment in a state of renunciation. The analyst must deny the patient who is longing for love the satisfaction he or she craves.

LIMITATIONS. At present, the predominant treatment constraints are often economic, relating to the high cost in time and money, both for patients and in the training of future practitioners. In addition, because clinical requirements emphasize such requisites as psychological mindedness, verbal and cognitive ability, and stable life situation, psychoanalysis may be unduly restricted to a diagnostically, socioeconomically, or intellectually advantaged patient population. Other intrinsic issues pertain to the use and misuse of its stringent rules, whereby overemphasis on technique may interfere with an authentic human encounter between analyst and patient, and to the major long-term risk of interminability, in which protracted treatment may become a substitute for life. The reification of the classic analytical tradition may interfere with a more open and flexible application of its tenets to meet changing needs. It may also obstruct a comprehensive view of patient care that includes a greater appreciation of other treatment modalities in conjunction with or as an alternative to psychoanalysis.

Ms. A, a 25-year-old articulate and introspective medical student began analysis complaining of mild, chronic anxiety, dysphoria, and a sense of inadequacy, despite above-average intelligence and performance. She also expressed difficulty in long-term relationships with her male peers.

Ms. A began the initial phase of analysis with enthusiastic self-disclosure, frequent reports of dreams and fantasies, and over idealization of the analyst; she tried to please him by being a compliant, good patient, just as she had been a good daughter to her father (a professor of medicine) by going to medical school.

Over the next several months, Ms. A gradually developed a strong attachment to the analyst and settled into a phase of excessive preoccupation with him. Simultaneously, however, she began dating an older psychiatrist and proceeded to complain about the analyst’s coldness and unresponsiveness, even considering dropping out of the analysis because he did not meet her demands.

In the course of analysis, through dreams and associations, Ms. A recalled early memories of her ongoing competition with her mother for her father’s attention and realized that failing to obtain his exclusive love, she had tried to become like him. She was also able to see how her increasing interest in becoming a psychiatrist (rather than following her original plan to be a pediatrician), as well as her recent choice of a man to date, were recapitulations of the past vis-à-vis the analyst. As this repeated pattern was recognized, the patient began to relinquish her intense erotic and dependent tie to the analyst, viewing him more realistically and beginning to appreciate how his quiet presence reminded her of her mother. She also became less disturbed by the similarities she shared with her mother and was able to disengage from her father more comfortably. By the fifth year of analysis, she was happily married to a former classmate, was pregnant, and was a pediatric chief resident. Her anxiety had attenuated and become situation-specific (i.e., she was concerned about motherhood and the termination of analysis). (Courtesy

Psychoanalytic Psychotherapy

Psychoanalytic psychotherapy, based on fundamental dynamic formulations and techniques that derive from psychoanalysis, is designed to broaden its scope. Psychoanalytic psychotherapy, in its narrowest sense, is the use of insight-oriented methods only. As generically applied today to an ever-larger clinical spectrum, it incorporates a blend of uncovering and suppressive measures.

The strategies of psychoanalytic psychotherapy currently range from expressive (insight-oriented, uncovering, evocative, or interpretive) techniques to supportive (relationship-oriented, suggestive, suppressive, or repressive) techniques. Although those two methods may seem antithetical, their precise definitions and the distinctions between them are by no means absolute.

The duration of psychoanalytic psychotherapy is generally shorter and more variable than in psychoanalysis. Treatment may be brief, even with an initially agreed-upon or fixed time limit, or may extend to a less definite number of months or years. Brief treatment is chiefly used for selected problems or highly focused conflict, whereas more prolonged treatment may be applied for more chronic conditions or for intermittent episodes that require ongoing attention to deal with pervasive conflict or recurrent decompensation. Unlike psychoanalysis, psychoanalytic psychotherapy rarely uses the couch; instead, the patient and therapist sit face to face. This posture helps to prevent regression because it encourages the patient to look at the therapist as a real person from whom to receive direct cues, even though transference and fantasy will continue. The couch is unnecessary because the free-association method is rarely used, except when the therapist wishes to gain access to fantasy material or dreams to enlighten a particular issue.

Expressive Psychotherapy

INDICATIONS AND CONTRAINDICATIONS. Diagnostically, psychoanalytic psychotherapy in its expressive mode is suited to a range of psychopathology with mild to moderate ego weakening, including neurotic conflicts, symptom complexes, reactive conditions, and the whole realm of nonpsychotic character disorders, including those disorders of the self that are among the more transient and less profound on the severity-of-illness spectrum, such as narcissistic personality disorders. It is also one of the treatments recommended for patients with borderline personality disorders (BPDs), although special variations may be required to deal with the associated turbulent personality characteristics, primitive defense mechanisms, tendencies toward regressive episodes, and irrational attachments to the analyst.

Ms. B, an intelligent and verbal 34-year-old divorced woman, presented with complaints of being unappreciated at work. Always angry and irritable, she considered quitting her job and even leaving the city. Her social life was also being negatively affected; her boyfriend had threatened to leave her because of her extremely hostile, clinging behavior (the same reason her ex-husband had given when he left her 9 years earlier after only 16 months of marriage). Her past included promiscuity and experimentation with various drugs, and, currently, she indulged in heavy drinking on weekends and occasionally smoked marijuana. She had held many jobs and had lived in various cities.

The eldest of three children of a middle-class family, she came from an unhappy and unstable home: her brother had been in and out of psychiatric hospitals; her sister had left home at the age of 16 after becoming pregnant and being forced to marry; and her overly controlling parents had subjected their children to psychological (and occasionally physical) abuse, alternating between heated arguments and passionate reconciliations.

Initially, Ms. B attempted to contain her rage in treatment, but it frequently surfaced and alternated with child-like helplessness; she interrogated the psychiatrist regarding his credentials, ridiculed psychodynamic concepts, constantly challenged statements, and would demand practical advice but then denigrate or fail to follow the guidance given. The psychiatrist remained unprovoked by her aggression and explored with her the need to engage him negatively. Her response was to question and test his continued concern.

When her boyfriend left her, she attempted suicide (she cut her wrists superficially), was briefly hospitalized, and, on discharge, was placed on a selective serotonin reuptake inhibitor (SSRI) for 6 months for her minor, but protracted, depression. The psychiatrist maintained their regular frequency of sessions despite her greater demands. Although she was puzzled by the steadiness of his interest, she gradually felt safe enough to express her vulnerabilities. As they explored her lack of full commitment to work, friends, and therapy, she began to understand the meaning of her anger in terms of the early abusive relationship with her parents and her tendency to bring it into contemporary relationships. With the psychiatrist’s encouragement, she also began to seek work and make small strides in relationship-oriented efforts. By the end of her second year of treatment, she decided to remain in the city, to stay at her place of employment, and to continue therapy. She needed to experience and practice her somewhat fragile new self, which included greater intimacy in relationships, additional mastery of work skills, and a more cohesive sense of self. (Courtesy of T. Byram Karasu, M.D.)

The persons best suited for the expressive psychotherapy approach have reasonably well-integrated egos and the capacity to both sustain and detach from a bond of dependency and trust. They are, to some degree, psychologically minded and self-motivated, and they are generally able, at least temporarily, to tolerate doses of frustration without decompensating. They must also have the ability to manage the rearousal of painful feelings outside the therapy hour without additional contact. Patients must have some capacity for introspection and impulse control, and they should be able to recognize the cognitive distinction between fantasy and reality.

GOALS. The overall goals of expressive psychotherapy are to increase the patient’s self-awareness and to improve object relations through the exploration of current interpersonal events and perceptions. In contrast to psychoanalysis, expressive psychotherapy modifies major structural changes in ego function and defenses in light of patient limitations. The aim is to achieve a more limited and, thus, select and focused understanding of one’s problems. Rather than uncovering deeply hidden and past motives and tracing

them back to their origins in infancy, the major thrust is to deal with preconscious or conscious derivatives of conflicts as they became manifest in present interactions. Although the therapy seeks insight, it is less extensive; instead of delving to a genetic level, greater emphasis is on clarifying recent dynamic patterns and maladaptive behaviors in the present.

MAJOR APPROACH AND TECHNIQUES. The primary modus operandi involves the establishment of a therapeutic alliance and early recognition and interpretation of negative transference. Only limited or controlled regression is encouraged, and positive transference manifestations are generally left unexplored unless they are impeding therapeutic progress; even here, the emphasis is on shedding light on current dynamic patterns and defenses.

LIMITATIONS. A general limitation of expressive psychotherapy, as of psychoanalysis, is the problem of emotional integration of cognitive awareness. The primary danger for patients who are at the more disorganized end of the diagnostic spectrum, however, may have less to do with the over intellectualization that is sometimes seen in neurotic patients than with the threat of decompensation from or acting out of, deep or frequent interpretations that the patient is unable to integrate properly.

Some therapists fail to accept the limitations of a modified insight-oriented approach and so apply it inappropriately to modulate the techniques and goals of psychoanalysis. Overemphasis on dreams and fantasies, zealous efforts to use the couch, indiscriminate deep interpretations, and continual focus on the analysis of transference may have less to do with the patient’s needs than with those of a therapist who is unwilling or unable to be flexible.

 


Psychotherapy Psychotherapy Reviewed by Web of Psychiatry on December 07, 2021 Rating: 5

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