[PAPER
3:
PSYCHOTHERAPY
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INTRODUCTION]
1
Types of psychotherapy:
Supportive: Includes counselling, general psychiatric follow-up. It aims to offer
practical and emotional support, provides an opportunity for ventilation of
emotions and guided problem solving discussions. The primary aim of
supportive psychotherapy is to support reality testing, provide ego support
and attempt to reestablish usual level of functioning. Usually employed in
otherwise healthy patients with overwhelming ongoing crises and those with ego
deficits. Also useful in those who are not psychologically motivated to ‘explore’
themselves. This is not time limited and the therapist must be predictable
available in times of need. Problem solving, advice, reinforcement and
reassurance are main tools.
Exploratory: aims to effect change in the individual’s abnormal thinking and
behaviour by exploration of underlying causes. Types include dynamic therapies
and cognitive behavioural therapies
o Dynamic therapies Based on psychoanalytic theory. Focus of clinical
attention is childhood experience and exploration of the
unconscious mind.
o Cognitive/behavioural therapies Based on learning theory and
cognitive theory. Focus of clinical attention is the ‘here and now’,
current behaviours and thoughts, and their modification
Exploratory or analytical Supportive psychotherapy
psychotherapy
Exploration of cause for symptoms No exploration – identifying and supporting
existing coping skills only
Often time limited No set boundaries – as and when needed
Seeking childhood trauma and Support through current crisis
developmental difficulties
Reasonable frustration tolerance Poor frustration tolerance
Good psychological-mindedness Poor psychological-mindedness
Intact reality testing Poor reality testing
Meaningful object relations Impaired object relations
Good impulse control Poor impulse control
Good therapeutic alliance poor therapeutic alliance
Adapted from Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th
Edition. Lippincott Williams & Wilkins 2007
Counselling
• Counselling may be thought of as a method of relieving distress
undertaken by means of a dialogue between two people. The aim is to
help the client or patient find their own solutions to problems, while being
supported to do so and being guided by appropriate advice.
• Techniques: Information giving, Client-focused discussion and problem
solving
• The different types include:
Information sharing/discussion, also called psycho education
Crisis management.
Problem-based counselling Directed towards a specific primary
problem, e.g. drug misuse
Risk counselling Used to guide an informed decision (e.g. pre-natal
interventions, genetic counselling). It is differentiated from other
© SPMM COURSE 2010
, [PAPER
3:
PSYCHOTHERAPY
-‐
INTRODUCTION]
2
forms of counselling by the fact that the counsellor is clearly the
expert and has access to specialist information.
Psychoanalytic models
Psychoanalysis: Psychoanalysis can be defined as a theory of psychological
structure and function with particularly emphasis on unconscious mental
processes; It can also be seen as an investigative method to explore causes of
mental experiences for therapeutic benefits; Finally psychoanalysis itself is a
method for treatment of various psychiatric disorders.
Object relation theory:
According to object relations theory – the ego exists only in relation to other
objects, which may be external or internal. ‘Object’ refers to both living persons
and non living concepts.
Melanie Klein was a major proponent of what came to be known as Object
relation theory later. Other prominent theorists include
1. Fairbairn
2. Kernberg
3. Guntrip
4. Winnicott
5. Balint
Kleinian theory:
1. Play interpretation was the major technique employed
2. maintained that oedipal development occurred earlier than what Freud
envisaged
3. According to Klein an infant possessed instinctual knowledge of body.
4. Weaning is symbolically equivalent to castration
5. Klein’s stages are not age specific – but the PSP and DP are said to occur
between 0-3 months (very early)
6. Her therapy is primarily about coping with ambivalence.
• Kleinian defenses – SIPDOG i.e. Splitting, introjection, projective identification,
Denial, omnipotence and grandiosity
Reparation phase – creativity emanates as an attempt to repair damage done by
‘destructive impulse’. Continues lifelong. In the absence of reparation, a maladaptive
defense called manic defense can emerge characterized by denial of reality (refusal to take
guilt), omnipotence and grandiosity.
Later the child realizes that both good and bad things emanate from unified single object
(whole). At same time weaning occurs – perceived as a loss. Subsequent guilt develops for
having destructive impulses against the mother. Depressive position – fear of loss of love
of object.
Projection of both bad and good impulses occurs followed by splitting of external world into
good and bad. Cannot unify these elements into one. Bad objects include non gratifying
bad breasts (parts). This leads to persecutory anxiety and the child is said to be in
Paranoid –schizoid position.
Soon after birth, fear of annihilation is present. This cannot be tolerated by the child and
projects this destructive impulse to external objects.
Klein’s paranoid schizoid position best explains the splitting, idealisation,
denigration and persecutory anxiety seen in borderline personality disorder.
© SPMM COURSE 2010
, [PAPER
3:
PSYCHOTHERAPY
-‐
INTRODUCTION]
3
Fairbairn:
Libidinal, antilibidinal and ideal parts of an object; also extended as
libidinal, antilibidinal and ideal self.
Winnicott:
Children’s psychological development occurs in a zone between reality and
fantasy called transitional zone. Play is an important aspect of
development of a child.
Transitional object refers to a soft toy, towel or any such objects that
help in transition from ideal objects of fantasy to real objects which are
not as reliable as those in fantasy. These serve as buffers against loss,
get invested with primary object’s qualities e.g. mother’s contact but
remain under the control of the child.
Good enough mother concept refers to the fact that a mother need not
be perfect – but good enough to provide growth sustaining environment
(holding).
Parental control and impositions can lead to development of a false self
different from the real self (theory of multiple self organizations).
‘Holding’ proposed by Winnicott has been modified and adapted for
psychotherapy. While administering psychotherapy, the affective and
cognitive dispositions of a therapist play important part. The cognitive
capacity of the therapist to maintain objectivity and focus on selected facts
during a discourse is called ‘containing’ (Bion). The affective disposition
of the therapist which helps in restraining oneself from retaliating to
negative transferences is called ‘holding’.
Defence mechanisms:
Defence mechanisms are not descriptions; they are explanations for certain
human behaviour and experiences. Hence they are not a part of descriptive
psychopathology. These defences operate both in normal individuals and under
pathological conditions. Anna Freud organised Freudian defences; Klein and later
contributors added some defence mechanisms. Vaillant (1977) classified them
and categorised them to mature, immature and neurotic defences. Kleinian
defences are sometimes called as psychotic defences. Using a narrow repertoire
of defences repeatedly and repeated use of immature or neurotic defences may
be associated with disease states or traits.
Mature defences:
Altruism: Using constructive and gratifying service to others to
receive a vicarious satisfaction. This does not involve giving up one’s
pleasures. Altruism is distinguished from altruistic surrender, in which
surrender of direct gratification of instinctual needs takes place to
satisfy the needs of others to the detriment of the self.
Humour: Here comedy is used to overtly express feelings and
thoughts without personal discomfort and without producing an
unpleasant effect on others. It allows the person to tolerate and yet
focus on troublesome aspects.
Anticipation: Here one plans realistically for future inner discomfort
and expects worse to occur with mental preparation. Note that
© SPMM COURSE 2010
, [PAPER
3:
PSYCHOTHERAPY
-‐
INTRODUCTION]
4
anticipation without specific target or goal is nothing but free floating
anxiety and this is not helpful; Anticipation mechanism is goal-directed
and implies careful planning for potential difficulties.
Sublimation: Achieving impulse gratification but only after altering a
socially objectionable impulse to a socially acceptable one. Sublimation
allows instincts to be channelled, rather than blocked.
Suppression: Consciously or semiconsciously postponing attention to
a conscious impulse or conflict. Issues may be deliberately cut off, but
they are not avoided. Discomfort is acknowledged but minimized.
Neurotic defences:
Displacement: The process by which interest and/or emotion is
shifted from one object onto another less-threatening, often less-
retaliating one. For example one who is told off by her consultant
during clinical supervision may displace the anger felt onto her
spouse or dog (though the reaction may be extremely different
from the two creatures!)
Dissociation: Temporarily but drastically modifying one's sense of
personal identity to avoid emotional distress. Fugue states and
hysterical conversion reactions are common manifestations of
dissociation. Dissociation may also be found in counter-phobic
behaviour; here a person with fear of heights takes up parachute
diving and experiences dissociation during the act.
Isolation: Splitting or separating an idea from the affect that
accompanies it but is repressed. Noted in OCD.
Rationalisation: Offering rational explanations in an attempt to
justify attitudes, beliefs, or behaviour that may otherwise be
unacceptable. Such underlying motives are usually instinctually
determined. It often involves finding excuses that will justify
unacceptable behaviours when self-esteem is threatened, often
seen in teenagers and those who abuse alcohol and drugs.
Reaction formation: This involves transforming an unacceptable
impulse into its exact opposite. Reaction formation is characteristic
of obsessional neurosis, but it may occur in other forms of
neuroses as well. If this mechanism is frequently used at any early
stage of ego development, it can become a permanent character
trait, as in an obsessional personality.
Repression: This refers to expelling or withholding from
consciousness an idea or feeling. Primary repression refers to the
curbing of ideas and feelings before they have attained
consciousness: secondary repression excludes from awareness
what was once experienced at a conscious level. Note that this
differs from suppression – suppression is mere postponement not
loss of thoughts from conscious perception.
Intellectualisation: This refers to excessively using intellectual
processes to avoid affective expression or experience. Here
needless emphasis is focused on the inanimate to avoid intimacy
with people; attention is paid to external reality to avoid the
© SPMM COURSE 2010
3:
PSYCHOTHERAPY
-‐
INTRODUCTION]
1
Types of psychotherapy:
Supportive: Includes counselling, general psychiatric follow-up. It aims to offer
practical and emotional support, provides an opportunity for ventilation of
emotions and guided problem solving discussions. The primary aim of
supportive psychotherapy is to support reality testing, provide ego support
and attempt to reestablish usual level of functioning. Usually employed in
otherwise healthy patients with overwhelming ongoing crises and those with ego
deficits. Also useful in those who are not psychologically motivated to ‘explore’
themselves. This is not time limited and the therapist must be predictable
available in times of need. Problem solving, advice, reinforcement and
reassurance are main tools.
Exploratory: aims to effect change in the individual’s abnormal thinking and
behaviour by exploration of underlying causes. Types include dynamic therapies
and cognitive behavioural therapies
o Dynamic therapies Based on psychoanalytic theory. Focus of clinical
attention is childhood experience and exploration of the
unconscious mind.
o Cognitive/behavioural therapies Based on learning theory and
cognitive theory. Focus of clinical attention is the ‘here and now’,
current behaviours and thoughts, and their modification
Exploratory or analytical Supportive psychotherapy
psychotherapy
Exploration of cause for symptoms No exploration – identifying and supporting
existing coping skills only
Often time limited No set boundaries – as and when needed
Seeking childhood trauma and Support through current crisis
developmental difficulties
Reasonable frustration tolerance Poor frustration tolerance
Good psychological-mindedness Poor psychological-mindedness
Intact reality testing Poor reality testing
Meaningful object relations Impaired object relations
Good impulse control Poor impulse control
Good therapeutic alliance poor therapeutic alliance
Adapted from Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th
Edition. Lippincott Williams & Wilkins 2007
Counselling
• Counselling may be thought of as a method of relieving distress
undertaken by means of a dialogue between two people. The aim is to
help the client or patient find their own solutions to problems, while being
supported to do so and being guided by appropriate advice.
• Techniques: Information giving, Client-focused discussion and problem
solving
• The different types include:
Information sharing/discussion, also called psycho education
Crisis management.
Problem-based counselling Directed towards a specific primary
problem, e.g. drug misuse
Risk counselling Used to guide an informed decision (e.g. pre-natal
interventions, genetic counselling). It is differentiated from other
© SPMM COURSE 2010
, [PAPER
3:
PSYCHOTHERAPY
-‐
INTRODUCTION]
2
forms of counselling by the fact that the counsellor is clearly the
expert and has access to specialist information.
Psychoanalytic models
Psychoanalysis: Psychoanalysis can be defined as a theory of psychological
structure and function with particularly emphasis on unconscious mental
processes; It can also be seen as an investigative method to explore causes of
mental experiences for therapeutic benefits; Finally psychoanalysis itself is a
method for treatment of various psychiatric disorders.
Object relation theory:
According to object relations theory – the ego exists only in relation to other
objects, which may be external or internal. ‘Object’ refers to both living persons
and non living concepts.
Melanie Klein was a major proponent of what came to be known as Object
relation theory later. Other prominent theorists include
1. Fairbairn
2. Kernberg
3. Guntrip
4. Winnicott
5. Balint
Kleinian theory:
1. Play interpretation was the major technique employed
2. maintained that oedipal development occurred earlier than what Freud
envisaged
3. According to Klein an infant possessed instinctual knowledge of body.
4. Weaning is symbolically equivalent to castration
5. Klein’s stages are not age specific – but the PSP and DP are said to occur
between 0-3 months (very early)
6. Her therapy is primarily about coping with ambivalence.
• Kleinian defenses – SIPDOG i.e. Splitting, introjection, projective identification,
Denial, omnipotence and grandiosity
Reparation phase – creativity emanates as an attempt to repair damage done by
‘destructive impulse’. Continues lifelong. In the absence of reparation, a maladaptive
defense called manic defense can emerge characterized by denial of reality (refusal to take
guilt), omnipotence and grandiosity.
Later the child realizes that both good and bad things emanate from unified single object
(whole). At same time weaning occurs – perceived as a loss. Subsequent guilt develops for
having destructive impulses against the mother. Depressive position – fear of loss of love
of object.
Projection of both bad and good impulses occurs followed by splitting of external world into
good and bad. Cannot unify these elements into one. Bad objects include non gratifying
bad breasts (parts). This leads to persecutory anxiety and the child is said to be in
Paranoid –schizoid position.
Soon after birth, fear of annihilation is present. This cannot be tolerated by the child and
projects this destructive impulse to external objects.
Klein’s paranoid schizoid position best explains the splitting, idealisation,
denigration and persecutory anxiety seen in borderline personality disorder.
© SPMM COURSE 2010
, [PAPER
3:
PSYCHOTHERAPY
-‐
INTRODUCTION]
3
Fairbairn:
Libidinal, antilibidinal and ideal parts of an object; also extended as
libidinal, antilibidinal and ideal self.
Winnicott:
Children’s psychological development occurs in a zone between reality and
fantasy called transitional zone. Play is an important aspect of
development of a child.
Transitional object refers to a soft toy, towel or any such objects that
help in transition from ideal objects of fantasy to real objects which are
not as reliable as those in fantasy. These serve as buffers against loss,
get invested with primary object’s qualities e.g. mother’s contact but
remain under the control of the child.
Good enough mother concept refers to the fact that a mother need not
be perfect – but good enough to provide growth sustaining environment
(holding).
Parental control and impositions can lead to development of a false self
different from the real self (theory of multiple self organizations).
‘Holding’ proposed by Winnicott has been modified and adapted for
psychotherapy. While administering psychotherapy, the affective and
cognitive dispositions of a therapist play important part. The cognitive
capacity of the therapist to maintain objectivity and focus on selected facts
during a discourse is called ‘containing’ (Bion). The affective disposition
of the therapist which helps in restraining oneself from retaliating to
negative transferences is called ‘holding’.
Defence mechanisms:
Defence mechanisms are not descriptions; they are explanations for certain
human behaviour and experiences. Hence they are not a part of descriptive
psychopathology. These defences operate both in normal individuals and under
pathological conditions. Anna Freud organised Freudian defences; Klein and later
contributors added some defence mechanisms. Vaillant (1977) classified them
and categorised them to mature, immature and neurotic defences. Kleinian
defences are sometimes called as psychotic defences. Using a narrow repertoire
of defences repeatedly and repeated use of immature or neurotic defences may
be associated with disease states or traits.
Mature defences:
Altruism: Using constructive and gratifying service to others to
receive a vicarious satisfaction. This does not involve giving up one’s
pleasures. Altruism is distinguished from altruistic surrender, in which
surrender of direct gratification of instinctual needs takes place to
satisfy the needs of others to the detriment of the self.
Humour: Here comedy is used to overtly express feelings and
thoughts without personal discomfort and without producing an
unpleasant effect on others. It allows the person to tolerate and yet
focus on troublesome aspects.
Anticipation: Here one plans realistically for future inner discomfort
and expects worse to occur with mental preparation. Note that
© SPMM COURSE 2010
, [PAPER
3:
PSYCHOTHERAPY
-‐
INTRODUCTION]
4
anticipation without specific target or goal is nothing but free floating
anxiety and this is not helpful; Anticipation mechanism is goal-directed
and implies careful planning for potential difficulties.
Sublimation: Achieving impulse gratification but only after altering a
socially objectionable impulse to a socially acceptable one. Sublimation
allows instincts to be channelled, rather than blocked.
Suppression: Consciously or semiconsciously postponing attention to
a conscious impulse or conflict. Issues may be deliberately cut off, but
they are not avoided. Discomfort is acknowledged but minimized.
Neurotic defences:
Displacement: The process by which interest and/or emotion is
shifted from one object onto another less-threatening, often less-
retaliating one. For example one who is told off by her consultant
during clinical supervision may displace the anger felt onto her
spouse or dog (though the reaction may be extremely different
from the two creatures!)
Dissociation: Temporarily but drastically modifying one's sense of
personal identity to avoid emotional distress. Fugue states and
hysterical conversion reactions are common manifestations of
dissociation. Dissociation may also be found in counter-phobic
behaviour; here a person with fear of heights takes up parachute
diving and experiences dissociation during the act.
Isolation: Splitting or separating an idea from the affect that
accompanies it but is repressed. Noted in OCD.
Rationalisation: Offering rational explanations in an attempt to
justify attitudes, beliefs, or behaviour that may otherwise be
unacceptable. Such underlying motives are usually instinctually
determined. It often involves finding excuses that will justify
unacceptable behaviours when self-esteem is threatened, often
seen in teenagers and those who abuse alcohol and drugs.
Reaction formation: This involves transforming an unacceptable
impulse into its exact opposite. Reaction formation is characteristic
of obsessional neurosis, but it may occur in other forms of
neuroses as well. If this mechanism is frequently used at any early
stage of ego development, it can become a permanent character
trait, as in an obsessional personality.
Repression: This refers to expelling or withholding from
consciousness an idea or feeling. Primary repression refers to the
curbing of ideas and feelings before they have attained
consciousness: secondary repression excludes from awareness
what was once experienced at a conscious level. Note that this
differs from suppression – suppression is mere postponement not
loss of thoughts from conscious perception.
Intellectualisation: This refers to excessively using intellectual
processes to avoid affective expression or experience. Here
needless emphasis is focused on the inanimate to avoid intimacy
with people; attention is paid to external reality to avoid the
© SPMM COURSE 2010
