Psychological Therapies

In psychiatry, imagine that the person is a tricycle. They have three wheels, each of equal importance. Now imagine one of the wheels malfunctioning.

In other areas of medicine, there is perhaps a clearer division between the taking of the history and the performance of a physical examination although again experienced physicians often integrate examination and history.

This is a simple metaphor I use when dealing with situations where ‘medications are not working’ even though perhaps the maximum dose of medications are being used or indeed a range of medication approaches have been trialed.

Tricycle by Antranias, C/- Pixabay

I am sure it is a concern you will often hear expressed in your psych rotations too.

The tricycle can come in many other forms. It can be a three legged stool or chair (I learnt this during a trainee lecture by Prof Sidney Bloch), a triangle, anything that has three sides or components. But each wheel of course represents one component of the biopsychosocial model of care.

This blog is dedicated to the psychological therapies which are just as important as the biological therapies in Psychiatry. Sadly, as students, we are often swept away by the biological side of psychiatry which is in itself a large body of information to learn. And the last thing needed is to add psychological therapies to the mix. I can just see myself back in my day as a student being all too overwhelmed by this, cringing at the thought of adding another component to an already heavy agenda.

When I talk about psychological therapies, I can spend all day and night talking about it. The emphasis of how important it is in mental health just highlights, at least to myself the uniqueness of Psychiatry training in ensuring that it should be incorporated into learning to complement the social and biological.

There are too many schools of psychotherapy to talk about comprehensively in a blog post. So this blog will attempt to simplify matters and in so doing I apologise to any particular branch of psychotherapies that may feel that I have oversimplified matters.  Feel free to leave a comment below if you do.

The information below is largely sourced from the American Psychological Association as well as the Encyclopedia of Psychology at Psychcentral.  Two other good sources of information about psychological therapies are available at the Australian Psychological Society and Psychology Tools.

Now its important to note that I’ve referenced here 4 sources from the psychology world.  And whilst it is fair to say that psychology has made the largest contribution to the development of psychotherapies, we should recognize that contributions have come from a range of sources, including psychiatry, social work, occupational therapy, addiction specialists and patients themselves.

Therapists generally draw on one or more theories of psychotherapy.

A theory of psychotherapy acts as a roadmap for psychologists: It guides them through the process of understanding clients and their problems and developing solutions.

Therapists generally draw on one or more theories of psychotherapy.

Approaches to psychotherapy fall into five broad categories:

1 Psychoanalysis and psychodynamic therapies.

The analytic and dynamic approach focuses on changing problematic behaviors, feelings, and thoughts by discovering their unconscious meanings and motivations. Psychoanalytically oriented therapies are characterized by a close working partnership between therapist and patient. Patients learn about themselves by exploring their interactions in the therapeutic relationship. While psychoanalysis is closely identified with Sigmund Freud and is one of the oldest types of therapies it has been extended and modified since his early formulations and remains an evolving are of therapy.

Dalmation by HuskyHerz C/- Pixabay

2 Behaviour Therapy.

Behavior therapy. This approach focuses on the role of learning’s role in developing both normal and abnormal behaviors. You will likely have come across some of the following concepts, many of which have made it into mainstream knowledge:

1. 1. Ivan Pavlov made important contributions to behavior therapy by discovering classical conditioning, or associative learning. Pavlov’s famous dogs, for example, began drooling when they heard their dinner bell, because they associated the sound with food.
   2. “Desensitizing” is classical conditioning in action: A therapist might help a client with a phobia through repeated exposure to whatever it is that causes anxiety.
   3. Another important thinker was E.L. Thorndike, who discovered operant conditioning. This type of learning relies on rewards and punishments to shape people’s behavior.  In a sense the learner through trial and error tries to figure out what will give them a reward.
   4. Several variations have developed since behavior therapy’s emergence in the 1950s. One variation is cognitive-behavioral therapy, which focuses on both thoughts and behaviors.

3 Cognitive Therapy.

Cognitive therapy emphasizes what people think rather than what they do.

1. 1. Cognitive therapists believe that it is dysfunctional thinking that leads to dysfunctional emotions or behaviors. By changing their thoughts, people can change how they feel and what they do.
   2. Major figures in cognitive therapy include Albert Ellis and Aaron Beck.

4 Humanistic Therapy.

This approach emphasizes people’s capacity to make rational choices and develop to their maximum potential. Concern and respect for others are also important themes.

1. 1. Humanistic philosophers like Jean-Paul Sartre, Martin Buber and Søren Kierkegaard influenced this type of therapy.
   2. Three types of humanistic therapy are especially influential. Client-centered therapy rejects the idea of therapists as authorities on their clients’ inner experiences. Instead, therapists help clients change by emphasizing their concern, care and interest.
   3. Gestalt therapy emphasizes what it calls “organismic holism,” the importance of being aware of the here and now and accepting responsibility for yourself.
   4. Existential therapy focuses on free will, self-determination and the search for meaning.

5 Integrative or Holistic Therapy.

Many therapists will say that they don’t tie themselves to any one approach. Instead, they blend elements from different approaches and tailor their treatment according to each client’s needs.

Many therapists will say that they don’t tie themselves to any one approach. Instead, they blend elements from different approaches and tailor their treatment according to each client’s needs.

If you are unable to remember anything, just remember one thing: CBT. Cognitive Behavioural Therapy.

To put it simply, it is a talking therapy that helps address unhelpful thinking patterns that lead to unhelpful behaviours. These unhelpful vicious cycle leads to treatment resistance ie ‘my medications are not working anymore’.

Try to think of CBT as a broad area of therapy with a range of techniques.  In most cases the therapist will elect to focus on a small number of these techniques which suit the person and their problem.  In some cases the therapist may choose to focus more on the behaviour side of CBT (for example desensitization for a phobia) in other cases they may choose to focus more on the congitive side (for example when dealing with low self-esteem as a primary cause of depressive thinking).

In most CBT treatments there will be some component of instruction and coaching in one or more relaxation, mediation or grounding* techniques as these generally aid the person when they come in contact with a trigger for their problem.  In fact the incorporation of a relaxation or grounding techniques is common place in a number of therapies these days with many therapies now incorporating the concept of mindfulness**.

*Grounding is a spiritual term, referring to centering your soul in your body, and in turn, connecting it with Mother Earth. When these connections are strong, it can help you feel safer and more in touch with the earth and Mother Nature. If you experience a lot of fear and anxiety in your day-to-day, it is possible that you have become ungrounded.

**Mindfulness is the psychological process of bringing one’s attention to the internal and external experiences occurring in the present moment, which can be developed through the practice of meditation and other training. The term ‘mindfulness’ is a translation of the Pali term sati,[6] which is a significant element of some Buddhist traditions. Large population-based research studies have indicated that the practice of mindfulness is strongly correlated with greater well-being and perceived health. This is applicable to society at large as well as specific settings such as workplaces and schools. Studies have also shown that rumination and worry contribute to mental illnesses such as depression and anxiety, and that mindfulness-based interventions are effective in the reduction of both rumination and worry.

There are other more complex therapies derived from CBT such as Dialectic Behavioural Therapy and Trauma based CBT. Even Eye Movement Desensitization and Reprocessing which is used in PTSD is based on CBT. But these are just big words that you do not need to worry about at your stage.

You can actually do CBT on yourself. That is the best way to learn, embrace and understand this indispensable, multipurpose therapy. It will be helpful for you in the long term on a personal and emotional level. There are now a number of free and quality online CBT websites (for example MoodGym which is for challenging depressive thoughts). I can also recommend the book ‘Self Esteem’ by McKay and Fanning to start off with. Just give it a go and let me know how you find it.