Psychopharmacology: Psychotherapies

B. Ego

While many of Freud’s ideas have fallen out of favour, it is indisputable that he provided psychiatry and the emerging field of psychotherapy with a new systematic way of viewing the mind and behaviour. Nearly all of the fundamentals of psychotherapy can be traced back to his work. His structural model sought to understand our instincts and drives and divided the mind into three parts: the id, the ego and the superego. The ego (B) refers to the mainly conscious part of the mind that composes rational thinking and balances the needs of the individual against the demands of the outside world. The id (C) refers to the mainly unconscious part of the mind that contains innate instincts such as sexuality and aggression. It is not a term widely used in psychiatric literature these days. The superego (E) is analagous to what we might call ‘conscience’ and contains our moral rules. Freud believed it developed from our identification

D. Repression

Denial and repression may often be confused. Defence mechanisms are fundamentally unconscious strategies employed by an individual to cope with reality and stress. They are not always maladaptive (see below). Denial (A) refers to a refusal to accept reality despite all logical evidence. It refers mainly to events that are currently occurring in the individual’s life. Repression (D) involves the unconscious exclusion of painful desires, thoughts or fears. In this case, the woman has unconsciously hidden the memory of seeing her partner in bed with another man in order to avoid reliving the intense pain this caused her. Idealization (B) involves perceiving another individual as having more positive traits or qualities than they may actually possess. It is actually part of the complex defence of splitting (E), in which the individual perceives things as either all ‘good’ (idealization), or all ‘bad’ (devaluation).

E. Sublimation

Sublimation (E) refers to transforming negative emotions or situations into positive feelings or behaviours and is classified as a ‘mature’ defence mechanism. Many artists are considered to have used this defence mechanism in order to ‘sublimate’ their nihilistic feelings about themselves and the world. Acting out (A) refers to the enactment of strong feelings that may have been stirred up during therapy, but enacted outside the therapy session. It is often destructive, for example the therapeutic investigation of emotional abuse that had been previously repressed may lead to feelings of anger that may be taken out on people close to the individual. It is not ‘cathartic’ and is usually unhelpful and possibly disastrous for ongoing therapy. Dissociation (B) refers to the modification of one’s personality or identity in order to avoid distress. In severe forms it may present as the controversial ‘multiple personality disorder’. This may result in a dissociative disorder, such as dissociative amnesia or fugue. Projection (C) is a defence mechanism used to decrease anxiety by ascribing one’s own thoughts, fears, attributes or emotions to the external world, usually another person, while denying them as one’s own. For example, a woman really dislikes her male co-worker. However, instead of addressing this, she projects this feeling by the belief that the co-worker dislikes her while saying she herself does not have a problem with him. Projective identification (D) can be thought of as a ‘self-fulfilling prophecy’ whereby in projected emotions or feelings, the recipient begins to alter their behaviour in order to make the behaviour ‘real’. Thus in the example above, the projective identification may lead to the co-worker actually starting to dislike the woman in question, whereas previously he may have had no problem with her.

A. Cognitive behavioural therapy (CBT)

CBT (A) is now the most prescribed form of psychotherapy in the NHS. It developed from both cognitive and behavioural models. It is usually short-term and used to address a specific problem. It focuses on the ‘here and now’ to a much greater extent than psychodynamic psychotherapy. It is very pragmatic, aiming to alleviate suffering and develop coping strategies, rather than necessarily getting to the ‘root’ of problems, although the therapist will often try and uncover ‘core beliefs’ the individual may hold about themselves and the world.

E. Systemic therapy

Systemic therapy (E), also known as family therapy, is an umbrella term for a group of models, theories and techniques in which the relationships between individuals (i.e. in systems) are explored. In this way the focus is very different from traditional psychoanalysis, although the two fields are in many ways seeing a growing trend of learning from each other. Family therapy incorporates many different theoretical models, but the fundamental principles are to address issues around relationships. Examples of types of family therapy include narrative therapy, solutionfocused therapy and strategic family therapy

E. Systemic therapy

Systemic therapy (E), also known as family therapy, is an umbrella term for a group of models, theories and techniques in which the relationships between individuals (i.e. in systems) are explored. In this way the focus is very different from traditional psychoanalysis, although the two fields are in many ways seeing a growing trend of learning from each other. Family therapy incorporates many different theoretical models, but the fundamental principles are to address issues around relationships. Examples of types of family therapy include narrative therapy, solutionfocused therapy and strategic family therapy

B. CBT

CBT (B) is the most evaluated and recognized form of psychotherapy for obsessive–compulsive disorder (OCD). One of the core concepts of CBT in OCD is challenging the idea of ‘magical thinking’ in which OCD sufferers believe that they will either have to act on their distressing thoughts or feelings or indeed that they have acted on them in the past. The treatment may also involve ‘exposure and response prevention’ therapy in which the individual is exposed to a stimulus that will provoke their obsessions but are prevented from performing their compulsions which would normally decrease their anxiety.

D. CBT is not useful in dementia

Certain cognitive and behavioural techniques may be very useful in dementia (D), both for people with dementia and their carers. It should not be assumed that cognitive impairment will automatically exclude people with dementia from benefiting from these therapies and techniques. CBT is often employed by mental health professionals without a full qualification under supervision from a qualified CBT therapist (A). This is an important part of training and as long as there is adequate supervision it is an acceptable and beneficial form of treatment. Many mental health professionals employ CBT ‘techniques’ in their everyday management and engagement with patients without this constituting ‘therapy’ as such. It is a common misconception that CBT does not make reference to early experiences (B).