[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
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
