Psychotherapy

Classification of Intervention Methods

Psychotherapeutic methods are divided into groups depending on the degree of physician involvement and the work with the patient's psychological defense mechanisms.

By the specialist's degree of activity:

• Directive methods: the physician takes an active role, giving instructions and advice while the patient remains passive. This is indicated in acute crises, panic, or when working with helpless patients. The main drawback is absolving the individual of responsibility for treatment.
• Non-directive methods: the physician uses targeted questioning without direct instructions. The patient is engaged in independently seeking solutions, which boosts their self-esteem and demonstrates their own inner resources.

By relation to psychological defense:

• Expressive methods: aimed at complete resolution of internal conflict by exposing the subconscious (from English to express).
• Supportive methods: reinforce already established adaptive behavioral patterns (from English to support). Their significant drawback is that they may encourage self-deception for the sake of a sense of security and keep the patient from actively solving problems.

There are also activating (urging toward struggle) and calibrating/calming (relieving anxiety during stress) approaches.

Main approaches and selection of therapy

The choice of tactics depends on the patient's thinking style and their clinical picture. As monotherapy, psychotherapy is used for mild psychosomatic and functional disorders (neuroses). In endogenous diseases, it is combined with pharmacotherapy.

• Cognitive methods: address logic and are indicated for patients with a predominance of the second signaling system (rational thinking). They include rational psychotherapy (the physician logically proves the patient's errors) and A. Beck's method (the patient is given a framework for independent analysis). Ambiguity is unacceptable here.
• Suggestive methods (Suggestion): act on emotions bypassing critical faculties. Indicated for suggestible patients with infantile traits (dominance of the first signaling system). Suggestion formulas must be concise and contain no negative particle "not".
• Hypnosis: induction into a trance through attention concentration and rhythmic influence. Can be directive or non-directive (M. Erickson). An important ethical rule: hypnosis is performed only within a medical facility in the presence of third parties.
• Behavioral methods: based on developing defense reflexes or inhibiting pathological ones. They include systematic desensitization, the token economy method (for children), and conditioned-reflex therapy for alcoholism (using apomorphine).

Forms of delivery and indirect influence

Work with the patient can be conducted individually (discussing intimate details, helping withdrawn individuals) or in a group. Group psychotherapy is indispensable for correcting maladaptive personality traits, as egocentrism and immaturity manifest vividly in a collective setting. The postulate states: "the group is always healthier than any of its individual members."

There are also indirect methods, where the influence is exerted through:

• The setting of the medical institution and the ward atmosphere.
• Relationships within the medical staff team.
• The route of drug administration and the use of placebos.
• Additional procedures (exercise therapy, massage).

Indispensable elements of the psychotherapeutic process

Regardless of the chosen school, specific phenomena first described by S. Freud are always present during treatment:

1. Transference (transfer): the patient unwittingly projects onto the physician feelings they experienced toward significant people from the past (ranging from childhood attachment to inappropriate irritation). The physician must encourage a rational analysis of these emotions.
2. Countertransference (countertransference): the physician's own irrational feelings toward the patient (pity, indignation, infatuation) driven by personal experience. The specialist is obligated to actively overcome these complexes.
3. Resistance: the patient's unconscious striving to leave everything unchanged. It manifests as missed appointments or avoidance of painful topics. Interestingly, the complete absence of resistance often indicates the patient's indifference to the outcomes.

Progress toward health does not happen smoothly, but in leaps via the mechanisms of insight (insight — realization) and catharsis (catharsis — purging, resolution of internal conflict). Termination of the course must always be logical and planned to prevent relapses and dependence on the therapist.

Autogenic training

This is an independent supportive relaxation method based on self-observation and autosuggestion (authored by J.H. Schultz). The deep causes of conflicts are not uncovered in the process.

Over the course of 4–6 weeks, the patient consistently masters a set of 6 target sensations:

1. Relaxation in the body muscles.
2. Warmth and heaviness in the limbs.
3. Slow and steady heartbeat.
4. Even and calm breathing.
5. Pleasant warmth in the celiac plexus area.
6. Pleasant coolness in the forehead area.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Therapy features and basic principles of anticonvulsant dosing.
• Specific and systemic adverse effects of anticonvulsant drugs.
• Drug-drug interactions and issues of polypharmacy.
• Features of Aaron Beck's cognitive psychotherapy.
• M. Erickson's non-directive hypnosis technique.

Other topics in "Chapter 17. Therapy of Mental Disorders. Basic Principles of Prevention and Rehabilitation"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.