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Psychotherapeutic Theory & Models

Week 2

Psychoanalytic Theory: Freud

� Topography of the Mind: Preconscious, Conscious, Unconscious

� Structure of the Mind: Id, Ego , Superego

� Drives

� Psychic energy (Libido)

� Anxiety

� Conscious Coping strategies

� Ego Defense Mechanisms (Unconscious responses)

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Psychoanalytic Theories

� Sigmund Freud: the father of psychoanalysis

� Supports that all human behavior is caused & can be explained

� Personality structure consists of three components

� Developed concept of transference and countertransference

� Current psychoanalysis focuses on

� discovering the causes of unconscious and repressed thoughts, feelings, and conflicts believed to cause the anxiety

� Help to gain insight in resolving these conflicts and anxieties

� Practiced on limited basis

� Cost

� Time constraints

Major Therapeutic Strategies

� 1) Make the Unconscious conscious

� 2) Strengthen the ego so that behavior is based more on Reality and less on instinctual drives

� Techniques: hypnosis, Free Association, Interpretation

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Interpersonal Theory:

Harry Stack Sullivan

� Key Concepts: Anxiety and Self-esteem

� “good me”, “bad me”, “not me”

� Anxiety is a “Chief disruptive force” in relationships

� Interpersonal security: sense of “total well being”

� Difficulty in living arises out of inability to satisfy needs to achieve interpersonal security

Interpersonal Theories

� Harry Stack Sullivan: interpersonal relationships

� 5 life stages: 1) infancy (birth to onset of language);

� 2) childhood (language to 5 years);

� 3) juvenile (5-8 years);

� 4) preadolescence (8-12 years);

� 5) adolescents (puberty to adulthood).

� 3 developmental cognitive modes: 1) Protaxic mode, 2)Parataxic mode, and 3) Syntaxic mode

� Therapeutic community/milieu

� Was one of primary modes of treatment but not practical now

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Gestalt Therapy (Frederick Perls)� “About the Here and Now”

� Key Concepts: People are responsible for finding their own way in life, accepting personal responsibility

� Unfinished Business creates anxiety

� Avoidance: not healthy

� Therapy techniques: Dialogue exercise, rehearsal, Exaggeration (What is the worst thing that could happen…….?)

Person Centered Therapy:

Carl Rogers

� Key Concepts: Client has potential for becoming aware of problems and means to solve them.

2) Focus is on the development of self-direction

3) Health is achieved through the congruence of the Ideal self & the Real self

Therapeutic Strategies: Openness, trust in self, genuineness, warmth, empathy, respect, active listening, reflection on feelings, unconditional positive regard

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Humanistic theories

� Maslow: Hierarchy of needs

� Theory helps nurse understand motivations and behavior change during life crisis

� 5 levels

� Basic needs foundation

� Safety and security

� Love and belonging

� Esteem needs

� Self-actualization

� Rogers: client-centered therapy

� Key to healing is the role of the client and therapist takes a supportive role

� Unconditional positive regard

� Genuineness

� Empathetic understanding

Behavioral Therapy: Pavlov, Skinner, Bandura

� Two Overriding Principles: 1) Understanding human behavior within this model differs fundamentally from a traditional psychodynamic model.

� 2) Strong emphasis on the Scientific Method to include an overt and testable conceptual framework that has measurable outcomes.

� Dialectical Behavioral Therapy: * used with Borderline Personality Disorders

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Behavioral Theories

� Pavlov: Classic conditioning

� Behavior can be changed through conditioning (external or environmental conditions or stimuli)

� Skinner: Operant conditioning

� Behavior learned through history/past experience

� If behavior could be changed thoughts and feelings would accompany

� Behavior modification therapy

� Positive/negative reinforcement

Behavioral Therapy Techniques

� 1) Problem Identification & Assessment

� 2) Role playing

� 3) Self monitoring: journaling

� 4) Behavioral Observation: used with children and parents to observe interaction patterns

� 5) Psychometric Evaluations: questionnaires & scales

� 6) Cognitive restructuring: Alter dysfunctional thinking

� 7) Assertiveness & Social skills training

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Existential Theories� Beck: Cognitive therapy

� How person perceives/interprets experience determines how feels and behaves

� Ellis: Rational emotive therapy

� Confrontation of “irrational beliefs” preventing accepting responsibility for self & behaviors

� Frankl: Logotherapy

� Help assume personal responsibility (looking for meaning in life is central theme)

� Perls: Gestalt therapy

� Focusing on identification of feelings in here and now (leading to self-acceptance

� Glasser: Reality therapy

� Focus is need for identity through responsible behavior; challenged to examine ways behavior impedes attempts to achieve life goals

Rational-Emotive Therapy:

Albert Ellis

� Key Concepts: Neurosis is irrational thinking & behaving

� Emotional problems are rooted in childhood but continue in the now

� A client’s belief system is the cause of emotional problems

� Goal of Therapy: Client gains insight into problems and then practices to change self-defeating behavior

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Therapeutic techniques: RET

� 1) Cognitive-disputing irrational beliefs through homework & changing language and thinking patterns

� 2) Emotive-Role playing & Imagery

� Usually associated with Behavior change & tailored to each individual client needs

Cognitive Behavioral Therapy

(Aaron Beck)

� Based on personality theory that asserts that how one thinks largely determines how one feels & behaves

� Goal is to alter a person’s interpretation of their situation, for example: If a patient is depressed they are only thinking in terms of hopelessness and self defeat and are likely to stay depressed.

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CBT Strategies

� Client and therapist collaborate to identify dysfunctional interpretations and try to modify them

� Guided Discovery of thinking pattern, experiences, and ways to facilitate a change in thinking patterns

� Cognitive Therapy: Highly structured and very individualized to each client , short term lasting 12-16 weeks, present centered, action oriented problem solving approach

Adlerian Theory

� Viewed human nature from a holistic, telecological, phenomenological, social, and constructivist perspective.

� Active co-creators of their world (self fulfilling prophecy)

� Therapist worked to empower the client

� Psychopathology resulted from feelings of inferiority, self-centeredness, some genetic influence and discouragement.

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Role of the Psychiatric Nurse: Peplau

� Based on Harry Sullivan’s Interpersonal theory

� Six nursing subroles of the nurse: Mother-surrogate, technician, manager, socializing agent, health teacher, counselor/psychotherapist (role most connected to Psy/mental health nurse)

� Phases of a Therapeutic Relationship:

Orientation, Working, Termination

Therapeutic Milieu (more inpatient )

� Management of the therapeutic environment to best facilitate the therapeutic process

� Involves a multidisciplinary team

� Nurses are role models

� Positive therapeutic relationships provide a model for healthy relationships

� Peer pressure and democratic structure create social skill enhancement ( especially with Adolescents)

� Allows staff to observe clients in social settings

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Conditions that promote a therapeutic

environment

� 1) Structure

� 2) Involvement

� 3) Containment: Safety first

� 4) Support: Consistency

� 5) Validation

Role of the APRN

� 1) Ensuring the physiological needs are being met

� 2) Encouraging independence

� 3) Reality orientation

� 4) Medication management

� 5) One – to- one relationship

� 6) Setting limits

� 7) Teaching

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Group therapy

� Collection of individuals with a shared interest (diagnosis), values, norms or purpose

� Types of groups: Task groups, Teaching groups, Supportive/Therapeutic, & Self help groups

� Ideal size 5-10; Membership can be Open or Closed

� Uses the principle of Universality

Yalom’s Phases of Group Development

� Yalom

� Initial or orientation phase

� Working phase

� Terminations phase

� Leadership style: Autocratic, Democratic, Laissez-Faire

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Group Therapies

� 1) Psychodrama: Members become “actors” in life situation scenarios

APRN-Provides a safe, supportive place for the character(s) to confront and resolve issues

� Family Therapy: based on four principles

A) A family is an interdependent group of people

B) Focus is on the family

C) Change in one member affects the entire family

D) The APRN facilitates communication & goal setting

Family Systems theory: Murray Bowen

� Used Genograms , Family is made up of interlocking relationships

� The more anxiety in the family the more the members will emotionally react verses thinking before acting

� Differentiation of Self is important

� Triangulation: a person focuses on another object or family member to relieve the anxiety they feel about another family member

� The more anxiety in a family, the more triangles and in turn the more dysfunction

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Therapeutic Techniques for Family

� Therapists coach family members to develop a more solid self to stand against anxiety & triangles

� Bowen focused on the family relationships and not the individuals

� Teach people to use “I think” rather than “I feel”

Structural Family Therapy:

Salvador Minuchin

� Key Concepts: Structure or Organization of the Family

� Subsystems

� Boundaries: Families with diffuse boundaries (enmeshed or blurred) have more Chaos

� Families with rigid boundaries (disengaged) have less emotional support

� Support unification, responsibilities, appropriate behavior & Open communication of family members

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Developmental Aspects of

Children & Adolescents

� Personality: deeply ingrained patterns of behavior, which include the way one relates to, perceives, and thinks about the environment and oneself.

� Behaviors from an early age may be modified in a later stage

� Stages can overlap

� Developmentally delayed individuals are “fixed” in certain developmental stages.

� Personality Disorders occur when personality traits become inflexible and maladaptive and cause distress

Developmental Contexts

� Failure to achieve developmental competencies

� Poor behavioral adaptation

� Maladaptive outcomes result from continuous malfunction in the caretaking environment

� The Parent-Child relationship and family functioning are critical to children’s effective coping with inevitable stress and/or negative forces

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Erickson’s Developmental Theory

� Trust vs Mistrust Birth to 18 months

� Autonomy vs Shame & Doubt 18 months to 3 years

� Initiative vs Guilt 3 to 6 years of age

� Industry vs Inferiority 6 to 12 years (Peer relations)

� Identity vs Role Confusion 12 to 20 years (Peer relations

� Intimacy vs isolation 18 to 25 years

� Generativity vs stagnation 25 to 65 years

� Integrity vs despair 65 to death

Cognitive Theory (Piaget)

� Based on the premise that human intelligence is an extension of biological adaptation or one’s ability for psychological adaptation to the environment

� Four Stages of Development:

� Sensorimotor: (0 to 2 years) movement & hold mental image

� Preoperational: (2 to 7 years) symbolic play

� Concrete Operational ( 7 to 11 ) value others

� Formal Operational (11-15+) abstract thinking & complex problem solving

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Piaget and Grief/Loss

� <5 Do not really understand death/ permancy

� 5-10 (concrete operational) abandonment fear that parents will die

� 10 years Understand that death happens to everyone

� Puberty (formal cognitive operations) understands death is inevitable but fear loss of control and will isolate & reject care

Stress & Anxiety

� Hans Selye: Adaptation syndrome –an emotional or physiological change due to a perceived event or “stressor”

� Adaptation is a Healthy response to stress with restoration of homeostasis

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“Fight or Flight” Syndrome

� Hypothalamus stimulates the sympathetic nervous system

� Sympathetic nervous system stimulates the adrenal medulla

� Adrenal medulla releases epinephrine and norepinephrine into the bloodstream

� Sustained Stress: Hypothalamus stimulates pituitary gland releases ACTH, which stimulates the adrenal cortex to release Glucocorticords, vasopresssin (ADH), Growth hormone, & Thyroid Stimulating hormone

Manifestations of Anxiety

� Physical: autonomic arousal

� Affective: edginess to terror

� Behavioral: avoidance to compulsions

� Cognitions: Worry, apprehension, obsessions

� Prevalence of Anxiety: Very common, more women than men, difficult to treat (treatment occurs over long time period)

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Goal of Anxiety Treatment

Not to eradicate the signal but to increase tolerance and the capacity to use and mange the

anxiety as a tool for survival.

Differential Diagnosis of Anxiety

� Rule out organic/medical illness r/t physical symptoms

� 5 factors in r/o organic causes of anxiety:

� 1) onset after age 35

� 2) lack of childhood/family anxiety

� 3) lack of any anxiety producing events

� 4) Lack of avoidant behavior

� 5) Poor response to anxiolytics

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Differential Diagnosis of Anxiety

� Some medications can cause anxiety

� Consider Substance abuse or withdraw* especially cannabis use/abuse

� Hyperthyroid can mimic panic attacks

questions

� Contact

� sharon.edwards@eku.edu