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 with
authority figures and is part conscious, part unconscious. The genital
stage (A) is one of Freud’s stages of early development that must be
passed through successfully to avoid problems later in life. The other
stages were anal and oral. It is his work on early development that has
perhaps been the most abandoned in current psychoanalytic thinking.
The Oedipus complex (D), in the strictest sense from Freud, took place
between the ages of 3 and 5 and is concerned with the child’s realization
of their gender, their resentment of never possessing what the opposite
parent has and their jealousy of the parental relationship. Freud’s model
was intensely phallocentric however, and it has been modified by current
psychoanalytic theorists to include both genders.

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

C. Core negative belief

Cognitive therapy seeks to address individual’s false beliefs about
themselves and the world around them. People with depression often
suffer with these beliefs more than people without depression (although
people with personality disorders will often also share some of these
beliefs). This represents a core negative belief (C), which are central ideas
about one’s self and represent ‘absolute truths’ by the individual. Core
beliefs can of course also be positive, but these tend to disappear with
the onset of disorders like depression

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).