Psychotherapy and defense mechanisms

Psychotherapy is the use of psychological methods to help patients modify undesirable emotions, attitudes, and behaviors. The most common types of psychotherapy are psychoanalysis, behavioral therapy, cognitive therapy, cognitive behavioral therapy, dialectical behavioral therapy, motivational interviewing, group therapy, couples therapy, family therapy, and schema therapy. Psychoanalytic theory has its origin in Freud's topographic and structural theories. According to Freud, defense mechanisms help individuals to mediate their reactions to internal emotional conflicts triggered by external stressors. Defense mechanisms are categorized into four levels: pathological, immature, neurotic, and mature defenses. This article examines mature defense mechanisms, which manifest in healthy adults, as well as pathological, neurotic, and immature defense mechanisms, all of which are associated with psychiatric disorders.

• Description
  • Focuses on improving awareness of repressed feelings and experiences
  • Aims to resolve conflicts in the subconscious (e.g., by studying dreams)
  • A strong therapeutic alliance (i.e., the bond between therapist and patient) is important for successful psychoanalysis therapy.
  • Countertransference: a complication in which the therapist projects unconscious feelings onto the patient (e.g., the therapist sees the patient as a sibling)
• Indications
  • Personality disorders (clusters B and cluster C)
  • Anxiety disorders
  • Sexual disorders (e.g., sexual dysfunction, paraphilic disorders) ^[3][4]
  • Depressive disorders
  • Healthy individuals under stress
  • Somatic symptom disorders
• Duration: 3–5 times per week for years
• Techniques
  • Transference
    • The patient projects unconscious feelings about significant persons in their childhood onto the therapist (e.g., the therapist is treated as a parental figure).
    • The therapist can gain insight into personal conflicts by interpreting these feelings.
  • Free association: The patient describes all thoughts that spontaneously occur during the therapy session.
  • Dream interpretation: identifying representations of the patient's urges and fears in their dreams to gain insight into subconscious conflicts

• Description
  • Similar to psychoanalysis but with less of an emphasis on dream analysis
  • Focuses on developing insight into and changing current behaviors, feelings, and thoughts by analyzing past experiences
  • Aims to gain insight into unconscious mental processes
  • The therapist aims to remain as neutral as possible, to allow the patient to develop their own interpretations.
• Indications
  • Anxiety disorders
  • Depressive disorders
  • Personality disorders
  • Anorexia nervosa
• Duration: once weekly for 6 months to years
• Techniques
  • Patient education: informing the patient about their condition and about the principles of psychodynamic therapy
  • The therapist takes a very thorough history to identify stressors and core patterns in the patient's behavior.
  • Promoting a strong therapeutic alliance

• Description
  • Focuses on identifying maladaptive behavioral patterns and problematic interpersonal relationships
  • Aims to help the patient maintain hope and cope with life challenges
  • Aims to improve the patient's self-esteem, adaptive skills, and behavioral functioning (i.e., performance in social environments)
• Indications
  • Anxiety disorders
  • Depressive disorders
  • Coping with a crisis or a transient problem
• Duration
  • Open-ended, from days to years
  • The weekly frequency is flexible and determined by the severity of symptoms and the patient's progress.
• Techniques
  • Promotion of a strong therapeutic by following a patient-centered approach (i.e., expressing interest, empathy, and acceptance)
  • The therapist provides reinforcement, encouragement, and guidance on available resources.
  • Patient counseling (often used as an adjunctive treatment)

• Description
  • Focuses on identifying and analyzing problematic interpersonal relationships (e.g., unresolved grief or conflicts) and/or life situations (e.g., change in jobs, geographical move)
  • Aims to improve communication skills and control over mood and behavior
• Indications
  • Depressive disorders
  • Eating disorders
• Duration: weekly sessions for 12–16 weeks
• Techniques
  • Medical model: The disease the patient suffers from (e.g., depressive disorder) is a clinical syndrome distinct from the patient's personality and should be explained similarly to other medical conditions (e.g., diabetes).
  • Identifying connections between the disease manifestation and life events (e.g., the connection between the death of a loved one and the development of an eating disorder)

Overview

• Description

  • Focuses on helping the patient to identify, reflect, and change maladaptive behavior that is triggered by specific stimuli (e.g., fear of spiders)
  • Aims to teach the patient possible alternatives to maladaptive behavior
  • Usually combined with cognitive therapy as cognitive behavioral therapy
• Indications
  • Phobias
  • Bipolar disorder
  • Borderline personality disorder (BPD)
  • Obsessive compulsive disorder (OCD)
  • Panic disorders
  • PTSD
  • Psychosis
• Duration: brief (5–20 sessions) ^[7]

Techniques

Conditioning

A biologically potent unconditioned stimulus (e.g., the smell of food) leads to a natural, unconditioned response (e.g., salivation).

• Classical conditioning: designed to produce an involuntary response
  • If the unconditioned stimulus is repeatedly paired with a neutral stimulus (e.g., the sound of a bell), the neutral stimulus can become a conditioned stimulus that leads to the same natural response, which is now a conditioned response (e.g., the sound of a bell leads to salivation).
  • Pavlov's dog experiment is a historical example of classical conditioning.
• Operant conditioning: designed to produce a voluntary response (see the “Skinner operant conditioning quadrants” table below)
  • Positive reinforcement: The addition of a stimulus in response to a behavior increases the behavior (e.g., an employee begins to work more hours because he gets a salary bonus for doing so).
  • Negative reinforcement: The removal of a stimulus in response to a behavior increases the behavior (e.g., a child improves her grades in order to be excused from doing chores).
  • Positive punishment: The addition of a stimulus in response to a behavior decreases the behavior (e.g., a driver stops parking illegally in response to a fine).
  • Negative punishment: The removal of a stimulus in response to a behavior decreases the behavior (e.g., a child stops acting out because his parents take away his video games when he behaves poorly).
• Extinction (psychology): the loss (unlearning) of a learned behavior due to discontinuation of a reward (in classical conditioning) or reinforcement (in operant conditioning)

Deconditioning

• Systemic desensitization: increasing the level of exposure to anxiety-provoking stimuli while performing progressive muscle relaxation
• Flooding: exposing the patient to real stimuli until they achieve complete relaxation in that situation
• Implosion: exposing the patient to an imaginary anxiety-provoking stimulus until they become more comfortable with it
• Biofeedback: using information on involuntary physiological processes to help the patient monitor and control their response to stimuli
• Token economy: reinforcing positive behaviors by providing tangible rewards
• Aversion therapy: using a nonrewarding stimulus to discourage negative behaviors

Skinner operant conditioning quadrants

• Description
  • Focuses on identifying and correcting faulty assumptions; and negative thoughts
  • Aims to improve patient awareness of emotions and thoughts
  • Usually combined with behavioral therapy as cognitive behavioral therapy
• Indications
  • Major depressive disorder
  • Paranoid personality disorder
  • Somatic symptom disorders
  • Anxiety disorders
  • OCD
  • Eating disorders
• Duration: brief (5–10 sessions)
• Techniques: relies mainly on thought exercises
  • Guided questioning: directing the patient's behavior and thought process toward a therapeutic goal by asking a series of graded questions
  • Journaling (psychiatry): The patient writes down their thoughts, feelings, and internal experiences to better understand their own ideas and emotions.
    • Self-monitoring by journaling behaviors, thoughts, and feelings (e.g., treatment for an eating disorder includes monitoring food intake by writing down every meal and the emotions/thoughts attached to eating)
    • Enables identification of triggers and problematic chains of behavior (e.g., stress-induced binge eating)
  • Cognitive restructuring: The patient identifies negative automatic thoughts (i.e., dysfunctional/negative view of the self, future, or world) in order to dispute them and eventually replace them with healthy thought processes.

• Description
  • Focuses on changing distorted, harmful, irrational, or ineffective beliefs, attitudes, and behavior patterns that lead to dysfunctional behaviors
  • Helps the patient to identify unhelpful and distorted thoughts
  • Helps the patient develop skills and strategies to alter abnormal behaviors and develop healthy coping mechanisms
  • Aims to improve the patient's control over their emotions and ability to deal with distress
• Indications
  • OCD
  • Trauma-related disorders
  • Schizophrenia
  • Substance use disorders
  • Phobias
  • Depressive disorders
  • Anxiety disorders
  • Eating disorders
• Duration
  • Usually for approx. 16 weeks
  • Twice weekly for the first 4 weeks
  • Once weekly for the remaining 12 weeks
• Techniques: combines techniques from cognitive therapy and behavioral therapy
  • Cognitive restructuring
  • Journaling (psychiatry)
  • Systemic desensitization
  • Patient education
  • The patient is encouraged to implement new skills; (e.g., discussing a faulty assumption with friends) or to set behavioral tasks (e.g., a patient with an eating disorder is asked to eat a feared food like ice cream) outside of therapeutic sessions.
• Subtypes and variants: exposure and response prevention ^[9]
  • A type of CBT in which the patient is guided through repeated and prolonged exposures to situations that provoke anxiety and/or obsessive thoughts and is encouraged to avoid compulsive behaviors
  • Indication: OCD

• Description
  • Focuses on teaching new skills (e.g., relaxation techniques)
  • Aims to reduce unhealthy and self-destructive behavior
• Indications
  • BPD
  • Depressive disorder associated with suicidal thoughts
  • Eating disorders
  • Trauma-related disorders
• Duration: once weekly for approx. 16 weeks
• Techniques
  • Mindfulness: a complex field that revolves around being fully present and aware of one's thoughts, feelings, and actions (e.g., practicing guided breathing, yoga asanas, meditation)
  • Emotional regulation: The patient is taught to become aware of their emotions and to assess them rationally.
  • Distress tolerance: The patient learns to better handle crises and stressful situations.
  • Interpersonal effectiveness: The patient is trained to recognize and assert their needs without coming into conflict with others.

MEDI: Mindfulness, Emotional regulation, Distress tolerance, and Interpersonal effectiveness are techniques of DBT.

Overview

• Description
  • A patient-centered counseling approach designed to promote behavioral change
  • Empowers patients to explore and resolve ambivalence toward change, identify goals for change, generate motivation to change, and reinforce a commitment to change
• Indications
  • Substance use disorders
  • Depressive disorders
  • Conditions requiring lifestyle changes (e.g., obesity, smoking)
  • Poor treatment and medication adherence
• DEARS principles
  • Determine discrepancy: Collaborate with the patient on determining what stands in the way of their will to change.
  • Express empathy: Develop an understanding of the patient's perspective and reflect that understanding back to them.
  • Avoid arguments: Avoid imposing your perspective of the issues standing in the way of change and their resolution on the patient.
  • Roll with Resistance: Accept that the patient may resist change.
  • Support self-efficacy: Help the patient develop their belief in and their capacity to adopt behaviors that effectuate change.
• OARS skills and techniques
  • Open-ended questions: Invite patients to relate their experiences and perspectives rather than guide them in a certain direction with leading questions.
  • Affirmation: Recognize the patient's strengths and acknowledge behaviors associated with positive change.
  • Reflective listening: Listen closely to and reflect on what the patient is saying and ensure you understand their perspectives and experiences.
  • Summaries: Recap the main points of a conversation at regular intervals, esp. at points of transition.

Processes

1. Engaging: establishing a working relationship based on trust
   • Provide an environment that makes the patient feel comfortable and safe.
   • Focus on building rapport with the patient, affirming their strengths, encouraging their autonomy, and addressing their questions.
   • Make an effort to understand and develop empathy for the patient's perspective using reflective listening.
2. Focusing: working with the patient to identify the desired change and develop an agenda to achieve it
   • Support the patient in defining a specific, clear, and relevant goal.
   • Set an agenda to achieve the change collaboratively.
   • Understand the reasons and values behind the goal for change.
3. Evoking: bringing forth the patient's own motivations and thoughts for change
   • Listen carefully for language related to change.
   • Support and encourage the patient's ideas and motivations reflected by language related to change.
   • Collaborate with the patient to understand the emotions associated with change.
   • Avoid challenging the patient if they are resistant to change or use language that moves them away from change.
   • Ask questions to guide the patient toward change.
   • Support the patient in developing and nurturing their intrinsic motivation.
4. Planning: support the patient in developing a plan of action based on their own insight and experiences to reinforce their commitment to change.
   • Summarize the content of previous interviews and reiterate past successes.
   • Collaborate on defining actions that bring about change and how to measure the success of these actions.
   • Support the patient in identifying and removing any barriers to change.

• Description
  • Aims to form a support network for individuals with similar diseases or difficulties
  • Allows direct interaction between therapists and patients, and direct interaction between patients
  • Certain groups can be peer-lead and do not need to have a therapist present (e.g., Alcoholics Anonymous).
• Indications
  • Personality disorders
  • Substance use disorders
  • Family and group disorders
  • Bereavement
  • Chronic or life-threatening conditions (e.g., diabetes, cancer)
• Duration: once weekly for months to years
• Techniques: one or more therapists help the group to solve emotional difficulties using various techniques
  • Psychoeducation
  • Cognitive techniques (e.g., cognitive restructuring)
  • Supportive techniques (e.g., patient counseling, providing resources, guidance, and encouragement)

• Description
  • Focuses on identifying and resolving familial dysfunctions and problems of individual members that affect the family as a whole
  • Aims to improve communication skills between family members
  • Aims to reduce and/or solve conflict
  • Emphasizes family strengths to overcome identified dysfunctions
  • Promotes a supportive environment
• Indications
  • Behavioral problems in family members (e.g., antisocial behavior in adolescents, substance use)
  • Conflict between parents, siblings, or parents and children
  • Changes and other challenges within the family (e.g., illness, divorce, death, relocation)
  • Trauma
  • Psychiatric disorders in family members; (e.g., major depressive disorder, bipolar disorder, substance use disorders, schizophrenia )
• Techniques
  • Psychoeducation
    • Education of family members about a psychiatric disorder that affects a family member
    • Introduction of techniques that family members can use to cope with the circumstances
  • Cognitive behavioral therapy

• Description: aims to reduce conflicts and improve communication skills between couples
• Indications
  • Sexual disorders
  • Motivated couples who are not suffering severe mental illness
• Duration: once weekly for weeks to years
• Techniques
  • Conjoint therapy: One therapist sees the couple together.
  • Concurrent therapy: Each person is seen separately by the same therapist.
  • Collaborative therapy: Each person is seen by a separate therapist.
  • Four-way therapy: Two therapists see the couple together (especially for sexual disorders).

• Description
  • See “Theory of schema therapy.”
  • Aims to diffuse harmful potential of maladaptive schemas (i.e., self-defeating emotional and cognitive patterns developed during childhood or adolescence)
  • Focuses on developing a greater sense of self-worth
• Indications
  • BPD
  • Posttraumatic stress disorder
  • Substance use disorders
  • Eating disorders
• Duration
  • Long-term treatment
  • Twice weekly for up to three years
• Techniques: combines techniques from different psychotherapeutic practices (e.g., CBT, psychodynamic therapy)

• Description: aims to improve or restore cognitive function including attention, memory, and executive function in patients with cognitive deficits
• Indication: cognitive impairment due to schizophrenia ^[17][18]
• Duration: usually 2–3 times per week for several months ^[19]
• Techniques
  • Completion of tasks of increasing complexity using a computerized or paper-based format
  • Often combined with individual or group therapies aimed at improving social functioning

• Description
  • Aims to improve social functioning in patients who have difficulty with everyday activities (e.g., social interaction, independent living, personal care) due to psychiatric or developmental conditions
  • Teaches patients how to break down complex social interactions (e.g., conversations) into simple steps
  • Teaches patients how to interpret information in a context-appropriate manner (e.g., evaluate potential responses to a given stimulus)
• Indications ^[17][21]
  • Psychiatric rehabilitation (e.g., schizophrenia)
  • Developmental disorders (e.g., autism spectrum disorder)
• Techniques
  • Roleplaying exercises
  • Behavioral therapy
  • CBT

Topographic Freudian model ^[22]

• Conscious (psychiatry)
  • Current awareness of ongoing thoughts and experiences
  • Secondary process thinking (e.g., logic, reasoning)
• Preconscious (psychiatry)
  • A level below conscious awareness
  • Repressed memories and/or thoughts of which one is not presently aware but are easily called into conscious awareness
• Unconscious (psychiatry)
  • Primitive primary process thinking (e.g., sex, aggression)
  • Normally repressed from conscious awareness because of negative associations (e.g., feelings of shame or guilt)
  • Plays a more prominent role in the behavior of adult individuals with mental illness (e.g., psychosis) and in children

Structural Freudian model ^[23][24]

• Id (psychiatry): unconscious; source of drive and instinctive impulses (e.g., sex, aggression, illogical)
• Super-ego (psychiatry)
  • Represents both the consciousness and the idealized self
  • Responsible for rational and reality-oriented thought
• Ego (psychiatry)
  • Mediates between environment, id, and super-ego
  • Employs defense mechanisms

Carl Jung theory ^[25]

• Ego (psychiatry)
  • Conscious mind
  • Current awareness of emotions, thoughts, and memories
• Personal unconscious (psychiatry)
  • Similar to the Freudian unconscious
  • Repressed memories and complexes (an organization of an individual's thoughts, feelings, attitudes, and memories concerning a particular concept)
• Collective unconscious (psychiatry)
  • Shared with other humans
  • Based on latent memories from the ancestral and evolutionary past, which shape the characteristics of the human species

Jungian archetypes

Some of the most important archetypes Carl Jung proposed include:

• Persona (psychiatry): the public presentation of the self; the real self is concealed to adapt to social norms or expectations
• Anima/animus (psychiatry): the unconscious, countersexual aspect of the biological sex in the human psyche
• Shadow (psychiatry): repressed and unconscious; source of instinctive, irrational impulses
• Self (psychiatry): overarching structure of the individual; unification of male and female and of unconscious and conscious

Theory of schema therapy

• Schema therapy was developed by Jeffrey Young.
• It is based on the notion that people acquire certain basic schemas (i.e., mental structures) that help them interpret and organize information and thereby establish certain behavioral patterns throughout the course of their lives.
• These schemas, in part, set the conditions for meeting psychological needs and therefore also influence behavior.
• E.g., childhood trauma can lead to maladaptive schemas that are difficult to access consciously and may be the root cause of a personality disorder.

Stages of psychosocial development according to Erik Erikson ^[26][27]

• Eight sequential stages of psychosocial development that determine the psychological characteristics and core beliefs an individual develops during their lifetime
• Each stage is characterized by an opposing tendency with which an individual is confronted and must resolve in order to develop a positive, adaptive or negative, maladaptive trait
• Psychosocial development is considered a lifelong process of continuously reevaluating and reintegrating the eight stages.

Overview ^[28]

• Definition
  • Primary tools of the ego used to cope with external stressors to avoid or reduce anxiety, restrict impulses, and avoid unpleasant feelings
  • Mostly unconscious
• Classification
  • Level 1 – Pathological/narcissistic: seen in children and in adult individuals with personality disorders
  • Level 2 – Immature (primitive): common in patients with personality disorders, patients suffering from psychosis, individuals with anxiety disorders, children, and adolescents
  • Level 3 – Neurotic: common in patients with OCD and/or anxiety
  • Level 4 – Mature (sophisticated): seen in normal adults

Pathological defenses ^[29][30]

Immature defenses ^[31]

Neurotic defenses ^[33]

Mature defenses ^[34]

“SASHA is a mature adult”: Sublimation, Altruism, Suppression, Humor, Anticipation are mature defenses.

• Definition: behavioral and mental strategies or skills that can be mobilized by an individual to aid in handling external and internal stressors (e.g., stress, illness) ^[35][36]
• Adaptive coping: behavioral and mental strategies that aid in responding to stressors in a positive and constructive manner ^[35][36][37]
  • Examples
    • Problem-focused coping: strategies that target the underlying cause of stress (e.g., ergonomical workplace to prevent and relieve health issues such as back pain)
    • Emotion-focused coping: strategies that reduce the negative emotions associated with a stressor (e.g., responding to a misfortune with humor, distancing, or acceptance)
    • Meaning-focused coping: cognitive strategies used to find meaning in or change the perspective on the stressful situation (e.g., meditation, mindfulness, positive reappraisal, reordering life priorities)
    • Social coping: seeking support within a community to reduce stress
  • Further categorized into
    • Reactive coping: strategies pursued in response to a stressor
    • Proactive coping: strategies pursued in anticipation of a stressor
• Maladaptive coping: conscious as well as unconscious thought patterns and behaviors engaged in for the short-term relief of stress that, however, increase stress in the long term. ^[35][36]
  • Examples: rumination, anger, disengagement, recreational drug or alcohol use
  • Persistence increases the risk of :
    • Major depressive disorder
    • Anxiety disorder
    • Sleep disorders
    • Substance use disorders and drug-seeking behavior
    • Self-harm