TREATMENT/THERAPY APPROACHES

• Psychoanalysis/Psychodynamic
Defense Mechanisms
• Brief Therapy
• Behavior Therapy
• Solution-Focused Therapy
• Cognitive Therapy
• Psychobiological Basis of Behavior

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 PSYCHOANALYSIS &
PSYCHODYNAMIC PSYCHOTHERAPY
• Freud
– Personality formed by early childhood
– Defense mechanisms protect against
anxiety
– Change is a process of insight

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 FREUD – KEY CONCEPTS
• STRUCTURAL
TOPOGRAPHICTHEORY
THEORY
– Conscious
Id
– Unconscious
Ego
– Preconscious
Superego

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 PSYCHOANALYSIS &
PSYCHODYNAMIC PSYCHOTHERAPY
• Interpretation of unconscious conflicts
• Bringing unconscious motivations into
consciousness = INSIGHT
• Seek development of more mature defense
mechanisms for dealing with conflict

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PSYCHODYNAMIC PSYCHOTHERAPY
• Stemmed from Freud
• Rejection of Freud’s psychosexual stages
• Child’s perceptions of world defined in 1st 5-6 years of
life and influence later views and bx
• Evolution
– Anna Freud, Jung, Adler, Sullivan, Horney
– Objects relations theory
– Attachment theory

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 PSYCHOLOGICAL CONFLICT
• Conflict between the agencies of the
structural model produces anxiety
• The anxiety is “signal anxiety” that alerts the
ego that a defense mechanism is required
• Main defense mechanism is repression

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 DEFENSE MECHANISMS
• Repression = “forgetting” = involuntary exclusion of
a painful or conflictual thought, impulse, or memory
from awareness
• Bars access to conscious awareness of
feelings/thoughts that would cause anxiety and
therefore disrupt the self-concept
• Repressed material continues to exert pressure

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 DEFENSE MECHANISMS
• EGO DEFENSE MECHANISMS – used to aid in
the maintenance of repression
• Primary functions of defenses
– Minimize anxiety
– Protect the ego
– Reinforce repression

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 DEFENSE MECHANISMS
• May hide variety of thoughts or feelings –
anger, fear, depression, greed, envy,
competitiveness, love, passion, admiration,
criticalness, dependency, selfishness,
grandiosity, helplessness
• Continuum from primitive to mature

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 DEFENSE MECHANISMS
• When defenses become a problem
– Use of “primitive” defenses – adult using “infant”
level of defense
– Having narrow range of defenses available – using
1 or 2
– Lack of flexibility – unable to shift from one to
another when appropriate

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 DEFENSE MECHANISMS
• Categories – proposed Axis
– High Adaptive
– Mental Inhibitions
– Minor Image-Distorting
– Disavowal
– Major Image-Distorting
– Action Level
– Level of Defensive Dysregulation

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 DEFENSE MECHANISMS
• SUPPRESSION (1st) (High Adaptive)
– You are vaguely aware of the thought or feeling
but try to hide it. Conscious analog of repression
– “I’m going to try to be nice to him/her”
– A student taking an exam is upset about an
argument with a friend but puts it out of her/his
mind in order to focus on the exam

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 DEFENSE MECHANISMS
• SUBLIMATION (1st) (high adaptive) – You
redirect the feeling into a socially productive
activity. Socially approved substitute for a
drive whose normal channel of expression is
blocked
– A boy who is impulsive and physically aggressive
by nature tries out for a football team.

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 DEFENSE MECHANISMS
• HUMOR (high adaptive) – the individual deals
with emotional conflict or stressors by
emphasizing the amusing or ironic aspects of
the conflict

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 DEFENSE MECHANISMS
• DISSOCIATION (2nd) (mental inhibition)
– Splitting off a group of thoughts or activities from
the main portion of consciousness,
compartmentalization
– A person has amnesia for the events surrounding
a fatal MVA in which he/she was the speeding
driver

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 DEFENSE MECHANISM
• REACTION FORMATION (1st) (mental
inhibition)
– You turn the feeling into its opposite.
Overcompensation for unacceptable impulses.
– A married woman who is attracted to one of her
husband’s friends treats him rudely.

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 DEFENSE MECHANISMS
• INTELLECTUALIZATION (1st) (mental inhibition)
–
– A type of rationalization, only more
intellectualized. The individual deals with
emotional conflict by the excessive use of abstract
thinking or making generalizations.
– A person learns that they have cancer. He/she
studies the physiology and treatment of cancer
w/o any emotion.

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 DEFENSE MECHANISMS
• DISPLACEMENT (1st) (mental inhibition)
– You redirect your feelings to another target.
Discharging pent-up feelings on people less
dangerous than those who initially aroused the
emotion.
– A 4-year-old boy is angry b/c he has just been
punished by his mother for drawing on his
bedroom wall. He begins to play war with his
soldier toys and has them fight with each other.

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 DEFENSE MECHANISMS
• DEVALUATION (1st) (minor image distortion)
– The individual deals with conflict by attributing
exaggerated negative qualities to self or others.
– One person becomes anxious re awareness of
growing love for another and begins to be overly
critical of the other person.

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 DEFENSE MECHANISMS
• IDEALIZATION (1st) (minor image distortion)
– Overestimation of the desirable qualities and
underestimation of the limitations of a desired
object or person.
– A lover speaks in glowing terms of the beauty and
intelligence of an average-looking woman who is
not very bright.

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 DEFENSE MECHANISMS
• RATIONALIZATION (1st) (disavowal)
– You come up with various explanations to justify the
situation while denying your feelings. Offering a socially
acceptable and apparently more or less logical explanation
for an act or decision that was actually produced by
unconscious impulses.
– A student fails an exam and complains that the lectures
were not well organized or clearly presented despite the
other students doing well on the exam.

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 DEFENSE MECHANISMS
• DENIAL (1st & 2nd) (disavowal) – You completely
reject the thought or feeling. Failure to
recognize obvious implications or
consequences of a thought, act, or situation.
– Alcoholic taking no responsibility for drinking and
the issues arising from it.

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 DEFENSE MECHANISMS
• PROJECTION (1st) (disavowal)
– You think someone else has your thought or
feeling. Attributing one’s thoughts or impulses to
another person.
– A person who is quite critical of others thinks that
people are joking about his appearance.
– A woman who denies she has sexual feelings
about a co-worker accuses him of trying to seduce
her.

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 DEFENSE MECHANISMS
• SPLITTING (2nd) (major image distortion)
– Viewing people as all good or all bad. Compartmentalizing
opposite affect states and failing to integrate the positive
and negative qualities of self or others. Ambivalent affects
cannot be experienced simultaneously.
– A patient who one day sees her nurse as loving, worthy
and kind then sees the same nurse the next day as hateful,
worthless, and cruel.

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 DEFENSE MECHANISMS
• PASSIVE AGGRESSIVE (1st) (action) –
– Dealing with conflict by indirectly and unassertively
expressing aggression. There may be overt compliance
masking covert resistance, resentment, or hostility.
Passive aggression often occurs in response to demands
for independent action or performance or the lack of
gratification of dependent wishes.
– A boss tells his secretary to get him coffee which is next to
his desk. The secretary “accidentally” spills the coffee on
him.

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 DEFENSE MECHANISMS
• HELP-REJECTING COMPLAINING (action)
– The person deals with conflict by complaining or
making repetitious requests for help that disguise
covert feelings of hostility or reproach toward
others, which are then expressed by rejecting
suggestions, advice, or help from others.
– The “Yes, But…” game in Transactional Analysis.

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 DEFENSE MECHANISMS
• REGRESSION (1st) –
– You revert to an old, usually immature bx to ventilate
feeling. With regression, to avoid anxiety, the personality
may suffer a loss of some of the development already
attained and may revert to a lower level of adaptation and
expression.
– 4-year-old, who has been toilet trained for over a year,
begins to wet her pants when her new baby brother is
brought home from the hospital.

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 DEFENSE MECHANISMS
• SOMATIZATION (2nd) –
– Conflicts are represented by physical symptoms
involving parts of the body innervated by the
sympathetic and parasympathetic system.
– A highly competitive and aggressive person,
whose life situation requires that such bx be
restricted, develops HTN.

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 DEFENSE MECHANISMS
• CONVERSION (2nd) –
– Conflicts are presented by px symptoms
involving portions of the body innervated by
sensory or motor nerves.
– A soldier who witnesses war atrocities
becomes blind.

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 DEFENSE MECHANISMS
• IDENTIFICATION
– Similar to introjection, but of less intensity. The
unconscious modeling of one’s self upon another
person or group.
– Teenager styles hair like favorite rock star.

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 DEFENSE MECHANISMS
• COMPENSATION (1st)
– Encountering failure or frustration in some sphere
of activity and then overemphasizing another.
– A businessman perceives his small physical stature
negatively. He tries to overcome this by being
aggressive, forceful, and controlling.

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 DEFENSE MECHANISMS
• DEFLECTION
– Redirecting attention from self to another.
– In group therapy redirecting attention to another
group member to avoid attention on self.
– Siblings fights to deflect from parents fighting.

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 BRIEF THERAPY
• Trend in psychotherapy for past several years
• Limited therapeutic goals
• Emphasis on client’s strengths
• Behavior modification and cognitive therapy
techniques
• Emphasis on crisis intervention
• Attention to the precipitating events in the present

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 BRIEF THERAPY
• Prefers pragmatism and least radical
intervention
• Does not believe in the notion of “cure”
• Maintains adult developmental perspective
• Emphasizes patient’s strengths and resources
• Presenting problems are taken seriously

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 BRIEF THERAPY
• Accepts that many changes will occur after therapy
and will not be observable by the therapist
• Sees being in the world as more important than
being in therapy
• Time constraints
• Early and accurate assessment
• Both therapist and client are active
• Goal directed

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 ASSESSMENT QUESTIONS
• What is the problem?
• Where does the problem occur?
• When does the problem occur?
• Who or what makes the problem occur?
• What is the feared consequence related to the
problem?
• How does this affect your life now?

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 BEHAVIOR THERAPY
• Classical Conditioning – Pavlov (1920’s)
– Pairing of stimulus that triggers physiological
response (involuntary) with a neutral stimulus
– After repeated pairings the neutral stimulus is able
to elicit the response
– Has been used with reducing vomiting after
chemo

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 BEHAVIOR THERAPY
• Operant Conditioning – Skinner (1950’s)
– Focuses on what variables precede (antecedent)
and follow (consequence) responses to learn
which ones control the behavior
– Concerned with the relationship b/w voluntary bx
and the environment
– Typical picture of behavior modification
– Per Skinner – mind, thought = “black box”

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 INCREASING A BEHAVIOR
• Shaping
• Modeling
• Imitation
• Reinforcement
– Positive Reinforcement – something good is added (+) to
encourage the desired bx
– Negative Reinforcement – something aversive is taken
away or can end (-) to encourage the desired bx

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 INCREASING A BEHAVIOR
• Positive Reinforcement (R+) – reward system
– Get paid for a job
– Child earns good grades, parents reward child with desired
toy
• Negative Reinforcement (R-)
– A child who is being scolded by his mother goes up to her
and kisses her, and the scolding stops
– Drivers maintain the speed limit to avoid a traffic ticket

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 DECREASING A BEHAVIOR
• Reinforce an incompatible behavior
– Can’t be anxious and relaxed at the same time
• Extinction – ignore the behavior
• Response Cost – decreases bx through loss or
penalty following the bx
– Fine for overdue book, grounding
– Aka negative punishment (P-)
• Punishment – decreases bx through addition of
something aversive
– AKa positive punishment (P+)

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REINFORCEMENT & EXTINCTION SCHEDULES
• Fixed Interval – a reward will occur after a fixed amount of
time
• Variable Interval – reinforcers will be distributed after a
varying amount of time
• Fixed Ratio – if a bx is performed X number of times, there
will be one reinforcement on the Xth performance
• Variable Ratio – reinforcers are distributed based on varying
numbers of the desired bx
• Random schedule – no correlation b/w bx and consequence
• Most powerful schedule ? - random

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 OTHER BEHAVIOR MODIFICATION
• Reciprocal Inhibition – eg, anxiety and relaxation
cannot exist at the same time
• Systematic desensitization – uses a hierarchy of less
to more distressing stimuli to desensitize person to
feared situation, client imagines being in certain
situations at various levels of distress and learns to
cope before moving on to the next level of distress
– Useful for phobias, eg, fear of heights, fear of snakes

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 OTHER BEHAVIOR MODIFICATION
• In vivo exposure – similar to systematic
desensitization but person is exposed to the “real”
thing, eg, snakes
• Flooding – person is flooded with the feared
object/event under very supervised conditions to
prove they will not die
• Thought stopping – imagining a stop sign and saying
“stop” inside head every time undesired thought
occurs, eg, self-deprecating thoughts

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 SOLUTION-FOCUSED THERAPY
CENTRAL CONCEPTS
• Focus is on the present and future
• Identify what is already working. Person has
the knowledge and may simply need
increased confidence about their observations
• Recognize and use existing strengths
• Keep concepts simple and meaningful

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 SOLUTION-FOCUSED THERAPY
CENTRAL CONCEPTS
• Use of pt/client’s language and values
• Respect for client’s worldview
• Use of right-brain thinking – humor, music,
images, stories, meditation, art, role-playing

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 SOLUTION-FOCUSED THERAPY
CENTRAL CONCEPTS
• Change occurs with change in behavior
• Changes occur in the pt’s real world
• Pts/clients are the most important experts in
their lives
• Therapist/nurse poses thoughtful questions
that help pt/client

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 SOLUTION-FOCUSED THERAPY
QUESTIONS
• MIRACLE QUESTION
– “Suppose one night there is a miracle while you
are sleeping and the problems that brought you to
the hospital (clinic) are resolved. Because you
were sleeping, you don’t know that a miracle has
happened. What do you suppose you will notice
is different the next morning that will tell you that
there has been a miracle?”

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 SOLUTION-FOCUSED THERAPY
QUESTIONS
• MIRACLE QUESTION cont’d
– “Who will be the first person to notice the next
day that something is different about you after the
miracle?”
– “What will be different between you and your
(mother, boss, husband) after the miracle?”

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 SOLUTION-FOCUSED THERAPY
QUESTIONS
• MIRACLE QUESTION cont’d
– “Are there times NOW that some of this miracle
happens even just a little bit?
– “Tell me about those times when this problem
doesn’t occur. How do you get that to happen?”

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 SOLUTION-FOCUSED THERAPY
QUESTIONS
• SCALING QUESTIONS
– “On a scale of 1 to 10, where 10 is the problem
solved and 1 is the worst it’s ever been, where are
you today?”
– “What would it take for you to go from a “3” to a
“3.5” or “4?”

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 SOLUTION-FOCUSED THERAPY
QUESTIONS
• COPING QUESTIONS
– “How have you prevented things from getting
worse?”
– “How did you manage to get yourself up this
morning?”
– “What keeps you going?”

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 COGNITIVE BEHAVIOR THERAPY
• Behavior Therapy – 1950’s
– Desensitization
– Behavior Modification
• Cognitive Therapy – 1960’s
– Rational-Emotive Therapy (Ellis) (pg. 712)
– Cognitive Therapy (Beck)

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 COGNITIVE THERAPY
• Cognition = act or process of knowing
• Cognitive therapy proposes that it is not the events
themselves that cause anxiety and maladaptive
responses but rather people’s expectations and
interpretations of these events
• Maladaptive responses come from distorted
thinking, such as errors of logic, mistakes in
reasoning or individualized views of the world that
do not reflect reality

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 COMMON DISTORTIONS
• OVERGENERALIZATION
– Draws conclusions about a wide variety of things based on
one event
– A student who has failed a test thinks, “I’ll never pass any
of my other exams.”
• PERSONALIZATION
– Relates external events to oneself when it is not justified
– “My boss said our company’s productivity was down this
year, but I know he was really talking about me.”

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 COMMON DISTORTIONS
• DICHOTOMOUS THINKING
– Thinking in extremes, that things are either all good or all
bad
– “If my husband leaves me, I might as well be dead.”
• CATASTROPHIZING
– Think the worst about people and events
– “I’d better not apply for that promotion at work because I
won’t get it and I’ll feel terrible.”

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 COMMON DISTORTIONS
• SELECTIVE ABSTRACTION
– Focusing on details but not on other relevant information
– A wife believes her husband doesn’t love her because he
works late, but she ignores his affection, the gifts he brings
her, and the special vacation they are planning together
• ARBITRARY INFERENCE
– Drawing a negative conclusion without supporting
evidence
– A young woman concludes “my friend no longer likes me”
because she did not receive a birthday card

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 COMMON DISTORTIONS
• MIND READING
– Believing that one knows the thoughts of another
without validation
– “They probably think I’m fat and lazy.”
• MAGNIFICATION/MINIMIZATION
– Exaggerating or trivializing the importance of
events
– “I’ve burned the dinner, which goes to show just
how incompetent I am.”

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 COMMON DISTORTIONS
• PERFECTIONISM
– Needing to do everything perfectly to feel good about
oneself
– “I’ll be a failure if I don’t get an A on all my exams.”
• EXTERNALIZATION OF SELF-WORTH
– Determining one’s value based on the approval of others
– “I have to look nice all the time or my friends won’t want
to be around me.”

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 COGNITIVE THERAPY
• Frequently paired with behavioral techniques
• Focus is on present thinking and bx
• Behavior is influenced by irrational beliefs and
automatic thoughts
• Focus on confronting the irrational, distorted thinking
• Use of humor
• Homework assignments
• Empirically based
• Other traits of brief therapy

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 COGNITIVE THERAPY
• Cognitive Restructuring
– Monitoring thoughts and feelings – mindfulness
– Questioning the evidence
– Examining alternatives

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 COGNITIVE RESTRUCTURING cont’d
• Decatastrophizing – helping client to evaluate
whether they are overestimating the catastrophic
nature of a situation, “what if” technique
• Reframing – changes a person’s perception of a
situation or bx, involves focusing on other aspects of
the problem or from a different perspective, eg,
suggesting that a mother’s overinvolvement with her
son is actually a sign of her loving concern rather
than only looking at as an obnoxious bx

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