EILEEN M.

COSTO, RN ADVANCED PSYCHIATRIC NURSING I KEY CONCEPTS IN PSYCHOTHERAPY Models and Morale Aims and Goals Types of Psychotherapy Limits of Psychotherapy Nurses qualifications, roles and function WHAT IS PSYCHOTHERAPY? Psychotherapy is an interpersonal process in which therapist communicate to patients that they understand them, respect them, and want to help them. Most procedures used by trained professionals to treat people with psychological problems involve understanding, respect, and helpfulness, but psychotherapy is unique by virtue of the intentional effort of the therapists to communicate their understanding of a patients difficulties and help him or her share in this understanding. When therapists communicate this kind of understanding to their patients and involve them as active agents in the treatment, they are providing psychotherapy. In contrast, when therapists shift their focus from communication of person-related understanding to telling their patients what to do or altering their body chemistry or environment, they are engaging in treatment procedures that are not psychotherapy, even though these procedures may also be psychotherapeutic. MODELS AND MORALE PSYCHODYNAMIC MODELS. Psychodynamic models focus upon the dynamics of the personality. It is assumed that unconscious forces shape and motivate behavior from "within." Psychodynamic theory stresses the relationship between therapist and client as a crucible for change. The therapist works on creating a safe environment for disclosure, exploration, and change, while simultaneously questioning and occasionally challenging the client. This model tends to emphasize emotional experience as key to personality functioning and change. Some specific forms of psychodynamic theory: Psychoanalysis. Originated by Freud and carried on by others, psychoanalysis is a very traditional model with a declining membership. The therapist strives to remain neutral and objective while analyzing and interpreting the client's words. Internal dynamics are emphasized, including subconscious wishes and motivations, especially such basic forces as sexual pleasure, control, and aggression. Object Relations. A more relational derivative of psychoanalysis, object relations theory stresses internal representations of self and others which serve as small-scale models for interpersonal relationships. Therapy focuses on establishing a safe holding environment and analysis of the development of mature understanding of self and others.

Analytical Psychology. Focuses on the principle that the personality represents a dynamic system of dynamic opposites derived from the archetypal experience of the collective unconscious, and has the power to heal itself. Therapy focuses on self-actualization through reunion of opposing tendencies and increased self-consciousness while encouraging spiritual development. COGNITIVE-BEHAVIORAL MODELS. Cognitive-Behavioral models focus upon thoughts and behavior as benchmarks of psychological functioning. It is assumed that behavior or thinking is the appropriate focus of therapeutic intervention. Therapy undertakes a systematic analyis and modification of problematic behavior or distorted thoughts. This model tends to focus on concrete and observable changes which may have a maximum effect on daily living and functioning. A couple of examples: Behavioral Therapy. Problematic behavior is analyzed, with particular attention to the antecedents and consequences of the problematic behavior. A thorough system of behavior-modification techniques is employed to modify problematic behaviors. Schema-Based Therapy. This type of therapy focuses upon recurring thought patterns which may have common themes and which may eventually distort thinking to the extent that it becomes unrealistic. Schemas act as kinds of thematic magnets that tend to organize experience in particular ways, resulting in mental associations and patterns of thinking which may become unrealistic and require modification through confrontation, reframing, and other techniques. SYSTEMS MODELS. The systems models take the individual in context of a more complex interpersonal system most typically the system of greatest concern is the family, but a system may comprise any social order such as a group, community or nation. Systems theory pays attention to the social and interpersonal forces that act upon the individual from without, and the ways in which the individual affects the system in turn. AIMS 1. 2. 3. AND GOALS Relieving patients emotional distress Assisting them in finding solutions to problems in their lives Helping them modify personality characteristics and behavior patterns that are preventing them from realizing their potential for productive work and rewarding interpersonal relationships.

There are many possible routes to these goals, including treatment procedures other than psychotherapy and fortuitous life experiences that improve individuals emotional state and expand their opportunities to find self-fulfillment. As noted, the defining characteristic of psychotherapy as a route to symptom relief and positive personality and behavior change is helping people understand themselves better as a vehicle for pursuing these goals. TYPES OF PSYCHOTHERAPY

1. Behavior Therapy-builds on the traditions derived from Pavlov and Skinner of classical and operant conditioning, accentuating the building of behavioural skills along with processes of learning. 2. Cognitive Therapy- prioritize thoughts, theorizing that thoughts come before and affect emotions. The most prominent methods in this school of approach, such as Becks cognitive therapy (Beck, 1976) or Elliss rational emotive therapy (Ellis, 1962), examine thoughts for logical errors and look to enable more sensible and balanced thinking. 3. Cognitive-Behavioral Therapy- is a psychotherapeutic approach, a talking therapy, that aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure. 4. Experiental Therapy- prioritize the role of emotion in human functioning. Experiential strategies focus on becoming more in touch with emotions and learning to express clearly those emotions so as to free the client from the residue of a stuck emotional life. 5. Mindfulness-and Acceptance-Based Theory- accentuate freeing of the self from the distractions imposed by daily life. 6. Postmodern/Poststructuralist Therapy- these approaches typically assume a position at a meta level to the therapy experience and remove the privileged person typically associated with therapist. Instead, each individual in the therapeutic dyad is viewed as having an equally important narrative. 7. Psychoanalytic Therapies- including psychoanalysis and the many variants that followed form the work of Freud, accentuate the internal process occurring within individuals and most especially the conflicts within individuals. These are also treatments that accentuate transferences; the carryovers form earlier relationships that appear in the relationship between the client and therapist, and the value of insight as a vehicle for change. 8. Existential Therapy- the accent here is on fully experiencing the meaning of being in the world, especially a word in which wars and death are realities. The existential approach aims for living in the moment and accentuating a profound search for meaning in existence. 9. Feminist Therapy- center on the belief that whatever the method chosen for intervention, therapy must actively promote an understanding of gender and the often-unstated beliefs that emerge in the treatment having to do with gender bias as well as equality of the sexes. 10.Couple and Family Therapies- focus not on the treatment of the individual but on the system. From the systemic perspective, individual behavior is viewed as nested in the exchanges between individuals. 11.Group Therapy- it is the use of group to deliver the treatment, adding a number of special group therapy curative factors such as group cohesion to the impact of the treatment. 12.Integrative Psychotherapy- refers to a new and particular form of psychotherapy with a set of theories and clinical practices that synthesizes concepts and methods from two or more schools/types of psychotherapy. 13.Technical Eclecticism and Multimodal Therapy- is based on the idea that humans are biological beings that think, feel, act, sense, imagine, and interact; and that each of these "modalities" should be addressed in psychological treatment.

LIMITS OF PSYCHOTHERAPY Limitations are set by various determinants: 1. Acuteness or chronicity of the present illness. Another is the precipitating factor, its intensity and the reality of the problem the patients faces. For example: grief which is naturally experienced after death of a loved one is realistic, understandable, normal psychological experience. However, a depression simulating grief may appear with no demonstrable or external realistic factor to provoke it; it may have symptoms with a few exceptions similar to those of grief, but the structure and the meaningfulness and the prognostic factors in the depression are quite different from those of a normal grief reaction. So the reality of the precipitating factor, its intensity and its acuteness are determining factors, as is the setting and timing of the precipitating. So it is in all illness. 2. Nature of the individual who is sick. How flexible is he? How emotionally healthy is he or has he been in the past? How adequate has he been in accepting the normal day by day deprivations and frustrations that all of us have to face in the world? How satisfactory has his adjustment been? What type of psychological defenses has he had to use in his life? Has he exaggerated these defenses? Has he inhibited himself too much? Has he become too passive, to submissive, too quiet, too restrained? Is he unable to express even the normal degree of aggression, the normal degree of hostile feelings toward his friends and acquaintances and family? Or is he withdrawn or unable to be normally affectionate or unable to engage in normal physical sexuality? So the nature of the person is another limiting factor. 3. Skill and knowledge and abilities of the therapist. What range he has in understanding of the patients problems. 4. Nature of the physician-patient relationship. What capacity has the patient, what capacity has the physician, to engage in this mutual reciprocal human interaction so that it can become meaningful and productive relationship, one in which the physician may help the patient mobilize his resources and aid him either to discharge or sometimes resolve certain emotions, or to utilize other means of the defense that may prove more effective and satisfactory than those he has been using. NURSES QUALIFICATIONS, ROLES AND FUNCTIONS Therapist has received training which provides specific techniques for communicating understanding in ways the other person can comprehend and accept. Although naturally intuitive individuals may be keenly sensitive to the thoughts and feelings of others, they usually cannot translate their sensitivity into the communication of understanding as skilfully and as consistently as individuals who have been trained to do so. Whereas professional therapists typically focus their sessions with patients on significant treatment issues, for example, inherently helpful but untrained people from whom others seek counsel tend to engage primarily in informal conversation and advice giving (Gomez-Schwartz & Schwartz, 1978 cited by Weiner & Bornstein 2009). Since psychotherapy is an interpersonal process, the essence of being a good psychotherapist is possessing interpersonal skills that promote positive outcome in treatment and displaying these skills effectively in encounters with patients.

POSSESSING REQUISITE INTERPERSONAL SKILLS The requisite interpersonal skills of effective psychotherapists have frequently been translated into three separate but related attributes often identified as therapist warmth, therapist genuineness, and therapist empathy. WARMTH- warmth is the means by which psychotherapists provide their patients an atmosphere in which they can feel relaxed, safe, and appreciated for who they are. Warm therapists value their patients as people, regardless of any negative attitudes they may have about a patients personal characteristics, lifestyle, or behavioural history; they accept unconditionally whatever their patients say or do as something that is part of them and worthy of being understood. Warm therapists refrain from passing judgment on their patients actions or assuming responsibility for their patients decisions. Instead, they maintain at all times a receptive, noncontrolling, and nonpossessive stance that preserves the patients dignity as an autonomous person. By valuing and accepting their patients without judging or dominating them, therapists display the warmth that patients require to feel secure in psychotherapy situation and overcome reservations about becoming involved in it. GENUINENESS- to derive maximum benefit from psychotherapy, patients must be able to describe their thoughts, feelings, and experiences in an open, truthful, and nondefensive manner. Patient candor is facilitated by therapist warmth, which promotes a sense of trust and security in the treatment situation. Beyond feeling safe, however, patients find it difficult to be open and truthful unless they perceive their therapist as relating to them in an open and truthful fashion. Therein lies the importance of therapist genuineness, which consists of engaging with patients in a direct personal encounter, rooted in honesty and free from artificiality. For therapists, being genuine means simply being themselves, that is, being authentic people who say only what they mean and do only what feels comfortable and natural. Sigmund Freud was emphatic that psycho-analytic treatment is founded on truthfulness, and he warned that therapists who are caught in a lie by a patient can never again generate the level of trust necessary for the patient to confide in them fully. As part of being truthful, therapists must avoid trying to sound definitive when they lack conviction or uncertain when they have a definite opinion. -forced smile -therapists talking to the patients vernacular when they cannot do so uncomfortably Being genuine does not however mean that therapists must express every feeling they have and disclose all their personal concerns. What it means is that any feelings or concerns therapists do express are sincere and congruent with their inner experiences. EMPATHY- is the ability to assume the perspective of other people and understand their needs and feelings. In psychotherapy, emphatic understanding consists of the therapists special sensitivity to the meaning of

what a patient says and does. Empathic therapists are able to perceive their patients thoughts and feelings accurately and recognize what they signify both for patients conscious, immediate experience and also for what may lie outside patients conscious awareness. To be effectively empathic, therapists must not only understand their patients but also communicate this understanding in ways that patients can accept. TRAINING AND EXPERIENCE 1. Psychotherapy should be conducted only by people who are trained to conduct it. Being warm, genuine, and empathic person provides a good basis for becoming an effective therapist, but to be fully effective, therapists need a thorough education in the nature of the personality processes and extensive training in the techniques of psychotherapy. Only with a solid grasp of personality dynamics and a polished repertoire of technical skills can therapists make informed decisions about what they should actually do: when they should express emphatic understanding and when they should express warmth, how much of either they should express at a particular time for a particular patient, and with what words or gestures they should express it. 2. Research has also confirmed various specific ways in which good training and relevant experience contribute to the therapists being able to display beneficial personal qualities in treatment. For example the more training and experience they have had, the more likely therapists are to be flexible in applying their skills as changing circumstances require, to be skilful in implementing complex therapy procedures that facilitate the patienttherapist relationship; to be able to avoid saying things to patients that they later regret, to be rated highly by their patients for their interpersonal skills; and to rate their own skill level highly. FREEDOM FROM NEUROTIC DIFFICULTIES To conduct psychotherapy effectively, therapists must be free from neurotic difficulties, which for present purposes can be defined as psychological issues and conflicts that interfere with their ability to respond openly and flexibly to the needs of the patients. To be free from neurotic difficulties, therapists must first of all be keenly aware of their own personality dynamics, particularly with respect to what tends to make them angry or anxious, how they feel about important figures in their life, and why they behave as they do in various situations. Only with a high level of self-awareness can therapists differentiate adequately between the implications of a patients behavior and their own unique reactions to that behavior. Therapists must also refrain from using psychotherapy relationship to gratify inappropriate personal needs. Psychotherapists can appropriately expect certain gratifications in their work, such an opportunity to be of help, to learn more about human behavior, to be respected for their integrity, and to be paid for their time. If therapists feel compelled to bolster their own self-esteem by dominating or depreciating their patients, if they have sadistic needs that lead them to be cruel or dependent needs that lead them to curry favour, if they have sexual needs that result in their acting seductively, or if they have fears of failure that cause them

prematurely to discharge patients who are progressing slowly, then their behavior is being governed by inappropriate social concerns and conflicts that prevent them from giving the necessary priority to their patients needs. Whatever quirks therapists may have in their personality and whatever adjustment difficulties they are having, these neurotic elements either (1) do not interfere with their objectivity and commitment to their patients need in psychotherapy situation or (2) are sufficiently within their selfawareness and self-control for them to recognize and counteract promptly any such interference that may arise with their ability to comprehend and address their patients needs. Long-standing tradition holds that therapists must undergo psychotherapy themselves in order to attain sufficient objectivity, commitment, selfawareness, and self-control to function effectively in their work. Postgraduate training programs in psychoanalysis and psychotherapy generally require a treatment experience, and surveys indicate that healthcare professionals interested in psychotherapy generally require a treatment experience, usually for purposes of personal enrichment rather than symptom relief. For therapists whose effectiveness is hampered by neurotic difficulties, personal psychotherapy may be a necessary means of acquiring competence in their work. For therapists who are prepared by their personal capacities and prior experiences to understand and meet the needs of the patients, personal psychotherapy may be irrelevant except as an educational experience.

THERAPIST-PATIENT INTERACTION Whatever their level of training, experience, and personal adjustment, therapists rarely work equally well with all patients. Therapists can expect to be more sensitive to the difficulties of some kinds of patients than others and more interested in helping some kinds of people than others and more interested in helping some kinds of people than others. In addition to learning in the course of their experience what types of treatment techniques they implement most comfortably, therapists typically come to recognize what types of patients and patient problems they treat most effectively. Even when therapists find it difficult to make such judgments about their clinical functioning, they should keep in mind that optimal psychotherapy outcome requires matching patients with therapists who can best communicate interest, understanding, and respect to them. (ex. People are good at working with people who are withdrawn, etc.) Therapists need to know enough about themselves and their skills to distinguish among cases in which being a good therapist will come easy for them, cases in which they will have to be especially alert and work especially hard to conduct the treatment effectively, and cases they should refer to a colleague better equipped to respond helpfully to this particular type of patient or problem.