Psychodynamic psychotherapy

Key concepts:

• The unconscious: Individual dynamic psychotherapy is based on the premise that a person's behaviour is influenced by unconscious factors (thoughts, feelings, fantasies). Evidence for the existence of unconscious activity include
  • Dreams
  • Artistic and scientific creativity
  • Hysterical symptoms
  • Abreaction
  • Parapraxes slips of the tongue.

• Psychological defences: Just as the immune system protects our physical integrity, so psychological vulnerability is shielded by psychological defences. As with the immune system, overactive defences can lead to trouble. They include:
  Psychotic defences:
  • Delusional projection
  • Denial
  • Distortion.
  Immature defences:
  • Projection
  • Schizoid fantasy
  • Dissociation
  • Acting out
  • Hypochondriasis
  • Passive aggression.
  Neurotic defences:
  • Repression
  • Displacement
  • Reaction formation
  • Intellectualization.
  Mature defences.
  • Altruism
  • Humour
  • Suppression
  • Anticipation
  • Sublimation.202
• Transference and counter-transference: The past patterns (transfers) our present reactions to people. If we have trusted our parents, we will be likely to trust our doctors, teachers, and friends. The intense psychotherapeutic relationship brings these assumptions to the fore where they can be examined, understood, and learned from. The doctor in turn has unconscious reactions to her patients based on the past, ie counter-transference. For example, if her mother was an alcoholic she may be oversolicitous, or rejecting, with alcoholic patients. The doctor's reactions are also a key to the patient's feelings: if a patient makes us feel rejected (as alcoholics often do), perhaps that person himself was rejected as a child and has turned to the bottle in compensation.

Assessment of suitability

Psychological understandibility

The patient's difficulties must be understandable in psychological terms

Psychological mindedness

The capacity to think about problems in psychological terms

Motivation

The patient must have sufficient motivation for insight and change.

Intelligence and verbal fluency

The ability to communicate thoughts and feelings through talking.

Introspectiveness

The ability to reflect and think about their feelings.

Dreams

The capacity to remember dreams.

Ego strength

The ability to tolerate frustrating or distressful feelings without engaging in impulsive behaviour.

Capacity to form relationships

There should be a history of at least one sustained relationship in the past or current life.

Specific indications

• Dissociative/Conversion disorders
• Depressive disorders
• Psychosomatic disorders
• Personality disorders
• Relationship problems
• Grief reactions.

Technique

The therapist provides a secure frame a regular time and place and her own consistency and acceptingness. The patient narrates vignettes about himself and his life usually about three per session. The therapist listens carefully, both to the stories and to her reactions to them. She then makes linking hypotheses, or interpretations that offer meaning to the patient. Previously inexplicable behaviour begins to make sense. At the same time the patient forms a close relationship with the therapist based on empathy, genuineness, and non-possessive warmth (shown experimentally to be key therapeutic factors) and, where necessary challenge. These may be novel experiences for the patient that can be internalized. The patient can work through his difficulties in the comparative safety of the therapeutic relationship, especially his reactions to ending, which will bring up previously unprocessed losses.

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Introduction to the psychotherapies

Medicine has three great branches: prevention, curing by technical means, and healing-and psychotherapy is the embodiment of healing: a holistic approach in which systematic human dialogue becomes a humanizing enterprise for the relief of suffering and the advancement of self-esteem. Questions such as what is the meaning of my life and what is significant? are answered in a different way after exposure to a gifted psychotherapist. Changes occur in cognition, feelings, and behaviour. This is why psychotherapy is dangerous and exciting: it changes people. Hence the need for supervision and ongoing training and self-awareness on the part of the therapist.

Psychotherapy stands in stark contrast to the increasingly questioned technical, machine-based realm of medicine, and we accord it great prominence here, in the hope that our explicit descriptions, and their reverberations throughout our books will produce corresponding reverberations in our minds and in our daily work in any branch of medicine, to remind us that we are not machines delivering care according to automated formulae, but humans dealing with other humans. So, taken in this way, psychotherapy is the essence of psychiatry-and the essence of all psychotherapy is communication. The first step in communication is to open a channel. The vital role that listening plays has already been emphasized.

It is not possible to teach the skills required for psychotherapy in a book, any more than it is possible to teach the art of painting in oils from a book. So what follows here is a highly selective tour round the gallery of psychotherapy, in an attempt to show the range of skills needed, and to whet the reader's appetite. It is not envisaged that the reader will try out the more complicated techniques without appropriate supervision.

The psychotherapies may be classified first in terms of who is involved in the treatment sessions: an individual, a couple, a family, or a whole group; and secondly they may be classified by their content and methods used: analytic, interpersonal, cognitive, behavioural.

Behavioural therapies

Aim to change behaviour, eg if avoiding crowded shops (agoraphobia) is the issue, a behavioural approach focuses on the avoidance-behaviour. Such approaches will define behavioural tasks that the patient is expected to carry out between sessions.

Cognitive therapy

Focuses on thoughts and assumptions, promulgating the idea that we respond to cognitive representations of events, not to raw events alone. If this is so, cognitive change may be required to produce emotional and behavioural change. So in the above example of agoraphobia, the therapist would encourage articulation of thoughts associated with entering crowds. The patient might report that she becomes anxious that she might be about to faint-fearing that everyone will think her a fool. These thoughts would be looked at using a Socratic approach: Have you in fact ever fainted? How likely would you be to faint? If someone fainted in front of you in a shop, what would you think? Are they foolish?

Long-term psychoanalytical therapies

Are concerned with the origin and meaning of symptoms. They are based on the view that vulnerability arises from early experiences and unresolved issues, eg from childhood. The therapist adopts a non-dominant stance, encouraging the patient to talk without inhibitions. The therapist encourages change by suggesting interpretations for the content of the patient's talk.

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Adenosine

Prescribing information

Termination/diagnosis of SVT

• By rapid intravenous injection into a central or large peripheral vein.
  • The recommended initial dose is 3 mg, but many patients do not respond to this, so some doctors begin with 6 mg.
  • If the first dose is ineffective, repeat after 1-2 minutes with 6 mg and then 12 mg.
  • Follow each dose with a large (10-20 mL) saline flush to ensure rapid delivery to the heart.
  • Do not increase the dose if high-degree AV block develops at any dose.
  • If adenosine is ineffective after 12 mg, stop and consider another drug (see box above) or direct current (DC) cardioversion.

Myocardial nuclear imaging (specialized use)

• By continuous intravenous infusion. Suggested dosage 140 micrograms/kg/min for 6 minutes.

Termination/diagnosis of SVT

• Adenosine works by causing temporary complete sinoatrial (SA) and atrioventricular (AV) block. This can allow normal sinus rhythm to resume.
• Obtain a 12-lead electocardiogram before treatment, to confirm the diagnosis.
  • In particular, this may well help distinguish an SVT with aberrant conduction from VT.
  • If the patient is compromised and you suspect VT, do not delay treatment by using adenosine for diagnostic purposes.
• Ensure that there are adequate facilities for resuscitation, and that the patient has continuous cardiac monitoring.
• Adenosine is given by intravenous bolus only. See below for a suggested regimen.

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Mental health and mental illness

The essence of mental health

Ideally, healthy humans have:

• An ability to love and be loved. Without this cardinal asset, human beings, more than all other mammals, fail to thrive.
• The power to embrace change and uncertainty without fear and to face fear rationally and in a spirit of practical optimism.
• A gift for risk-taking free from endless worst-case-scenario-gazing.
• Stores of spontaneous joie de vivre, and a wide range of emotional responses (including negative emotions, such as anger; these may be important for motivation, as well as being a natural antidote to pain).
• Efficient contact with reality: not too little; not too much. (As T S Eliot said, humankind cannot bear very much reality.)
• A rich fantasy world enabling hope and creativity to flourish.
• A degree of self-knowledge to encourage the humane exercising of the skill of repairing the self and others following harm.
• The strength to say I am wrong, and to learn from experience.
• An adequate feeling of security and status within society.
• The ability to satisfy the requirements of the group, combined with a freedom to choose whether to exercise this ability.
• Freedom of self-expression in whatever way he or she wants.
• The ability to risk enchantment and to feel a sense of awe.
• The ability to gratify his own and others' bodily desires.
• A sense of humour to compensate should the foregoing be unavailable.

Happiness need not be an ingredient of mental health; indeed the merely happy may be supremely vulnerable. All that is needed is for their happiness to be removed. The above are important as they are what a person needs should this misfortune befall him. The above may also be seen as a sort of blueprint for our species' survival.

The essence of mental illness

Whenever a person's abnormal thoughts, feelings, or sensory impressions cause him objective or subjective harm that is more than transitory, a mental illness may be said to be present. Very often the harm is to society, but this should not be part of the definition of mental illness, as to include it would open the door to saying that, for example, all rapists or all those opposing the society's aims are mentally ill. If a person is manic (p 354), and not complaining of anything, this only becomes a mental illness (on the above definition) if it causes him harm as judged by his peers (in the widest sense of the term). One feature of mental illness is that one cannot always rely on the patient's judgment, and one has to bring in the judgment of others, eg family, GP, or psychiatrist. If there is disparity of judgment, there is much to be said for adopting the principle of one person one vote, provided it can be shown that the voters are acting solely in the interests of the person concerned. The psychiatrist has no special voting rights here otherwise the concepts of mental health and illness become dangerously medicalized. Just because the psychiatrist or GP is not allowed more than one vote, this does not stop them from trans- illuminating the debate by virtue of his or her special knowledge.

For convenience, English law saves others from the bother of specifying who has a mental illness by authorizing doctors to act for them. This is a healthy state of affairs only in so far as doctors remember that they have only a small duty to society, but a larger duty to their patient (not, we grant, an overriding duty in all instances eg when murder is in prospect).

Learning disabilities (mental impairment/retardation)

This is a condition of arrested or incomplete development of mind which is especially characterized by subnormality of intelligence.

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