Psychological Therapies: Study Guide for Nurses

Psychological therapies (psychotherapy, or talk therapy) use verbal communication and evidence-based technique to help patients cope with emotional, behavioral, and mental health problems, including depression, anxiety disorders, personality disorders, and posttraumatic stress disorder (PTSD). The therapist listens actively, works with the patient to find the cause, and helps build strategies for coping. Therapy runs one-on-one, paired (couples), or in groups, and may use art, music, or movement alongside talking. The goal is insight, and none of it works without a trusting relationship between therapist and patient. Know what each approach targets and who it fits.

Psychoanalysis (Psychodynamic) and Related Therapies

Psychoanalysis and its relatives (psychoanalytically oriented and brief dynamic psychotherapies) build on Freud's concepts of the unconscious mind, defense mechanisms, and transference. Childhood experience shapes current thought and behavior, so a link between past and present can be drawn. The central strategy is to uncover experiences repressed in the unconscious and integrate them into conscious awareness and personality. This work is intensive and demands long-term commitment.

To recover repressed experiences, therapists use free association (in psychoanalysis the patient lies reclined on a couch facing away from the therapist and says whatever comes to mind; in related therapies the patient sits in a chair facing the therapist), dream interpretation (examining unconscious conflicts and impulses), and analysis of transference reactions (examining past relationships).

The ideal candidate is age 40 and younger, not psychotic, has good relationships with others (no antisocial or borderline personality disorder), has a stable life situation (not mid-divorce), and has the time and money for treatment. Classic psychoanalysis runs 4 to 5 times a week for 3 to 4 years; related therapies are briefer and more direct at 12 to 40 weekly sessions.

Cognitive Behavioral Therapies (CBT)

CBT combines cognitive therapy and behavioral psychotherapy. It rests on learning theory: unlearn maladaptive behavior patterns and alter negative thinking, and the symptoms ease. Unlike psychoanalysis, it does not examine unconscious conflict. A common use is phobias, where the patient gradually faces the fear until he can handle it while relaxed.

Specific CBTs

Systematic desensitization treats phobias. Where classical conditioning once paired an innocuous object with a fear-provoking situation until the object itself became frightening, desensitization pairs an increasing dose of the fear-provoking stimulus with a relaxing stimulus. Through reciprocal inhibition (you cannot be fearful and relaxed at once), the patient grows less anxious on future exposure.

Aversive conditioning treats paraphilias and addictions (pedophilia, smoking). A maladaptive but pleasurable stimulus is paired with an aversive or painful one (a shock) until the two associate, and the patient stops the behavior because he now links it automatically to an unpleasant response.

Flooding and implosion treat phobias. The patient is exposed to an overwhelming dose of the feared stimulus, actual (flooding) or imagined (implosion), until habituation removes the fear.

Token economy increases positive behavior in severely disorganized (psychotic), autistic, or intellectually disabled patients. Operant conditioning reinforces positive behaviors (combing, bathing) with rewards, and the patient repeats them to earn the reward.

Biofeedback treats hypertension, Raynaud disease, migraine and tension headaches, chronic pain, and temporomandibular joint (TMJ) pain. Operant conditioning supplies ongoing physiologic information (blood pressure readings) that acts as reinforcement (when pressure drops), which the patient uses with relaxation techniques to control visceral changes like heart rate, smooth muscle tone, and blood pressure.

Cognitive therapy treats mild to moderate depression, somatoform disorders, and eating disorders. Over 15 to 25 weeks the patient learns to identify distorted, negative thoughts about himself and replace them with positive, self-assuring ones as symptoms improve.

Other Therapies

Group therapy serves people with a common problem (rape victims), people with personality disorders or other interpersonal problems, and people who struggle with therapists as authority figures. Groups meet 1 to 2 hours weekly and give members a place to express feelings and offer each other feedback, support, and friendship. The nurse or therapist facilitates and observes interpersonal interactions rather than directing. In leaderless groups no one holds authority and members support and help each other; twelve-step groups like Narcotics Anonymous (NA) and Overeaters Anonymous (OA) follow the Alcoholics Anonymous (AA) leaderless model.

Family therapy serves children with behavioral problems, families in conflict, and people with eating disorders or substance abuse. Techniques include mutual accommodation (members work toward meeting each other's needs), normalizing boundaries between subsystems to reduce dysfunctional alliances of two members against a third, and redefining blame so members reconsider their own responsibility for problems.

Supportive and interpersonal therapy serves people in a life crisis and chronically mentally ill people managing ordinary life. It helps them feel protected and supported through crisis. Interpersonal therapy builds interpersonal skills over 12 to 16 weekly sessions on the premise that problems like anxiety and depression stem from difficulty dealing with others.

Dialectical behavior therapy (DBT) was developed for borderline personality disorder (BPD) and has since been adapted for eating disorders, self-harm, and substance abuse.