# Textbook of Psychiatry/Psychotherapy for Medical Students

The word psychotherapy comes from ancient Greek words psychē, meaning spirit or soul, and therapeia, to nurse or cure. Today, psychotherapy is a general term that refers to any of a range of techniques in which an intentional interpersonal dialogue is used to treat psychological distress or problems in living. Although some forms of psychotherapy are conducted in group settings, it is typically delivered in one-to-one sessions with a mental health provider. Provision of psychotherapy was initially restricted to psychiatrists but has evolved to now include diverse practitioners including psychologists, social workers, nurses, and counselors. Psychotherapeutic techniques are quite diverse but all are built around an experiential relationship through dialogue meant to enhance individual adaptation via healthier modes of communication and behavioral responses.
Over the years, psychotherapy and psychopharmacology have emerged as standard interventions to help patients overcome psychiatric illnesses. These treatment approaches can be used individually or in combination. Currently, substantial evidence confirms the efficacy of many psychotherapeutic modalities. Evidence is especially clear for time-limited therapies in the management of anxiety and mood disorders and also in promotion of health and sense of well-being in patients with schizophrenia, bipolar disorder, and chronic medical problems. Therapeutic alliance and the skill of the therapist are the most important factors determining the outcome of any form of psychotherapy.
This chapter provides the medical student with a brief overview of key forms of psychotherapy. Given that a substantial literature in the field has accumulated over decades of research, this review provides only an overview of the therapeutic techniques. This chapter offers brief descriptions of the following subtypes of psychotherapy:
* Psychodynamic therapy
* Brief psychodynamic therapy
* Behavioral therapy
* Cognitive behavioral therapy
* Interpersonal therapy
* Dialectical behavior therapy
* Family therapy
* Couples therapy
* Supportive therapy
* Group therapy

## Psychodynamic Therapy (PDT)

Psychodynamic therapy defined the practice of psychiatry in the first half of twentieth century. It evolved mainly from Sigmund Freud’s psychoanalytical principles, with significant contributions from Anna Freud, Karl Jung, and Melanie Klein, among many others. The basic emphasis is on how early childhood experiences are vital in molding and establishing the psychological mechanisms which predominantly drive the unconscious. The aim of psychodynamic therapy is to identify, bring to notice, and reprocess repressed conflicts from previous experiences which are being unconsciously enacted in current interpersonal interactions leading to maladaptive patterns of behavior. PDT works best for mild to moderate problems in adjustment, as well as for depressive, anxiety, and personality disorders (1). Characteristics of patients who often do well with this form of therapy include those with psychological mindedness, motivation to get better, and the ability to trust and collaborate with therapists.
PDT can be long-term (1-5 sessions/week for a number of years), intermittent, or brief (<6 months in duration or 6-40 sessions in total). Irrespective of the duration, this form of therapy begins with a comprehensive assessment which lasts between 1-4 sessions. Apart from history taking, this phase involves explaining the process of therapy to the patient, and evaluating whether the patient has the ego-strength and is suitable to undergo PDT. Initial elements of transference and counter-transference (which are described soon herein) also may begin to emerge. Follow up sessions usually take place at a particular time every week. Therapeutic alliance is one of the most important factors determining the outcome of PDT.
Exploration of the unconscious drive is done by free association and dream analysis. In free association, the patient is encouraged to speak whatever comes to his mind without inhibition or censorship. The therapist uses "active listening" and looks for patterns or references relating to current interpersonal and developmental conflicts which can help understand the unconscious process. Freud’s critical work on dreams has led to the use of dream analysis in understanding the unconscious. Freud called dreams as "the royal road to the unconscious." He described dream work as the process by which a latent dream is converted to a manifest dream by symbolization, displacement and condensation. In dream analysis, the therapist tries to reverse this process and thereby, identify the latent components, which in turn, reveal the unconscious desire.
During the course of psychodynamic therapy, the processes of transference, counter-transference and resistance repeatedly occur which may indicate or lead to the underlying unconscious conflicts or desires. The therapist must be aware of and assess these phenomena in therapy. Transference is an emotion experienced by a patient towards the therapist which is based on experiences from previous relationships. Counter-transference is the emotion evoked in therapist towards the patient which is determined by his or her past experiences. The therapist’s efforts to understand transference helps in understanding how the past is continually re-enacted in present. Counter-transference is important to recognize as it might interfere with therapy.
Resistance is the unconscious blocking of the therapeutic process. It can manifest in a number of ways such as showing up late for appointments, staying silent during sessions and avoiding talking about core issues. Defense mechanisms constitute the executive function of the ego and help reduce anxiety. They can be healthy or pathological. Key defenses include denial, projection, splitting, projective identification, undoing, isolation of affect, intellectualization, introjection, and repression. Suppression, sublimation and humor are identified as mature defense mechanisms.
Therapists work with patients to identify and deal with transference, resistance, and defense mechanisms. Several strategies are used to achieve this such as making an observation, interpretation, clarification and validation. Therapy eventually guides the patient in reprocessing previous conflicts which, in turn, helps break the maladaptive behavior patterns of the present. As the goals of therapy are realized and the patient has consolidated the tools learnt to overcome conflicts and maladaptive behaviors, the termination phase of therapy begins, with the therapist setting a date to end sessions.
It is important for therapists to have their own therapy to understand their own contribution to the therapeutic process. Good supervision and peer support are also vital tools.
Principles of psychodynamic therapy have revolutionized physician-patient interactions in all specialties. Even though in some respects it has fallen out of favor recently in comparison to briefer therapies, PDT still holds a unique position in psychotherapy and to a great extent underlies all the psychotherapies currently available. Longer term outcome studies reveal that psychodynamic therapies may yield profound and permanent personality maturation.

## Brief Psychodynamic Therapy (BPT)

Alexander and French listed the benefits of time limited therapy using psychodynamic principles. In this era of emphasis on optimal resource utilization and cost-benefit analysis for interventions brief therapies have regained popularity. Such brief therapies may emphasize issues to do with cognitive, behavioral or psychodynamic (2). Similar to long-term psychodynamic therapy, BPT aims to identify and reprocess repressed conflicts from previous experiences which are being unconsciously enacted in the current interpersonal interactions and thus causing maladaptive patterns of behavior. However, BPT differs from long-term psychodynamic therapy in several aspects.
The usual number of sessions in BPT varies from 12-40 and is usually completed in six months, following an initial comprehensive assessment that establishes a therapeutic alliance and identifies the major problem area (3). Using this as a template for future sessions, developmental conflicts, defense mechanisms, transference, counter-transference, and resistance are identified and reprocessed to promote a corrective emotional experience in therapy. Given a shorter duration of therapy, the therapist has a more active role compared to long-term psychodynamic therapy, which involves a substantial reliance on limited but sometimes pivotal interpretations. In BPT, the therapist uses challenge, confrontation, and anxiety-provoking techniques while guiding the patient towards conflict resolution (4). Considering such an active and often anxiety- provoking therapeutic work to achieve outcomes, it is important that patients in BPT are able to trust and work with the therapist and also can openly acknowledge emotional distress from an interpersonal viewpoint (5).
Several types of BPT have evolved based on drive, relational, and integrative (using both drive and relational) models. Examples include:
* Brief focal psychotherapy (Tavistock-Malan): This involves an average of 20 sessions focused on internal conflicts present since childhood and processing of transference reactions. The termination date is determined after a few sessions.
* Time limited psychotherapy (Boston University-Mann): This usually consists of 12 sessions focused on resolution of the chronic distress due to negative self-image.
* Short-term dynamic psychotherapy (McGill University-Davanloo): This entails a flexible approach over 5-25 sessions aimed at resolution of oedipal conflict.
* Short-term anxiety provoking psychotherapy (Harvard University-Sifneos): This aims to resolve oedipal conflict via anxiety-provoking questions and confrontation.
Clinical applications: BPT has been shown to be effective for a variety of anxiety disorders including panic disorder, phobias, generalized anxiety disorder (GAD), and post traumatic stress disorder (PTSD). Patients with depressive and eating disorders of mild-moderate severity also benefit from this therapeutic approach. Well-designed research studies are needed in the future to assess its long-term efficacy (6).

## Behavioral Therapy

Behavioral Therapy (BT) utilizes techniques derived from both Pavlov’s classical and Skinner’s operant conditioning. BT identifies maladaptive behaviors as the source of psychological distress and attempts to improve quality of life by altering and modifying these. BT works best for specific behavioral symptoms such as phobias and compulsions.
Several subtypes of BT have been developed for use either alone or in combination with pharmacotherapy or cognitive therapy for treatment of a variety of psychiatric disorders:
a) Systemic desensitization: This technique, initially developed by Wolpe, is particularly helpful for phobic disorders with a clearly identifiable precipitating factor. In the initial phases, relaxation techniques including deep breathing and progressive muscle relaxation are taught and practiced. A hierarchy of anxiety-provoking stimuli is constructed with the help of the patient. For example, a person afraid of using an elevator would go through therapeutic steps of first imagining standing in front or riding the elevator, then on to seeing pictures of elevator, then going to a building with an elevator, standing in front of the elevator, and eventually taking the elevator. Therapy moves from the least anxiety- provoking stimulus to highest (7). The patient is first exposed to the least anxiety- provoking stimulus and then encouraged to use the relaxation techniques till the anxiety decreases. This phenomenon, called reciprocal inhibition, continues until the patient is habituated and no longer feels anxious in response to that particular stimulus. Once this is achieved, therapy will progress along the hierarchy to the next stimulus. This process is repeated until the patient is ready to move to the next step on the hierarchy.
b) Flooding/Implosion: This is based on the concept that escape or avoidance of an anxiety-causing situation (phobia) maintains the fear. Patients are exposed to anxiety- provoking stimulus (not graded exposure) either in vivo (flooding) or imaginary (implosion) and not allowed to leave till their anxiety subsides (habituation). Compared to systemic desensitization, flooding leads to severe anxiety initially and may not be tolerated very well by some patients.
c) Aversion therapy: This is based on a "punishment model" and used to treat substance abuse disorders and paraphilias. A maladaptive behavior is combined with aversive (noxious) stimulus to decrease the repetition of maladaptive behavior. An example of this is an individual with alcohol dependence is given disulfiram. The next time this individual drinks alcohol, he will experience adverse effects such as nausea, vomiting, flushing and headache. Similar techniques have been used to treat paraphilias. Though aversive conditioning may be effective initially, there is skepticism about compliance and long term benefits.
d) Exposure and response prevention: This is a key technique to treat Obsessive Compulsive Disorder (OCD) (8). Patients are trained to refrain from performing rituals (compulsions) despite having increased anxiety stemming from obsessional thoughts, images or impulses (response prevention). For example, a patient whose obsessions involve fear of contamination is asked to touch various surfaces (exposure) but refrain from washing hands (response prevention). Over time, this helps to break the vicious cycle of compulsive acts in response to obsessions.
e) Token economy: This is commonly used in settings where children, adolescents, and patients with mental retardation are treated. Desired adaptive behaviors are reinforced with tokens such as stars or tickets. Tokens are accumulated and exchanged at the end of a specified time period for gifts such as snacks, toys, watching television, or playing video games. When maladaptive behaviors occur then there is a penalty with a certain number of tokens is taken away. What makes a behavior desired or maladaptive and the rewards/penalty associated with them are clearly communicated in advance to the patients. Hence this technique promotes acquisition of good behaviors and autonomy.
f) Modeling: A patient initially observes a peer or a therapist perform a desired behavior that is positively reinforced. This is followed by the patient imitating the behavior to also get rewarded for this enactment. This leads to learning adaptive behaviors. Modelling is also referred to as social learning.
g) Shaping: This involves gradual change from a learned response to a desired one. Shaping is brought about by positive reinforcement of successive approximations of desired behavior.
h) Cognitive behavioral therapy (CBT): In CBT, behavioral techniques are used as an adjunct to cognitive strategies that reinforce learning. Examples include activity scheduling, graded task assignment, relaxation exercises, assertiveness training, thought record, coping cards, and biofeedback. Details of CBT are listed in the next section.

## Cognitive Behavioral Therapy

Cognitive Behavioral therapy (CBT) was initially developed by Aaron T Beck for treatment of depressive disorders (9). Since then, CBT has gained widespread acceptance for managing anxiety disorders and has also been tailored to help patients with bipolar disorder, eating disorders, personality disorders, substance abuse disorders, and even psychotic disorders. CBT is a short term therapy with emphasis on collaborative relationship between therapist and patient.
Theoretical background: Information processing utilizes cognitive representations also termed as core beliefs or schemas. These schemas and the resulting automatic thoughts influence emotions and behavior and help deal with a great number of stimuli that we are constantly being exposed to (10). Multiple factors at the biological, developmental, social levels contribute to the formation of schemas.
Psychiatric disorders are characterized by dysfunctional schemae and maladaptive thoughts (cognitive distortions) that lead to abnormal affect and maladaptive behavioral patterns that reinforce core beliefs. Examples of dysfunctional core beliefs include Beck’s cognitive triad of pervasive negativity towards self, world, and the future as well as excessive fear of physical or psychological danger in anxiety disorders (11). Commonly seen cognitive distortions include over-generalizing, selective abstraction, minimization/ magnification, catastrophizing, and dichotomous thinking. CBT aims to empower patients with the ability to become aware of and change these maladaptive core beliefs and cognitive distortions.
CBT does not claim this model is the causal factor of psychopathology and reiterates the importance of taking into account multiple etiological factors including biological, social stressors. The usefulness of pharmacotherapy in helping patients is also noted (13).
Outline of CBT Sessions: The total number of hourly sessions varies from 5-20, with an average number being 12-16. Patients with residual symptoms or recurrent illness may find "booster" sessions helpful to maintain response (14). The first few sessions are aimed at getting comprehensive history and identifying current problems. Based on the problems, an attempt is made to elicit, test, and modify maladaptive schemae and cognitive distortions. Formal joint agenda setting, homework, and feedback are important tools to reinforce learning, maintain focus, and move in the right direction. Socratic questioning, emotional state during sessions (15), imagery, and role play are useful in uncovering and dealing with cognitive distortions. Generation of alternatives, examining evidence, decatastrophizing, reattribution, thought recording, and cognitive rehearsal are some of the techniques used to modify schemae/cognitive distortions (16).

### Thought Record
#### Event

    What happened? What were you doing? Who was involved? Automatic thought
    Note down the most important thoughts/images which troubled you during that time.

#### Emotion

    Which feelings or emotions (sadness, anxiety, anger etc)
    Did you feel in that situation?

#### Adaptive answer

    What is the evidence for the automatic thought? Are there any alternative explanations for the event? Result
    Asses how much do you believe now in your automatic thoughts (0-100%) and in the intensity of your emotions (0-100%)
Adapted from http://www.scielo.br/img/revistas/rbp/v30s2/en_a02tab04.gif
Clinical Applications: There is significant research supporting efficacy of CBT in depressive and anxiety disorders (17). CBT has also been shown to be effective for dysthymia and in combination with medications for major depressive disorder, panic disorder, OCD, and generalized anxiety disorder. CBT principles have been used for modifying overvalued ideas seen in eating disorder and for symptom recognition, relapse prevention, and medication adherence in psychotic illnesses and bipolar disorder.

## Interpersonal Therapy

Interpersonal psychotherapy (IPT) is a brief, time-limited therapy developed in the 1970s for the treatment of depression. This approach is based on the premise that depression is often closely intertwined with the patient’s interpersonal relationships. The goals of IPT include reduction in symptoms and enhancement of communication skills in significant relationships. IPT is thus unique in its focus on improving patient interpersonal relations and social functioning and, thereby, improving depressive symptoms. Over the years, IPT has gradually evolved to become one of the foremost treatment modalities for depression, apart from pharmacotherapy and cognitive behavioral therapy (CBT). IPT assumes the development and maintenance of depressive symptoms occurs in a social and interpersonal context and, further, that the onset, response to treatment, and outcomes are influenced by interpersonal relations between the patient and significant others.
Historically, Harry Stack Sullivan’s interpersonal theory of emotions formed the basis of interpersonal therapy. Over the years, Klerman and Weissman became leading exponents of and researchers in the field. Techniques utilized by these authors focus on the goals of 1) changing communication, and 2) solving interpersonal problems to help improve interpersonal relationships to improve emotional well-being. In contrast to CBT, IPT focuses on changing relationship patterns (not on distortions in cognitions); furthermore, there is minimal focus on systematized homework assignments in IPT. Typically, IPT is time-limited and usually once-a-week, for 12 to 20 sessions. The approach taken by most IPT therapists is to identify one or two problem areas and correlate the interpersonal aspects of these issues with symptom formation and maintenance. IPT can be divided into three phases: the initial phase, the middle phase and the termination phase.
Initial Phase: This is focused on a confirmation of the diagnosis of depression and education about depressive symptoms. This is followed by understanding significant interpersonal relationships and, thereafter, identifying target problem areas. After confirming the suitability for IPT, the therapist introduces principles of IPT to the patient, conducts an interpersonal inventory, and establishes a working formulation in the interpersonal context. The patient is assigned a limited sick role’ to provide relief from performing the social role. The interpersonal formulation is based on one of four key interpersonal problem areas: grief, interpersonal deficits, interpersonal role disputes, or role transitions.
Middle Phase: This largely involves therapy "work." The therapist works with the patient to implement specific strategies related to one of the four problem areas. Furthermore, the therapist highlights how changes in patient interpersonal relationships relate to changes in symptomatology.
Termination Phase: Here the therapist discusses termination and encourages patients to understand and describe specific changes in their psychiatric symptoms, especially as they relate to improvements in the identified problem area. The therapist also assists the patient in consolidating gains, and helping him identify early warning signs of symptom recurrence.

## Dialectical Behavior Therapy (DBT)

DBT evolved mainly from Marsha Linehan’s efforts to decrease chronic suicidal/self-injurious behavior in patients with borderline personality disorder (BPD) (18). DBT uses a combination of cognitive, behavioral, and supportive strategies along with acceptance and mindfulness principles. It aims at enhancing and expanding patient motivation as well as their capability to reduce dysfunctional behavior.
Theoretical background: Emotional vulnerability is dependent on biological factors such as temperament and impulse dyscontrol. In the presence of an invalidating environment (such as parental/caretaker neglect or abuse), emotional dysregulation may emerge which constitutes the core problem (19). In response to stress, these patients engage in maladaptive behaviors such as suicidal, self-injurious, or avoidance to escape from distressing emotions (20). Such a pattern is often reinforced and learned. DBT uses problem solving, validation, and dialectics to break this cycle and develop healthier ways to manage stress.
Initially while problem solving, behavioral analysis is used to identify the sequence of internal events (emotional state), external events (stimulus), and consequences associated with problem behavior. Several strategies such as cognitive modification, behavioral skills training, solution analysis, didactic approach, and insight development are used to break the maladaptive cycle. Validation is a process of non-judgmental, active listening with communication of acceptance of patient’s experiences.
Dialectical strategies underlie all the principles used in DBT and promote acceptance and change, flexibility with stability, and nurturing with challenging, to help patients overcome their limitations.
Outline of DBT Sessions: In the pretreatment stage, orientation is provided and informed consent and commitment to the program are obtained. The initial duration of ongoing DBT is usually one year (21). Priority is given to replace risky behaviors such as suicidal or self injurious behaviors with healthy alternatives.
DBT is delivered in four different settings: individual therapy, group skills training, telephone consultation, and therapist consultation. Patients individually meet for one hour every week with their primary therapist and review their treatment goals. This therapist is responsible for coordination of care across all the modes.
Group skills training uses a didactic approach and empowers patients with skills such as:
* Mindfulness to increase awareness and be in the present moment
* Emotional regulation to understand and accept emotions and thereby, reduce emotional vulnerability.
* Interpersonal communication skills
* Self-management to promote realistic goal setting, dealing effectively with environmental factors and relapse prevention
An individual therapist is available for telephone consultation at all times for crisis intervention. If the primary therapist is not available, coverage is arranged. Furthermore, therapists meet once a week for consultation, peer supervision, and feedback about using DBT effectively.
Clinical Applications: Most of the DBT research has focused on treatment of Borderline Personality Disorder. DBT has been shown to be effective in reducing suicidal/self injurious behaviors, and number of hospitalizations (22). Studies of the efficacy of DBT are ongoing in patients with substance abuse, eating disorders, and depression.

## Family Therapy

This focuses on the family system as a whole. Family therapy views the functionality of the system as a whole to decipher individual behavior patterns amid complex interactions within the family system. It assumes people are best understood as operating in systems and treatment must include all relevant parts of the system. While many clinicians view families as an important aspect of understanding individual illness and treatment; others view family disequilibrium as the core issue, with individual illness a result of or solution to such disharmony (23).
Von Bertalanffy’s concept of "general systems theory" introduced principles that provide an organismic approach to understanding biological beings. General systems theory applies to biological processes of considerable complexity since any living system must have boundaries in order to regulate its exchange with systems outside of itself. Over the years, general systems theory has been applied to the assessment of family systems and subsystems that also must have clear boundaries to stay functional. Further work by Minuchin helped define a continuum of families ranging from enmeshed (with permeable and diffuse boundaries) to disengaged (inappropriate rigid boundaries). Families with clear boundaries lie in the middle of this continuum and are considered the most functional. A significant related concept is that of "Family homeostasis," by which as a system, the family unit attempts to maintain a relatively stable state; when subjected to an incongruent force, it tries to restore back to a state of pre-existing equilibrium (24).
While conducting a comprehensive initial evaluation, a convenient tool used for family assessment is the three-generational genogram. Initially developed by Bowen, this genogram maps family relationships and provides a structure with which difficulties are explored by the therapist. During the initial phase of treatment, the therapist tries to better understand family strengths, preferred styles of thinking, contributory cultural issues, and the life cycle phase for the family. Furthermore, the therapist establishes and strengthens therapeutic relationships, defines goals of therapy, and switches focus from the individual to the family. The middle stage, where majority of therapy "work" happens, is an attempt to bring about change. This middle stage focuses on goals defined as primary. These goals could involve persistently inflexible patterns of family functioning, definition of family boundaries, or presentation of alternative modes of interacting for the family. The termination phase involves a review with the family of goals that were or were not achieved. The original problems and alternatives suggested are revisited and often the sequences leading to the pathology are reconstructed. The therapist also acknowledges problems may arise in the future and suggests how the family might then use skills they learned to help solve any such future conflicts (25).
Therapists use other techniques to assist dysfunctional families. Reframing involves the therapist understanding the patient’s or family’s perspective or frame and countering this frame with another alternate view. Enactment involves the playing out of the family problems in the session. Boundary making is utilized to change the psychological distance between family members. Unbalancing techniques are used to change the hierarchical relationship of members of a family system or subsystem. Paradoxical techniques are occasionally used to make the family unit understand why a symptom is being maintained in their system (24, 25).

## Couples Therapy (CT)

Psychotherapists experienced in couples therapy can assist in a number of ways (24). Therapy can help couples perceive and appreciate differences in ongoing individual challenges and the struggles rotted in the relationship. The life history of each person in couples therapy is important as is the history of the relationship itself. Different values, assumptions, and expectations may not be intentional, much less, personal. Mundane concerns over children, careers, and life transitions often stir up misunderstandings, stress, and unnecessary stress between couples. Thus, couples in therapy may gain perspective, learn new skills, discuss struggles and resentments without rancor. Couples’ issues often include intimacy, power, decision making, parenting, leisure activities, and miscommunication (24). Outline of CT Sessions: Psychodynamic review of problems with either one or both partners can address misunderstandings that inevitably arise when two families unite formally in marriage or informally by way of sustained intimacy. In practical terms, both partners are usually seen together by two co-therapists at weekly to monthly intervals for an average of 6-10 sessions of 1-1½ hours. Clinical Applications: To resolve conflicts, couples must confide in a therapist to safely explore sources of and possible solutions to problems or failings in the relationship. Such exploration needs to be taken up in an open, understanding, reassuring manner in order for a couple’s relationship to heal and grow. One or both in a couple may harbor concerns that inhibit their acceptance of therapy. Unstated fears often persist that a psychotherapist will be judgmental or partisan. Similar fears that the therapy will drive the couple apart rather than draw them closer commonly occur. One partner may fear that a shameful or guilt-ridden secret will be uncovered. Stigma for having marital problems is a frequent anxiety. However, not only is seeking out help is a healthy sign of maturity and hope rather than insecurity, it can be the basis upon which a couple may renew trust, esteem, and conviviality (24).

## Supportive Therapy (ST)

Supportive psychotherapy is the most widely practiced form of individual psychotherapy today. As such, supportive psychotherapy is a general term for widely used techniques that improve, if not optimize, adaptation by way of directly addressing situational stress, such as chronic illness—mental or somatic—as well as acute stress as with bereavement. Supportive psychotherapy often spans a long term with brief contacts, although it can take a limited form of more extended sessions within a brief period (26). Outline of ST Sessions: The general framework of supportive psychotherapy include attention to indications and patient selection, treatment phases, session management, professional boundaries, as well as a wide range of issues in the therapeutic relationship, e.g., therapeutic alliance, transference, countertransference, and therapist self-disclosure. The synthetic nature of supportive psychotherapy can be conceptualized across four major areas (26):
* Establishment and maintenance positive therapeutic alliances
* Formulation of patient problems, i.e., how to come to a thorough understanding for patient evaluation and case formulation)
* Targeting realistic treatment goals for and with patients, i.e., help maintain or reestablish best possible levels of patient function in the face of limitations to do with personality, talent, and existential circumstances
* Fluency in expressions to patients, i.e., practical techniques of immediate and frequent use.
Clinical Applications: Supportive psychotherapy is actually a continuum from merely supportive efforts such as a case manager may use, toward more expressive psychotherapy appropriate to the level of patient psychopathology and resilience. Supportive psychotherapy is especially pertinent for patients vulnerable to psychotic regression in the course of non-directive psychodynamic psychotherapy, or who have limited capacity to forge and sustain close relationships, or who are less skilled at verbalizing distress. Regardless of the clientele, essential aspects of supportive therapy include close attention to and elicitation of expressed emotions as "ventilation" as well as possible insight. It also includes overt explanation and education by the therapist to assist patient understanding of themes, struggles, and conflicts in their lives in order to facilitate confidence that such difficulties can be overcome. Similarly, supportive psychotherapy can entail open expressions by the therapist that are intended to boost confidence or restore morale. Supportive psychotherapy also often includes counseling advice or direct recommendations about specific problems.

## Group Therapy (GT)

Every human being is raised in group environments. In fact, there are multiple groups interacting with any individual—families, schools, religious or social clubs, or work. Group psychotherapy can address inadequacies acquired in earlier group experiences from childhood through adolescence and beyond. In group therapy, patients join together with others to share problems or concerns, to better understand themselves and others, and to learn from and with others. It helps patients enhance interpersonal relationships and otherwise learn about themselves. It mobilizes feelings of isolation, depression or anxiety that the group and/or leader can help interpret so patients may make significant change and feel better about the quality of their lives (27). Outline of GT Sessions: For over 60 years, group therapy has been widely used as a standard treatment to help group members share and resolve problems of their own as well as those of their group peers. Group psychotherapy entails a small number of people (generally no more than eight or ten) who meet together regularly (most often weekly) under the guidance of one (or sometimes two) therapists (28). Clinical Applications: Supportive, behavioral, cognitive, and psychodynamic approaches arise in the course of group therapy. Most commonly, dynamic group therapy fosters a wide variety of transference relationships than is likely in individual therapy. Group therapy has given rise to a great many permutations that include more didactic or focused therapeutic themes. For example, anxiety management or social skills groups combine cognitive and behavioral techniques to treat specific problems common to all group members. Self-help groups such as Alcoholics Anonymous frequently rely on techniques of group dynamic that also build a supportive and instructive milieu. Moreover, principles of group therapy and group dynamics underlie broader applications in other settings such as business consultation, schools management, and community organizations.

## Patient Selection

No clear rules govern the referral of patients to particular modes of psychotherapy. Still, the suitability of particular patients for particular therapeutic techniques can be broadly outlined. Some basic principles of selection are:
* Patients who are vulnerable to psychotic breakdown are unsuited to non-directive approaches
* Patients who have little capacity of making and sustaining relationships
* Patients who are less verbally able are also relatively unsuited to non-directive approaches.
Psychotherapy can redress problems in prior critical learning periods. One such critical learning period is early childhood (about 2 to 5 years). Heinz Kohut emphasized that here, parents or other adults "mirror the grandiose self" of the child (28). This grandiosity derives from how children are (or should be) surrounded by praise and love with every minor achievement warmly applauded. However, as is all too clear in any psychiatric clinic, not every child had sufficient such tonic boosting to inure solid self-image. Indeed, many exit childhood sensing that they are unwanted, fundamentally bad, or failures or less favored than a sibling, and so on.
A second critical learning period for self-esteem is adolescence when parental influences wane or even become negative, while peer group influences become vital and avidly sought as peer group acceptance fosters high self-esteem. Yet many adolescents are rejected by their peers—they may be unattractive, disabled, or newcomers to an area where the peer group is "full" and does not require or even stigmatizes new arrivals. Such rejection by peers can further compound low self-esteem acquired early childhood or even efface high self-esteem previously engendered by parents. Self-esteem is difficult to alter after adolescence. It is true that important life events may have effects both positive, such as success in college or career, or negative as in being rejected by a desirable college or failing in a career. But in the clinic many successful, happily married people still have problems ensuing from bad experiences in early childhood or adolescence. It takes a time and effort to substantially improve self-esteem.
Ferdo Knobloch recognized the value of "corrective experience," elaborating ideas of Alexander and French (29) who saw how therapy can offer a re-run of bad experience. Knobloch (30) noted how individual psychotherapy can refurbish defects in the original parent/child relationship when, over a long course of care with a reassuringly supportive therapist, the patient can overlay bad early learning with newly positive experiences. Such therapy emphasizes the importance of childhood experiences as the therapist adopts aspects of the role of parent via patient transference. Here the good therapist is able to elevate the patient into something of an equal, in the way that a good parent eventually assists a child to separate and individuate as a health, self-actualized adult.
However, if low self-esteem arose in negative adolescent experiences, individual therapy cannot effect a re-run. Parent figures are importent at this stage. What is instead needed is a re-run with a group that represents the adolescent peer group. This re-run can most effectively be achieved with group therapy, as other treatment group members understudy the role of adolescent peers. Here transference is not to the therapist but to the peer group as a whole.

## Summary

Research that spans neuroscience and psychoanalysis is rapidly enhancing the scientific foundation of all types of psychotherapy as insights accrue concerning critical learning periods, narrative capacity, and neuroscientific discoveries in of existential adaptation. In practical terms, the sequelae of negative childhood events are perhaps best addressed by individual therapy whereas those due to adversities in adolescence are likely to benefit from group therapy. It is less widely appreciated but quite important to appreciate that such research also directly links psychotherapy to evolution, particularly the emotive and rational capacities and reactivities of highly social species such as Homo sapiens. Most patients are able to give a clear account of how they felt about themselves in childhood and adolescence, and these reports should be taken into account in deciding between individual and group therapy as well as in guiding the course of any dynamic therapy toward the resolution of and recovery from problems in living.

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## About the Authors

* Dr. Bestha is a Resident Psychiatrist in the Creighton-Nebraska program in Omaha, Nebraska USA
* Dr. Madaan is an Assistant Professor of Psychiatry at Creighton University in Omaha, Nebraska USA
* Dr. Wilson is Professor and Chair of Psychiatry and Professor of Anthropology at Creighton University in Omaha, Nebraska USA