Introduction

In mental health, a number of different theories are used as models to explain human behavior. There are three main theories of psychotherapy that commonly used in Malaysia such as behavioral model, cognitive behavioral and psychodynamic (or psychoanalysis).

This section describes each of the psychotherapies in relation to the underlying theory which it is associated.

1. 1. Psychoanalysis psychotherapy.

      This form of treatment is based on Sigmund Freud’s theories of a dynamic unconscious and psychological conflict. The major goals of this form of therapy are:-

      1. to help the patients develop insight into unconscious conflicts, which are based on unsolved childhood wishes and are manifested as symptoms
      2. to develop more consciously adult patterns of interacting and behaving.

      There are two types:

      1. insight-oriented or expressive psychotherapy
      2. supportive or relationship psychotherapy.

      In this therapy:-

      1. Patients are seen 1-2 times a week
      2. Patients suitable for this therapy include those with a wider range of symptomatic and multiple problems such as patients with personality disorders, patients with serious ego vulnerabilities, particularly psychotic patients.
      3. The essential element is support, rather than the development of insight.
      4. Patients in a crisis situation, such as acute grief, also are suitable.
      5. It can be long term, lasting many years, especially in the case of chronic patients
      6. Support can take the form of limit-setting, increasing reality testing, reassurance, advice, and help with developing social skills.

1. 1. Behavior therapy

      This theory is based on BF Skinner and Bandura work that emphasis on maladaptive behavior can change without insight into its underlying causes. Behavioral symptoms are taken at face value and not as symptoms of deeper problem.
      Behavior therapy is based on the principles of learning theory, including operant and classic conditioning. Operant conditioning is based on the premise that behavior is shaped by its consequences; that is, if behavior is positively reinforced it will increase, if it is punished it will decrease, and if it elicits no response it will be extinguished.

      Behavioral techniques include the following:

      1. 1. Token economy. A form of positive reinforcement used with inpatients. A patients is rewarded with various tokens (e.g food, passes) for performing desired behaviors, eg dressing in street clothes, attending group therapy.
      1. 1. Systematic desensitization. A technique in which a patient with avoidant behavior linked to a specific stimulus, eg heights or airplane travel, its asked to construct a hierarchy of anxiety-provoking images in his or her imagination from the least to the most fearful, staying at each level of the hierarchy until anxiety diminishes. When this procedure is perfomed in real life rather than imagined, it is called graded exposure.
      1. Relaxation technique. There are many forms of relaxation that can be taught to patient in handling their symptoms such as deep breathing exercise, progressive muscle relaxation, autogenic relaxation exercise and also imagination exercise.

1. Cognitive Behavior Therapy

   Cognitive Behavior Therapy (CBT) is based on the theory from Albert Ellis and Aaron Beck promoted that behavior is secondary to the way in which persons thinkabout themselves and their roles in the world. Maladaptive behavior is secondary to ingrained, stereotyped thoughts, which can lead to cognitive distortions or errors in thinking.

   The theory is aimed at correcting these cognitive distortions and the self-defeating behaviors that result from them. Therapy is short-term, generally 6-12 sessions over 12 weeks, during which patients are made aware of their own distorted cognitions and the assumptions on which the questions are based.

   Homework is assigned: patients are asked to record what they are thinking in certain stressful situations (such as, “I’m no good” or ” No one cares about me”)and to ascertain the underlying, often relatively unconscious, assumptions that fuel the negative cognitions.This process has been called “recognizing and correcting automatic thoughts”.

   The cognitive model of depression includes the cognitive triad, which is a description of the thought distortions that occur when a person is depressed. The trial includes:-

   1. negatives view of the self
   2. a negative interpretation of present and past experience
   3. a negative expectation of the future.

   CBT has been most successfully applied to the treatment of mild to moderate, nonpsychotic depressions. It also has been effective as an adjunctive treatment with substance abusers and in increasing compliance with medication. CBT can be offer individually or in group format.

   The abovementioned theories can be applied in several forms of psychotherapy session such as:-

   1. 1. Motivational interviewing

         Motivational Interviewing refers to a client-centered counseling approach. It use semi-directive method of engaging intrinsic motivation to change behavior In Motivational Interviewing (a) therapist recognizes and accepts the fact that clients who need to make changes in their lives, and (b)therapist gives counseling at different levels of readiness to change their behavior.

         Motivational interviewing is based upon four general principles:

         1. Express empathy
         2. Develop discrepancy
         3. Roll with resistance
         4. Support self-efficacy
   1. 1. Family therapy
   1. Family therapy is based on the theory that a family is a system that attempts to maintain homestasis, regardless of how maladaptive the system may be. This theory has been called a family systems orientation, and the techniques include focusing on the family rather than on the identified patients.
   1. One example is the triangulated child- the child who is identified by the family as the patient is actually serving to maintain the family system by becoming involved in a marital conflict as a scapegoat, referee, or even surrogate spouse. The therapist’s job is to help the family understand the triangulation process and address the deeper conflict that underlies the child’s apparent disruptive behavior.
   1. Techniques include reframing and positive connotation ( a relabeling of all negatively expressed feelings or behaviors as positive); for example, “this child is impossible” becomes ” this child is desperately trying to distract and protect you from what he or she perceives is an unhappy marriage”
   1. Other goals of family therapy include changing maladaptive rules that govern a family, increasing awareness of cross-generational dynamics, balancing individuation and cohesiveness, increasing one-on-direct communication and decreasing blaming and scapegoating.
   1. 1. Interpersonal therapy (IPT)
   1. IPT is a short-term psychotherapy, lasting 12-16 weeks, developed specifically for the treatment of nonbipolar, nonpsychotic depression. Intrapsychic conflicts are not addressed. Emphasis is on current interpersonal relationships and on strategies to improve the patient’s interpersonal life. Antidepressant medication is often used on adjunct to IPT. The therapist is very active in helping to formulate the patient’s predominant problem areas, which define the treatment focus.
   1. 1. Group therapy
   1. Group therapies are based on as many theories as are individual therapies. Group range from those that emphasize support and an increase in social skills, to those that emphasize specific symptomatic relief, to those that work through unresolved intrapsychic conflicts.
   1. Group tend to meet 1-2 times a week, usually for 1 ¬½ hours. They may be homogenerous or heterogeneous, depending on diagnosis. Examples of hemogenerous groups include those for weigh-reduction and smoking-cessation, as well as groups whose members share the the same medical or psychiatric problem. e.g patients with acquired immunodeficiency syndrome (AIDS), posttraumatic stress disorder, or substance use disorders.
   1. Certain types of patients do not do well in certain types of groups. Psychotic patients who need structure and clear direction do not well in insight-oriented groups. Paranoid patients, antisocial personalities, and substance abusers can benefit from group therapy but do not do well in heterogeneous insight-oriented groups. In general, acutely psychotic or suicidal patients do not do well in groups.
   1. 1. Couples and marital therapy
   Marital or couples therapy is an effective tool for helping each member of the couple to achieve self-knowledge while working on their problems. Couples and marital therapy encompasses a wide range of treatment techniques with the goal of increasing marital satisfaction or addressing marital impairment. As with family therapy, the relationship rather than either of the individuals is viewed as the patient.

Conclusion

To sum up, discussion with patient and therapist is essential in order to determine the best treatment in dealing with the problems.