Psychotherapy is the use of psychological methods to help patients modify undesirable emotions, attitudes, and behaviors. The most common types of psychotherapy are psychoanalysis, behavioral therapy, cognitive therapy, cognitive behavioral therapy, dialectical behavioral therapy, motivational interviewing, group therapy, couples therapy, family therapy, and schema therapy. Psychoanalytic theory has its origin in Freud's topographic and structural theories. According to Freud, defense mechanisms help individuals to mediate their reactions to internal emotional conflicts triggered by external stressors. Defense mechanisms are categorized into four levels: pathological, immature, neurotic, and mature defenses. This article examines mature defense mechanisms, which manifest in healthy adults, as well as pathological, neurotic, and immature defense mechanisms, all of which are associated with psychiatric disorders.
|Overview of common psychotherapies |
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|CBT) (|| || || |
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|Family therapy|| || || |
|Couples therapy|| || || || |
|Schema therapy|| || || |
Details of psychotherapies
- Duration: 3–5 times per week for years
- Focuses on improving awareness of repressed feelings and experiences
- Aims to resolve conflicts in the subconscious (e.g., by studying dreams)
- A strong therapeutic alliance (i.e., the bond between therapist and patient) is important for successful psychoanalysis therapy.
- Countertransference: a complication in which the therapist projects unconscious feelings onto the patient (e.g., the therapist sees the patient as a sibling)
- Transference: The patient projects unconscious feelings about significant persons in their childhood onto the therapist (e.g., the therapist is treated as a parental figure). The therapist can gain insight into personal conflicts by interpreting these feelings.
- Free association: The patient describes all thoughts that spontaneously occur during the therapy session.
- Dream interpretation: identifying representations of the patient's urges and fears in their dreams to gain insight into subconscious conflicts
Psychodynamic psychotherapy 
- Duration: once weekly for 6 months to years
- Similar to psychoanalysis but with less of an emphasis on dream analysis
- Focuses on developing insight into and changing current behaviors, feelings, and thoughts by analyzing past experiences
- Aims to gain insight into unconscious mental processes
- The therapist aims to remain as neutral as possible, to allow the patient to develop their own interpretations.
- Patient education: informing the patient about their condition and about the principles of psychodynamic therapy
- The therapist takes a very thorough history to identify stressors and core patterns in the patient's behavior.
- Promoting a strong therapeutic alliance
Supportive psychotherapy 
- Coping with a crisis or a transient problem
- Open-ended, from days to years
- The weekly frequency is flexible and determined by the severity of symptoms and the patient's progress.
- Focuses on identifying maladaptive behavioral patterns and problematic interpersonal relationships
- Aims to help the patient maintain hope and cope with life challenges
- Aims to improve the patient's self-esteem, adaptive skills, and behavioral functioning (i.e., performance in social environments)
Interpersonal therapy 
- Duration: weekly sessions for 12–16 weeks
- Focuses on identifying and analyzing problematic interpersonal relationships (e.g., or conflicts) and/or life situations (e.g., change in jobs, geographical move)
- Aims to improve communication skills and control over mood and behavior
- Medical model: The disease the patient suffers from (e.g., depressive disorder) is a clinical syndrome distinct from the patient's personality and should be explained similarly to other medical conditions (e.g., diabetes).
- Identifying connections between the disease manifestation and life events (e.g., the connection between the death of a loved one and the development of an eating disorder)
- Duration: brief (5–20 sessions) 
- A biologically potent unconditioned stimulus (e.g., the smell of food) leads to a natural, unconditioned response (e.g., salivation).
Classical conditioning: designed to produce an involuntary response
- If the unconditioned stimulus is repeatedly paired with a neutral stimulus (e.g., the sound of a bell), the neutral stimulus can become a conditioned stimulus that leads to the same natural response, which is now a conditioned response (e.g., the sound of a bell leads to salivation).
- Pavlov's dog experiment is a historical example of classical conditioning.
Operant conditioning: designed to produce a voluntary response (see the “Skinner operant conditioning quadrants” table below)
- Positive reinforcement: The addition of a stimulus in response to a behavior increases the behavior (e.g., an employee begins to work more hours because he gets a salary bonus for doing so).
- Negative reinforcement: The removal of a stimulus in response to a behavior increases the behavior (e.g., a child improves her grades in order to be excused from doing chores).
- Positive punishment: The addition of a stimulus in response to a behavior decreases the behavior (e.g., a driver stops parking illegally in response to a fine).
- Negative punishment: The removal of a stimulus in response to a behavior decreases the behavior (e.g., a child stops acting out because his parents take away his video games when he behaves poorly).
- Extinction (psychology): the loss (unlearning) of a learned behavior due to discontinuation of a reward (in classical conditioning) or reinforcement (in operant conditioning)
- Systemic desensitization: increasing the level of exposure to anxiety-provoking stimuli while performing progressive muscle relaxation
- Flooding: exposing the patient to real stimuli until they achieve complete relaxation in that situation
- Implosion: exposing the patient to an imaginary anxiety-provoking stimulus until they become more comfortable with it
- Biofeedback: using information on involuntary physiological processes to help the patient monitor and control their response to stimuli
- Token economy: reinforcing positive behaviors by providing tangible rewards
- Aversion therapy: using a nonrewarding stimulus to discourage negative behaviors
|Skinner operant conditioning quadrants|
|Increased behavior||Decreased behavior|
|Addition of a stimulus|
|Removal of a stimulus|
Cognitive therapy 
- Duration: brief (5–10 sessions)
Techniques: relies mainly on thought exercises
- Guided questioning: directing the patient's behavior and thought process toward a therapeutic goal by asking a series of graded questions
Journaling (psychiatry): The patient writes down their thoughts, feelings, and internal experiences to better understand their own ideas and emotions.
- Self-monitoring by journaling behaviors, thoughts, and feelings (e.g., treatment for an eating disorder includes monitoring food intake by writing down every meal and the emotions/thoughts attached to eating)
- Enables identification of triggers and problematic chains of behavior (e.g., stress-induced binge eating)
- Cognitive restructuring: The patient identifies negative automatic thoughts (i.e., dysfunctional/negative view of the self, future, or world) in order to dispute them and eventually replace them with healthy thought processes.
Cognitive behavioral therapy (CBT) 
- Usually for approx. 16 weeks
- Twice weekly for the first 4 weeks
- Once weekly for the remaining 12 weeks
- Focuses on changing distorted, harmful, irrational, or ineffective beliefs, attitudes, and behavior patterns that lead to dysfunctional behaviors
- Helps the patient to identify unhelpful and distorted thoughts
- Helps the patient develop skills and strategies to alter abnormal behaviors and develop healthy coping mechanisms
- Aims to improve the patient's control over their emotions and ability to deal with distress
Techniques: combines techniques from cognitive therapy and behavioral therapy
- Cognitive restructuring
- Journaling (psychiatry)
- Systemic desensitization
- Patient education
- The patient is encouraged to implement new skills; (e.g., discussing a faulty assumption with friends) or to set behavioral tasks (e.g., a patient with an eating disorder is asked to eat a feared food like ice cream) outside of therapeutic sessions.
Dialectical behavioral therapy (DBT) 
- Duration: once weekly for approx. 16 weeks
- Focuses on teaching new skills (e.g., relaxation techniques)
- Aims to reduce unhealthy and self-destructive behavior
- Mindfulness: a complex field that revolves around being fully present and aware of one's thoughts, feelings, and actions (e.g., practicing guided breathing, yoga asanas, meditation)
- Emotional regulation: The patient is taught to become aware of their emotions and to assess them rationally.
- Distress tolerance: The patient learns to better handle crises and stressful situations.
- Interpersonal effectiveness: The patient is trained to recognize and assert their needs without coming into conflict with others.
Motivational interviewing 
- Lifestyle changes (e.g., weight loss)
- Duration: approx. 2–4 sessions
OARS: Open-ended questions, Affirmation, Reflections, and Summaries are communication skills for motivational interviewing.
- Duration: once weekly for months to years
- Aims to form a support network for individuals with similar diseases or difficulties
- Allows direct interaction between therapists and patients, and direct interaction between patients
- Certain groups can be peer-lead and do not need to have a therapist present (e.g., Alcoholics Anonymous).
- Techniques: one or more therapists help the group to solve emotional difficulties using various techniques
Family therapy 
- Duration: once weekly for months to years
- Focuses on identifying family dysfunctions and individual problems that affect the entire family
- Aims to reduce conflict, improve communication skills, and help family members accommodate one another
- Emphasizes family strengths to overcome identified dysfunctions
- Addressing boundaries that are too permeable (e.g., allowing a child to smoke cigarettes) or too rigid (e.g., not allowing any social contact outside of the family)
- CBT techniques (e.g., improving communication skills, cognitive restructuring)
Couples therapy 
- Sexual disorders
- Motivated couples who are not suffering severe mental illness
- Duration: once weekly for weeks to years
- Description: aims to reduce conflicts and improve communication skills between couples
- Conjoint therapy: One therapist sees the couple together.
- Concurrent therapy: Each person is seen separately by the same therapist.
- Collaborative therapy: Each person is seen by a separate therapist.
- Four-way therapy: Two therapists see the couple together (especially for sexual disorders).
Schema therapy 
- Long-term treatment
- Twice weekly for up to three years
- Techniques: combines techniques from different psychotherapeutic practices (e.g., CBT, psychodynamic therapy)
Topographic Freudian model 
- Current awareness of ongoing thoughts and experiences
- Secondary process thinking (e.g., logic, reasoning)
- A level below conscious awareness
- Repressed memories and/or thoughts of which one is not presently aware but are easily called into conscious awareness
- Primitive primary process thinking (e.g., sex, aggression)
- Normally repressed from conscious awareness because of negative associations (e.g., feelings of shame or guilt)
- Plays a more prominent role in the behavior of adult individuals with mental illness (e.g., ) and in children
Structural Freudian model 
- Id (psychiatry): unconscious; source of drive and instinctive impulses (e.g., sex, aggression, illogical)
- Represents both the consciousness and the idealized self
- Responsible for rational and reality-oriented thought
- Mediates between environment, id, and super-ego
Carl Jung theory 
- Conscious mind
- Current awareness of emotions, thoughts, and memories
- Personal unconscious (psychiatry)
Collective unconscious (psychiatry)
- Shared with other humans
- Based on latent memories from the ancestral and evolutionary past, which shape the characteristics of the human species
Some of the most important archetypes Carl Jung proposed include:
- Persona (psychiatry): the public presentation of the self; the real self is concealed to adapt to social norms or expectations
- Anima/animus (psychiatry): the unconscious, countersexual aspect of the biological sex in the human psyche
- Shadow (psychiatry): repressed and unconscious; source of instinctive, irrational impulses
- Self (psychiatry): overarching structure of the individual; unification of male and female and of unconscious and conscious
Theory of schema therapy
- Schema therapy was developed by Jeffrey Young.
- It is based on the notion that people acquire certain basic schemas (i.e., mental structures) that help them interpret and organize information and thereby establish certain behavioral patterns throughout the course of their lives.
- These schemas, in part, set the conditions for meeting psychological needs and therefore also influence behavior.
- E.g., childhood trauma can lead to maladaptive schemas that are difficult to access consciously and may be the root cause of a personality disorder.
- Eight sequential stages of psychosocial development that determine the psychological characteristics and core beliefs an individual develops during their lifetime
- Each stage is characterized by an opposing tendency with which an individual is confronted and must resolve in order to develop a positive, adaptive or negative, maladaptive trait
- Psychosocial development is considered a lifelong process of continuously reevaluating and reintegrating the eight stages.
|Stages of psychosocial development according to Erik Erikson|
|Stage||Period||Opposing tendencies||Adaptive trait||Factors that promote the development of adaptive traits|
|Stage 1|| |
Basic trust vs. basic mistrust
Fulfillment of emotional and physical needs (e.g., experiencing reliability and affection, access to food)
|Stage 2|| |
Autonomy vs. shame, doubt
Establishing a balance between dependence/safety and independence/self-control
|Stage 3|| |
Initiative vs. guilt
Encouragement and guidance in social interactions, self-assertion, and cooperation
|Stage 4|| |
Industry vs. inferiority
Reasonable academic expectations, reinforcing initiative, providing praise for accomplishments
|Stage 5|| |
Identity integration vs. identity confusion
Exploration of self-identity, personal goals, sexual and occupational experiences
|Stage 6|| |
Intimacy vs. isolation
Formation of friendships and relationships
|Stage 7|| |
Generativity vs. stagnation, self-absorption
Involvement in community, contributing to society, engaging with younger generations (e.g., parenting, teaching)
|Stage 8|| |
Integrity vs. despair
Retrospection and recognition of life accomplishments
- Primary tools of the ego used to cope with external stressors to avoid or reduce anxiety, restrict impulses, and avoid unpleasant feelings
- Mostly unconscious
- Level 1 – Pathological/narcissistic: seen in children and in adult individuals with
- Level 2 – Immature (primitive): common in patients with , patients suffering from psychosis, individuals with anxiety disorders, children, and adolescents
- Level 3 – Neurotic: common in patients with OCD and/or anxiety
- Level 4 – Mature (sophisticated): seen in normal adults
Pathological defenses 
|Overview of pathological defenses|
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|Projection (psychiatry)|| || |
|Denial (psychiatry)|| || |
|Distortion (psychiatry)|| || |
Immature defenses 
|Overview of immature defenses|
|Acting out (psychiatry)|| || |
|Regression (psychiatry)|| |
|Primitive idealization (psychiatry)|| || |
|Blocking (psychiatry)|| || |
|Identification (psychiatry)|| || |
|Passive aggression (psychiatry)|| || |
|Somatization (psychiatry)|| || |
|Undoing (psychiatry)|| || |
|Fixation (psychiatry)|| || |
|Fantasy (psychiatry)|| || |
Neurotic defenses 
|Overview of neurotic defenses|
|Controlling (psychiatry)|| |
|Displacement (psychiatry)|| || |
|Intellectualization (psychiatry)|| || |
|Isolation of affect (psychiatry)|| || |
|Rationalization (psychiatry)|| || |
|Reaction formation (psychiatry)|| |
|Repression (psychiatry)|| |
|Externalization (psychiatry)|| |
|Dissociation (psychiatry)|| || |
|Sexualization (psychiatry)|| || |
|Inhibition (psychiatry)|| |
Mature defenses 
|Overview of mature defenses|
|Sublimation (psychiatry)|| || |
|Altruism (psychiatry)|| || |
|Suppression (psychiatry)|| |
|Humor (psychiatry)|| || |
|Anticipation (psychiatry)|| || |
“SASHA is a mature adult”: Sublimation, Altruism, Suppression, Humor, Anticipation are mature defenses.
- Definition: behavioral and mental strategies or skills that can be mobilized by an individual to aid in handling external and internal stressors (e.g., stress, illness) 
Adaptive coping: behavioral and mental strategies that aid in responding to stressors in a positive and constructive manner 
- Problem-focused coping: strategies that target the underlying cause of stress (e.g., ergonomical workplace to prevent and relieve health issues such as back pain)
- Emotion-focused coping: strategies that reduce the negative emotions associated with a stressor (e.g., responding to a misfortune with humor, distancing, or acceptance)
- Meaning-focused coping: cognitive strategies used to find meaning in or change the perspective on the stressful situation (e.g., meditation, mindfulness, positive reappraisal, reordering life priorities)
- Social coping: seeking support within a community to reduce stress
- Further categorized into
- Reactive coping: strategies pursued in response to a stressor
- Proactive coping: strategies pursued in anticipation of a stressor
- Maladaptive coping: conscious as well as unconscious thought patterns and behaviors engaged in for the short-term relief of stress that, however, increase stress in the long term.