In the context of psychoanalysis, catharsis provides relief by assaulting the ego.

Evidence for Efficacy and Practicality

CBT-I is an empirically validated brief psychotherapy, with 70–80% of treated participants experiencing clinical benefits and symptom reduction. Evidence for the efficacy of CBT-I is well documented, which has led to its recognition as a first-line treatment for insomnia in the National Institutes of Health Consensus Statement. Treatment effects are well sustained and patients often continue to improve even after the active treatment phase is completed. Although initially used in the treatment of primary insomnia patients, more recent research has found that CBT-I is also effective in patients with other psychiatric and medical comorbidities. CBT-I demonstrates longer-term benefits than pharmacotherapy and has minimal side effects associated with treatment.

CBT-I is generally well accepted by patients with insomnia and is actually preferred to pharmacological treatment, by patients. One of the limitations of the treatment is that a patient's success and improvement are entirely dependent on his or her own motivation and willingness to invest the time and effort into implementing these strategies. Although CBT-I is generally a brief therapy, several follow-up sessions are necessary to promote compliance, enhance motivation, and optimize outcomes. Patients who present with comorbid conditions and those taking hypnotic medications may require additional sessions.

CBT-I is not necessarily incompatible with pharmacological therapy for insomnia. In some patients, they may serve to complement each other. Pharmacotherapy often produces prompt improvement in sleep, whereas CBT-I tends to lead to longer term, sustained results. When combining treatments, part of the treatment strategy includes developing a medication withdrawal plan and then supervising the withdrawal.

Despite the high prevalence of insomnia and the strong efficacy of CBT-I, the majority of individuals with chronic insomnia remain untreated. Numerous reasons have been given for this dichotomy, including time costs of initial treatment, the relative scarcity of CBT-I therapists, and physicians lack of familiarity with CBT-I as a viable treatment option for insomnia. Currently, the field of behavioral sleep medicine has been working on addressing these challenges by continuing to train and accredit providers, ensure proper reimbursement for service, and educate other providers about the availability and accessibility of this treatment for insomnia.

A stepped-care model for delivering CBT-I has been developed in order to optimize resources and provide more accessible clinical care. Such a model would provide graduated levels of cognitive behavioral interventions, including self-help books, interactive web-based programs, brief behavioral treatments, manualized group CBT-I treatment, and finally, individualized treatment provided by a certified specialist in behavioral sleep medicine.

2 Interpersonal Therapy

1.10.4.4 Strategic Family Therapy

Strategic family therapy seeks to address specific problems that can be dealt with in a shorter time frame than other therapy modalities. It is one of the major models of both family and brief psychotherapy. The theory of strategic family therapy was inspired by Milton Erickson and Don Jackson, with many other influences, for example Salvador Minuchin, Gregory Bateson, and other prominent early family therapists. Strategic family therapy grew along with, and out of, other theories, most importantly, structural family therapy in the late 1960s and early 1970s at the Mental Research Institute in Palo Alto, and later at the Philadelphia Child Guidance Center. The main proponents and creators of the theory were Jay Haley and Cloe Mandanes (1976). One of the guiding principles in strategic family therapy is that problems apparently residing in one individual are frequently associated with the difficulties resulting from a family's need to reorganize themselves at transitional stages (i.e., birth of a child, child leaving home in the transition from adolescence in adulthood). Being strategic is inherent to people, in the way that we are involved in predicting how others may think, feel, and act. Haley (1976) characterizes this as indicative of a constant power struggle in which family members are trying to influence each other and define themselves. The strategic approach, in contrast to the structural approach, does not have a normative concept of the family that should exist according to set hierarchies and subsystems. The focus is rather on the family strategies about the perception of the problems and how to solve them. Attempted solutions and behavioral responses that actually maintain the problem require challenging and shifting with alternatives promoted by the therapist are the key features of strategic family therapy. Therapy sessions in the Strategic Family Therapy are divided in five stages. The brief therapy stage seeks to observe the family's interactions, create a calm and open mood for the session, and attempts to get every family member to take part in the session. The problem stage is where the therapist poses questions to the clients to determine what their problem is and why they are in therapy. The interactional stage is where the family is urged to discuss their problem so the therapist can better understand their issues and understand the underlying dynamics within the family. Some of the dynamics that strategic family therapists seek to understand are, the hierarchies within a family, the coalitions between family members, and the communication sequences that exist. The goal-setting stage is used to highlight the specific issue that needs to be addressed, this issue is both identified by the family members and the therapist. In addition, when discussing the presenting problem initially identified by the family, the family and the therapist work together to come up with goals to fix the problem, and better define the parameters for attaining those goals. The final stage of the initial session is the task-setting stage. In the task-setting stage, the therapist wraps up the session by coming up with concrete homework assignments or directives the family can do outside of therapy to start to change their problems. Additional therapy sessions seek to further gain understanding to a family's problems, dynamics, and to dig deeper in addressing their needs through a confident, controlling, and compassionate therapist.

Further interventions are the prescription of symptoms, relabeling and paradoxical interventions. Prescribing the symptom is the therapist's invitation or challenge to exaggerate a specific symptom within the family to help the family understand how damaging that symptom is to the family. By the therapist changes the connotation of one symptom from negative to positive. In this way, the family can view the symptom in a new context or have a new conceptual understanding of the symptom. Finally, a paradoxical intervention is similar to prescribing the symptom, but is a more in-depth intervention and often equated with reverse psychology (for example prescribing a time to procrastinate for someone with procrastination problems or asking a client with fear of failing to willingly fail at something). The goal is to demonstrate the need of the behavior and the experience of controlling or non-controlling a behavior.

Treatment

The field has made tremendous progress in developing better psychotherapies for mental illness. We are no longer confined to long-term psychodynamic psychotherapy or psychoanalysis for all psychiatric conditions. Today, we have briefer psychotherapies as well as psychotherapies that target particular issues such as interpersonal difficulties, psychotherapies that focus on a particular condition (e.g., dialectical behavior therapy for borderline personality disorder), and psychotherapies that focus on modifying behavior rather than providing psychological insight.

There have also been significant developments in our ability to treat mental illness with medications. For manic–depressive illness, certain anticonvulsant medications have been determined to be effective in addition to lithium. This is important since only 70% of patients with manic–depressive illness respond to lithium alone and others are unable to tolerate lithium because of side effects. For depression, there are at least six different classes of medication that are effective. These medications are effective in approximately 50–60% of patients; however, approximately 80% of patients will respond to at least one antidepressant. Similar progress has been made in the pharmacological treatment of psychosis (e.g., schizophrenia) and anxiety disorders. The newer medications are frequently better tolerated than earlier medications.

The newest approach in caring for individuals with mental illness is to use a disease management program. Perhaps best developed for depression, this approach utilizes quantitative measures of the patient's symptoms to inform treatment (i.e., is the individual responding to treatment) and various combinations of medication and psychotherapy as well as patient and family education. Since depression is a relapsing illness, teaching about the illness (e.g., how to recognize early signs of relapse and how to respond when these signs appear) can have a profound impact on the course of illness. Working with the patient and family to improve adherence to the treatment regimen can also dramatically improve the outcome. By employing these multiple approaches in depression, it is not unreasonable to have the complete remission of symptoms as a treatment goal.

Despite remarkable therapeutic progress, there are still no cures. We are beginning to understand certain factors that make psychotherapy effective (e.g., correction of cognitive distortions), but more progress is required. Our medications are not universally effective and also cause side effects. Currently, we lack reliable methods for predicting who will respond to a particular medication and who will develop side effects. Moreover, certain medications (e.g., lithium and clozapine) require frequent monitoring to prevent serious adverse reactions.

Finally, the treatment of children with mental disorders is particularly challenging. Our knowledge base is less well developed than for adults, as are our methods for intervening with families, schools, and social welfare systems. In addition, the legal and ethical considerations in the treatment of children can be quite perplexing so that it is often difficult to know what is in the best interest of the child.

Psychotherapist Reactions to Termination

In 1992, Stephen Quintana and William Holahan extended Marx and Gelso's (1987) research to therapists by asking 85 psychotherapists what termination activities they engaged in and having them rate their clients' reactions to termination. Each psychotherapist was asked to choose two recent short-term psychotherapy cases—a case where the psychotherapy outcome was successful and a case where the psychotherapy outcome was unsuccessful. Like Marx and Gelso, Quintana and Holahan found that clients' reactions (as rated by their psychotherapists) to psychotherapy termination were significantly more positive than negative. Not surprisingly, in unsuccessful cases, clients were significantly more likely to devalue psychotherapy. The ranking of termination activities by psychotherapists corresponded closely to client rankings of activities in the Marx and Gelso study. In successful cases, however, psychotherapists were more likely to discuss the course of counseling, client affective reactions to termination, and the end of counseling than in unsuccessful cases. This research suggested that psychotherapists did a more complete job of discussing termination issues with clients from successful psychotherapy cases than with those from unsuccessful cases.

In 1993, Susan Boyer and Mary Ann Hoffman tested the hypothesis that psychotherapists' reactions to termination would be affected by the impact of previous losses in their lives and their perceptions of clients' sensitivity to loss. They asked 165 licensed psychologists each to think of a client that they had seen for a minimum of 25 sessions. Psychotherapists rated how sensitive they perceived these clients were to loss. Psychotherapists also answered questions about their own grief reactions to past and present losses as well as questions about their perceptions and feelings surrounding termination with the clients. They found that psychotherapists' past grief reactions, present grief reactions, and perceived client loss positively predicted psychotherapists' anxiety surrounding termination. Psychotherapists' loss and perceived client loss, however, were unrelated to psychotherapists' feelings of satisfaction with termination.

Malan's model of individual psychotherapy

David Malan's work over many years evaluating treatment at the Tavistock Clinic in London led to the development of a brief focal psychotherapy model which adhered more closely to the psychoanalytic model than any of the others described in this chapter (Malan 1979). In his studies of brief psychotherapy models he found that interpretations by the therapist of a patient's hidden feelings in the context of the transference relationship with the therapist produced the best outcome. He illustrated this as two related triangles. First is ‘the triangle of conflict’ in which the three vertices are: (1) ‘hidden’ (unconscious) impulse which causes the person to feel, (2) anxiety which is relieved by (3) defences which keep the impulse out of awareness. Second is the ‘triangle of person’ in which a patient's feelings about (1)the parent (‘p’) are reflected in their views of (2) third parties (the other – ‘o’) and their views of (3) the therapist (‘T’) in the transference. The therapist uses these triangular relationship models to become aware of defended hidden painful feelings, bring them to the patient's attention and interpret their meaning to the patient in the context of their relationship with their parent and the therapeutic relationship – ‘the T/P link’ above. Malan's book gives a very lively account of the use of this model with many clinical examples (Malan 1979) – see also Ashurst in Holmes (1991) for a more detailed description of this and several other brief psychotherapy models, and their use in an NHS psychotherapy department.

Nonmedication-based approaches in children and adolescents

A healthy lifestyle and regular waking and sleep routine are strongly recommended for children and adolescents suffering from narcolepsy. It is important to ensure that late afternoon naps (after school) do not interfere with nighttime sleep periods.

Although no studies demonstrating their effectiveness are available, measures aimed at enabling one or more daytime sleep periods are generally recommended. One to two routine naps of 20–30 minutes increase daytime wakefulness and psychomotor performances. Nutritional advice, regular meal times, and physical activity should also be encouraged at an early stage in children and adolescents, in order to avoid weight gain and to help maintain regular growth.

Brief psychotherapy is often required to enable the child to accept the loss of their previous healthy state and progressively accept the reality of a disabling chronic condition.

Associations of patients also play a vital role, allowing young patients to exchange information and advice on managing their disease, interacting with their peers, frequently in the form of group meetings, internet forums, or meetings at holiday camps.

For those children who will receive pharmacotherapy from a very young age, but also in adolescence, training and education are crucial to enhance the benefit of the treatment. Having to be treated on a daily basis represents a challenge for many youngsters, who are sometimes reluctant to take medication every day. Most medications are prescribed during the daytime period and given during the main meals. However, recent treatments such as sodium oxybate, although not yet approved for children and adolescents, are given at bedtime and 4 hours after sleep onset, requiring specific and operant strategies from the child as well as efficient supervision from the parents.

III.A.1. Variations on the Analytical Theme

The prototypic embodiment of the psychoanalytic or psychodynamic theme is, of course, classical psychoanalysis. The variations on the dynamic theme reflect overt and covert modifications of theoretical conceptualizations as well as methodological and technical applications in practice. These include attempts to partially or completely transcend the biological focus of Freud with more interpersonal, social, ethical, and cultural considerations (e.g., Alfred Adler, Karen Horney, Harry Stack Sullivan, Erich Fromm, Frieda Fromm-Reich-mann, and Alfred Meyer); to extend or enhance the ego with earlier or more adaptive endowments (e.g., Federn and Melanie Klein); to enlarge man's temporality with a time focus on his primordial past (e.g., Jung), his present and/or his future (e.g., Adler, William Stekel, Otto Rank, and Rado); to expand treatment procedures by altering the range and goals of treatment (e.g., Otto Rank, Franz Alexander, Helena Deutsch, and Albert Karpman); to shift from ego to self psychology (e.g., Heinz Kohut), to narcissism as a character disorder (e.g., Otto Kernberg) to develop guidelines for short-term psychotherapy with anxiety-provoking techniques (e.g., Peter Sifneos), and even brief treatment of serious illness within the context of a single interview (e.g., David Malan); to revise the role of the therapist's personality and relationship to the patient by making the therapist a more direct, flexible, and/or active participant (e.g., Adler, Sullivan, Rank, Alexander, Stekel, Sandor Ferenczi, and Victor Rosen); to emphasize the developmental approach to diagnosis and treatment (e.g., T. Byram Karasu, James Masterson) at perhaps the opposing end of the analytic spectrum, to restore the psychophysical balance of man by focusing equally on the physical half of the psychophysical split (e.g., Sandor Rado and Jules Masserman) and/or substituting an approach to therapeutic cure from the somatic side by trading the traditional change mode of insight for a reversal back to the earlier catharsis by means of the bodily release of conflictual tensions (e.g., Wilhelm Reich).

The fundamental goals of the interpersonal approach relate to the need to maintain good interpersonal relations and social adaptability; they include reconstruction of present maladaptive relationships and, where possible, restoration of past losses. This means both coping with immediate stressful interactions and forming better or new relationships by developing problem-solving strategies and mastery in social skills. In 1984 Gerald Klerman and Myrna Weissman formulated a short-term, manualized form of interpersonal therapy (IPT), specifically applicable, but not limited to, depression.

In practice, a seasoned dynamic therapist is more broadly defined. This refers to the integration of drive, ego, object relations, and self approaches, and to the more global synthesis of conflict and deficit models. This integrative model of psychotherapeutic practice acknowledges the joint impact on psychic structure formation of unresolved conflictual urges and wishes interfaced with early environmental deficiencies and traumas in the real-object world of the patient. In terms of treatment, it recognizes the pivotal roles of both erotic and narcissistic transferences in the therapist–patient relationship and in the respective stances and strategies of the listening and empathic presence.

Davanloo's View of Transference Neurosis

A unique and important view on transference neurosis has been observed and developed in the last few decades. Habib Davanloo, though not a psychoanalyst, had training in psychoanalysis earlier in his career. In the 1950–1970s, he became well known as one of the pioneers in the field of brief dynamic psychotherapies. Along with David Malan, Peter Sifneos and James Mann, he developed his own model of brief psychotherapy. Disillusioned with the increasingly protracted course of psychoanalyses and like Freud, troubled by interminable analyses, he developed a model for psychotherapy that dramatically shortened the course of treatment compared to traditional psychoanalysis, without sacrificing the goals of neurotic symptom resolution and structural characterological change. Though a full elucidation of his metapsychological theory and his technique go beyond the scope of this discussion, a brief synopsis would be useful to understand his approach to transference neurosis. Specifically, Davanloo developed a targeted therapy that was focused on the twin factors of transference feelings and resistance. He called his therapy “Intensive Short-term Dynamic Psychotherapy” or IS-TDP. Davanloo chose not to be passive in the therapeutic relationship; rather he systematically developed an active method (called the central dynamic sequence) which was intended to maximize the patient's resistance. Once the resistance reached a critical threshold, and the patient was successfully turned against the resistance, Davanloo theorized the resistance was overcome by the unconscious therapeutic alliance that developed between patient and therapist. At this point, the patient experienced powerful unconscious feelings in the transference, which were then clearly seen to be linked to important past figures. This experience of powerful unconscious feelings entering the conscious realm is referred to as an “unlocking of the unconscious.” Davanloo's theories and techniques have been the subject of widespread acclaim and critique over the past several decades.

Unlike Freud and some of the contemporary analysts cited above, Davanloo takes an uncompromising position on the transference neurosis. He believes it to be a completely morbid force which is to be avoided at all costs. Metapsychologically, Davanloo believes that a transference neurosis is a neurosis transferred from one person to another. While it can be a manifestation of the patient transferring unconscious relationships, feelings and conflicts onto the therapist, it can also involve psychopathology and unconscious conflicts in the therapist being transferred on to the patient. That is, the patient's unconscious becomes “invaded” as it were, by the unconscious of the therapist. Rather than seeing a transference neurosis as a developmentally appropriate and necessary stage of treatment, Davanloo sees it as a treatment failure. Davanloo believes that the transference neurosis results in a patient's original neurosis being obscured in the unconscious. In addition, he noted that this process can take place between any two people in a close intimate relationship. In that sense, the transfer of neurosis can occur in a marital relationship, intergenerational parent (or grandparent) child relationship or even in professional relationships. Though some may argue that this is not what psychoanalysis means by transference neurosis, Davanloo has shown that this transferred neurosis, like the transference neurosis in psychotherapy has the same morbid effects on the patient's defensive structure and character.

Davanloo's recent work has centered on a closed circuit training program in Montreal which has been in operation since 2007. Many professional therapists have been involved and all sessions are audio-visually recorded and analyzed. Much of this work has focused on understanding whether or not a transference neurosis is in operation in the unconscious, and if so, what can be done to remove it (if possible). Readers who are interested in pursuing these ideas are encouraged to explore the references for more comprehensive publications on this subject.

Psychiatric disorders arising in pregnancy

Any psychiatric illness may have its onset during pregnancy. The relatively low incidence of severe psychotic illnesses such as schizophrenia and bipolar disorder means that they rarely arise de novo during pregnancy. These disorders are dealt with later in this chapter. The widely held belief that pregnancy is protective against psychotic illness is not supported by the literature. Pregnancy is, however, protective against suicide, studies suggesting reductions in suicide rates of between 65% and 95% (Marzuk et al 1997, Appleby 1991). Certain psychiatric disorders may come to attention more frequently during pregnancy than at other times, either as a consequence of increased healthcare contact or because of an aetiological link with the pregnant state. Some of these are considered below.