CHAPTER 15: THERAPY
Jacquelyn Eisen and Maya Strauss
HISTORY OF TREATMENT
Bleeding
 Drilling Holes in Head
 Administering Electric Shocks


A trained therapist uses psychological techniques
to assist someone seeking to overcome difficulties
achieve personal growth.
DORTHEA DIX

“I…call your attention to the state of the insane
persons confined within the common weath, in
cages”
MENTAL HEALTH HOSPITALS EMPTYING
Introduction of therapeutic drugs
 Community based treatment programs.

THERAPY

Pyschotherapy Integration: Attempts to
combine a selection of assorted techniques into a
single, coherent system
THERAPY

Eclectic Approach: an approach to
psychotherapy that, depending on the client’s
problems, uses techniques from various forms of
therapy
THERAPY
Psychotherapy: treatment involving
psychological techniques; consists of interactions
between a trained therapist and someone seeking
to overcome psychological difficulties or achieve
personal growth.
 4 Major Theories:

Psychoanalytic
 Humanistic
 Behavioral
 Cognitive

THERAPY- PSYCHOANALYSIS

Psychoanalysis
Freud believed the patient’s free associations, resistances,
dreams, and transferences – and the therapist’s
interpretations of them – released previously repressed
feelings, allowing the patient to gain self-insight
 use has rapidly decreased in recent years

Neo-Freudians: psychologists today who use psychoanalysis
FREUD & PSYCHOANALYSIS
Hypnosis is unreliable
 Goal: unearth the past in hope of unmasking the present

THERAPY- PSYCHOANALYSIS
Free Association: say whatever comes to mind
 Interpretation: the analyst’s noting supposed dream
meanings, resistances, and other significant behaviors
in order to promote insight
 Transference: the patient’s transfer to the analyst of
emotions linked with other relationships


love or hatred for a parent
THERAPY - PSYCHOANALYSIS
Resistance: blocking from consciousness of
anxiety-laden material
 Latent Content: Underlying but censored,
meaning of a dream.

THERAPY - PSYCHOANALYSIS
Goal of dream analysis: determine the meaning of dreams
 Criticism: interpretations cannot be proven or disproven



Rebuttal: It helps the patients.
Costly: 3 times a week at $100 an hour

More costly than psychodynamic because there is more sessions
THERAPY

Psychodynamic theory: Drives from psychoanalysis,
views individuals as responding to unconscious forces
and childhood experiences. Seeks to enhance self insight.
THERAPY

Interpersonal Psychotherapy: A brief
variation of psychodynamic therapy, has been
effective in healing depression.

Helps people gain insight into roots of their
difficulties.
HUMANISTIC THERAPY
Aim is to boost self-fulfillment.
 Similarity between this and psychodynamic:


Attempt to reduce inner conflicts by providing new insight
HUMANISTIC VS. PSYCHOANALYSIS THERAPISTS
Present and future vs. past
 Conscious vs. unconscious
 Responsibility vs. hidden determinants
 Promote growth vs. cure illness

HUMANISTIC THERAPY

Insight Therapies: Aim to improve
psychological functioning by increasing client’s
awareness of underlying motives and defenses.
HUMANISTIC THERAPY

Client-Centered Therapy
humanistic therapy developed by Carl Rogers
 therapist uses techniques such as active listening
within a genuine, accepting, empathic environment
to facilitate clients’ growth
 GAE (genuine, accepting, empathy)

NON-DIRECTIVE THERAPY VS. PSYCHOTHERAPY

Feedback (insight)
CARL ROGERS
“Thank god, somebody heard me. Somebody knows
what it is like to be me.”
 Goal: accept and understand the client
 3 Hints that Rogers gives for us to actively listen more:

Paraphrase
 Invite clarification
 Reflect feeling

HUMANISTIC THERAPY

Active Listening: empathic listening in which the
listener echoes, restates, and clarifies


ERSC (England rugby supporters club)
Unconditional Positive Regard: Caring, accepting,
non-judgmental attitude, Rogers believed to be conducive
to developing self-awareness and self acceptance.
BEHAVIOR THERAPY
Behavior Therapy: therapy that applies learning
principles to the elimination of unwanted behaviors
 Counter conditioning: uses classical conditioning to
evoke new responses to stimuli that trigger unwanted
behaviors

MARY COVER JONES
Systematic Desensitization
 Peter is afraid of rabbits
 Caged rabbit when he eats  closer each day
 2 months later, Peter has a rabbit in his lap
while eating
 Didn’t get credit because she’s a woman

BEHAVIOR THERAPY: MALADAPTIVE BEHAVIORS

Treating phobias and sexual disorders

Learned behaviors replaced by constructive behaviors
MOWRER

Conditioning: Don’t wet the bed

Wet the bed  Alarm
¾ of the time it was effective
 Boosts self image

BEHAVIOR THERAPY


Exposure Therapy: treat anxieties by exposing people (in
imagination or reality) to the things they fear and avoid
EX:
BEHAVIOR THERAPY

Systematic Desensitization
type of counter conditioning
 associates a pleasant, relaxed state with gradually
increasing anxiety-triggering stimuli
 commonly used to treat phobias

BEHAVIOR THERAPY

Progressive relaxation: relax one muscle
group after another until completely relaxed
BEHAVIOR THERAPY

Virtual Reality Exposure Therapy:
Progressively exposes people to simulations of
their greatest fear (ex: spiders, flying, speaking)

It feels like it’s real so it gives a greater relief from
fears.
BEHAVIOR THERAPY

Aversive Conditioning
type of counter-conditioning that associates an
unpleasant state with an unwanted behavior
 Nausea pill in alcohol  don’t want alcohol anymore
 Short term solution

MENUSTIK (1983)

Drinking Aversion & Cognitive Influence
 At
a bar versus the therapist’s office, they know that they can
drink without the fear of nausea
BEHAVIOR THERAPY

Behavior Modification: Reinforcing desired
behaviors and withholding reinforcement for
undesired behaviors or punishing them
REAL LIFE POSITIVE REINFORCEMENT
In school, children behave more rationally
 Intellectual disability kids can care for
themselves
 Kids with autism can learn to interact

LOVAAS (1987)
Uncommunicative autistic toddlers need intense
treatment
 Many improve

BEHAVIOR THERAPY

Token Economy


an operant conditioning procedure that rewards desired
behavior
patient exchanges a token of some sort, earned for
exhibiting the desired behavior, for various privileges or
treats
BEHAVIOR THERAPY

Token Economy Criticisms:
How durable is the behavior?
 Is it right to control others behaviors?


We should:

Shift patients towards other rewards
COGNITIVE THERAPY

Cognitive Therapy
teaches people new, more adaptive ways of thinking and
acting
 based on the assumption that thoughts intervene between
events and our emotional reactions
 Teach more constructive ways of thinking

AARON BECK
Originally trained in Freudian techniques
 Now is a cognitive therapist
 Reverse clients creating bad beliefs about
themselves

MEICHENBAUM
Stress inoculation training
 Teaches people to reconstruct their thinking in
stressful situations
 Advice to someone that studies hard, but is
extremely negative prior to testing:


Relax
SELIGMAN (2002)

After being trained to dispute their negative
thoughts, depression-prone children and college
students exhibit a halved rate of future
depression
COGNITIVE THERAPY

Cognitive Behavior Therapy: popular
integrated therapy that combines cognitive and
behavior therapies

Changing self defeating thinking and behavior
SCHWARTZ (1996)
OCD people re-labled their compulsive thoughts
 Have an urge versus actually doing it

COGNITIVE THERAPY

The Cognitive
Revolution
COGNITIVE THERAPY

A cognitive
perspective on
psychological
disorders
COGNITIVE THERAPY

Cognitive
therapy for
depression
COGNITIVE THERAPY

Cognitive-Behavioral Therapy:

a popular integrated therapy that combines cognitive
therapy (changing self-defeating thinking) with behavior
therapy (changing behavior)
GROUP AND FAMILY THERAPIES

Benefits



Price (more than one person)
Find others with similar problems
Get feedback as they try things out
GROUP AND FAMILY THERAPIES

Family Therapy: treats the family as a system,
views an individual’s unwanted behaviors as
influenced by or directed at other family members
GROUP AND FAMILY THERAPIES

Goals:
 Heal
relationships
 Mobilize

family resources
Success:
 Helps
families cope with disorders
GROUP AND FAMILY THERAPIES

Support Groups
Anorexia
 AIDS
 Illness
 Hearing loss


No Support Groups
Ulcers
 Migraine
 Hypertension
 Vision loss

GROUP AND FAMILY THERAPIES

AA
114,000 groups
 2 million+ members
 Effectiveness:

Project Match
 Moos + Moos

GROUP AND FAMILY THERAPIES

Characteristics of a 12 Step Program
Members admit powerlessness
 Seek help
 Take the message to others

GROUP AND FAMILY THERAPIES

Support groups reflect:
Longing for community
 Connectedness

REMEMBER:
INCREASE 1991 TO 2004
25% increase
 Justified placing hope in psychotherapy

CLIENT TESTIMONIALS TELL US…

We can affirm its effectiveness
PSYCHOTHERAPY CRTICISMS
Often enter therapy in crisis
 People may need to believe it’s worth it.
 Speak kindly of therapist.

JOAN MCCORD: 500 MA BOYS

Years later the kids say that without therapy
many of them would be in jail.

Clinician’s perspective could often be inflated
when judging whether the treatment was
effective because they treasure compliments.
EVALUATING PYSCHOTHERAPIES

Placebo effect: power of belief in a treatment.
EVALUATING PSYCHOTHERAPIES

Regression toward the mean

tendency for extremes of unusual scores to fall back
(regress) toward their average
EVALUATING PSYCHOTHERAPIES

Meta-analysis

procedure for statistically combining the results of
many different research studies
EVALUATING PSYCHOTHERAPY

Examples of Regression to the Mean:
Students who higher than usual on a test will be
closer to the average the second time
 ESP loses power second time
 Bad half and a normal second half (game)


Why someone would attribute a therapist for
their success when it isn’t:

Start out better then eventually go back to normal.
PHYSICIANS, BLEEDING, & TYPHOID FEVER

The control group improved on bed rest
HANS EYSENCK

Effectiveness of Psychotherapy:


2/3 receiving psychotherapy for non-psychotic
disorders improved remarkably
Problems:

His sample was small (only 24 studies of
psychotherapy outcomes in 1952)
EVALUATING PSYCHOTHERAPIES

Best way to study outcome research:

Randomized clinical trials

Randomly assign people on waiting list and later evaluate
everyone.
SMITH (1980)
Clients end up 80% better than those not treated
 5 Subsequent studies:


Those not undergoing therapy often improve, but
those undergoing therapy are more likely to improve.
PSYCHOTHERAPY IS COST EFFECTIVE
Search for other treatment drops
 Boosts well being
 Reduces long term cost

BEHAVIORAL PROBLEMS THAT BENEFITTED
FROM BEHAVIORAL CONDITIONING THERAPIES
Bed-wetting
 Phobias
 Marital Problems
 Compulsions
 Sexual Disorders

COGNITIVE THERAPY EFFECTIVENESS
Coping with Depression’
 Lowering suicide risk

I DON’T RECOMMEND..,
Energy Therapies
 Recovered-Memory Therapies
 Facilitated Communication
 Crisis Debriefing
 Rebirthing Therapies

DEFINING:

Evidence-Based Practice: clinical decision
making that integrates best available research
with clinical expertise and patient characteristics
and preferences.
EVALUATING PSYCHOTHERAPIES
EVALUATING PSYCHOTHERAPIES

To whom do
people turn for
help for
psychological
difficulties?
EVALUATING PSYCHOTHERAPIES
Number of
persons
Average
untreated
person
Poor outcome
80% of untreated people have poorer
outcomes than average treated person
Average
psychotherapy
client
Good outcome
EVALUATING PSYCHOTHERAPIES
EVALUATING ALTERNATIVE THERAPIES
EMDR (Eye movement desensitization and
reprocessing): therapy illustrating the
differences between scientific and pseudo
scientific therapy techniques
 Francine Shapiro – walking in a park and
observing anxious thoughts vanish as her eyes
spontaneously darted about.

FRANCINE SHAPIRO & EMDR
Tested 22 people by moving finger in front of
eyes: reductions in stress after one session
 Amount Trained:



Countries that use it:


70,000
70
Credibility:
Chambless
 Bisson & Andrews

EMDR SKEPTICS

Eye movement is not therapeutic
EVALUATING ALTERNATIVE THERAPIES

Seasonal Affective Disorder: Winter time
depression



Oversleeping
Gaining weight
Light Therapy Works:
90 minutes of light vs. none – those with light were
more improved
 30 minutes of exposure is relief
 Morning light works best

COMMONALITIES AMONG PSYCHOTHERAPIES

Hope for demoralized people

Participant’s beliefs may function as a placebo
New perspectives
 Empathetic, trusting, caring relationship
 New attitude  open to making changes

THERAPISTS

effective therapists are empathic people who seek to
understand another’s experience; who communicate their
care and concern to the client; and who earn the client’s
trust and respect through respectful listening, reassurance,
and advice.
COGNITIVE, PSYCHODYNAMIC, INTERPERSONAL

The empathic therapists of both persuasions
would help clients
evaluate themselves
 link one aspect of their life with another
 gain insight into their interactions with others.

THERAPISTS

Therapeutic Alliance: emotional bond between
therapists and their client
THERAPISTS

Paraprofessional Attribute:


New perspective offered by a caring person
People that need/seek therapy:
Feel supported by close relationships
 Enjoy friendship


Therapists attempt to enhance:

Sensitivity, openness, personal responsibility, and
sense of purpose
THERAPIES AND MINORITIES
Immigrant problems: different kind of culture
 Problems from a minority viewpoint: reluctant to
use mental health services
 Asian American viewed therapists from a
collectivist background as more empathetic and
had a stronger alliance.

If religious, find
a therapist with a
similar religion as
you.
Albert Ellis
Rational-emotional therapy
 Nothing is supreme (vs. Bergin who thought God
is supreme and everything else is virtue)
 Most important: psychotherapists personal
beliefs influence their practice

THERAPISTS AND THEIR TRAINING

Clinical psychologists
Most are psychologists with a Ph.D. and expertise in
research, assessment, and therapy, supplemented by a
supervised internship
 About half work in agencies and institutions, half in
private practice

THERAPISTS AND THEIR TRAINING

Clinical or Psychiatric Social Worker
A two-year Master of Social Work graduate program plus
postgraduate supervision prepares some social workers to
offer psychotherapy, mostly to people with everyday
personal and family problems
 About half have earned the National Association of Social
Workers’ designation of clinical social worker

THERAPISTS AND THEIR TRAINING

Counselors
Marriage and family counselors specialize in problems
arising from family relations
 Pastoral counselors provide counseling to countless people
 Abuse counselors work with substance abusers and with
spouse and child abusers and their victims

THERAPISTS AND THEIR TRAINING

Psychiatrists
Physicians who specialize in the treatment of psychological
disorders
 Not all psychiatrists have had extensive training in
psychotherapy, but as M.D.s they can prescribe
medications. Thus, they tend to see those with the most
serious problems
 Many have a private practice

BIOMEDICAL THERAPIES

Biomedical therapy: prescribed medications or
medical procedures that act directly on the
patient’s nervous system.
*only psychiatrists can offer
COMPARISONS

Psychotherapy is to psychological disorders as
biomedical therapy is to serious disorders.
BIOMEDICAL THERAPIES
Psychopharmacology: study of the effects of drugs
on mind and behavior
 Lithium: chemical that provides an effective drug
therapy for the mood swings of bipolar (manicdepressive) disorders (salt)

BIOMEDICAL THERAPIES

The emptying of U.S. mental hospitals
BIOMEDICAL THERAPIES

Enthusiasm diminishes after any new
treatment…
Normal recovery among untreated patients
 Recovery due to placebo

BIOMEDICAL THERAPIES

Double-Blind Procedure is used to establish the
legitimacy of the drug. (No bias at all)
BIOMEDICAL THERAPIES

Psychoses: disorders in which hallucinations or
delusions indicate some loss of contact with
reality

Drugs that calmed people from this were found
accidentally.
BIOMEDICAL THERAPIES
DRUG THERAPIES

Antipsychotic drugs: drugs used to treat schizophrenia
and other forms of severe thought disorder.
Chlorpromazine (Thorazine) – dampens responsiveness to
irrelevant stimuli
 Mimics dopamine – occupies receptor sites and blocks activity


Reinforces that too much dopamine  schizophrenia
BIOMEDICAL THERAPIES
DRUG THERAPIES

Tardive Dyskinesia: involuntary movements of
the facial muscles, tongue, and limbs; a possible
neurotoxic side effect of long-term use of
antipsychotic drugs that target certain dopamine
receptors.

Dopamine and serotonin receptors for negative
symptoms
DRUG THERAPIES

Antipsychotic drug side effects:


Increase risk of obesity and diabetes
Positive Gain:

Able to return to work and have near normal lives
DRUG THERAPIES

Anti-anxiety Drugs: drugs used to control
anxiety and agitation.
DRUG THERAPIES

Anti-depressant Drugs: drugs used to treat
depression; also increasingly prescribed for
anxiety. Different types work by altering the
availability of various neurotransmitters.
DRUG THERAPIES

Anti-anxiety:
Depress CNS activity
 Xanax


Psychological dependence, physiological
dependence, withdrawal, insomnia, anxiety
DRUG THERAPIES

Anti-depressants are standard drug treatment
for anxiety disorders. Works on OCD.
DRUG THERAPIES
Neurotransmitters serotonin and nonepinephrine by
upping availability
 Prozac partially blocks reuptake of serotonin.

DRUG THERAPIES
SSRI (Selective serotonin reuptake inhibitor):
Prozac, Zoloft, Paxil
 Most effective way to administer is by patch.
 1987  2001, 70%  89% with SSRIs

BARBER (2008)
11% women taking anti-depressants
 5% men taking anti-depressants

DRUG THERAPIES
4 weeks to work
 Diminishes sexual desire
 Delay because up serotonin = neurogenesis (new brain
cells), reducing stress including loss of neurons

DRUG THERAPIES

Without drugs:
Cognitive therapy
 Exercise


To hit it from above and below use both:
Cognitive Therapy
 Anti-Depressants

DRUG THERAPIES

Only the most severely depressed patients should
take these meds.
DRUG THERAPIES
There is no link between adolescent SSRI
prescriptions and suicide.
 Less suicides when treated with meds (long run)

BIOMEDICAL THERAPIES
Electroconvulsive Therapy (ECT): therapy for
severely depressed patients in which a brief electric
current is sent through the brain of an anesthetized
patient
 Introduced 1938
 Originally 100 volts

BIOMEDICAL THERAPIES: ECT
Under anesthetic for 30 to 60 seconds of electric
current.
 Patients don’t remember it.
 Works for 4 out of 5 people
 Doesn’t cause brain damage.

BIOMEDICAL THERAPIES: ECT

It works because it calms the nerves that cause
depression.
BIOMEDICAL THERAPIES

Repetitive Transcranial Magnetic Stimulation
(rTMS): the application of repeated pulses of magnetic
energy to the brain; used to stimulate or suppress brain
activity
BIOMEDICAL THERAPIES

rTMS vs ECT: no seizures or memory loss
KLEIN (1999)

67 Israelis with major depression:
50% stimulated patients improved
 25% placebo patients improved

KLEIN (1999)

Worked because the stimulation energized depressed
patient’s relatively inactive left frontal lobe.
MAYBERG

8 out of 12 people implanted with electrodes and
pacemaker stimulator experienced relief
BIOMEDICAL THERAPIES

Psychosurgery: surgery that removes or
destroys brain tissue in an effort to change
behavior

Not used often because its irreversible
BIOMEDICAL THERAPIES

Lobotomy: now-rare psychosurgical procedure once
used to calm uncontrollably emotional or violent
patients
BIOMEDICAL THERAPIES
Rosemary Kennedy had lobotomy done
 Moniz won the Nobel prize
 Abandoned in 1950: calming drugs available

BIOMEDICAL THERAPIES
Benefits: short and cheap
 Bad Characteristics: produced lethargic,
immature, uncreative person

THERAPEUTIC LIFESTYLE CHANGES
Brains/Bodies designed for physical activity and
social engagement
 Mind and Body

AMISH & DEPRESSION BEING OBSOLETE
1.
2.
3.
4.
Strong Community Ties
Sunlight Exposure
Tons of Sleep
Strenuous Physical Activity
ILARDI TEAM & REDUCING DEPRESSION
Aerobic Exercise
 Adequate sleep
 Light exposure
 Social Connection
 Nutritional Supplement

ALBEE (1986)

Increase the risk of doing more than necessary
“IT IS BETTER TO PREVENT THAN TO CURE”

Help those who haven’t had a chance

Get a vaccine instead of a cure