Chapter 15 Therapy Josef F. Steufer/Getty Images Chapter Overview • Introduction to Therapy and the Psychological Therapies • The Biomedical Therapies and Preventing Psychological Disorders Introduction to Therapy and the Psychological Therapies • Over the ages, a mix of treatments and methods have been attempted to treat people with psychological disorders • Treatments have ranged from harsh to gentle • Reformers Philippe Pinel (1745–1826) and Dorothea Dix (1802–1887) pushed for: – Gentler and more humane treatments – Construction of mental hospitals • Since the 1950s, drug therapies and community-based treatment programs have replaced most of the hospitals THE HISTORY OF TREATMENT Visitors to eighteenth-century mental hospitals paid to gawk at patients, as though they were viewing zoo animals. William Hogarth’s (1697–1764) painting captured one of these visits to London’s St. Mary of Bethlehem hospital (commonly called Bedlam). Treating Psychological Disorders 15-1: HOW DO PSYCHOTHERAPY AND THE BIOMEDICAL THERAPIES DIFFER? • Psychotherapy – A trained therapist uses psychological techniques to assist someone seeking to overcome difficulties or achieve personal growth. • Biomedical therapy – Offers medications and other biological treatments; prescribed medications or procedures that act directly on the person’s physiology. • Eclectic approach – Approach to psychotherapy that uses techniques from various forms of therapy. Psychoanalysis and Psychodynamic Therapies 15-2: WHAT ARE THE GOALS AND TECHNIQUES OF PSYCHOANALYSIS, AND HOW HAVE THEY BEEN ADAPTED IN PSYCHODYNAMIC THERAPY? • First major psychological therapy was developed by Sigmund Freud. • Psychoanalysis: Freud’s therapeutic technique. 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. • It helped form the foundation for treating psychological disorders, and it continues to influence modern therapists working from the psychodynamic perspective. Psychoanalysis and Psychodynamic Therapies The Goals of Psychoanalysis – To help patients release energy devoted to id-egosuperego conflicts – To bring patients’ repressed feelings into conscious awareness – To give patients insight into origins of their problems – If successful, patients may then achieve healthier, less anxious lives Introduction to Therapy and the Psychological Therapies Psychoanalysis and Psychodynamic Therapies The Techniques of Psychoanalysis – Historical reconstruction of childhood experiences influencing adulthood; initially through hypnosis and later through free association. – Resistance: The blocking from consciousness of anxiety-laden material. – Interpretation: Analyst providing meanings to thoughts, dreams, resistances, and other significant behaviors and events in order to promote insight. – Transference: Occurs when the patient transfers to the analyst emotions linked with other relationships (such as love or hatred for a parent). Psychoanalysis and Psychodynamic Therapies Psychodynamic Therapy • Psychodynamic therapy: Therapy deriving from the psychoanalytic tradition; views individuals as responding to unconscious forces and childhood experiences, and seeks to enhance self-insight. • Influenced by Freud’s ideas, but focus on how to help people understand their current symptoms by focusing on themes across important relationships, including childhood experiences and the therapist relationship. • Goal: Help people explore and gain perspective on defended-against thoughts and feelings. • Technique: Client-centered face-to-face meetings. Psychoanalysis and Psychodynamic Therapies Psychodynamic Therapy FACE-TO-FACE THERAPY In this type of therapy session, the couch has disappeared. But the influence of psychoanalytic theory may not have, especially if the therapist seeks information from the patient’s childhood and helps the patient reclaim unconscious feelings. Humanistic Therapies 15-3: WHAT ARE THE BASIC THEMES OF HUMANISTIC THERAPY? WHAT ARE THE SPECIFIC GOALS AND TECHNIQUES OF ROGER’S CLIENTCENTERED APPROACH? – Theme: Emphasis on people’s potential for selffulfillment. – Goals: To reduce inner conflicts that interfere with natural development and growth; help clients grow in self-awareness and self-acceptance promoting personal growth. – Given that humanistic therapies aim to give clients new insights, as is the case with psychodynamic therapies, both are often referred to as insight therapies. Humanistic Therapies How humanistic therapies differ from psychodynamic therapies: • Focus is to aid growth in self-awareness and selfacceptance, not cure illness. • The path to growth is taking responsibility for one’s feelings and actions, and on focusing on the present and future rather than the past. Rogers’ client-centered therapy: • Non-directive, person-centered therapy that focuses on person’s conscious self-perceptions. • Therapists foster growth by exhibiting genuineness, acceptance, and empathy. • Therapy involves active listening and unconditional positive regard. • Believed that most people possess resources for growth. Humanistic Therapies ACTIVE LISTENING Carl Rogers (right) empathized with a client during this group therapy session. Behavior Therapies 15-4: HOW DOES THE BASIC ASSUMPTION OF BEHAVIOR THERAPY DIFFER FROM THE ASSUMPTIONS OF PSYCHODYNAMIC AND HUMANISTIC THERAPIES? WHAT TECHNIQUES ARE USED IN EXPOSURE THERAPIES AND AVERSIVE CONDITIONING? • Behavior therapists (unlike those with an insight therapy approach) doubt the healing power of self-awareness, believing instead that problem behaviors are the problem • View learning principles as useful tools for eliminating problematic behaviors • Aim to replace problematic behaviors with constructive behaviors – Constructive behaviors may be learned through classical or operant conditioning Behavior Therapies Classical Conditioning Techniques • This cluster of behavior therapies derives from principles developed in Ivan Pavlov’s conditioning experiments. • We learn various behaviors and emotions through classical conditioning; maladaptive symptoms are similarly examples of conditioned responses. • As well, we can unlearn responses through new conditioning. Counterconditioning uses classical conditioning to evoke new responses to stimuli that are triggering unwanted behaviors; includes exposure therapies and aversive conditioning. Exposure Therapies • Treat anxieties by exposing people (in imagination or actual situations) to the things they fear and avoid; includes systematic desensitization and virtual reality exposure therapy. • Systematic desensitization: Associates a pleasant, relaxed state with gradually increasing, anxiety-triggering stimuli. Virtual Reality Exposure Therapy • Treats anxiety by progressive exposing people to creative electronic simulations of their greatest fears, such as airplane flying, spiders, or public speaking. Within the confines of a room, virtual reality technology exposes people to vivid simulations of feared stimuli, such as walking across a rickety bridge high off the ground. Behavior Therapies Classical Conditioning Techniques Aversive Conditioning – Aversive conditioning creates a negative (aversive) response to a harmful stimulus or unwanted behavior. – Goal: Transform a positive response to a harmful stimulus to a negative response; conditioning an aversion to something the person should avoid. – Technique: Unwanted behavior is associated with unpleasant feelings. – Ability to discriminate between aversive conditioning situation in therapy and all other situations can limit treatment effectiveness. – Often used in combination with other treatments. AVERSION THERAPY FOR ALCOHOL ABUSE Therapists gave people with a history of alcohol abuse a mixed drink containing alcohol and a drug that produces severe nausea. After repeated treatments, some people developed at least a temporary conditioned aversion to alcohol. (Classical conditioning terms: US is unconditioned stimulus, UR is unconditioned response, NS is neutral stimulus, CS is conditioned stimulus, and CR is conditioned response.) Behavior Therapies Operant Conditioning 15-5: WHAT IS THE MAIN PREMISE OF THERAPY BASED ON OPERANT CONDITIONING PRINCIPLES, AND WHAT ARE THE VIEWS OF ITS PROPONENTS AND CRITICS? Behavior modification techniques derive from B. F. Skinner’s operant conditioning principle that voluntary behaviors are influenced by their consequences. – Desired behavior reinforced – Positive reinforcement used to shape behavior – Undesired behavior not reinforced, sometimes punished – Behavior shaped using positive reinforcers – Behaviors rewarded that come closer to desired behavior – In institutional settings, therapists may create a token economy Behavior Therapies Operant Conditioning • There has been both criticism and support for behavior modification techniques. • Critics express two concerns: – Token economies may produce behavior changes that disappear when rewards end. – Controlling the behavior of others is authoritarian and unethical. • Proponents argue that treatment with positive rewards is more humane than punishing people or institutionalizing them for undesired behaviors. Cognitive Therapies 15-6: WHAT ARE THE GOALS AND TECHNIQUES OF COGNITIVE THERAPY AND OF COGNITIVEBEHAVIORAL THERAPY? • Behavior therapy is more appropriate for specific fears and behaviors than for a wide assortment of behaviors or wide-ranging anxiety. • Cognitive therapies – Teaches people new, more adaptive ways of thinking. – Assumes that thoughts intervene between events and our emotional reactions. – Anxiety-provoking thoughts are usually negative. – Cognitive therapy aims to change negative thoughts to perceiving them in a new and constructive way. A COGNITIVE PERSPECTIVE ON PSYCHOLOGICAL DISORDERS The person’s emotional reactions are produced not directly by the event but by the person’s thoughts in response to the event. Cognitive Therapies Beck’s Therapy for Depression – Aaron Beck (Beck et al., 1979): Changing people’s thinking can change their functioning. – Gentle questioning seeks to reveal irrational thinking. – Persuade people to change their perceptions (dark, negative, and pessimistic). – Catastrophizing: Relentless, overgeneralized, selfblaming behavior. – People trained to recognize and modify negative selftalk, and to restructure their thinking in stressful situations. – The benefits of positive self-talk are not restricted to depressed people; we all talk to ourselves and studies show the effectiveness of self-talk that is positive, not negative. Cognitive Therapies Cognitive Therapies Cognitive-Behavioral Therapy – Cognitive-behavioral therapy (CBT) is an integrative therapy that combines cognitive therapy (changing selfdefeating thinking) with behavior therapy (changing behavior). – Aims to alter the way clients act AND they way they think. – Helps people learn to replace their catastrophizing thinking with more realistic appraisals and to practice behaviors that are incompatible with their problem. • For example, those who fear social situations might learn to restrain the negative thoughts surrounding their social anxiety and practice approaching people. – A newer CBT variation, dialectical behavior therapy (DBT), helps change harmful, even suicidal, behavior patterns: • Aims to teach both acceptance and change. • Combines cognitive training with emotion regulation. Group and Family Therapies Group Therapy 15-7: WHAT ARE THE AIMS AND BENEFITS OF GROUP AND FAMILY THERAPIES? • Group therapy is conducted with groups rather than individuals: – Provides benefits from group interaction – Does not provide the same degree of therapist involvement with each client – Saves therapists’ time and clients’ money – Encourages exploration of social behaviors and social skill development – Enables people to see that others share their problems – Provides feedback as clients try out new ways of behaving Group and Family Therapies Family Therapy • Family therapy assumes that no person is an island: – Attempts to open up communication within the family, working with multiple family members to heal relationships and mobilize family resources – Help family members to discover and use conflict resolution strategies – 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 Family Therapy FAMILY THERAPY: This type of therapy often acts as a preventive mental health strategy. • The therapist helps family members understand how their ways of relating to one another create problems. • The treatment’s emphasis is not on changing the individuals, but on changing their relationships and interactions. Group and Family Therapies Self-Help Groups – More than 100 million Americans belong to small religious, interest, or support groups – Group members support each other emotionally – Often focus on stigmatized or hard-to-discuss illnesses – Alcoholics Anonymous (AA) a successful support group: • Uses a program emulated by many other self-help groups • Reports 2.1 million members in 115,000 groups worldwide • Found to be as effective as other treatment interventions – Self-help groups provide support for those living alone, feeling isolated, addicted, bereaved, divorced, or just those seeking fellowship and growth Evaluating Psychotherapies Is Psychotherapy Effective? 15-8: DOES PSYCHOTHERAPY WORK? HOW CAN WE KNOW? We can assess psychotherapy’s effectiveness by looking at client perceptions, clinician perceptions, and outcome research. Clients’ Perceptions • Client testimonials: Almost 90% report improvement after therapy • Critics note reasons for skepticism: – People often enter therapy in crisis – Clients believe that treatment will be effective – Clients generally speak kindly of their therapists – Clients want to believe the therapy was worth the effort Evaluating Psychotherapies Is Psychotherapy Effective? Clinicians’ Perceptions • Clients justify entering psychotherapy by emphasizing problems, and leaving by emphasizing well-being. • Therapists are most aware of failure of other therapists; the same client, finding only temporary relief, may be a “success” story in several therapists’ files. • Therapists, like the rest of us, are vulnerable to cognitive errors, such as confirmation bias and illusory correlation. Evaluating Psychotherapies Is Psychotherapy Effective? Outcome Research • Research indicates that two-thirds of those receiving treatment for disorders not involving hallucinations or delusions improved markedly. • However, research also indicates that those not undergoing treatment often improve. • Randomized clinical trials and meta-analyses provide the following conclusions: – Those undergoing psychotherapy are more likely to improve, and to improve more quickly. – Those undergoing psychotherapy also have a less chance of relapse. – Psychotherapy is cost-effective; when people seek psychological treatment, their search for other medical treatment drops. TREATMENT VERSUS NO TREATMENT Number of persons These two normal distribution curves based on data from 475 studies show the improvement of untreated people and psychotherapy clients. The outcome for the average therapy client surpassed the outcome for 80 percent of the untreated people. (Data from Smith et al., 1980.) Evaluating Psychotherapies Which Psychotherapies Work Best? 15-9: ARE SOME PSYCHOTHERAPIES MORE EFFECTIVE THAN OTHERS FOR SPECIFIC DISORDERS? Some forms of psychotherapy work best for particular problems: – Behavior therapies: Bed-wetting, phobias, compulsions, marital problems, and sexual dysfunctions – Psychodynamic therapy: Depression and anxiety – Cognitive and cognitive-behavioral therapies: Anxiety, depression, and posttraumatic stress disorder – Therapy is most effective when problems are clear-cut – Evidence-based practice: Integration of best available research with clinicians’ expertise and patients’ characteristics, preferences, and circumstances Evaluating Psychotherapies Which Psychotherapies Work Best? Evaluating Psychotherapies Evaluating Alternative Therapies 15-10: HOW DO ALTERNATIVE THERAPIES FARE UNDER SCIENTIFIC SCRUTINY? – Abnormal states often return to normal and the placebo effect can mislead effectiveness evaluation Eye Movement Desensitization and Reprocessing (EMDR) – Some effectiveness shown – Therapy comes not from the eye movement but rather from the exposure therapy nature of the treatments (plus some placebo effect) Light Exposure Therapy – Relief from depression symptoms for those with a seasonal pattern of major depressive disorder – Light therapy activates a brain region that influences the body’s arousal and hormones Evaluating Psychotherapies How Do Psychotherapies Help People? 15-11: WHAT THREE ELEMENTS ARE SHARED BY ALL FORMS OF PSYCHOTHERAPY? Three basic benefits for all psychotherapies: – Hope for demoralized people – New perspective for oneself and the world, leading to new behaviors – Empathic, trusting, caring relationship • Therapeutic alliance: A bond of trust and mutual understanding between a therapist and client, who work together constructively to overcome the client’s problem Evaluating Psychotherapies How Do Psychotherapies Help People? A CARING RELATIONSHIP Effective counselors, such as this chaplain aboard a ship, form a bond of trust with the people they are serving. Evaluating Psychotherapies Culture and Values in Psychotherapy 15-12: HOW DO CULTURE AND VALUES INFLUENCE THE THERAPIST-CLIENT RELATIONSHIP? • Psychotherapists’ beliefs and values influence their practice. • Differences in cultural values can create a mismatch between therapist and client. • Many North American and European therapists reflect their culture’s individualism: – Tend to prioritize personal desires and identity • Clients may be from collectivist cultures: – More mindful of others’ expectations • APA-accredited therapy-training programs provide training in cultural sensitivity. • Highly religious clients may prefer religiously similar therapists. Evaluating Psychotherapies Finding a Mental Health Professional 15-13: WHAT SHOULD A PERSON LOOK FOR WHEN SELECTING A THERAPIST? • A person seeking therapy is encouraged to ask about – Treatment approach – Values – Credentials – Fees • Perhaps the most important consideration in effective therapy is whether the potential client feels comfortable and able to establish a bond with the therapist. The Biomedical Therapies and Preventing Psychological Disorders • Biomedical therapy involves any of the following: – Changing the brain’s functioning by altering its chemistry with drugs – Affecting its circuitry with electrical stimulation, magnetic impulses, or psychosurgery – Influencing its responses with lifestyle changes • Drug therapies are the most widely used biomedical treatments. • Primary care providers provide most of the drugs for anxiety and depression, followed by psychiatrists (and psychologists in some U.S. states). Drug Therapies 15-14: WHAT ARE THE DRUG THERAPIES? HOW DO DOUBLE-BLIND STUDIES HELP RESEARCHERS EVALUATE A DRUG’S EFFECTIVENESS? • Psychopharmacology – Study of drug effects on mind and behavior. – Its discoveries have helped make drug therapy the most widely used biomedical therapy and emptied mental hospitals. • New drug treatments often treated with enthusiasm that diminishes after considering rates of normal recovery among untreated persons and recovery due to the placebo effect. • Double-blind procedures are used to evaluate drug effectiveness. Drug Therapies Antipsychotic Drugs • Antipsychotic drugs Drugs used to treat schizophrenia and other forms of severe thought disorder. – Mimic certain neurotransmitters (e.g., blocking activity of dopamine). – Reduce overreaction to irrelevant stimuli. – First-generation antipsychotic drugs such as Thorazine may produce sluggishness, tremors, twitches, and tardive dyskinesia. – Newer-generation antipsychotics have fewer side effects. – Successfully used with life-skills programs and family support to treat schizophrenia, allowing many patients to leave hospitals. Drug Therapies Antianxiety Drugs • Antianxiety drugs: Drugs used to control anxiety and agitation. – Depress CNS activity, so should not be used in combination with alcohol; Xanax or Ativan are examples. – Often successfully used in combination with psychotherapy. – May reduce symptoms without resolving underlying problems. – Upon stopping, regular users may have increased anxiety, insomnia, and other withdrawal symptoms. • Anxiety is increasingly treated not by antianxiety drugs, but by antidepressants. Drug Therapies Antidepressant Drugs • Antidepressant drugs: Drugs used to treat depression, anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder. (Several widely used antidepressant drugs are selective serotonin reuptake inhibitors—SSRIs.) – Many increase availability of norepinephrine or serotonin, which elevate arousal and mood. – Increased serotonin promotes neurogenesis, the birth of new brain cells. – Effectiveness sometimes questioned due to spontaneous recovery and placebo effect, especially for those with milder symptoms. Drug Therapies Mood-Stabilizing Medications • Mood-stabilizing drugs: – Depakote: Originally used to treat epilepsy, but found useful for controlling manic episodes – Lithium: Simple salt that levels out the emotional highs and lows of bipolar disorder • Reduces risk of suicide for those with bipolar disorder • Lower crime rates reported as well • Although we do not fully understand why, lithium works. Brain Stimulation Electroconvulsive Therapy 15-15: HOW ARE BRAIN STIMULATION AND PSYCHOSURGERY USED IN TREATING SPECIFIC DISORDERS? • Electroconvulsive therapy (ECT): Manipulates brain by shocking it; used for severely depressed patients. • Despite the name, it involves the administration of general anesthetic and a muscle relaxant that prevents convulsions. • Causes less memory disruption (just of the preceding hours before treatment) than earlier versions. • Editorial in the Journal of the American Medical Association (2001) concluded that ECT methods among the most positive treatment effects in all of medicine; reduces suicidal thoughts. • Researchers are still exploring the reasons for effectiveness. Brain Stimulation Alternative Neurostimulation Therapies Magnetic Stimulation – Neural stimulation technique used to treat depression. – Repetitive transcranial magnetic stimulation (rTMS) sends magnetic energy to brain surface through coiled wire held close to brain; used to stimulate or suppress brain activity. – Few side effects aside from possible headaches. – Initial studies have found a small antidepressant benefit. – How it works is unclear; repeated stimulation energize left frontal lobe, prompting new neural circuits. Brain Stimulation Alternative Neurostimulation Therapies Deep Brain Stimulation – Another neural stimulation technique used to treat depression. – Manipulates depressed brain via implanted electrodes; inhibits activity related to negative emotions and thoughts. – Further research is needed, but deep brain stimulation may help not only depressed patients, but also people with obsessive-compulsive disorder and with drug and alcohol addictions. Brain Stimulation Psychosurgery • Psychosurgery – Surgery that removes or destroys brain tissue in an effort to change behavior – Is irreversible and thus the least-used biomedical therapy • Lobotomy – Psychosurgical procedure developed by Egas Moniz in the 1930s, and once widely used to calm uncontrollably emotional or violent patients. – Procedure cut the nerves connecting the frontal lobes to the emotion-controlling centers of the inner brain. – Reduced symptoms, but at great cost. • Today, less invasive techniques used; MRI-guided microsurgery used as a last resort for uncontrollable seizures and severe disorders. Therapeutic Lifestyle Change 15-16: HOW, BY TAKING CARE OF THEMSELVES WITH A HEALTHY LIFESTYLE, MIGHT PEOPLE FIND SOME RELIEF FROM DEPRESSION? HOW DOES THIS REINFORCE THE IDEA THAT WE ARE BIOPSYCHOSOCIAL SYSTEMS? • We are integrated biopsychosocial systems. Thus, our exercise, nutrition, relationships, recreation, relaxation, and religious or spiritual engagement all affect our mental health. • Reasons Stephen Ilardi (2009) has developed training seminars promoting therapeutic lifestyle change: – Human brains and bodies were designed for physical activity and social engagement. – Ancestors hunted, gathered, built in groups; some groups still do, with little evidence of disabling depression. – Outdoor activity in natural environments reduces stress and promotes health. Therapeutic Lifestyle Change • Regular aerobic exercise rivals the healing power of antidepressant drugs, and a complete night’s sleep boosts mood and energy. • Depressed people who undergo a program involving the following therapeutic lifestyle changes often gain some relief: – Aerobic exercise – Adequate sleep – Light exposure – Social engagement – Negative-thought reduction (anti-rumination) – Better nutrition Preventing Psychological Disorders and Building Resilience Preventive Mental Health 15-17: WHAT IS THE RATIONALE FOR PREVENTIVE MENTAL HEALTH PROGRAMS, AND WHY IS IT IMPORTANT TO DEVELOP RESILIENCE? – Many psychological disorders might be prevented by changing oppressive, esteem-destroying environments into more benevolent, nurturing environments that foster growth, self-confidence. – Risk of depression, alcohol use disorder, suicide when a person’s sense of competence, personal control and selfesteem are low. – Risk factors include poverty, meaningless work, constant criticism, unemployment, racism, and sexism. – Community psychologists focus on creating environments that support psychological health. Preventing Psychological Disorders and Building Resilience Building Resilience • Resilience: The personal strength that helps most people cope with stress and recover from adversity and even trauma. – Faced with trauma, most adults exhibit resilience. Can be seen in New Yorkers after 9/11, spinal cord injury patients, and others. • Posttraumatic growth may be an outcome when struggling with challenging crises. – Positive psychological changes in many cancer survivors, who report a greater appreciation for life, more meaningful relationships, increased personal strength, changed priorities, and a richer spiritual life.
