psychotherapy
How does the cause of psychological disorders relate to treatment?
How do you know if you need therapy?
How do you find the right therapist for you?
What is the difference between individual and group therapies?
Does psychotherapy work?
Are psychotherapists generalists or do they specialize?
Can psychological disorders be prevented?
The Basis of psychotherapy
Thoughts and behavior, normal and abnormal, have complex origins, arising from the interaction
between psychological (mental processes), biological, and social influences. This is called the BIOPSYCHO-SOCIAL MODEL. Treatment approaches emphasizes one or more of these influences,
depending on the degree to which each contributes to disordered behavior.
•Psychological approach focuses on the contributions of mental processes to treat
disorders, including psychoanalysis, humanistic therapy, cognitive behavioral therapy
(CBT), and other approaches.
•Biological approach uses medications to treat mental disorders, and other medical
interventions, such as electroconvulsive therapy (ECT), transcranial magnetic
stimulation (TMS), and neurosurgery.
•Social approach focuses on changing the social environment in which individuals live
to reduce the disorder. These approaches include group, couples, and family therapy,
as well as community psychology.
For example, schizophrenia has clear origins in biology and the symptoms are treated
by medication. By contrast, phobias are caused by mental processes associated with
experience, and are therefore treated psychologically. Anxiety disorders can be treated
using biological, psychological, and social approaches. A therapist’s approach to
treatment is based on scientific evidence, their training, and their knowledge for the
effectiveness of different treatments. The diagram on the right shows some of the
areas of focus for the bio-psycho-social model.
We’ve come a long way, but there are still few clear-cut, hard and fast answers in treatment. The complexity of behavior makes it difficult to study and
fully understand the origins and influences on most behaviors. A therapist must have the endurance to work with tentative and conflicting information
while also being able to interpret problems, conceptualize someone’s life, and help them improve.
Seeking psychotherapy
There are no set criteria to determine when a person requires therapy. Some seek therapy because they want to be happier and do better, even though they
are “fine” or even very successful to a casual observer. Others function well with some obvious exceptions. Some are more disturbed or may be court
remanded. Generally, therapy is sought when a person experiences one or more of the four D’s beyond what is comfortable for them or tolerated by society:
• Dysfunction. Impairment in ordinary aspects of life, such as: family, job, friendships, romance, lawful behavior.
• Distress. Behavior is upsetting to the client, and results in agitation, fear, or stress related problems.
• Deviance. Behavior is atypical or intolerable to the average community member
• Dangerousness. Behaviors endanger themselves (neglecting basic needs and hygiene, suicidal) or others (violence, neglect, unlawful acts)
There are over 400 types of professionally recognized therapies, each emphasizing different combinations of the bio-psycho-social model. Most can be
grouped into general categories, called “schools”. For example, psychodynamic therapies emphasizes the unconscious mind, cognitive- behavioral
therapies emphasizes altering thoughts to affect behavior, and family therapies emphasize the effect of personal relationships on mental health. The goal
of therapy is to have a successful outcome by improving your mental health, which improves quality of life. Regardless of the differences between schools
of therapy, effective therapies have the following in common:
• Creation of a therapeutic alliance, a relationship based on trust and a common goal to overcome the client’s suffering. This is called rapport
(pronounced rapoor).
• Opportunity for the client to engage in self-examination and self-direction. Therapists help patients understand the reasons for their behaviors,
triggers and provide strategies for change. Clients can use the information to change their own behaviors.
• Opportunity to receive encouragement from the therapist on a regular basis. Personal change is hard. We get discouraged, we exaggerate our
setbacks, we overcriticize and lose faith in ourselves. A therapist is more objective, providing appropriate perspective, constructive suggestions, and
motivation to continue moving forward.
• Affirmation of the client’s desire to change and improve. Many clients are reluctant to seek therapy or are dissuaded by trusted others from doing so.
Reasons include biases, fears, and personal motives. Sometimes, the therapist is the only one validating the client’s desire to live a happier and
healthier life.
• Confidentiality. It is difficult to reveal innermost thoughts and fears to people who may judge, dislike, or harm us. Information shared during a
therapeutic session will not be revealed to others. (Note: limits on confidentiality are discussed in Social and Legal Issues chapter).
Cultural Influences on Seeking psychotherapy
Our knowledge of the prevalence of mental illness and psychotherapy for people in other countries and non-whites in the U.S. is limited. This area of psychology
is growing and in desperate need of more clinicians, researchers, and students. The information provided for you, here, is an overview of what we know, but
may not capture the full experience of different cultures, races, or ethnicities.
In the US, racial and ethic minorities are less likely to seek treatment than whites, and more likely to seek help from clergy, healers, family and friends. The main
reasons for not seeking therapy are as follows:
---- Deep-seated beliefs or stigmas that mental illnesses are not real illnesses or reflect a personal/familial failing. This stigma reduces treatment seeking,
likelihood of having family and social support, the ability to cope with symptoms, and treatment success. The consequences are extreme distress and disability,
worsening of symptoms and a higher risk for suicide.
---- Mistrust. This is the largest barrier to seeking treatment stemming from experienced and historical discrimination and persecution. A significant proportion
(up to half) of minority groups believe they have been treated unfairly by their health care provided (compared to only 5% whites). Evidence confirms that racial
and ethnic minorities frequently experience negative bias and microaggressions from health professionals. The mistrust in physical health care spills over to
mental health care. Anti-health groups aggravate this by targeting minority communities with fear messages. For example, the Children’s Health Defense
released the film Medical Racism: The New Apartheid to cause mistrust of the COVID-19 vaccination in Black communities. The film presents data from research
studies and CDC charts, and discussions from health experts suggesting vaccines to be a civil rights issue, especially harmful for Black people. Unfortunately, the
film is a sham documentary. The filmmakers inserted snippets from original interviews with well-credentialled experts into points that supported the
filmmaker’s narrative. But, those interviewed had the exact opposite perspectives! The film makes false claims about findings and CDC charts; at least one study
had already been retracted by the journal for dishonesty. The film attempts to present as a vehicle for social justice, with vaccines as the injustice. However, its
nefarious use of scientific reports and experts makes it a purposeful misinformation campaign that targets Black people. The Children’s Health Defense is backed
by millionaires and politicians, and they are among the “Disinformation Dozen” producing 65% of anti-vaccine misinformation on social media.
---- Representation. Many people prefer a therapist of the same race, ethnicity, religion, or country of origin. As it currently stands, there is a shortage of
psychotherapists, especially in rural, low-income, and non-white and ethnic communities. Recent demographic data shows that 5% of psychologists are Asian,
5% Hispanic, 4% Black/African American, and 1% multi-racial or other. Racial and ethnic minorities comprise about 30% of the U.S. population. Where
psychotherapy is already stigmatized, being unable to find a cultural ally in therapy (or any therapist at all) presents a significant barrier.
---- Effectiveness. Non-whites and ethnic minorities may also be concerned that a therapist who does not know their culture would not be able to sufficiently
understand their problem and help them. This concern is not unfounded, as different cultures have different styles of communication and emphasize some
symptoms over others. An effective psychotherapist should understand cultural differences in communication.
Use it, right now: Advice for finding a therapist
Essentials of the Therapeutic Process
• Trust and mutual positive regard is critical. It can be established in the first
meeting but can take longer. It should be established within the first few sessions
because progress requires trust. If you do not feel like you can trust, be honest, or
be safe with your therapist within the first few sessions  find another.
• Cultural, spiritual, religious background may be important to you. Find the
therapist with whom you are comfortable, can be honest with, and that you think
will best understand your experiences, thoughts, emotions, and actions.
• Be skeptical of overconfidence and claims of amazing results.
• Expect at least some small improvement within a few months of starting. Ask for
your therapist’s input if this doesn’t happen. If the therapist is unwilling to discuss
your improvement find another.
• Be an active participant in your own treatment – nobody “fixes” you, rather, you
receive help in changing your own life. A successful outcome of therapy requires
significant effort from the client.
• No one way of doing psychotherapy is right for every client. Use your knowledge
to “shop” for the therapist who will work best with you. Talk to more than one
therapist before committing to one. If your current therapist seems wrong for
you find another. This is not a criticism of you or the therapist, they may be
very good, and you may be very willing, but the fit just does not feel right to you.
What to Expect from a therapist, within a few sessions
• Determine your current issues or difficulties. This is a transparent process, where
the therapist will ask you many questions, discuss their understanding of your
problems, and help you prioritize problems.
• A treatment plan. The therapist will seek your input and agreement with goals
and targets for treatment, and a general timeframe. The plan should be
periodically revisited to assess progress and modify when needed. It should be
clear enough for you to be active in your treatment and recognize progress.
How to Find
a Therapist
Crisis: For emotional or psychiatric distress and need of immediate
intervention. In Atlantic County:
• Psychiatric intervention program (PIP): Provides evaluation and appropriate
referral for clients to outpatient mental health services or inpatient
treatment. Can provide telephone referral, support and guidance. 24 hours
a day, 7 days a week, 609-344-1118
• Adult Intervention Crisis Services (AIS): Offers comprehensive, short-term
behavioral health services to Atlantic County residents, 18 or
older. Alternative to emergency room treatment when not in danger of
hurting himself/herself or others. 866-750-6612, AtlantiCare Behavioral
Health Services, 1601 Atlantic Ave. Atlantic City, NJ 08401
Names and Contacts of therapists in your area:
• Psychology Today, Find a Therapist:
https://www.psychologytoday.com/us/therapists/
• American Psychological Association (APA), Psychologist Locator:
https://locator.apa.org
• National Register of Health Service Psychologists, Find a Psychologist:
https://www.findapsychologist.org/
• Your health insurance company will likely have a list of psychotherapists
covered by your plan. Your physician may have specific recommendations.
Mental Health Association. Local organizations that may give
recommendations or direct you to a resource who can. In Atlantic County:
Mental Health Association of Atlantic County:
4 East Jimmie Leeds Road, Suite 8, Galloway NJ 08205
PHONE: 609-652-3800, EMAIL: MHAAC@MHANJ.ORG
Psychodynamic Therapy (psychoanalysis)
The psychodynamic school is based on the ideas of Sigmund Freud: behavior and personality are determined by
unconscious struggles. “Unconscious” means unaware.
Sessions are usually one-on-one, often with the patient lying on a couch. The patient talks about personal concerns,
anxieties, thoughts and emotions. These conscious statements are interpreted by the therapist to determine
their real meaning hidden in the unconscious mind.
(current awareness)
This image shows an analogy of different levels of consciousness to an iceberg, where ‘consciousness’
is only the tip of what really lies beneath. Consciousness refers to thoughts and perceptions in our
current awareness. We can state them aloud, work with them mentally, picture them in our heads,
and recognize our emotions. The preconscious level includes memories and knowledge that we are
not currently thinking about but could if we wanted or needed to, or if our current situation
brought them to mind.
At the unconscious level are elements that drive our thoughts, perceptions, behaviors, and
emotions without our conscious awareness that they are doing so. We are unaware of these
things because they are too painful, would alter our self image, conflict with our beliefs about
right and wrong, risk social acceptance, or ruin important relationships.
However, these unconscious elements do get expressed in our conscious life but are disguised
or distorted to preserve our self image or protect us. The therapist's role is to understand how,
why, and when a client’s observable behaviors are reflections of the unconscious mind,
and to help the client resolve unconscious issues causing distress or abnormal behaviors.
(easily moved to awareness)
(not accessible to awareness, therapist can uncover)
Where does all this jockeying of thoughts occur? How is beneficial versus harmful, or aware versus unaware, decided? According to Freud, the mind is structured
as three parts: ego, id, and superego. Ego determines which and how unconscious wishes, experiences, and urges are available to conscious life. The ego desires to
satisfy unconscious urges for pleasure (id) and desire to be a social, moral ideal (superego), but these often conflict. The ego figures out how to satisfy the id and
the superego, given the reality of a current situation. For example, you see your friend eating a delicious dessert. The id wants you to grab it, but the superego
wants you to not take from others. Seeing neither as realistic (you could lose a friend, violence is bad, you could starve to death), the ego resolves to ask your
friend to share. If they say no, the id says knock them down and take it, the superego says not to, so the ego gives you the conscious thoughts that you did not
want it anyway, you could ask someone else to share, you could try bargaining or just get your own. You’ll get what you want, but in a way that protects your ego’s
version of reality and a situation. Ego, id, and superego are hypothetical categories, without scientific evidence for their existence.
Therapeutic Goals:
A woman goes to a psychoanalyst, who diagnoses her with depression. Over a series of
sessions, she may come to recognize on a conscious level that she has been treated
unreasonably and cruelly by her husband and is able to blame him rather than herself as the
cause of her distress. She resolves to do something to change the situation. Her depression
Catharsis: relief through release of emotions associated
‘lifts’ as her anger is ‘released.’ Another explanation is that one kind of emotional response
with unconscious cause of the distress.
(depression) was replaced by a more accurate one (anger).
Clinical Techniques: These techniques are all designed to reveal the unconscious mind to the therapist and require active interpretation by the therapist.
Free-Association: The client says what comes to mind as a free flow or in response to word prompts, without interruption or censorship from the therapist. The
rationale is that the associations between one thought and the next or a series of thoughts reflects personal experiences (there is lots of scientific evidence for
this). Talking freely and continuously reveals the associations.
Insight: become consciously aware of and understand the
unconscious thoughts and feelings causing the distress.
Dream Analysis: The client records their dreams, and the therapist analyzes the symbolism as a window into the unconscious. These are interpreted in the
context of each client’s specific experiences and problems. Combined with free- association, the therapist determines what consciously remembered elements
(manifest content) of the dreams represent about the unconscious (latent content).
Transference: The therapist provokes the client to project feelings about someone else onto the therapist. This could also happen without provocation. For
example: Michelle became very angry with her therapist when he discussed the possibility of homework activities. Through the exploration of the anger with the therapist, Michelle
discovered that she was experiencing transference of unresolved anger toward an authoritarian elementary school teacher.
Defense mechanisms: Expressions of unconscious struggles in a way that protects the person from facing painful or difficult unconscious issues. The therapist
attempts to identify defense mechanisms used by the client. Some examples include:
• Repression: Forgetting motivated by an unwillingness to know a painful experience (failing to remember abuse).
• Projection: Accusing others of a behavior or feeling that you have (a person who feels inferior constantly accuses others of being stupid or incompetent).
• Reaction Formation: Behaving opposite, often exaggerated, to unconscious feelings or wishes (a misogynist devoted to his wife).
• Denial: denying the existence of painful thoughts, behaviors or feelings (an abuser pointing out how good they have been for victim)
• Rationalization: Explaining away a behavior with an alternate set of facts or perspectives to avoid painful feelings or discomfort with a choice. (A husband
who finds out his wife cheated on him claims to not have loved her, anyway)
Three Main Criticisms of Psychoanalysis.
• The process may take years, several sessions per week, costing thousands of dollars.
• It is complex and elaborate, requiring many years of training and practice to implement well.
• There is little scientific evidence supporting psychoanalytic theory. No one really knows why it sometimes does or does not work.
• Despite these and many other criticisms, the therapeutic techniques have been effective for many people.
Cognitive Behavioral Therapy (CBT)
Based on the idea that thoughts and feelings affect behaviors. Psychological disorders arise from the influence of
inappropriate or irrational thoughts and feelings on behavior. Negative thoughts lead to negative feelings which
lead to problematic behavioral responses. This becomes a repeating and reciprocal cycle, as shown in this diagram.
Irrational thoughts are referred to as COGNITIVE DISTORTIONS. Some examples include:
Filtering: Magnifying negative details, ignoring positive ones
Overgeneralization: drawing a general conclusion based on a single piece of evidence
Catastrophizing: Believing the worst possible consequence
Labeling: applying unhealthy label to oneself or others
Emotional reasoning: Feelings are believed to reflect how things really are
Therapeutic Goals
-- Transform problematic thoughts, emotions, and behaviors to be more realistic and beneficial
-- Train the client to recognize and interrupt a negative though-feeling-behavior cycle.
Clinical Techniques to change thoughts, feelings and behaviors
Cognitive Restructuring and Reframing: Teaches clients to frame negative thoughts into more constructive and positive thoughts. For example: “I blew
the presentation because I’m totally useless” can become “That wasn’t my best work, but I’m a valuable employee and I contribute in many ways.”
Guided Discovery: Inaccurate beliefs are challenged, to replace with rational ones. Method include:
-- Asking client for evidence or presenting examples of the opposite
-- Cost/benefits: list possible explanations or behavioral choices (pros and cons) to be more objective and less polarized (‘best”, “worst”).
-- Distancing: Thinking about a problem from an alternate perspective (would 100 random people do the same?) to help objectivity.
Behavioral Experiments: People anxious about doing something (e.g., work or party) are asked to predict possible consequences and then test the
predictions by doing the behavior.
Rewards for desirable behaviors.
Humanistic Therapy
This is based on the idea that people are able and strive to achieve their full potential. Psychological problems arise when an
individual’s current self-concept is different from their ideal image of themselves. The self-concept develops from limits and
expectations placed on us by ourselves and others. This therapy changes the self-concept to align better with the client’s
ideal self-image.
Therapeutic Goals:
Self-actualization: Overcome all the obstacles to maximizing one’s
potential. This pyramid shows those obstacles as a hierarchy of needs,
where one level of needs must be met in order to reach the next level.
For example, security of family, property and health (safety needs) are
of secondary importance to eating and breathing (physiological needs).
Similarly, one cannot pursue their passions, follow moral principles, be
creative or effectively solve problems (self-actualization needs) until the
have the confidence and self-esteem (Esteem needs) to do so.
Clinical Techniques to change self-concept:
Therapeutic Alliance (discussed previously): First promoted by the
humanistic therapists, this has become critical to any psychotherapy.
A therapeutic alliance in humanistic therapy requires the following:
-- Unconditional Positive Regard: the therapeutic alliance is strongest when
the therapist values, cares about, and accepts the client, regardless of how
they feel or behave. This has been compared to the regard a parent has for
their child.
-- Empathy: Therapist actively listens and accurately understands the client’s
personal feelings and perspectives
-- Genuine: The therapist is nonjudgmental and does not interpret client’s
free-flowing thought sand feelings.
The main criticism of humanistic therapy is that the techniques and the
concepts are not well-defined and therefore, difficult to measure. That is, if
you do not know what self-esteem or passions look like, then how do you
know they’ve been achieved? As a result, it has been suggested that
humanistic therapy is more subjective than scientific, and the therapeutic
alliance is effective because it is common sense.
psychotherapies with Groups
Family Systems Therapy treats the person in the context of the family. Rather than treating the family as a whole unit, psychologists recognize that
families include several different relationships (e.g., parent-child, mother-father, sibling, grandparent-child) , and that families are constantly
changing. An individual’s problems may arise or be exacerbated as a result of the family relationships, or the family may be integral to improving the
individual’s disorder. Moreover, when a family member develops a psychological or medical disorder, those relationships may be crucially affected.
The goal of family systems therapy is to help families adapt to changes (or trauma), identify harmful patterns, improve relationships and
communication, and determine how each member can contribute to better health of all family members. For example (from mayoclinic.org):
Your adult son has depression. Your family doesn't understand his depression or how best to offer support. Although you're worried about your son's well-being,
conversations with your son or other family members erupt into arguments and you feel frustrated and angry. Communication diminishes, decisions go unmade, family
members avoid each other, and the rift grows wider.
In such a situation, family therapy can help you:
--- Pinpoint your specific challenges and how your family is handling them
--- Learn new ways to interact and overcome unhealthy patterns of relating to each other
--- Set individual and family goals and work on ways to achieve them
Group therapy involves the treatment of 5-10 clients or patients who meet in a group led by one or two therapists on an ongoing basis. There are several
different kinds of group therapy. Some focus on learning to have better relationships, some focus on persistent life problems (e.g., substance use and
co-dependence), some focus on skill building (e.g., anger management), and some do a combination. The benefits include reducing feelings of
marginalization and isolation, feedback and support from other members, recognizing shared experiences, and a safety net for taking risks between
sessions. Group therapy sessions also cost less than individual sessions. The techniques employed in group therapy may be from any school of
psychotherapy or a combination. To maximize the benefits for group members, consideration is given for:
- Appropriateness: Group therapy is not appropriate for people who are likely to learn additional maladaptive behaviors from others (e.g., OCD), are
currently in crisis (e.g., suicidal), who may not be productive (e.g., refuse to participate) or could be harmful to other members (e.g., ASPD).
- Match to group: Age, preferences, stage of recovery, type of disorder, and severity of symptoms are considered. Clients in a group cannot be helped
if they cannot relate to other members or the focus of the therapy is not aligned with their needs. Women in women-only groups tend to
complete treatment programs, use more services, self-assess as doing better, and benefit longer after the treatment than when placed in
mixed groups. Evaluation of client match to the group is ongoing, where setbacks or rapid progress, new information and additional diagnoses
may require switching or adding groups to the treatment plan.
Self-help groups work in a similar way but there is no therapist involved. Some are led by other trained professionals such as, clergy or addictions
counselors. Some are led by peers who have the same problem. Self-help groups are free, take place in an informal setting (house of worship,
community center, member’s house) and have positive effects on people with addictions, grief, or coping with trauma, chronic illness or disability.
Other Trends in psychotherapy
Brief therapy models in which the therapist and client agree to a certain length, number of meetings, expectations and goals for the treatment are
becoming more popular. The goal is to identify a specific problem and provide solutions to reduce suffering as quickly as possible. It can be used in most
therapy types, even psychoanalysis, but is not useful for severe disorders (e.g., schizophrenia, depression, bipolar). The key is that the focus be on the solution
to a problem, not its origin. For example:
If a client is struggling with excruciating shyness, but typically has no trouble speaking to his or her coworkers, a solution-focused therapist would target the client’s interactions at
work as an exception to the client’s usual shyness. Then, the client and therapist will work as a team to find out how the exception is different from the client’s usual experiences
with the problem and develop strategies to apply to a variety of other social situations.
Eclectic Therapists do not use a single method exclusively, but a combination of approaches. This is very common. For example, psychodynamic and
humanistic therapists incorporate techniques from cognitive-behavioral therapy, and CBT may borrow from them, too. A therapist will implement the
techniques they believe most likely to help their clients or refer them to someone else.
Sports Psychologists address performance (“mental edge”) and mental health issues, unique or occurring in athletes. These include, coping with injury and
preparing for “comeback”, performance anxiety, and building resilience to cope with losses, wins, and negative criticism. The following is how one psychologist
helped Michael Phelps (28 Olympic Golds for swimming) cope with the anxiety of high-stakes competition:
We simulate the pressure. So, for instance, we will make them physically and psychologically tired through a tough training session and then we get them to compete. We even get
people to cheer or boo. This kind of simulation helps us push their boundaries. We also use pre-performance routines or rituals. Michael Phelps, for instance, always has his music
on. He blocks everybody out. In the end, it’s about hours and hours of practice—both physical and mental.
School Psychologists help students overcome obstacles to success. They work with a wide range of problems including academic performance, problems at
home, bullying, mental health, and special needs. They collaborate with students, teachers, parents, school counselors, and administrators.
A 12-year-old boy was referred by the teacher for his academic problems. Complaints reported by his teacher were weak in studies, problem in reading and writing and didn’t
speak in class. During the clinical interview he reported being fearful during an oral test in class or while reading in class, difficulty in memorizing science lesson, difficulty in
reading and writing difficult words, and that some classmates make fun of him. Different assessment modalities like behavioral observation, Clinical Interview, Subjective rating
scale, Baseline charts, Emotional behavioral assessment (School children problem scale), Academic assessment (reading, coping, Dictation), Cognitive assessment (paired associate
learning test, reading, digit span test, logical memory test) and reinforce identification were done with the child in order to assess his problem. The assessment revealed that he
was victim of bullying. Counseling strategies included: rapport building, prioritizing goals , daily activity scheduling and psycho-education, assertiveness training, cost and benefit
analysis, study skills, changing old rules assumptions into new rules assumptions. Overall, client’s behavior was cooperative in every activity. Outcome of the therapeutic
intervention [after 10 sessions] was fruitful as he learned assertiveness and he was also not afraid of telling his authoritative figure about any bully issues at school.
Gerontology/Eldercare fosters well-being for long-term care residents with efforts to prevent cognitive decline, cope with illnesses or dementia, and
address feelings of isolation and boredom. They also help people caring for elderly relatives to cope with the added responsibility while balancing their
careers and other family responsibilities.
Effectiveness of psychotherapy
Research studies on effectiveness look at patient outcomes: did the patient improve? Different methods have been used to test the effectiveness of a therapy
by comparing it to other aspects that could cause improvement, such as:
---- Placebo Effects. People may improve because they expect to and therefore, help themselves get better without realizing it. To determine placebo effects, a
study would compare a group that had real therapy (e.g., pill with medication) to a group that only thought they had therapy (e.g., pill with no medication).
---- Spontaneous Remission. Sometimes, people just naturally improve over time. Those studies compare improvements over time for a group with therapy to a
control group receiving no therapy.
---- Nonspecific Effects. People may improve with any therapy, and it may not matter which therapeutic method is used. Those studies compare a group
receiving one kind of therapy to another group receiving a different kind.
•
Overall, the therapeutic approaches we have
discussed show moderate to large improvements
over those receiving no therapy. An evaluation of
the published reports on therapy across a variety
of disorders indicates that those in therapy are
about 80% better off that those who do not.
•
They may not differ much in their effectiveness for
some disorders.
•
Cognitive-behavior therapy shows the most
consistent, long-term benefits across the widest
variety of disorders, from moderate to severe.
This table shows which therapies are typically effective
(+) for different disorders.
Psychodynamic
Schizophrenia
Depression
Bipolar
OCD
Stress Coping
PTSD
Anxiety Disorders
Eating Disorders
Borderline PD
Antisocial PD
Relationships
+
+
+
+
+
CBT
+
+
+
+
+
+
+
+
+
+
+
Group/
Family
Humanistic
Medication
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
Focusing on prevention
Community Psychology addresses threats to mental health in the social environment, or on lack of fit between individuals and their environment.
Community psychologists focus on the needs of groups rather than individuals. They emphasize preventing or lessening mental illness, social problems, and
quality of life in communities and organizations. They interact with people in communities and design program that better communities and empower people
to live healthier and happier lives. Some steps that would help in community prevention efforts:
• Ban environmental toxins, such as lead paint and pesticides in schools and community parks.
• Promote good prenatal care and education
• Promote full employment
• Provide high quality and affordable childcare
• Improve educational opportunities
• Educate community on how to recognize and address emerging problems
• Help formerly institutionalized people to adjust and contribute to mainstream
• Reduce community stressors, such as crime or access to services
Positive psychology is a scientific approach that focuses on an individual’s strengths, positive emotions (happiness), characteristics (gratitude, resilience),
and institutions. The goal is to help people build and maintain well-being and life satisfaction. One technique for achieving well-being is mindfulness.
Mindfulness is paying conscious attention to thoughts, feelings, and behaviors in-the-moment, and taking steps to adjust and align them with steps to wellbeing. This approach contrasts with other therapies that focus mainly on recovery or coping with illness and past experiences, instead of maintaining wellness.
Steps to well-being include:
• Experiencing more positive emotions by doing things in your daily routine that make you happy
• Increase engagement by pursuing hobbies, developing skills and education
• Dedicate yourself to a cause that is bigger than you through employment, volunteering, mentoring, or hobbies
• Focus on achieving and accomplishing goals in balance with other important things such as work, family, and community
Health Psychology promotes health, prevents illness, and improves health care. They study motivation for engaging in healthy and health-risky behaviors
and the choices that have positive impacts the health of individuals, families and communities. Their goal is to help people control their health. For example,
• help patients manage chronic diseases, such as cancer or diabetes, for better health outcomes.
• help soldiers and veterans prepare for fight, cope with PTSD and life adjustment, and prevent suicide.
• Work with schools to design programs that fight obesity or substance abuse, such as cafeteria choices and physical education
• Work with hospitals to encourage patient follow-up
Application: grief therapy
It is common for therapists to use an eclectic approach by borrowing a variety of techniques from different schools of psychotherapy. Let’s look closely at a
report published in 2021 by three therapists at the Danish National Center for Grief describing their grief intervention program for young adults (age 20 – 27).
The clients had lost one or both parents and were suffering from mild to severe prolonged pathological grief (a.k.a., complex grief). Bereavement in young
adulthood has been associated with many mental health problems including physical illness, suicide, low self esteem, low life satisfaction, academic, job and
social difficulties. These are exacerbated in complex grief and increase risks for long-term mental health problems. This is how their program works:
Consistent with group therapy considerations, clients were placed into groups that matched their severity of symptoms. One group had mild and moderate
grief complication, and another had severe. Consistent with a brief therapy model, the mild-moderate group was limited to 18 sessions. The severe group
followed a traditional approach, where number of session was determined by individual progress and some members shifted out later than others.
The sessions also combined elements of group and individual therapy. Each client worked one-on-one with the psychologist while the other group members
silently listened and reflected on the relevance to their own grief experiences. This enabled for an individualized intervention and strengthened the
therapeutic alliance, while simultaneously reducing isolation, identifying with and learning from others, and gaining peer support. The following are some of
the ways they applied techniques from the variety of psychotherapies that we have discussed:
GOAL: Understanding, coming to terms with, and developing a continuing bond with deceased parent
Transference to bring previous conflicts with parents to the surface and then work on those feelings. (Psychodynamic)
Writing letters to help integrate different experiences with the parent, reinterpret the relationship, and reconnect with the parent. (CBT)
GOAL: Promoting positive personal development, fulfillment, and meaning
Create meaningful life stories (Humanistic Psychology)
GOAL: Develop a healthy style of thinking about pain of loss while adjusting to life without the deceased parent
Psychoeducation about the process of grief and adjustment in small manageable portions (CBT)
GOAL: Confront, accept, adjust, and manage grief feelings to promote mental health and daily well-being
Timeline of experiences with parent’s illness and death to gain insight into thoughts and feelings that were previously unconscious (Psychodynamic) and as
guided discovery to reevaluate thoughts and feelings to develop alternate explanations and perspectives (CBT)
Identify defense mechanisms that create problems in their life because they stem from unresolved emotions, such as anger (Psychodynamic)
Photo viewing stimulates feelings and memories that may have been forgotten or repressed (Psychodynamic) and restructure feelings of despair into
sources of comfort and connection. (CBT)
Develop a vocabulary that enables talking and thinking about their grief to stop avoidance or uncontrolled expressions patterns
Mindfulness exercises to regulate physical reactions to grief and focus on current improvements (Positive Psychology)
Cognitive restructuring and reframing targeting feelings of guilt, shame, and anger to diminish grief and related dysfunctional behaviors. (CBT)
Psychological testing
In practice, diagnosing psychological problems is much more complicated that checking off symptoms in the DSM-5. Determining a treatment plan also goes far
beyond knowing different schools of psychotherapy. Psychotherapists use interviews, medical and psychiatric histories, and a variety of psychological tests to
assess a client’s behaviors, thought patterns, sources of symptoms, and uniqueness of each client’s symptom cluster and severity. The more information a
therapist can gather about a client, the better they can develop effective treatment plans and modify as needed.
There are many kinds of psychological tests to help therapists understand clients. A therapist selects tests based on several factors including, the kind of
information they need, cost, and their qualifications for administration. Extensive research and scrutiny of psychological tests ensure that they are valid and
reliable. Validity refers to accuracy of the test or it’s ability to detect what is claims to be detecting. For example, if a test claims to measure psychopathy, then the
score would reveal psychopathy when psychopaths take the test. Reliability refers to consistency of the test. For example, if a test indicates schizophrenic
symptoms, then it should always indicate as such for that individual and people like them, no matter how many times they take it. It is unreliable if a person can
take the test multiple times and get different results each time. The following are some examples of commonly used and widely respected psychological tests.
Minnesota Multiphasic Personality Inventory (MMPI-3): Assesses personality traits and psychopathology. Personality is the consistent patterns with which
we tend to respond. Mostly used in a clinical setting, it is not generally useful for non-pathological people. The MMPI-3 tests degree of dysfunction on 52
psychological aspects. For example, internalizing, includes suicide ideation, hopelessness, self-doubt, worry, inhibition, and anger proneness; externalizing,
includes impulsivity, family conflict, and excitation. Also, five different dimensions of personality psychopathology are assessed (aggressiveness,
psychoticism, behavior control, negative emotionality/neuroticism, and introversion). An individual’s MMPI-3 profile is extensive, complex, and unique. It has
been used to screen for employment, determine parent suitability, and as evidence in criminal cases and parole hearings. The MMPI-3 requires a “C-level”
qualification for administering and interpreting the test, which means that a doctorate and extensive training is required for valid results.
Symptom Checklist: 90-Revised (SC-90-R): Evaluates intensity and breadth of psychological distress across nine symptom categories (somatization,
obsessive–compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism). Like the MMPI-3, SC-90-R
provides a profile that is unique to an individual. It is not as extensive as the MMPI and enables a therapist to rapidly identify a client’s symptoms and
associated psychopathology. It has a “Level A” qualification, meaning any reasonable person can follow the manual to administer and interpret.
Wechsler Adult Intelligence Scales (WAIS-IV): The WAIS-IV assesses intellectual functioning (16 years old +). The score is commonly called an intelligence
quotient (IQ). IQ tests measure cognitive (thinking) abilities, not factual knowledge or skill someone has in any domain. I may have more knowledge than
you, but the WAIS-IV could believably indicate that you have a higher IQ. High, average, and low IQ is determined by comparison to others at the same age or
stage of development. Low (or high) IQ means lower (or higher) cognitive ability than the comparison group. An average IQ score is 85 – 115. The WAIS-IV
measures verbal comprehension (language use and reasoning), perceptual reasoning (spatial comprehension, reasoning and problem solving), working
memory (attention, mental manipulations and control), and processing speed (how quickly cognitive tasks can be completed). Like the MMPI-3, the WAIS-IV
requires “C-level” qualifications.