Chapter 13:
Therapies
I. Historical Background
A. Early treatments
1. Cave men: Demon possession, “trephining”
2. Greeks: Hippocrates' humors, bleeding, cuppings, emetics, poultices
3. Middle ages--person in league with Devil: torture, physical pain
4. 1792: Pinel and reform in France
5. 1800s: Benjamin Rush, Dorothea Dix and reform in the US, relatively humane treatment
6. 1905: general paresis
7. Early 1900s: Clifford Beers and further reform in the US
“mental hygiene” approach,
emphasized prevention and treatment
B. Modern treatment
1. Evaluation: assessment of presenting condition (symptoms)
2. Decision: inpatient/institutionalization or outpatient?
3. Trend in 1960s toward deinstitutionalization
Drug therapy => outpatient treatment
C. Definition of psychotherapy
Psychotherapy is the informed and planful application of techniques, derived from
established psychological principles, by persons qualified through training and
experience to understand these principles and apply these techniques, with the
intention of assisting individuals to modify such personal characteristics as feelings,
values, attitudes, and behaviors, which are judged by the therapist to be maladaptive or
maladjusted. from Meltzoff and Kornreich (1970): Research in Psychotherapy
D. Professions involved in psychotherapy
1. Psychiatrist: MD with further training in a mental health facility
2. Clinical psychologist: doctoral work at a university or professional school
a. PsyD: diagnosis, therapy
b. PhD: diagnosis, therapy, research
3. Psychoanalyst: doctoral work in Freudian clinical psychology or psychiatrist whose mental
health training is in Freudian clinical psychology
4. Counseling psychology: adjustment
5. School psychology: academic environment
6. MSW: interviewing, therapy,
treatment => home and community
7. Psychiatric nurse: in hospitals
II. Psychoanalysis (Insight Therapy)
A. Nature of problem
1. Psychological problems are symptoms of repressed inner conflicts among personality
structures: sexual and aggressive impulses of id vs. constraints imposed by super-ego vs.
ability of ego to accommodate conflicting demands of id and super-ego
2. Analyst’s task is to bring these hidden conflicts to conscious awareness so that ego can deal
with them constructively.
B. Processes (in Psychoanalysis)
1. “Fact finding”
Free-association
Resistance
Dream analysis: manifest vs latent content
Transference
2. “Interpretation” according to Freudian personality structure and dynamics
3. “Working Through” by bringing problem to consciousness
C. Role of Analyst:
1. Initially an impatient sounding board
2. Later active interpretation
3. Assist client to gain insight into repressed feelings and feelings.
4. Assist client to “Work Through” old conflicts
D. Evaluation and criticisms
1. Requires substantial time and money
2. Patients: highly motivated and verbal
III. Rogers' "Client-centered" Therapy (Insight Therapy)
A. Nature of problem
Process of reaching one's potential -- namely, to become a fully functioning individual -- is
blocked by circumstances or other people (parents, teachers, spouses) such that one's
development is channeled along lines that are troublesome. Result: Lack of congruence
between the ideal self and the real self.
B. Processes
1. Therapist’s role: Provide a context in non-directive atmosphere, facilitate, establish
conditions for change
a. Unconditional positive regard
b. Empathic understanding
c. Reflect feelings, clarify
d. Be genuine
e. Develop insight, own goals and values
2. Client's role: agent for change
C. Evaluation and criticisms
Patients: highly motivated and verbal
IV. Behavior Therapies
A. Nature of problem
1. Maladaptive classical/operant conditioning experiences: many instances of troublesome
behavior are learned
2. Provide alternative experiences so that people learn new, more productive, and more
adaptive behaviors
B. Techniques based on classical conditioning
1. Systematic desensitization
a. Gradually associating a new response (relaxation) with a fearful stimulus.
b. Hierarchy of Fears initially established.
c. Former response is gradually modified by progressing through hierarchy
d. Process: recondition using appetitive US
2. Flooding/implosive therapy
a. Direct, rapid confrontation with anxiety-provoking stimulus
b. Implosive therapy developed by Thomas Stampfl of UW-M
c. Process: decondition through extinction
3. Aversive counterconditioning
a. Pairing an unwanted object with a painful or undesirable stimulus.
b. Used in alcohol, obesity, smoking cessation. A Clockwork Orange.
c. Process: recondition using aversive US
C. Techniques based on operant conditioning
1. Behavior contracting
Therapist and client agree on reinforcements for achieving set goals
2. Token Economy
3. Rehearsal
4. Systematic use of reinforcement principles: shaping, satiation
D. Modeling
Desired behaviors are learned (vicariously) by watching others perform them (and hopefully be
rewarded): Albert Bandura and Social/Cognitive-Learning theory.
V. Cognitive Therapies
A. Stress Inoculation Therapy
Coping in stressful situations improved by learning more adaptive self-talk
B. Albert Ellis’s Rational-Emotive Therapy (RET)
1. Nature of problem -- irrational, self-defeating beliefs
2. Beliefs are based on absolutes, with little room for variation
3. Techniques
Therapist confronts/challenges client about beliefs to remove them
C. Aaron Beck's Cognitive Therapy
1. Nature of problem
Depression from negative thoughts, self-critical, unrealistic expectations, downward
spiral from generalizations
2. Techniques
a. Less confrontational than RET
b. Support for developing more realistic ways of thinking
c. Modify cognitive distortions
VI. Group Therapies
A. Group Therapy is type of therapy where clients meet regularly to interact and help one another
achieve some insight into their feelings and behavior. Usually there is a leader/therapist.
B. Self-Help Groups
Groups structured around common problems (e.g., AA, NA); 12 Step approaches
C. Family Therapy
1. Nature of problem: systems theory approach
a. Problem can be in the family as a unit, between husband/wife, or parents/children
b. The entire family likely needs assistance
2. Techniques
a. improve communication
b. share responsibility
c. reduce conflict and heighten empathy
d. change ways that family members satisfy each others' needs
D. Couple (Marital) Therapy
1. Nature of problem
a. dysfunctional patterns of communication
b. unfulfilled mutual expectations lead to dissatisfaction, hostility, misattributions about
partner
2. Techniques to improve patterns of communication and interaction
a. Formal schedule of exchanging benefits
b. Clarify misinterpretations-communication skills (Deborah Tannen/John Gray)
c. Empathy training
VII. Biological Therapies
A. Drug Therapies
1. Antipsychotic: major tranquilizers (e.g., thorazine, haldol)
a. Very effective for positive symptoms (hallucinations)
b. Less effective for negative symptoms (social withdrawal), though newer ones are
better
2. Antidepressants (e.g., Prozac)
Prozac and SSRIs block reuptake of serotonin
3. Lithium for manic-depression/ bipolar disorder (see Table 13-1)
4. Can have serious side effects with prolonged use
5. Antianxiety: minor tranquilizers (e.g., valium, xanax)
a. Produce calm and mild euphoria
b. Used for general tension, anxiety
6. Psychostimulants (e.g., ritalin)
a. Heighten alertness and arousal
b. Used for ADHD
7. Sedatives
a. Produce calm and drowsiness.
b. Used to treat agitation or induce sleep.
B. ECT (electroconvulsive therapy)
1. Currently used for treating prolonged or severe depression, esp. in the elderly.
2. An electrical current is passed through the brain producing a seizure.
3. Side effects: Memory impairment and confusion
4. Reasons for effectiveness are unclear
C. Psychosurgery: Prefrontal lobotomy
D. Do drugs cure?
VIII. Institutionalization and its Alternatives
A. De-institutionalization
1. Policy of treating mentally ill patients within the larger community or half-way houses.
2. Although a fine idea in principle, it has proved less than stellar in practice.
B. Alternative forms of treatment
C. Prevention
IX. Gender Differences in Treatments
A. Incidence: More women than men receive psychotherapy
B. Concerns
1. More therapists are men than women
2. Do women receive equal treatment?
3. Women receive more prescriptions for medications
C. APA Guidelines
X. Cultural Differences in Treatments
A. Symptomatology
B. Concerns
XI. Evaluating Effectiveness of Psychotherapy
A. Formal Features of Psychoanalytic, Client-centered, and Behavior Therapies: Comparison among
major perspectives on therapy (see also Summary Table on p. 473)
B. Difficulties in evaluating effectiveness
1. Spontaneous remission
2. Who measures outcome?
Individual? Therapist? Third party?
3. What outcome is measured? Insight or change in actual behavior?
4. In practice, many theoretical outlooks tend to converge, producing eclectic therapists
C. Effectiveness of Various Forms of Therapy
1. Being in some therapy seems better than no therapy or placebo for most disorders.
2. Better improvement if in therapy for longer period.
3. In general, cognitive and behavioral therapies seem slightly more effective than insight
therapies.
4. Some therapeutic techniques seem better suited to some types of disorders.
a. Behavior therapy: phobias, bulimia, OCD
b. Drugs reduce severity of schizophrenic symptoms
5. In most other cases, different forms of therapy yield about the same kinds of effects
D. Does a given form of therapy work (better than ...)?
E. When a given form of therapy works, does it work for the reasons it says it does?
F. May work for a common set of reasons, related to interpersonal characteristics of therapist, rather
than kind of therapy. When a given form of therapy works, it works because the therapist
1. Establishes an interpersonal relationship of warmth and trust with client
2. Reassures and supports the client
3. Understands and accepts the client as person
4. Desensitizes the client’s problems
5. Reinforces the client’s adaptive responses