Chapter 15

Psychotherapy

Any approach that uses psychological, rather than biological, means to treat psychological disorders

n Insight therapies

• Approaches to psychotherapy based on the notion that psychological well-being depends on self-understanding

n Understanding of one’s own thoughts, emotions, motives, behavior, and coping mechanisms

n Psychodynamic therapies

• Attempt to uncover childhood experiences that are thought to explain a patient’s current difficulties

n Psychoanalysis

• Freud’s first psychodynamic therapy

• Uses free association, dream analysis, and transference

Psychodynamic Therapies

n Free association

• Technique used to explore the unconscious by having patients reveal whatever thoughts, feelings, or images come to mind

n Analyst pieces together the free-flowing associations, explaining their meanings

n Helps the patient gain insight into troubling thoughts and behaviors

n Resistance

• When a patient avoids revealing certain painful or embarrassing thoughts

n Halting speech, “forgetting” appointments, or arriving late

n Dream analysis

• Areas of repressed emotional concerns expressed symbolically in dreams

Psychodynamic Therapies

n Transference

• An emotional reaction that occurs during psychoanalysis

• Patient displays feelings and attitudes toward the analyst that were present in another significant relationship

• Freud believed it to be an essential part of therapy

n Patient can relive troubling experiences from the past with the analyst as a parent substitute

n Aids in resolving any hidden conflicts

n Brief psychodynamic therapy

• Patient and therapist agree beforehand about what issues to work on rather than waiting for them to emerge

• Therapist assumes active role

n emphasizes the present rather than the past

• As effective as other therapies

n For patients without multiple psychological disorders

Humanistic Therapies

Assume people have the ability and freedom to lead rational lives and make rational choices

n Person-Centered Therapy

• A nondirective, humanistic therapy

n Developed by Carl Rogers

• Therapist creates an accepting climate and shows empathy

n Unconditional positive regard

• Frees clients to be themselves, releasing their natural tendency toward self-actualization

• Psychological disorders result when a person’s natural tendency towards self-actualization is blocked by oneself or others

• Therapist empathizes with client’s concerns and emotions

n Reflecting listening used in responses, allowing the client to control the direction of the sessions

n Also called nondirective therapy

• Rogers rejects all forms of therapy that cast the therapist as an “expert” who prescribes something to “cure” the problem

Interpersonal Therapy

Brief psychotherapy designed to help depressed people understand and cope with problems relating to their interpersonal relationships

n Four specific types of interpersonal problems

• Unusual or severe responses to death of a loved one

• Interpersonal role disputes

• Helps understand others’ points of view

• Explore options for bringing about change

• Difficulty adjusting to role transitions

• Divorce

• Career change

• Retirement

• Deficits in interpersonal skills

• Use role playing and analysis of communication styles

• Develop interpersonal skills to initiate and sustain relationships

• 12 to 16 weekly sessions

• Effective, with low drop-out rate

Humanistic Therapies

Assume people have the ability and freedom to lead rational lives and make rational choices

n Person centered therapy (aka client-centered therapy)

• Developed by Carl Rogers

• People grow towards self-actualization if allowed to develop naturally

• Disorders result when a person’s natural tendency is blocked by self or others

• Unconditional positive regard

n An accepting environment created by the therapist

n Utilizes reflecting listening, allowing client to direct session

• Therapist as “expert” rejected by Rogers

Gestalt Therapy

n Originated by Fritz Perls

n Emphasizes importance of clients’ fully experiencing, in the present moment, their feelings, thoughts, and actions

n Client must then take responsibility for them

n Goal of gestalt therapy

• Help clients achieve a more integrated self and become more authentic and self-accepting

• Learn to assume personal responsibility for their behavior rather than blaming society, past experiences, parents, or others

n Directive Therapy

• Any type of therapy in which the therapist takes an active role in determining the course of therapy sessions and provides answers and suggestions to the patient

• “Getting in touch with your feelings” a major objective

• Those in need of therapy carry around unfinished business

• Empty Chair technique role plays past relationships

Relationship Therapy

Relationship Therapy

Family Therapy

n Involves entire family

n Goal is to help family members reach agreement on changes that will help heal the family unit

• Improve communication

• Create understanding

• Enhance harmony within the group

n Dynamics of the family unit

• How family members communicate

• How they act towards and view each other

n Positive effect on treating disorders and clinical problems

• Sexual dysfunctions

• Schizophrenia (when therapy accompanies medication)

n Reduces relapse by reducing criticism, hostility, or emotional over-involvement

• Adolescent drug abuse

Group Therapy

n Several clients (7-10 usually) meet regularly with one or more therapists to resolve personal problems

• Less expensive than regular therapy

• Provides individuals with:

n Sense of belonging

n Opportunity to express feelings

n Opportunity to get feedback from other members

n Chance to give and receive help and emotional support

n Self-help group

• Usually not led by a professional therapist

• Provides people who share a common problem the chance to meet and get support

• Most focus on a single problem (drug abuse or depression)

• Alcoholics Anonymous

n The oldest and best known with 1.5 million members world wide

n Derivatives include Gamblers Anonymous, Overeaters Anonymous, Narcotics Anonymous, Sex Addicts Anonymous

Can give individuals a sense of belonging.

Provides the emotional opportunity to give and receive support.

Behavior Therapies

n Based on the idea that abnormal idea is learned

• Not a sign of an underlying disorder

n If afraid to fly, then fear of flying is the problem

n Applies the principles of operant and classical conditioning, or observational learning

n Eliminate inappropriate or maladaptive behaviors and replace them with more adaptive responses

• Doesn’t change the individual’s personality structure or search for the origin of the problem

n Behavior modification

• Uses learning principles to eliminate inappropriate or maladaptive behaviors and replace them with more adaptive responses

Behavior Modification Therapy
Based on Operant Conditioning

n Seek to control the consequences of behavior

n Extinction of undesirable behaviors accomplished by:

• Terminating or withholding the reinforcement

• Seek to reinforce desirable behavior to increase its frequency

• Best done in hospitals, prisons, and schools classrooms

n Token economies

• Rewards appropriate behavior with tokens

n Poker chips, coupons, play money, stars, stickers, etc.

• Tokens later exchanged for desired goods and/or privileges

n Weekend passes, candy, gum, TV time, etc.

• Undesirable behaviors can be “fined” a certain number of tokens

Behavior Modification Therapy
Based on Operant Conditioning

Behavior Therapies
Based on other Learning Theories

n Systematic desensitization

• Used to treat fears by training clients in deep muscle relaxation

• Then they confront a hierarchy of anxiety producing situations

n Real or Imagined)

• Repeated until they remain relaxed even in the most feared situation

• Highly successfully treatment for eliminating fears and phobias in a short period of time

n Flooding

• Used to treat phobias by exposing clients to feared object or event for an extended period of time until anxiety decreases

n Client with a fear of heights may stand on roof of high building until anxiety subsides

• Sessions do not end until patients are markedly less afraid

• In vivo flooding (real life) works faster – up to 6 sessions

A Possible Hierarchy of Fears

Use what you have learned about systematic desensitization to create a step-by-step approach to help someone overcome a fear of taking tests.

The person’s hierarchy of fears begins with reading in the syllabus that a test will be given and culminates in actually taking the test.

Fill in successive steps, according to a possible hierarchy of fears, that will lead to the final step.

Behavior Therapies
Based on other Learning Theories

n Exposure and response prevention

• Exposes patients with obsessive-compulsive disorder to stimuli that trigger obsessions and compulsive rituals

n Touching a doorknob, piece of unwashed fruit, or garbage bin

• Patients resist performing the compulsive rituals for progressively longer periods of time

n Washing hands, bathing, etc.

• Therapist identifies trigger thoughts, objects, or situations

• Typically 10 treatment sessions over 3-7 weeks bring improvement in 60-70% of patients

• Less relapse than those treated with drugs alone

• Also useful in treatment of posttraumatic stress disorder

Behavior Therapies
Based on other Learning Theories

n Aversion therapy

• Negative behavior is paired with a painful, sickening, or otherwise aversive stimulus until the behavior becomes associated with pain or discomfort

n Electric shock, emetics (cause nausea and vomiting), antabuse

• Antabuse reacts violently with alcohol causing a person to retch and vomit until the stomach is empty

n Painting fingernails with bitter-tasting coating to stop nail chewing

n Participant modeling

• Appropriate response to a feared stimulus is modeled in graduated steps

• Client attempts to imitate the model step by step while the therapist gives encouragement and support

• Most phobias can be extinguished in only 3 or 4 hours

Cognitive Therapies

Assume maladaptive behavior can result from irrational thoughts, beliefs, and ideas

• Often called cognitive-behavioral approach

• Combine cognitive insight with methodological behavioral approach

• Therapists seek to change the way clients think

n Determine effectiveness by assessing changes in the client’s behavior

• Effective in treatment of:

n Anxiety disorders

n Hypochondriasis

n Psychological drug dependence

n Pathological gambling

Cognitive Therapies

n Rational emotive therapy

• Directive form of psychotherapy designed to challenge client’s irrational beliefs about themselves and others

n Based on Ellis’ ABC Theory

• = activating event

• = person’s belief about the event

• = emotional consequence that follow

• Ellis claims it is not the event itself that causes the emotional consequence, rather it is the person’s belief about the event

• A does not cause C

• B causes C

• If the belief is irrational, then the emotional consequence can be extreme distress

The ABC’s of Rational-Emotive Therapy

Cognitive Therapies

n Rational emotive therapy

• Ellis believes clients do not benefit from warm, supportive therapeutic approaches that do not address the irrational thoughts that underlie the problem

• As irrational beliefs are replaced, emotional reactions become appropriate and less distressing, eventually leading to constructive behaviors

• Client’s are taught they can not control demands of others but can control their emotional reactions

• Relaxation techniques often taught to control emotional reactions

• RET equally effective with systematic desensitization

Cognitive Therapies

n Beck’s cognitive therapy

• Help patients stop negative thoughts as they occur and replace them with more objective or positive thoughts

• Automatic thoughts cause misery of depression and anxiety:

n “To be happy I must be liked by everyone.”

n “If people disagree with me, it means they don’t like me.”

• Depressed people hold a negative view of present, past, and future experiences

n “It has never worked and I can’t make it happen.”

• Notice only negative unpleasant things

n Fail to recognize positive events and feelings

• Jump to the wrong conclusions

n “No one likes me.”

Cognitive Therapies

n Beck’s cognitive therapy

• Therapist identifies and challenges irrational thoughts

• Sets up a plan and guides the client so life experiences become evidence to refute false beliefs

• Homework assignments given to track automatic thoughts and feelings evoked by them; clients write substitute rational thoughts

• Brief, lasting 10-20 sessions

• Extensive research demonstrates high success rate with:

n Mild to moderate depression

n Panic disorder

n Generalized anxiety disorder

n Cocaine addiction, insomnia, and bulimia

n Negative and positive symptoms of schizophrenia

n Less likely to relapse than those treated with antidepressant drugs

Beck’s Cognitive Therapy

Biological Therapies

n Therapy based on the assumption that psychological disorders are symptoms of underlying physical problems

n Includes drug therapy, electroconvulsive therapy, and psychosurgery

n Millions of people take medications for psychological problems

n Drug therapy

• Antipsychotic drugs

n Drugs used to control severe psychotic symptoms

• Delusions, hallucinations, disorganized speech and behavior

n Inhibiting dopamine activity

• Also known as neuroleptics

• Thorazine, Stelazine, Compazine, Mellaril

• 50% of patients have a good response

• Long-term use may lead to tardive dyskinesia

n Almost continual twitching and jerking of face and tongue and squirming movements of the hands and trunk

Biological Therapies

n Antipsychotic drugs

• Atypical neuroleptics (newer drugs)

• Clozapine, Risperidone, Olanzipine

n Target both dopamine and serotonin

n Marked improvement in quality of life – tardive dyskinesia is rare

n Treat both positive and negative effects of schizophrenia

Antidepressant Drugs

n Act as mood elevators for severely depressed people and are also prescribed to treat some anxiety disorders

n 65-75% of patients report significant improvement

n 40-50% report complete recovery

• Placebo studies demonstrate almost equal effectiveness

• Responses to antidepressants a combination of physiological effects on the brain and the patient’s confidence in effectiveness of treatment

n Tricyclics – first generation of antidepressants

• Block reuptake of norepinephrine and serotonin into axon terminals

n Enhances the action of these neurotransmitters in the synapses

• Side effects include:

n Sedation, fatigue, dizziness, nervousness, dry mouth, forgetfulness, and weight gain

n Weight gain #1 reason (20 or more pounds) people stop taking them despite benefit

Antidepressant Drugs

n Second generation antidepressants

• Selective serotonin reuptake inhibitors

n Block the reuptake of serotonin increasing availability at the brain synapses

• Fewer side effects and safer in case of overdose

• Effective in treating:

n Obsessive-compulsive disorder

n Social phobia

n Panic disorder

n Generalized anxiety disorder

n Binge eating

• Side effects

n Sexual dysfunction

• Returns to normal when drug is discontinued

n Increase in suicide risk not substantiated

Antidepressant Drugs

n Monoamine oxidase inhibitors (MAOI)

• Block the action of an enzyme that breaks down norepinephrine and serotonin in the synapses

• Increase the availability of norepinephrine and serotonin

• Usually prescribed to patients who do not respond to other antidepressants

• Similar side effects to tricyclic antidepressants plus patients must avoid certain foods to reduce the risk of stroke

n Lithium and anticonvulsant drugs

• Naturally occurring salt used to treat bipolar disorder

• Effectiveness in treating depression and bipolar is unmatched

• 40-60% of patients experience a recurrence

• Monitoring blood level necessary to prevent nervous system damage

• Anticonvulsant drugs effective treating bipolar symptoms with fewer side effects

Anti-Anxiety Drugs

n Benzodiazepines

• Valium, Librium, and Xanax

• Prescribed more often than any other class

• Effective in treating panic disorder and anxiety

• Xanax

n Works fast and has few side effects

n Relapse is likely if discontinued

n Withdrawal symptoms include intense anxiety

n Disadvantages of Drug Therapy

• Difficulty establishing proper dosages

• Help with symptoms but do not cure psychological disorders

• Maintenance doses are required to prevent relapse

• Increase in homeless population

Drugs Used to Treat Psychological Disorders

Psychiatric Drugs for
Children and Adolescents

n Number of children in U.S. taking psychiatric drugs between 5-6%

n Typical and atypical neuroleptics to treat psychotic symptoms

• May be used to treat autism

n Response to antidepressants similar to that in adults

• Higher incidence of suicidal thinking

n Diagnosis and drug treatment of children with bipolar disorder is controversial

n Tranquilizers

• Used only in unusual circumstances

• May have opposite effect – agitating not calming

Electroconvulsive Therapy

n An electric current is passed through the right hemisphere of the brain

n Usually reserved for severely depressed patients who are suicidal and don’t respond to other treatments

n Highly effective for major depression

n Unilateral ECT used today instead of bilateral ECT

• Equally effective with milder cognitive side-effects

n Patients are given anesthesia, controlled oxygenation, and a muscle relaxant

n When effective, ECT:

• Changes the biochemical balance in the brain

• Reduces cerebral blood flow in the prefrontal cortex

• Triggers delta waves

n No structural brain damage demonstrated in MRI or CT scans

Psychosurgery

Brain surgery performed to alleviate serious psychological disorders or unbearable chronic pain

• Severe depression, anxiety, or obsessions

n Lobotomy

• The first surgery severing neural connections between the frontal lobes and the deeper brain centers involved in emotions

• Initially a tremendous contribution, however treatment left patients in a severely deteriorated condition

n Modern psychosurgery

• Results in less intellectual impairment

• Surgeons deliver electrical currents through electrodes to destroy smaller, localized areas of brain tissue

• Helpful with obsessive-compulsive disorder

• Results still not predictable and consequences are irreversible

• Treatment is considered experimental and an absolute last resort

Evaluating the Therapies

n Various therapeutic approaches share many similarities

• Several help clients reflect on their own thoughts and/or emotions

n Most therapists use a set of core techniques regardless of perspective

n Specific elements distinguish therapeutic approaches from one another

n Overall:

• Psychotherapy is better than receiving no treatment

• No one type of treatment is more effective than another

n Behavioral therapies show slight overall advantage

n Cognitive and interpersonal therapies show advantage for depression

n Patient’s view of effectiveness

• Believe they benefit substantially from psychotherapy

• Equally satisfied with psychologist, psychiatrist, or social worker

• The longer a patient was in therapy, the more he/she improved

n 6 months +

• Patients taking Prozac or Xanax believed it helped them

• Psychotherapy seemed to work as well as psychotherapy plus drugs

Mental Health Professionals

Culturally Sensitive Therapy

n Knowledge of clients’ cultural backgrounds guides the choice of therapeutic interventions

n The meaning of symptoms, outcomes, and responses to therapy are viewed within a cultural context

n Cultural difference may affect the therapeutic alliance

n Language differences can pose problems

• Bilingual patients more fluent in Spanish but speaking English may exhibit “symptoms” causing therapist to misdiagnose:

n Hesitations

n Backtracking

n Delayed responses to questions

• Affect results on standardized tests

n Need to consider immigration experiences on thoughts and emotions

Culturally Sensitive Therapy

n Cultural models should be included with interventions

• Native American healing circles

n Promote physical, mental, emotional, and spiritual well-being

n May also include discussion, meditation, and prayer

n Address group differences that can affect therapy results

• African Americans are less likely to follow medication instructions

• Compliance increased by understanding the importance of kinship and community relationships within the culture

n Have the patient participate in a support group of members with the same disorder, medication, and culture

• Discuss racial perspectives prior to beginning therapy

Gender-Sensitive Therapy

n Takes into account the effects of gender on both the therapist’s and the client’s behaviors

n Therapist must examine own gender-based prejudices

• Assuming men are more logical and women more emotional

n Knowledge of real differences between sexes is important

• Emotional expression interventions may be less effective for men due to gender-role socialization

n Men may see therapy as a sign of weakness or threat to masculinity

• Therapist should avoid creating defensiveness in male clients

n Avoid using research findings as a basis for stereotyping

• More variation within each gender than across genders

• Consider each man or woman as an individual

• Placing too much emphasis on sensitivity can lead to misinterpreting client

• May consider problems arising from gender-role conflict incorrectly

Is E-Therapy Right for You?

Typically involves the exchange of email messages over a period of hours or days, but can also include video-conferencing and telephone sessions

n Advantages of E-therapy

• Less inhibited than face-to-face sessions

• Less expensive

• Do not have to be in the same place at the same time

n Random schedule

n Live in remote areas

• Therapist can keep accurate records of interactions

• Helpful if client is good at expressing thoughts and feelings in writing

Is E-therapy Right for You?

n Disadvantages of E-therapy

• Imposters can pose as therapists

• No present system for regulating or licensing e-therapists

• Ethical problems

n Possible breaches of confidentiality

• Lack of visual or auditory input limits possible feedback and response to manifest symptoms

n Finding an E-therapist

• Verify credentials via a third party

n Licensing or certification board

• Get real-world contact information

n Address and phone number

• Verify that you will receive personal replies to messages

• Find out in advance how much the therapist charges