Chapter 15 Psychotherapy. The Treatment Process, continued Treatments: How many types are there?...

Chapter 15

Psychotherapy

The Treatment Process, continued

• Treatments: How many types are there?– All psychotherapies involve “a helping

relationship (the treatment) between a professional (the therapist) and another person in need of help (the client)”.

– There are three main categories of therapy:1. Insight therapies.2. Behavior therapies.3. Biomedical therapies.


• Clients: Who seeks therapy?– Approximately 15% of Americans seek

mental health services each year.– The most common problems are

excessive anxiety and depression.– People seek treatment for milder

problems, such as making a career decision, as well.

– Women, people with medical insurance, and people with more education are all more likely to seek treatment.


Clients: Who seeks therapy?, continued– Unfortunately, many who need therapy do

not receive it (see Figure 15.2).– Common barriers to seeking treatment

include

• Lack of health insurance.

• The “stigma” associated with receiving mental health services.

Figure 15.2. Therapy utilization rates. Olfson and colleagues (2002) gathered data on the use of nonhospital outpatient mental health services in the United States in relation to various demographic variables. In regard to marital status, utilization rates are particularly high among those who are divorced or separated. The use of therapy is greater among those who have more education and, in terms of age, utilization peaks in the 35-44 age bracket. Females are more likely to pursue therapy than males are, but utilization rates are extremely low among ethnic minorities. (Data from Olfson et al., 2002)


• Therapists: Who provides treatment?– Psychologists and psychiatrists are the

most common providers of treatment.– However, therapy is also provided by

other professionals, including

• Psychiatric social workers.

• Psychiatric nurses.

• Counselors.


Therapists, continued– Clinical psychologists and counseling

psychologists “specialize in the diagnosis and treatment of psychological disorders and everyday behavioral problems”.

– Both require a doctoral degree (Ph.D., Psy.D., or Ed.D).

– Psychologists are more likely to use behavioral methods over psychoanalysis.

– Psychologists also do psychological testing and conduct research.


Therapists, continued– Psychiatrists “are physicians who

specialize in the treatment of psychological disorders”.

– Psychiatrists focus on more severe disorders (e.g., schizophrenia).

– Psychiatrists earn an M.D. and typically emphasize drug therapies (psychologists cannot prescribe medication).

– Psychiatrists are also more likely to use psychoanalysis.


Therapists, continued• Other mental health professionals

– Psychiatric social workers work as part of a treatment “team” with a psychologists or psychiatrist.

– They have a master’s degree and usually help patients integrate back into the community.

– Psychiatric nurses earn a bachelor’s or master’s degree and usually work with hospitalized patients.

Insight Therapies, continued

• Insight therapies “involve verbal interactions intended to enhance clients’ self-knowledge and thus promote healthful changes in personality and behavior”.– Insight therapies include

• Psychoanalysis.• Client-centered therapy.• Positive psychology.• Group therapy.


• Psychoanalysis was developed by Sigmund Freud, and “emphasizes the recovery of unconscious conflicts, motives, and defenses through techniques such as free association, dream analysis and transference”.– Probing the unconscious

• Therapists use two techniques to probe the unconscious in an attempt to identify unresolved conflicts causing the client’s neurotic behavior.


Psychoanalysis, continued– In free association, “clients

spontaneously express their thoughts and feelings exactly as they occur, with as little censorship as possible”.

– In dream analysis, “the therapist interprets the symbolic meaning of the client’s dreams”.

– Both techniques require the therapist to interpret the clues that these methods provide about unconscious conflicts.


Psychoanalysis, continued– Interpretation “involves the therapist’s

attempts to explain the inner significance of the client’s thoughts, feelings, memories, and behaviors”.

– Resistance “involves largely unconscious defensive maneuvers intended to hinder the progress of therapy”.• Clients may resist by “forgetting”

appointments or being hostile toward the therapist.


Psychoanalysis, continued– Transference “occurs when clients start

relating to their therapists in ways that mimic critical relationships in their lives”.

– Although classical psychoanalysis (as performed by Freud) is rare today, newer versions of the therapy are used and are referred to as psychodynamic approaches.


• Client-centered therapy “is an insight therapy that emphasizes providing a supportive emotional climate for clients, who play a major role in determining the pace and direction of their therapy”.– This approach is rooted in the humanistic

perspective and the work of Carl Rogers.– Therapists try to foster self-acceptance

and personal growth in their clients.– Therapists also help clients restructure

their self-concept to better correspond with reality.


Client-centered therapy, continued– Therapeutic climate

• Rogers believed three elements were necessary to promote positive changes in therapy:1. Genuineness (honest

communication).2. Unconditional positive regard

(therapist remains supportive, non-judgmental).

3. Empathy (therapist understands issues from client’s point of view).


Client-centered therapy, continued– Therapeutic process

• With this approach, the client and therapist work together almost as equals.

• The therapist’s key task is clarification – “reflecting the client’s statements with enhanced clarity”.

• The main goal of therapy is to help clients become more aware of, and comfortable with, their “genuine selves”.


• Therapies inspired by positive psychology– Well-being therapy, developed by Giovanni

Fava, focuses on “self-acceptance, purpose in life, autonomy, and personal growth”.

– Positive psychotherapy – “ attempts to get clients to recognize their strengths, appreciate their blessings, savor positive experiences, forgive those who have wronged them, and to find meaning in their lives”.

• It has been successful in treating depression (see Figure 15.5).

Figure 15.5. Positive psychotherapy for depression. In a study of the efficacy of positive psychotherapy, it was compared to treatment as usual (clinicians delivered whatever treatment they deemed appropriate) and to treatment as usual combined with antidepressant medication. At the end of 12 weeks of treatment, symptoms of depression were measured with the widely used Hamilton Rating Scale for Depression. The mean depression scores for each group are graphed here. As you can see, the positive psychotherapy group showed less depression than the other two treatment groups, suggesting that positive psychotherapy can be an effective intervention for depression.

SOURCE: Adapted from Seligman, M.E.P., Rashid,T.,& Parks, A.C.(2006). Positive psychotherapy. American Psychologist, 61, 774-778. (Figure 2, p. 784).


• Group therapy “is the simultaneous treatment of several or more clients (typically five to ten people) in a group”.– Participants’ roles

• In group therapy, participants function like “therapists” for each other.

• The most important role is that of providing emotional support for fellow members of the group.


Group therapy, continued– Advantages of the group experience

1. Clients realize their problems are not unique.

2. It provides an opportunity to practice and enhance social skills.

3. Certain problems are well-suited for group therapy. In “peer self-help groups”, all members share the same kind of problem (e.g., Alcoholics Anonymous) and can provide support for each other.


• Evaluating insight therapies– It is difficult to compare the effectiveness

of one type of insight therapy to another because of the allegiance effect, in which researchers often find the most support for the therapeutic approach they use.

– Despite this, many studies have shown insight therapy to be superior to placebo and to produce lasting effects.

– Also, most people find therapy beneficial.


Evaluating insight therapies, continued

• Common factors that make various insight therapies effective:

1. Developing an alliance with a professional helper.

2. Emotional support and empathic understanding from the therapist.

3. The cultivation of hope, positive expectations.


Evaluating insight therapies, continued4. Provision of a rationale for one’s problems

and a method for alleviating them.5. The opportunity to express feelings,

confront problems, gain new insights, and learn new patterns of behavior.


• Therapy and the recovered memories controversy– Much debate has centered around clients’

“recovery” of forgotten memories of traumatic events, including abuse by parents.

– This is controversial because it is not possible to be absolutely certain whether or not the memory is real.


Therapy and recovered memories, continued– Furthermore, some recovered “memories”

of abuse have been proven to be false, and people (e.g., parents) have been falsely accused of crimes they did not commit.

– Psychologists are sharply divided on the issue.

– Proponents argue that recovered memories are genuine and valuable.


Therapy and recovered memories, continued– Critics cite research showing that false

memories can be “implanted” in experimental conditions.

– Critics also argue that clients, confused about the source of their troubles, are persuaded by therapists who are overly eager to attribute problems to childhood abuse.

Behavior Therapies, continued

• Insight therapists believe that behaviors are symptoms of underlying psychological issues.

• In contrast, behavior therapists argue that the behaviors themselves are the problem.

• Thus, behavior therapies “involve the application of the principles of learning to direct efforts to change clients’ maladaptive behaviors”.


• Behavior therapy is based on two assumptions:

1. Behavior is a product of learning.

2. What has been learned can be unlearned.

• Clients’ vague complaints are redefined in terms of concrete, specific goals.

• Specific procedures are then used for specific kinds of problems to reach the goal.


• Systematic desensitization “is a behavior therapy used to reduce clients’ anxiety responses through counterconditioning”.– The goal with this technique is to break

down the association between the conditioned stimulus (or the stimulus that triggers fear) and the conditioning response of anxiety (see Figure 15.7).

Figure 15.7. The logic underlying systematic desensitization. Behaviorists argue that many phobic responses are acquired through classical conditioning, as in the example diagrammed here. Systematic desensitization targets the conditioned associations between phobic stimuli and fear responses.


Systematic desensitization, continued– Before beginning, the therapist helps the

client build a fear hierarchy, or a list of progressively more frightening versions of the conditioned stimulus (see Figure 15.8).

– Then, the client is trained in deep muscle relaxation.

– Finally, the client pairs the learned relaxation with each step of the hierarchy until anxiety to the fear stimulus is reduced.

Figure 15.8. Example of an anxiety hierarchy. Systematic desensitization requires the construction of an anxiety hierarchy like the one shown here, which was developed for a woman with a fear of heights who had a penchant for hiking in the mountains.


• Aversion therapy “is a behavior therapy in which an aversive stimulus is paired with a stimulus that elicits an undesirable response”.– For example, as shown in Figure 15.9, an

alcoholic’s desire to drink could be weakened by pairing a nausea-inducing drug with alcohol.

– Aversion therapy is used with a wide range of undesirable behaviors including gambling, shoplifting, and smoking.

Figure 15.9. Aversion therapy. Aversion therapy uses classical conditioning to create an aversion to a stimulus that has elicited problematic behavior. For example, in the treatment of drinking problems, alcohol may be paired with a nausea-inducing drug to create a conditioned aversion to alcohol.


• Social skills training “is a behavior therapy designed to improve interpersonal skills that emphasizes shaping, modeling, and behavioral rehearsal”.– First, the client watches socially skilled

people model (or demonstrate) successful interactions with others.

– In behavioral rehearsal, the client practices modeled techniques through role-playing exercises – and eventually – in real life.

– Shaping is used to get clients to handle gradually more demanding social situations.


• Cognitive-behavioral treatments blend verbal and behavioral interventions.

• Cognitive therapy “is a treatment that emphasizes recognizing and changing negative thoughts and maladaptive beliefs”.– It emerged from the work of two former

psychoanalysts: Albert Ellis and Aaron Beck (this chapter will focus on the work of Aaron Beck).


Cognitive therapy, continued– According to Beck, depression is caused by

errors in thinking, and people who experience depression are more likely to1. Blame their setbacks on personal

inadequacies.2. Focus selectively on negative events.3. Make overly pessimistic projections about

the future.4. Draw negative conclusions about their

self-worth.


Cognitive therapy, continued– The main goal of cognitive therapy is to

change the way clients think.– The therapist’s goal is to help clients

detect automatic negative thoughts and to use more reasonable standards of evaluation.

– The therapist primarily sets the pace and direction of treatment.


• Evaluating behavior therapies– Generally, behavior therapies are very

effective. This is especially true with regard to treatment of• Anxiety problems, phobias, OCD, and

schizophrenia.• Sexual dysfunction.• Drug-related problems and eating

disorders.• Hyperactivity.• Autism and mental retardation.

Biomedical Therapies, continued

• Biomedical therapies “are physiological interventions intended to reduce symptoms associated with psychological disorders”.

• Two prominent biomedical therapies are– Drug therapy.– Electroconvulsive (ECT).

Biomedical Therapies, continued:

• Treatment with drugs– Psychopharmacotherapy (or drug

therapy) “is the treatment of mental disorders with medication”.

– Therapeutic drugs fall into four main categories:1. Antianxiety drugs.2. Antipsychotic drugs.3. Antidepressant drugs.4. Mood stabilizers.


Treatment with drugs, continued• Antianxiety drugs “relieve tension,

apprehension, and nervousness”.– Two common antianxiety drugs are Valium

and Xanax.– These drugs provide fast relief.– However there is the risk for abuse,

dependency, overdose, and withdrawal effects.

– Newer drugs such as Buspar act slower, with fewer sedative side effects.


Treatment with drugs, continued

• Antipsychotic drugs “are used to gradually reduce psychotic symptoms, including hyperactivity, mental confusion, hallucinations, and delusions”.– They are typically used to treat

schizophrenics or other patients in a delusional state.

– Common antipsychotics include Thorazine, Mellaril, and Haldol.


Treatment with drugs, continued– Antipsychotics work gradually (two to

seven days), and reduce symptoms in about 70% of patients.

– They do have unpleasant side effects, however, including

• Dry mouth, constipation.

• Drowsiness.

• Tremors, muscular rigidity, and impaired coordination.


Treatment with drugs, continued– A more serious, but rare, side effect is a

condition called tardive dyskinesia, “a neurological disorder marked by chronic tremors and involuntary spastic movements”, which is irreversible.

– Atypical antipsychotics are a newer class of drugs with a lower risk of these side effects (e.g., clozapine, olanzapine, & quetiapine).


Treatment with drugs, continued

• Antidepressant drugs “gradually elevate mood and help bring people out of a depression”.– The most commonly used antidepressants

today are SSRIs (selective seratonin reuptake inhibitors) that work by affecting the brain chemical, seratonin (e.g., Zoloft).

– SSRIs also work for some anxiety disorders.


Treatment with drugs, continued– Side effects of SSRIs include

• Weight gain.

• Sleep problems.

• Sexual dysfunction.– More recently, research has raised concern

that SSRIs may possibly increase the risk for suicide, especially in adolescents.


Treatment with drugs, continued– The newest class of antidepressants are

SNRI, which work on seratonin and norepinephrine receptors.

– Preliminary data suggests they produce stronger antidepressant effects than SSRIs.

– However, there may be more side effects, including elevated blood pressure.


Treatment with drugs, continued• Mood stabilizers “are drugs used to control

mood swings in patients with bipolar mood disorders”.– Lithium has long been used to treat bipolar

disorder, but has dangerous side effects, including• Toxicity or death at high concentrations.• Kidney and thyroid gland problems.

– Newer drugs (e.g., Valproate) appear to be as effective, with fewer side effects.


• Evaluating drug therapies– Benefits

• Drugs provide relief for severe disorders that cannot be helped by other therapies.

– Critics argue that• Drugs only treat symptoms, not underlying

causes of disorders.• Drugs are overprescribed; people are

overmedicated.• Side effects may be worse than the

symptoms drugs are used to treat.


• Electroconvulsive therapy (ECT) “is a biomedical treatment in which electric shock is used to produce a cortical seizure accompanied by convulsions”.– ECT is primarily used to treat depression.– Patients are given a light anesthetic and

muscle relaxers to prevent spinal fractures.

– Electric current is applied for about a second, which triggers a brief seizure.

– Typically, patients receive 6-12 treatments over the course of a month.


ECT, continued

• Effectiveness of ECT– Proponents of ECT claim it is very

effective for depression in patients that do not respond to medication.

– Opponents argue that it is not more effective than placebo and carries serious risks.


ECT, continued

• Risks associated with ECT– ECT proponents admit that memory loss

and impaired attention are mild, temporary side effects of the treatment.

– Critics argue that these cognitive problems are more serious and sometimes permanent.

Current Trends and Issues, continued

• Grappling with constraints of managed care– Before the 1990s, with the fee-for-service

system, doctors charged patients fees for whatever services were necessary. Patients were then reimbursed through insurance or the government.

– This system changed to a managed care system in the 1990s, in which people enroll in prepaid plans (typically run by HMOs) and make small copays for services.


Managed care, continued– Managed care was developed in an

attempt to control inflation of medical costs.

– However, critics assert that, in an attempt to control costs, healthcare has been rationed and access to some medically necessary services has been limited.

– This is especially true in the mental health field, in which HMOs may not recognize the necessity of certain treatments.


Managed care, continued– In addition, critics argue that, as a result of

managed care, mental health patients• Are often underdiagnosed (to avoid

having to prescribe costly treatments).• Are not referred to mental health

specialists by primary physicians.• Are limited in the number of

psychotherapy sessions, or length of treatment, they can have.


Managed care, continued– Critics also argue that managed care has

created barriers to access, such as• Requiring referrals from primary care

physicians who don’t have appointments available for weeks or months.

• Rerouting patients to less expensive master’s-level counselors who may not be able to handle serious disorders.

• Prescribing older, less expensive drugs.


• Blending approaches to treatment– It is becoming increasingly common for

therapists to draw from various therapeutic approaches to treat a client.

– Studies show that there is, indeed, merit to this idea.

– Today, most therapists describe themselves as eclectic – “drawing ideas from two or more systems of therapy” (see Figure 15.15).

Figure 15.15. The leading approaches to therapy among psychologists. These data, from a survey of 531 psychologists who belong to the American Psychological Association’s Division of Psychotherapy, provide some indication of how common an eclectic approach to therapy has become. The findings suggest that the most widely used approaches to therapy are eclectic, psychodynamic, and cognitive-behavioral treatments. (Based on data from Norcross, Hedges, & Castle, 2002).


• Increasing multicultural sensitivity in treatment– Minority groups are especially unlikely to

seek and utilize therapy.

1. Cultural barriers– Some cultures emphasize assistance

from family, clergy, etc., over mental health professionals.

– Some cultures have difficulty trusting the medical (and mental health) establishment.


Increasing multicultural sensitivity, continued2. Language barriers

– Effective communication is critical to therapy, and cultural differences in language can act as a barrier to treatment.

3. Institutional barriers– Most therapists have only been trained

to interact with white, middle-class clients and are unfamiliar with the cultural backgrounds of various ethnic groups.


Increasing multicultural sensitivity, continued

• What can be done?

– Recruit and train minority therapists.

– Train therapists how to work more effectively with a culturally diverse clientele.

– Research how to modify current approaches so that they are more compatible with a diverse clientele.

Application: Looking for a Therapist, continued

• Where do you find therapeutic services?– Contrary to popular belief, most therapists do

not operate in private practice.

In fact, many work in

• Institutional settings (such as community mental health centers).

• Human service agencies.

• See Figure 15.16 for more information.

Figure 15.16. Sources of therapeutic services. Therapists work in a variety of organizational settings. Foremost among them are the five described here.


• Is the therapist’s profession or sex important?– Researchers have not found any reliable link

between the therapists’ profession (e.g., psychologist versus psychiatrist) and therapeutic efficacy.

– However, psychiatrists are the only mental health professionals who can prescribe medication.


– This is a subjective matter. – Thus, if the client thinks he or she will feel more

comfortable with a therapist of the same gender, then that person should find one that is the same gender.

• Is therapy always expensive?– Not necessarily. Costs can be reduced by

• Seeking treatment from providers who are not in private practice (e.g., human service agencies).

• Using health insurance.


• Is the therapist’s theoretical approach important?– For certain types of problems, certain

theoretical approaches are a better fit.– For example,

• Cognitive therapy is best for panic disorders.

• Behavior therapy (systematic desensitization) is best for phobias.

• OCD is best treated with behavior therapy and medication.


• What is therapy like?– It is important to have realistic expectations

about therapy.– Therapy is usually a slow process.– Therapy is hard work.– Your therapist is only a facilitator. Ultimately,

you have to make changes in your behavior or personality in order to see improvement.

Chapter 15 Psychotherapy. The Treatment Process, continued Treatments: How many types are there?...

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