Chapter 13

Methods of Therapy

LECTURE OUTLINE

I. What is Psychotherapy?

A. Psychotherapy: a systematic interaction between a therapist and a client that:

1. Applies psychological principles to affect the client’s thoughts, feelings, or behavior in order to;

a. Help the client overcome psychological disorders,

b. Adjust to problems in living,

c. Or develop as an individual.

2. Essentials

a. Systematic interaction

b. Psychological Principles

c. Thoughts, feelings, and behavior

d. Psychological disorders, adjustment problems, and personal growth

B. The History of Therapies.

1. Treatments often reflected demonological thinking.

2. Asylums built for warehousing not treatment.

a. Bedlam derives from St. Mary’s of Bethlehem the London asylum.

3. Humanitarian reform began in:

a. Paris with Philippe Pinel at the La Bicetre hospital.

b. England with William Tuke.

c. America with Dorothea Dix.

4. Mental Hospitals: gradually began replacing asylums.

a. In the mid 1950s more than a million people resided in facilities.

5. The Community Mental Health Movement: attempt to maintain new patients as outpatients and to serve patients who have been released from mental hospitals.

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II. Psychoanalytic Therapies: Digging Deep Within.

A. Based on the thinking of Freud.

1. Assume that psychological disorders reflect early childhood experiences and internal conflicts.

B. Traditional Psychoanalysis.

1. Psychoanalysis can extend for months, even years.

a. The aim is to provide insight into the conflicts that are the cause of the person’s problems.

b. Catharsis is a spilling forth of repressed conflicts and guilt.

2. Free Association.

a. Hypnosis allowed clients to focus on repressed conflicts.

b. Free association: the client is made comfortable and asked to talk about anything that comes to mind.

3. Resistance: clients may not talk about threatening ideas. These ideas are repressed.

4. Interpretation: the process of showing the client how revealed ideas illustrate deep seated feelings and conflicts.

5. Transference: clients respond to the therapist with the attitudes and feelings they have toward other people in their lives.

a. Often clients reenact their childhood conflicts.

6. Dream Analysis.

a. Freud believed that dreams were the royal road to the unconscious.

i. Dreams are determined by unconscious processes as well as the events of the day.

ii. Unconscious impulses are expressed in dreams as a form of wish fulfillment.

b. Perceived dream content is called the manifest content.

c. The hidden or symbolic content is called the latent content.

C. Short-Term Dynamic Therapies.

1. The modern approach is:

a. Briefer and less intense.

b. Focus on revealing unconscious material and breaking through defenses.

c. Client and therapist usually sit face to face rather than having the client lie on a couch.

d. The therapist is usually directive.

e. Usually more focus on the ego and less emphasis on the Id.

i. Sometimes referred to as ego analysis.

f. Many “second generation” of psychoanalysts believed that Freud put too much emphasis on sex and aggression and underestimated the role of the ego.

2. Interpersonal Psychotherapy (ITP) focuses on clients’ relationships rather than their childhoods.

a. Usually lasts no longer than 9-12 months.

b. Anxiety and depression occur within social relationships.

III. Humanistic Therapies: Strengthening the Self.

A. The focus is on quality of the client’s subjective, conscious experience.

1. Focus on the here and now.

B. Client-Centered Therapy: Removing Roadblocks to Self Actualization.

1. Client centered therapy is intended to help people get in touch with their genuine feelings and pursue their own interests, regardless of other people’s wishes.

2. Clients are free to make choices and control our destinies.

3. Psychological problems arise from roadblocks placed in the path of self-actualization.

4. Client centered therapy is non-directive and focuses on helping the person feel whole. To achieve this the therapist has the following qualities:

a. Unconditional positive regard.

b. Empathetic understanding.

c. Genuineness.

C. Gestalt Therapy: Getting It Together.

1. Gestalt therapy was originated by Fritz Perls.

2. The approach assumes that people disown parts of themselves and don social masks.

3. The goal is to integrate conflicting parts of their personality.

4. Gestalt therapy is highly directive.

5. People are free to make choices and to direct their own personal growth.

IV. Behavior Therapy: Adjustment Is What You Do.

A. Behavior therapy (behavior modification) focus is on what people do.

1. Applies the principles of learning to directly promote desired behavioral change.

a. The principles of conditioning and observational learning.

B. Fear-Reduction Methods.

1. Systematic desensitization is a method for reducing phobic responses.

a. The client learns to handle increasingly disturbing stimuli while anxiety is being counterconditioned.

i. Counterconditioning: a response that is incompatible with anxiety is made to appear under conditions that usually elicit anxiety.

ii. Feared objects are “arranged” in a hierarchy according to their ability to trigger anxiety.

b. Virtual therapy uses elaborate equipment to present the arranged fears.

2. Modeling relies on observational learning. Clients model individuals dealing with the feared object.

C. Aversive Conditioning.

1. Controversial procedure in which painful or aversive stimuli are paired with unwanted impulses.

a. The effectiveness of this approach is uncertain.

2. Rapid smoking is an aversive conditioning method designed to help smokers quit by having smokers inhale every six seconds or by having smoke blown into the smoker’s face while they are smoking.

D. Operant Conditioning Procedures.

1. We tend to repeat behavior that is reinforced.

2. Behavior that is not reinforced tends to become extinguished.

3. The Token Economy.

a. Patients must use tokens to purchase things they like.

b. Tokens are reinforcements for productive activities.

4. Successive Approximations.

a. Successive approximations is often used to help clients build good habits.

5. Biofeedback Training (BFT).

a. Help clients become more aware of, and gain control over, various bodily functions once thought to be beyond conscious control including:

i. Heart rate

ii. Blood pressure

6. Social Skills Training.

a. Employ self monitoring, coaching, modeling, role playing, behavioral rehearsal and feedback.

b. Often used to help formerly hospitalized patients maintain jobs and apartments in the community.

7. Assertive Training is a form of social skills training often carried out in groups.

a. Clients are trained to express their genuine feelings and refuse unreasonable requests.

V. Cognitive Therapies: Adjustment Is What You Think (and Do).

A. Cognitive therapy focuses on changing the beliefs, attitudes and automatic types of thinking that create and compound their client’s problems.

1. Heighten insight into current cognitions.

2. Appraisals of unfortunate events can heighten our discomfort and impair our coping ability.

B. Cognitive Therapy: Correcting Cognitive Errors.

1. Cognitive Triad:

a. Expect the worst of themselves.

b. Expect the worst of the world at large.

c. Expect the worst of the future.

2. Therapists need to challenge beliefs that are not supported by evidence.

a. Clients need to become personal scientists and challenge beliefs that are not supported by evidence.

b. Cognitive errors contribute to client’s miseries by:

i. Clients selectively perceive.

ii. Clients overgeneralize.

iii. Clients magnify or blow out of proportion.

iv. Clients engage in absolutist thinking.

C. Rational Emotive Behavior Therapy: Overcoming “Musts” and “Shoulds”.

1. Rational emotive behavior therapy (REBT) focuses on beliefs about events as well as the events.

a. Many harbor irrational beliefs.

i. The irrational belief that we must have the love and approval of people who are important to us.

ii. The irrational belief that we must prove ourselves to be thoroughly competent, adequate, and achieving.

b. The methods are directive and active.

i. Ellis suggested that we need less misery, less blaming and more action.

D. Towards a Cognitive-Behavioral Therapy

1. Many theorists consider cognitive therapy to be a collection of techniques that are a part of behavior therapy.

a. Beck refers to this approach as cognitive-behavioral.

b. Now referred to as cognitive-behavioral therapy (CBT).

i. An integration of the two approaches.

E. Life Connections: Tackling Depression with Rational Thinking.

1. Rational Thinking.

a. People tend to:

i. Internalize blame.

ii. See problems as stable and global.

iii. Catastrophize problems.

iv. Minimize accomplishment.

b. These are cognitive errors, which need to be challenged.

VI. Group Therapies.

A. Advantages to group therapies:

1. It is economical.

2. Provides more information and life experience for clients to draw on.

3. Appropriate behavior receives group support.

4. Affiliating with people with similar problems is reassuring.

5. Group members provide hope for other members.

6. Many clients practice social skills in a relatively non-threatening atmosphere.

B. Group therapy is not for everyone.

1. They may not want to disclose their problems to a group.

C. Couple Therapy.

1. Intended to enhance their relationships by improving their communication skills and helping them manage conflict.

a. Corrects power imbalances.

b. Ways of dealing with depression and anger.

c. Ways to solve problems.

2. Typical approach is cognitive-behavioral.

D. Family Therapy.

1. Family therapy is a form of group therapy.

a. Family interaction is studied and modified to enhance the growth of individual family members and the family unit as a whole.

b. Focus on individuals with low self-esteem to increase tolerance.

c. Increase communication and encourage growth and autonomy.

VII. Does Psychotherapy Work?

1. In 1952 Hans Eysenck published a review of psychotherapy research and determined that the rate of improvement among people in psychotherapy was no greater than the rate of spontaneous remission.

2. Meta-analysis (statistical averaging) is now used and shows that psychotherapy is effective.

B. Analysis of the Effectiveness of Therapy.

1. Smith and Glass found that:

a. Psychodynamic and client-centered are most effective with well-educated, verbal, strongly motivated clients.

b. Gestalt therapy wasn’t as effective.

2. Shadish found that:

a. Psychotherapy is generally effective.

b. The more therapy the better.

c. Therapy is more effective when the outcome measures reflect the treatment.

3. It is not enough to ask which type of therapy is most effective. We must ask which type is most effective for a particular problem and a particular patient.

4. Does therapy work because of specific factors from the treatment or is it due to the non-specific factors such as the formation of the client-therapist relationship?

5. Cognitive-behavioral therapy has been used to help anorexic and bulimic individuals.

a. Also used to treat anxiety disorders, social skills deficits and problems in self-control.

6. A combination of CBT and drug therapy has helped those with schizophrenia.

VIII. Biological Therapies.

A. Biological therapies apply what is known of people’s biological structures and processes to the amelioration of psychological disorders.

B. Drug Therapy: In search of the Magic Pill?

1. Antianxiety drugs.

a. Valium is usually prescribed for patients who complain of generalized anxiety or panic attacks.

b. Depresses activity of the central nervous system.

i. This, in turn, decreases sympathetic activity and the feeling of nervousness and tension.

c. Side effects.

i. Sedation is the most common side effect.

ii. When use is stopped, clients may experience anxiety rebound.

iii. Can induce physical dependence.

2. Antipsychotic Drugs.

a. Antipsychotic drugs reduce agitation, delusions, and hallucinations.

i. Clozaril acts by blocking dopamine receptors in the brain.

3. Antidepressants.

a. Antidepressants are used to help clients with eating disorders, panic attacks, obsessive-compulsive disorders and social phobia.

b. May stem from problems in the regulation of noradrenaline and serotonin.

i. Antidepressants work by increasing levels of neurotransmitters.

c. Serotonin-reuptake inhibitors (Prozac) block the reuptake of serotonin.

d. Usually takes weeks to build up to therapeutic levels.

4. Lithium.

a. Lithium is used to flatten out cycles of manic behavior and depression.

b. Affects the functioning of neurotransmitters, including glutamate.

c. Side effects include:

i. Hand tremors.

ii. Memory impairment.

iii. Excessive thirst.

iv. Urination.

5. Does Drug Therapy Work?

a. Drug therapy has helped many people with severe psychological disorders.

b. Antipsychotic drugs largely account for the reduced need for the use of restraints and supervision of hospitalized patients.

i. They have allowed hundreds of thousands of former mental hospital residents to lead largely normal lives in the community.

c. Comparisons of psychotherapy and drug therapy in the treatment of depression suggest that cognitive therapy is as effective as antidepressants.

i. The combination of psychotherapy and drug therapy has been shown to be effective in treating depression, panic disorder, bulimia.

d. No chemical can show a person how to change an idea or solve an interpersonal problem.

C. Electroconvulsive Therapy.

1. Used mainly for people with major depression who do not respond to antidepressants.

2. Electrodes are attached to the temples and an electrical current strong enough to produce a convulsion is induced.

3. Patients are given a sedative so that they are asleep during the treatment.

4. Patients typically obtain one ECT treatment three times a week for up to 10 sessions.

D. Electroconvulsive therapy is controversial.

1. Many professionals are distressed by the thoughts of passing an electric current through a patient’s had producing convulsions.

2. Side effects of ECT include:

a. Memory problems.

i. Though the effects may be temporary.

E. Psychosurgery.

1. Prefrontal lobotomy: a pick like instrument severs the nerve pathways that link the prefrontal lobes of the brain to the thalamus.

a. Intended to sever thought from emotion.

b. Egas Moniz brought the procedure to the U.S. in the 1930s.

c. Side effects:

i. Hyperactivity.

ii. Distractibility.

iii. Impaired learning ability.

iv. Overeating.

v. Apathy.

vi. Withdrawal.

vii. Epileptic-type seizures.

viii.Reduced creativity.

ix. Death.

d. This method has been largely discontinued in the U.S.

IX. A Closer Look: Eye Movement Desensitization and Reprocessing

A. A therapeutic technique used to treat stress disorders.

B. EMDR patients are asked to imagine a traumatic scene while the therapist moves a finger rapidly back and forth before their eyes for about 20-30 seconds.

1. The client follows the finger while keeping the troubling scenes in mind.

C. Research suggests that this is helpful for clients.

D. Why it works is still questioned.

1. May be due to the therapeutic alliance created.

2. Other exposure therapies also work.

E. Conclusion: Exposure therapy helps people cope with trauma. Eye movements may not be needed.

X. A CLOSER LOOK: Psychotherapy and Ethnicity.

A. People from ethnic minorities are less likely than European Americans to seek therapy. The reasons why include:

1. Unawareness that therapy would help.

2. Lack of information about the availability of services.

3. Distrust of professionals.

4. Language barriers.

5. Reluctance to open up about personal matters.

6. Cultural inclinations toward other approaches.

7. Negative experiences with professional authority figures.

B. Psychotherapy and Ethnic Minority Groups.

1. Clinicians need to be sensitive to culture.

a. They need to develop multicultural competence.

i. African Americans may need help to cope with the effects of prejudice and discrimination. African Americans often assume that people should manage their own problems and are suspicious of therapists.

ii. Asian Americans tend to stigmatize people with psychological disorders. The Asian tradition is to practice restraint in public and prefer to receive concrete advice.

iii. Latino and Latin Americans value the interdependency in the family. Therapists need to use methods that are consistent with the client’s values.

iv. Native Americans feel a loss of cultural identity and social disorganization. Therapy should focus on strengthening cultural identity, pride and cohesion.

2. What should therapists do?

a. Interact with clients in the language requested by them, referring if necessary.

b. Using methods that are consistent with the client’s values and levels of acculturation.

c. Develop therapy methods that incorporate client’s cultural values.

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