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Copyright © 2010 Pearson Education, Inc. All rights reserved

Understanding Psychology 9th Edi4on

Charles G. Morris and Albert A. Maisto

Chapter 13 Therapies


Psychotherapy refers to the use of psychological techniques to treat personality and behavior disorders.


ENDURING ISSUES

•  Stability–Change § The underlying assumpCon behind psychotherapy is the belief that people are capable of changing.


ENDURING ISSUES (con’t)

•  Mind–Body § Biological treatments for psychological disorders are an aspect of the mind-‐body enduring issue.

Walker_Maryann Thursday, January 19, 2012 10:42:39 AM ET

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ENDURING ISSUES (con’t)

•  Diversity–Universality § The challenges therapists face when treaCng people from cultures other than their own.


INSIGHT THERAPIES

LEARNING OBJECTIVES •  Describe the common goal of all insight therapies. Compare and contrast psychoanalysis, client-‐centered therapy, and Gestalt therapy.

•  Explain how short-‐term psychodynamic therapy and virtual therapy differ from the more tradi4onal forms of insight therapy.


INSIGHT THERAPIES

§  Insight therapies are a variety of individual psychotherapies designed to give people a beMer awareness and understanding of their feelings, moCvaCons, and acCons in the hope that this will help them to adjust.

§  Three major insight therapies: psychoanalysis client-‐centered therapy Gestalt therapy.


Psychoanalysis

§  Psychoanalysis is designed to bring hidden feelings and moCves to conscious awareness so that the person can deal with them more effecCvely.

§  In Freudian psychoanalysis, the client is instructed to talk about whatever comes to mind. This process is called free associa4on.

§  Freud believed that the resulCng “stream of consciousness”would provide insight into the person’s unconscious mind.


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§  Clients transfer to their analyst feelings they have toward authority figures from their childhood. This process is known as transference.

§  As therapy progresses, the analyst takes a more acCve role and begins to interpret or suggest alternaCve meanings for clients’ feelings, memories, and acCons. The goal of interpretaCon is to help people to gain insight to become aware of what was formerly outside their awareness.

§  Psychodynamic personality theory has changed significantly. Many of these changes have led to modified psychoanalyCc techniques as well as to different therapeuCc approaches.


Client-‐Centered Therapy

§  Client-‐centered (or person-‐centered) therapy is a nondirecConal form of therapy developed by Carl Rogers that calls for uncondiConal posiCve regard of the client by the therapist with the goal of helping the client become fully funcConing.

§  Rogers called his approach to therapy client centered because he placed the responsibility for change on the person with the problem.


§  Rogers believed that people’s defensiveness, anxiety, and other signs of discomfort stem from their experiences of condi3onal posi3ve regard.

§  The cardinal rule in person-‐centered therapy is for the therapist to express uncondi3onal posi3ve regard—that is, to show true acceptance of clients no maMer what they may say or do.

§  Rogers felt that this was a crucial first step toward clients’ self-‐acceptance.


Gestalt Therapy §  Gestalt therapy is largely an outgrowth of the work of Frederick (Fritz) Perls at the Esalen InsCtute in California.

§  By emphasizing the present and encouraging face-‐to-‐face confrontaCons, Gestalt therapy aMempts to help people become more genuine in their daily interacCons. The therapist is acCve and direcCve, and the emphasis is on the whole person.

§  Gestalt therapists use various techniques such as the empty chair technique to try to make people aware of their feelings.


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Recent Developments

§  Others have developed hundreds of variaCons on this theme. Most involve a therapist who is far more acCve and emoConally engaged with clients than tradiConal psychoanalysts thought fit.

§  These therapists give clients direct guidance and feedback, commenCng on what they are told rather than just neutral listening.


§  The most dramaCc and controversial change in insight therapies is virtual therapy.

§  The delivery of health care over the Internet or through other electronic means is part of a rapidly expanding field known as telehealth.

§  Although most therapists believe that online therapy is no subsCtute for face-‐to-‐face. interacCons evidence suggests that telehealth may provide cost-‐effecCve opportuniCes for delivery of some mental health services.


§  Another general trend in recent years is toward shorter-‐term “dynamic therapy.” For most people, this usually means meeCng once a week for a fixed period. In fact, short-‐term psychodynamic therapy is increasingly popular among both clients and mental health professionals

§  Insight remains the goal, but the course of treatment is usually limited—for example, to 25 sessions.


BEHAVIOR THERAPIES

LEARNING OBJECTIVES •  Explain the statement that “Behavior therapies sharply contrast with insight-‐ oriented approaches.”

•  Describe the processes of desensi4za4on, ex4nc4on, flooding, aversive condi4oning, behavior contrac4ng, token economies, and modeling.


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BEHAVIOR THERAPIES

§  Behavior therapies sharply contrast with insight-‐oriented approaches.

§  They are focused on changing behavior, rather than on discovering insights into thoughts and feelings.

§  Behavior therapies are based on the belief that all behavior, both normal and abnormal, is learned.


Therapies Based on Classical CondiConing Several variaCons on classical condiConing have been used to treat psychological problems:

§  Systema4c desensi4za4on is a behavioral technique for reducing a person’s fear and anxiety by gradually associaCng a new response (relaxaCon) with sCmuli that have been causing the fear and anxiety.

•  The key to success may not be the learning of a new condiConed relaxaCon response, but rather the ex3nc3on of the old fear response through mere exposure.

•  The technique of flooding is a less familiar and more frightening desensiCzaCon method. It involves full-‐intensity exposure to a feared sCmulus for a prolonged period of Cme.


§  Aversive condi4oning is a type of behavioral therapy technique aimed at eliminaCng undesirable behavior paMerns by teaching the person to associate them with pain and discomfort.


Therapies Based on Operant CondiConing

In operant condi3oning, a person learns to behave a certain way because that behavior is reinforced:

§  One therapy based on the principle of reinforcement is called behavior contrac4ng.

§  Another therapy based on operant condiConing is called the token economy.

•  Token economies are usually used in schools and hospitals, where controlled condiCons are most feasible.

•  People are rewarded with tokens or points for appropriate behaviors, which can be exchanged for desired items and privileges.


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Therapies Based on Modeling

Modeling – Learning a behavior by watching someone else perform it -‐ can also be used to treat problem behaviors.

§  Albert Bandura and colleagues helped people to overcome a snake phobia by showing films in which models gradually moved closer and closer to snakes.

§  Modeling techniques have also been successfully used as part of job training programs.


COGNITIVE THERAPIES

LEARNING OBJECTIVES •  Describe the common beliefs that underlie all cogni4ve therapies.

•  Compare and contrast stress-‐inocula4on therapy, ra4onal-‐emo4ve therapy, and Beck’s cogni4ve therapy.


COGNITIVE THERAPIES

§  Cogni4ve therapies are based on the belief that if people can change their distorted ideas about themselves and the world, they can also change their problem behaviors and make their lives more enjoyable.


Stress-‐InoculaCon Therapy

§  Stress-‐inocula4on therapy is a type of cogniCve therapy that trains clients to cope with stressful situaCons by learning a more useful paMern of self-‐talk.

§  Stress-‐inoculaCon therapy works by turning the client’s thought paMerns into a kind of vaccine against stress-‐induced anxiety.


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RaConal-‐EmoCve Therapy §  Ra4onal-‐emo4ve therapy (RET) is a direcCve cogniCve therapy based on the idea that clients’ psychological distress is caused by irraConal and self-‐defeaCng beliefs and that the therapist’s job is to challenge such dysfuncConal beliefs.

§  RaConal-‐emoCve therapists confront such dysfuncConal beliefs vigorously, using a variety of techniques, including persuasion, challenge, commands, and theoreCcal arguments.

§  Studies have shown that RET o]en enables people to reinterpret negaCve beliefs and experiences more posiCvely, decreasing the likelihood of depression.


Beck’s CogniCve Therapy

§  One of the most important and promising forms of cogniCve therapy for treaCng depression is known simply as cogni4ve therapy, someCmes referred to as “Beck’s cogniCve therapy.”

§  Beck believes that depression results from inappropriately self-‐criCcal paMerns of thought. Self-‐criCcal people have unrealisCc expectaCons, magnify failures, make sweeping negaCve generalizaCons based on liMle evidence, noCce only negaCve feedback from the outside world, and interpret anything less than total success as failure.

§  CogniCve therapists are much less challenging and confrontaConal than raConal-‐emoCve therapists.


GROUP THERAPIES

LEARNING OBJECTIVES •  Describe the poten4al advantages of group therapy compared to individual therapy.

•  Compare and contrast family therapy, couple therapy, and self-‐help groups.


GROUP THERAPIES

§  Group therapy is a type of psychotherapy in which clients meet regularly to interact and help one another achieve insight into their feelings and behavior.

§  Group therapy allows both client and therapist to see how the person acts around others.


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§  Group therapies also have the advantage of social support -‐ a feeling that one is not the only person in the world with problems.

§  Group members can help one another learn useful new behaviors, like how to disagree without antagonizing others.

§  Group interacCons can lead people toward insights into their own behavior, such as why they are defensive or feel compelled to complain constantly.


Family Therapy

§  Family therapy is a form of group therapy that sees the family as at least partly responsible for the individual’s problems and that seeks to change all family members’ behaviors to the benefit of the family unit as well as the troubled individual.

§  Although family therapy is appropriate when there are problems between husband and wife or parents and children, it is increasingly used when only one family member has a clear psychological disorder.


§  The goal of treatment in these circumstances is to help mentally healthy members of the family cope more effecCvely with the impact of the disorder on the family unit, which in turn helps the troubled person.

§  Family therapy is also called for when a person’s progress in individual therapy is slowed by the family (o]en because other family members have trouble adjusCng to that person’s improvement).


Couple Therapy

§  Couple therapy is a form of group therapy intended to help troubled partners improve their problems of communicaCon and interacCon.

§  Previously termed marital therapy, the term “couple therapy” is considered more appropriate today because it captures the broad range of partners who may seek help.


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§  Most couple therapists concentrate on improving paMerns of communicaCon and mutual expectaCons.

§  In empathy training, each member of the couple is taught to share inner feelings and to listen to and understand the partner’s feelings before responding.

§  This technique requires more Cme spent listening, grasping what is really being said, and less Cme in self-‐defensive rebuMal.

§  Other couple therapists use behavioral techniques, such as helping a couple develop a schedule for exchanging specific caring acCons.


Self-‐Help Groups §  Since individual treatment can be expensive, more and more people faced with life crises are turning to low-‐cost self-‐help groups.

§  Most groups are small, local gatherings of people who share a common problem and who provide mutual support.

§  Alcoholics Anonymous is perhaps the best-‐known self-‐help group, but self-‐help groups are available for virtually every life problem.


§  Studies have demonstrated that self-‐help can indeed be effecCve.

§  Such groups also help to prevent more serious psychological disorders by reaching out to people who are near the limits of their ability to cope with stress.


EFFECTIVENESS OF PSYCHOTHERAPY

LEARNING O B J E C T I V E S •  Summarize the research evidence that psychotherapy is, in fact, more effec4ve than no therapy at all. Briefly describe the five major results of the Consumer Reports study.

•  Describe the common features shared by all forms of psychotherapy that may account for the fact that there is liZle or no overall difference in their effec4veness. Explain the statement that “Some kinds of psychotherapy seem to be par4cularly appropriate for certain people and problems”; include examples.


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EFFECTIVENESS OF PSYCHOTHERAPY §  Researchers have found that roughly twice as many people (two-‐thirds) improve with formal therapy than with no treatment at all.

§  Many people who do not receive formal therapy get therapeuCc help from friends, clergy, physicians, and teachers. Thus, the recovery rate for people who receive no therapeu3c help at all is quite possibly even less than one-‐third.

§  Psychotherapy works best for relaCvely mild psychological problems and seems to provide the greatest benefits to people who really want to change.


§  A very extensive study designed to evaluate the effecCveness of psychotherapy under the direcCon of psychologist MarCn E. P. Seligman (1995) was reported by Consumer Reports.

•  The vast majority of respondents reported significant overall improvement a]er therapy.

•  There was no difference in the overall improvement score among people who had received therapy alone and those who had combined psychotherapy with medicaCon.

•  No differences were found between the various forms of psychotherapy.

•  No differences in effecCveness were indicated between psychologists, psychiatrists, and social workers, although marriage counselors were seen as less effecCve.

•  People who received long-‐term therapy reported more improvement than those who received short-‐term therapy.

Copyright © 2010 Pearson Education, Inc. All rights reserved Copyright © 2010 Pearson Education, Inc. All rights reserved

Which Type of Therapy is Best for Which Disorder?

Are some forms of psychotherapy are more effecCve than others?

§  Most of the benefits of treatment seem to come from being in some kind of therapy, regardless of the parCcular type.

§  Some psychologists have focused their aMenCon on what the various forms of psychotherapy have in common, rather than emphasizing their differences.


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•  All forms of psychotherapy provide people with an explana0on for their problems. Along with this explanaCon o]en comes a new perspecCve, providing people with specific acCons to help them cope more effecCvely.

•  Most forms of psychotherapy offer people hope. Because most people who seek therapy have low self-‐esteem and feel demoralized and depressed, hope and the expectaCon for improvement increase their feelings of self-‐worth.

•  All major types of psychotherapy engage the client in a therapeu0c alliance with a therapist. Although their therapeuCc approaches may differ, effecCve therapists are warm, empatheCc, and caring people who understand the importance of establishing a strong emoConal bond with their clients that is built on mutual respect and understanding.


BIOLOGICAL TREATMENTS LEARNING O B J E C T I V E S •  Explain why some clients and therapists opt for biological treatment instead of psychotherapy.

•  Describe the major an4psycho4c and an4depressant drugs including their significant side effects.

•  Describe electroconvulsive therapy and psychosurgery, their effec4veness in trea4ng specific disorders, and their poten4al side effects. Explain why these are “last resort treatments” that are normally used only other treatments have failed.


BIOLOGICAL TREATMENTS §  Biological treatments -‐ a group of approaches including medicaCon, electroconvulsive therapy, and psychosurgery -‐ may be used to treat psychological disorders in addiCon to, or instead of, psychotherapy.

§  Clients and therapists opt for biological treatments for several reasons: •  some people are too agitated, disoriented, or unresponsive to be helped by psychotherapy.

•  biological treatment is virtually always used for disorders with a strong biological component.

•  biological treatment is o]en used for people who are dangerous to themselves and to others.


§  TradiConally, the only mental health professionals licensed to offer biological treatments were psychiatrists, who are physicians.

§  However, some states now permit specially trained psychologists to prescribe drugs.

§  Therapists without such training o]en work with physicians who prescribe medicaCon for their clients.

§  In many cases where biological treatments are used, psychotherapy is also recommended.

•  MedicaCon and psychotherapy used together are generally more effecCve for treaCng major depression.


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Drug Therapies

MedicaCon is frequently and effecCvely used to treat a number of psychological problems:

§  An4psycho4c drugs are drugs used to treat very severe psychological disorders, parCcularly schizophrenia.

•  AnCpsychoCc medicaCons someCmes have dramaCc effects. People with schizophrenia who take them can go from being perpetually frightened, angry, confused, and plagued by auditory and visual hallucinaCons to being totally free of such symptoms.


•  AnCpsychoCc drugs can have a number of undesirable side effects -‐ blurred vision, weight gain, and consCpaCon are among the common complaints, as are temporary neurological impairments such as muscular rigidity or tremors.

•  A very serious potenCal side effect is tardive dyskinesia, a permanent disturbance of motor control, parCcularly of the face (uncontrollable smacking of the lips, for instance), which can be only parCally alleviated with other drugs.


§  A second group of drugs, known as an4depressants, is used to combat depression.

•  UnCl the end of the 1980s, there were only two main types of anCdepressant drugs; monoamine oxidase inhibitors (MAO inhibitors) and tricyclics.

•  Both drugs work by increasing the concentraCon of the neurotransmiMers serotonin and norepinephrine in the brain.

•  Both are effecCve for most people with serious depression, but both produce a number of serious and troublesome side effects.


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•  Another group of psychoacCve drugs, known as selec3ve serotonin reuptake inhibitors (SSRIs), work by reducing the update of serotonin by the nervous system, thus increasing the amount of serotonin acCve in the brain.

•  A number of SSRIs are available to treat depression, including Paxil (paroxeCne), ZoloF (sertraline), and Effexor (venlafaxine HCl).

•  AnCdepressant drugs are not only used to treat depression, but also have shown promise in treaCng generalized anxiety disorder, panic disorder, obsessive-‐compulsive disorder, social phobia, and posMraumaCc stress disorder.


§  Bipolar disorder is frequently treated with lithium carbonate.

•  Lithium is not a drug, but a naturally occurring salt that is generally quite effecCve in treaCng bipolar disorder and in reducing the incidence of suicide in bipolar paCents.


§  Psychos3mulants heighten alertness and arousal. •  Some psychosCmulants, such as Ritalin, are commonly used to treat children with aMenCon-‐deficit hyperacCvity disorder (Ghuman, Arnold, & Anthony, 2008). In these cases, they have a calming, rather than sCmulaCng, effect.

•  Some professionals worry that psychosCmulants are being overused, especially with young children (S. Rose, 2008).


§  An3anxiety medica3ons, such as Valium, are commonly prescribed as well. Quickly producing a sense of calm and mild euphoria, they are o]en used to reduce general tension and stress. Because they are potenCally addicCve, however, they must be used with cauCon.

§  Seda3ves produce both calm and drowsiness, and are used to treat agitaCon or to induce sleep. These drugs, too, can become addicCve.


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Electroconvulsive Therapy

§  Electroconvulsive therapy (ECT) is most o]en used for cases of prolonged and severe depression that do not respond to other forms of treatment

•  The technique involves briefly passing a mild electric current through the brain or, more recently, through only one of its hemispheres.

•  Treatment normally consists of 10 or fewer sessions of ECT.


•  No one knows exactly why ECT works, but its effecCveness has been clearly demonstrated.

•  In addiCon, the fatality rate for ECT is markedly lower than for people taking anCdepressant drugs.

•  Side effects include brief confusion, disorientaCon, and memory impairment, though research suggests that unilateral ECT produces fewer side effects and is only slightly less effecCve than the tradiConal method.


Psychosurgery §  Psychosurgery is a type of brain surgery performed to change a person’s behavior and emoConal state. It is rarely used today.

•  In a prefrontal lobotomy, the frontal lobes of the brain are severed from the deeper centers beneath them.

•  The assumpCon is that in extremely disturbed people, the frontal lobes intensify emoConal impulses from the lower brain centers (chiefly, the thalamus and hypothalamus).

•  Unfortunately, lobotomies can work with one person and fail completely with another -‐ possibly producing permanent, undesirable side effects, such as the inability to inhibit impulses or a near-‐total absence of feeling.


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INSTITUTIONALIZATION AND ITS ALTERNATIVES

LEARNING OBJECTIVE §  Describe the process of deins4tu4onaliza4on and the problems that have resulted from it. Iden4fy alterna4ves to deins4tu4onaliza4on including the three forms of preven4on.


INSTITUTIONALIZATION AND ITS ALTERNATIVES

§  For persons with severe mental illness, hospitalizaCon has been the treatment of choice in the United States for the past 150 years.

§  Several different kinds of hospitals offer such care. •  General hospitals admit many affected people, usually for short-‐term stays unCl they can be released to their families or to other insCtuConal care.

•  Private hospitals—some nonprofit and some for profit—offer services to people with adequate insurance.

•  Veterans AdministraCon hospitals admit veterans with psychological disorders.


§  The development of effecCve drug therapies starCng in the 1950s led to a number of changes in state hospitals

§  People who were agitated could now be sedated with drugs, which was considered an improvement over the use of physical restraints.

§  The second major, and more lasCng, result of the new drug therapies was the widespread release of people with severe psychological disorders back into the community—a policy called deins4tu4onaliza4on.


DeinsCtuConalizaCon §  The pracCce of placing people in smaller, more humane faciliCes or returning them under medicaCon to care within the community intensified during the 1960s and 1970s.

•  By 1975, 600 regional mental health centers accounted for 1.6 million cases of outpaCent care.

§  In recent years, however, deinsCtuConalizaCon has created serious challenges:


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•  Discharged people o]en find poorly funded community mental health centers—or none at all.

•  Many are not prepared to live in the community. Those who return home can become a burden to their families, especially when follow-‐up care is inadequate.

•  The quality of residenCal centers such as halfway houses can vary, with many providing poor care.

•  The paCents are further burdened by the social sCgma of mental illness.

•  Many released paCents have been unable to obtain follow-‐up care or housing and are incapable of looking a]er their own needs.

•  Consequently, many have ended up literally on the streets. •  Without supervision, they have stopped taking the drugs that made their release possible in the first place and their psychoCc symptoms have returned.


AlternaCve Forms of Treatment

§  Kiesler (1982b) examined 10 controlled studies in which seriously disturbed people were randomly assigned either to hospitals or to an alternaCve program.

§  Even though the hospitals to which some people in these studies were assigned provided very good paCent care—probably substanCally above average for insCtuCons in the United States—9 out of the 10 studies found that the outcome was more posiCve for alternaCve treatments than for the more expensive hospitalizaCon.


PrevenCon §  Primary preven4on refers to efforts to improve the overall environment so that new cases of mental disorders do not develop.

§  Secondary preven4on involves idenCfying high risk groups—for example, abused children, people who have recently divorced, those who have been laid off from their jobs, veterans, and vicCms of terrorist incidents.

•  Interven3on is the main thrust of secondary prevenCon—detecCng maladapCve behavior early and treaCng it promptly.


•  One form of intervenCon is crisis interven3on, which includes such programs as suicide hotlines or short-‐term crisis faciliCes where therapists can provide face-‐to-‐face counseling and support.

§  The main objecCve of ter4ary preven4on is to help people adjust to community life a]er release from a mental hospital.

•  For example, granCng passes for paCents to leave the insCtuCon for short periods prior to release, halfway houses for the transiCon period, outpaCent programs and community educaCon.


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CLIENT DIVERSITY AND TREATMENT

LEARNING OBJECTIVE •  Explain how gender and cultural differences can affect the treatment of psychological problems and the training of therapists.


Gender and Treatment

§  There are significant gender differences in the prevalence of many psychological disorders.

§  In part, this is because women have tradiConally been more willing than men to admit that they have psychological problems and need help to solve them, and because psychotherapy is more socially accepted for women than for men.

§  However, the number of males willing to seek psychotherapy and counseling has increased .

§  Researchers aMribute this growth to the changing roles of men in today’s society: Men are increasingly expected to provide emoConal as well as financial support for their families.


§  In most respects, the treatment given to women is the same as that given to men, a fact that has become somewhat controversial in recent years.

§  CriCcs of “equal treatment” have claimed that women in therapy are o]en encouraged to adopt tradiConal, male-‐oriented views of what is “appropriate”; male therapists may urge women to adapt passively to their surroundings.


Culture and Treatment

§  When psychotherapist and client come from different cultures, misunderstandings of speech, body language, and customs are almost inevitable.

§  Even when client and therapist are of the same naConality and speak the same language, there can be striking differences if they belong to different racial and ethnic groups.


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§  One of the challenges for U.S. therapists in recent years has been to treat immigrants, many of whom have fled such horrifying circumstances that they arrive in the United States exhibiCng PTSD.

§  UlCmately, the best soluCon to the difficulCes of serving a mulCcultural populaCon is to train therapists of many different backgrounds so that members of ethnic, cultural, and racial minoriCes can choose therapists of their own group if they wish to do so.


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