TherapiesChapter 14

• Psychotherapy - use of psychological Psychotherapy - use of psychological techniques to treat problems in techniques to treat problems in personality and behavior (as opposed personality and behavior (as opposed to biological therapies)to biological therapies)

• General categoriesGeneral categories– insight therapies– behavioral therapies– cognitive therapies– group therapies

PsychotherapyPsychotherapy

Insight TherapiesInsight Therapies

• A variety psychotherapies designed to A variety psychotherapies designed to give people a better awareness and give people a better awareness and understanding of their feelings, understanding of their feelings, motivations, and actionsmotivations, and actions

• Types of insight therapiesTypes of insight therapies– psychoanalysis

– client-centered therapy

– gestalt therapy

PsychoanalysisPsychoanalysis

• Based on Freud’s belief that anxiety Based on Freud’s belief that anxiety and other problems are symptoms of and other problems are symptoms of inner conflictsinner conflicts

• Many of these conflicts have their Many of these conflicts have their origins in childhood traumasorigins in childhood traumas

• These conflicts are “unconscious”These conflicts are “unconscious”

• The goal of therapy is to make them The goal of therapy is to make them conscious and understoodconscious and understood

Techniques used in PsychoanalysisTechniques used in Psychoanalysis

• hypnosis: hypnosis: by Freud early in his careerby Freud early in his career

• free association:free association: patient is encouraged to patient is encouraged to talk without inhibition about whatever talk without inhibition about whatever thoughts or fantasies come to mind.thoughts or fantasies come to mind.

• dream interpretation: dream interpretation: therapist discovers therapist discovers the real meaning “the real meaning “latent contentlatent content” from ” from the patient’s description of his dreams the patient’s description of his dreams ““manifest contentmanifest content””

TransferenceTransference• transference: transference: an essential part of an essential part of

psychoanalysis. Patient reacts to the psychoanalysis. Patient reacts to the analyst with feelings held toward analyst with feelings held toward childhood and other authority figures.childhood and other authority figures.

• positive transference: positive transference: warn loving feelings warn loving feelings expressed toward the analystexpressed toward the analyst– usually happens early in the therapy process

• negative transference: negative transference: angry hostile angry hostile feelings expressed toward the analystfeelings expressed toward the analyst– usually happens later as therapy becomes harder

• counter-transference: counter-transference: analyst analyst unintentionally tranfers HIS feelings for unintentionally tranfers HIS feelings for others onto the patientothers onto the patient

• insight: insight: The goal of psychoanalysis. The goal of psychoanalysis. Awareness of previously unconscious Awareness of previously unconscious feelings and how they influence present feelings and how they influence present behaviorbehavior

• current status: current status: psychoanalysis is NOT psychoanalysis is NOT among the more commonly used among the more commonly used therapies todaytherapies today

Transference (cont.)Transference (cont.)

Client-Centered TherapyClient-Centered Therapy

• a “a “NondirectiveNondirective” form of therapy developed by ” form of therapy developed by the “humanist” the “humanist” Carl RogersCarl Rogers

• Rogers used the term Rogers used the term ““client”client” rather than rather than ““patient”patient” to highlight the more active and to highlight the more active and equal role of the clientequal role of the client

• goal is to make the client goal is to make the client “fully functioning”“fully functioning”

• One who is One who is ““fully functioningfully functioning” ” is reaching his is reaching his full potential, taking responsibility, and living full potential, taking responsibility, and living life to its fullestlife to its fullest

• unconditional positive regard: unconditional positive regard: the patient the patient is fully accepted by the therapist despite is fully accepted by the therapist despite his/her faults (within reason)his/her faults (within reason)

• The therapist must be The therapist must be nondirectivenondirective and and reflect or “reflect or “mirrormirror” back to the client what ” back to the client what he/she has saidhe/she has said

• current status: current status: This client-therapist This client-therapist relationship may be the “key” element in relationship may be the “key” element in therapy. Rogers’ ideas do not receive the therapy. Rogers’ ideas do not receive the attention they should!attention they should!

Client-Centered TherapyClient-Centered Therapy

Gestalt TherapyGestalt Therapy

• a confrontive “a confrontive “in your facein your face” style of therepy ” style of therepy developed by developed by Frederick “Fritz” PerlsFrederick “Fritz” Perls

• emphasizes the “emphasizes the “wholenesswholeness” of the ” of the personality and living in the “personality and living in the “here-and-nowhere-and-now””

• recall that the term “recall that the term “GestaltGestalt” means “whole”” means “whole”

• The The GOALGOAL is to make the person whole, is to make the person whole, responsible and self sufficient (in all ways, responsible and self sufficient (in all ways, emotional, financial, etc.)emotional, financial, etc.)

• therapy takes place in the “therapy takes place in the “Here and NowHere and Now””

• Fritz Perls encouraged Fritz Perls encouraged face-to-faceface-to-face confrontationsconfrontations to help people become more to help people become more genuine or “real” in their day-to-day genuine or “real” in their day-to-day interactionsinteractions

• The therapist is The therapist is activeactive and and directivedirective..

• current status: current status: not a widely used methodnot a widely used method

Gestalt TherapyGestalt Therapy

Behavior TherapiesBehavior Therapies

• All behavior is learned. Therefore, bad All behavior is learned. Therefore, bad behaviors can be unlearned and new more behaviors can be unlearned and new more adaptive behaviors learned.adaptive behaviors learned.

• behavior therapies are based on the principles behavior therapies are based on the principles of:of:– classical conditioning

– operant conditioning

– modeling (social learning)

Use of Classical ConditioningUse of Classical Conditioning• systematic desensitization:systematic desensitization: Technique for Technique for

reducing fears and phobias by pairing a reducing fears and phobias by pairing a new response (relaxation) with stimuli that new response (relaxation) with stimuli that have been causing the fear and anxiety.have been causing the fear and anxiety.

• Joseph Wolpe: Joseph Wolpe: isis the developer of the developer of systematic desensitizationsystematic desensitization

• Wolpe’s focus is on promoting relaxation Wolpe’s focus is on promoting relaxation because (he feels) you cannot be both because (he feels) you cannot be both anxious and relaxed at the same timeanxious and relaxed at the same time

1. the client learns relaxation techniques 1. the client learns relaxation techniques such as deep breathing and muscle such as deep breathing and muscle relaxationrelaxation

2. a “hierarchy” or listing of fearful 2. a “hierarchy” or listing of fearful situations is createdsituations is created

3. the client is gradually exposed to more 3. the client is gradually exposed to more fearful and difficult situations while fearful and difficult situations while using the relaxation techniques using the relaxation techniques

Systematic desensitization involves 3 stepsSystematic desensitization involves 3 steps

Other Uses of Classical ConditioningOther Uses of Classical Conditioning

• flooding:flooding: idea is to eliminate anxiety idea is to eliminate anxiety through intense and prolonged exposure to through intense and prolonged exposure to anxiety-producing stimuli. “Extinction” is anxiety-producing stimuli. “Extinction” is the mechanism of changethe mechanism of change

• example: example: someone with a fear of someone with a fear of contamination, as in OCD, might have to contamination, as in OCD, might have to handle garbage until their fears subsidehandle garbage until their fears subside

• flooding can also be done “flooding can also be done “imaginallyimaginally” as ” as opposed to “opposed to “in vivoin vivo” (in reality) ” (in reality)

Other Uses of Classical ConditioningOther Uses of Classical Conditioning

• aversive conditioning:aversive conditioning: eliminating eliminating undesirable behaviors by associating them undesirable behaviors by associating them with pain and discomfortwith pain and discomfort

• examples:examples:– drug-induced nausea paired with alcohol– shock paired with puffing on a cigarette– bad tasting nail coating for nail biting– shock paired with a pedophile’s sexual response

Use of Operant ConditioningUse of Operant Conditioning

• behavior contracting:behavior contracting: client and therapist client and therapist agree on goals and reinforcements the client agree on goals and reinforcements the client will receive upon reaching those goals.will receive upon reaching those goals.

• token economy:token economy: Patients earn tokens Patients earn tokens (reinforcers) for desired behaviors and (reinforcers) for desired behaviors and exchange them for desired items or privileges.exchange them for desired items or privileges.

• token economy: token economy: the the ONLYONLY therapy therapy demonstrated effective with hospitalized demonstrated effective with hospitalized schizophrenicsschizophrenics

ModelingModeling

• based on based on Albert Bandura’s Social Albert Bandura’s Social Learning TheoryLearning Theory

• the patient learns desired behaviors by the patient learns desired behaviors by observing a “observing a “modelmodel” perform those ” perform those behaviors and imitating the behaviorsbehaviors and imitating the behaviors

• uses include overcoming fears (e.g., uses include overcoming fears (e.g., snake phobia) or learning new skills snake phobia) or learning new skills (social skills training)(social skills training)

Cognitive TherapiesCognitive Therapies

Goal is to change Goal is to change “maladaptive belief “maladaptive belief systems” systems” held by the patientheld by the patient

• stress-inoculation therapystress-inoculation therapy

• Albert Ellis’s rational-emotive-therapyAlbert Ellis’s rational-emotive-therapy

• Beck’s cognitive therapyBeck’s cognitive therapy

Stress-Inoculation TherapyStress-Inoculation Therapy

• helps clients prepare for stressful situationshelps clients prepare for stressful situations

• differs from systematic desensitization in that differs from systematic desensitization in that it is “pre-emptive” it is “pre-emptive”

• Steps involvedSteps involved– discussing beliefs and their accuracy with

therapist

– getting familiar (practice) with the situation

– actually entering and coping with the situation

• examples: dental work, air travel, surgeryexamples: dental work, air travel, surgery

Cognitive Therapy and RETCognitive Therapy and RET Both Both EllisEllis and and BeckBeck assume distress is assume distress is

caused by irrational and self-defeating caused by irrational and self-defeating beliefs and the therapist’s job is to beliefs and the therapist’s job is to challenge those dysfunctional beliefs.challenge those dysfunctional beliefs.

Examples ofIrrational/self-defeating beliefs:Examples ofIrrational/self-defeating beliefs:– “musts” and “shoulds”– all or none (black and white) thinking– over-generalization– personalization

• directive: directive: cognitive therapists are cognitive therapists are directive and tell the client what is directive and tell the client what is rational and what is notrational and what is not

• expert therapists: expert therapists: the therapists are the the therapists are the expertsexperts (in contrast to Rogers’ approach)(in contrast to Rogers’ approach)

• homework: homework: the client may be sent out on the client may be sent out on assignments to test his/her beliefs assignments to test his/her beliefs

• logical argument: logical argument: is used to convince the is used to convince the client of the irrationality of his beliefsclient of the irrationality of his beliefs

Cognitive Therapy and RETCognitive Therapy and RET

Group TherapiesGroup Therapies

• Many are modeled after individual therapies Many are modeled after individual therapies (e.g., Gestalt, client centered)(e.g., Gestalt, client centered)

• particularly well suited to problems involving particularly well suited to problems involving interaction with others (e.g., social phobia)interaction with others (e.g., social phobia)

• Types of group therapiesTypes of group therapies– family therapy

– marital/couples therapy

– self-help/support groups

Advantages of Group TherapyAdvantages of Group Therapy

• Allows therapist to see how client acts Allows therapist to see how client acts around others.around others.

• Offers a client social support system.Offers a client social support system.

• Client can develop new behaviors via Client can develop new behaviors via observational learning and modeling.observational learning and modeling.

• Interaction with others may lead to Interaction with others may lead to insight into one’s own behavior.insight into one’s own behavior.

• Less expensive than individual therapy.Less expensive than individual therapy.

Self-help/Support GroupsSelf-help/Support Groups• Come in a wide varietyCome in a wide variety

• Usually there is NO professional leaderUsually there is NO professional leader

• Can provide information and support at Can provide information and support at minimal or no chargeminimal or no charge

• Alcoholics Anonymous is one exampleAlcoholics Anonymous is one example

• In many cases, someone who has In many cases, someone who has suffered a disorder may have more suffered a disorder may have more insight into problems than a professionalinsight into problems than a professional

Family TherapyFamily Therapy

• The family “system” is the patient.The family “system” is the patient.

• Often one person is the scapegoat for Often one person is the scapegoat for the family’s problems.the family’s problems.

• Family relationships (dynamics) are Family relationships (dynamics) are targeted.targeted.

• Problems can cross generations (e.g., Problems can cross generations (e.g., grandparents sabotaging parents’ grandparents sabotaging parents’ efforts)efforts)

Marital/Couples TherapyMarital/Couples TherapyFocus is on improving: Focus is on improving:

1 poor communication: 1 poor communication: People often don’t People often don’t listen to each other. They may be listen to each other. They may be fighting about one thing when they are fighting about one thing when they are really angry about something else.really angry about something else.

2 correcting unrealistic expectations: 2 correcting unrealistic expectations: especially true for young couples. They especially true for young couples. They may have unrealistic ideas about what the may have unrealistic ideas about what the other is capable of or “should” be doing.other is capable of or “should” be doing.

Effectiveness of PsychotherapyEffectiveness of Psychotherapy

Data from the Consumer Reports Survey

Note: a change score of 180 (not 0) indicates “no change”

Does Psychotherapy Work?Does Psychotherapy Work?

• About 2/3 of people say therapy helped them.About 2/3 of people say therapy helped them.

• About 1/3 of people improve without therapy. About 1/3 of people improve without therapy.

• Starting with Hans Eysenck in 1952, many have Starting with Hans Eysenck in 1952, many have questioned (and continue to question) the questioned (and continue to question) the effectiveness of psychotherapyeffectiveness of psychotherapy

• Many studies supporting therapy (such as the Many studies supporting therapy (such as the Consumer Reports Survey) may be flawed.Consumer Reports Survey) may be flawed.

• This question continues to be difficult to answerThis question continues to be difficult to answer

Does Psychotherapy Work?Does Psychotherapy Work?

• In general, no one therapy appears to be In general, no one therapy appears to be more effective than another. Why?more effective than another. Why?

• The “main ingredient” may be just having The “main ingredient” may be just having someone to talk to (as in client centered someone to talk to (as in client centered therapy) therapy)

• Experts agree that therapy may be more Experts agree that therapy may be more effective for specific minor problems (fear effective for specific minor problems (fear of flying) than for more general and severe of flying) than for more general and severe problems (major depression or OCD) problems (major depression or OCD)

Biological TreatmentsBiological Treatments• A group of treatment that focus on A group of treatment that focus on

changing the “biology” of the brain.changing the “biology” of the brain.

• May be used alone or in conjunction with May be used alone or in conjunction with psychotherapy.psychotherapy.

• Types of biological treatments:Types of biological treatments:– medications/drugs

– electroconvulsive therapy (ECT)

– psychosurgery

Basic Categories of DrugsBasic Categories of Drugs

• antipsychotics:antipsychotics: used to treat very severe used to treat very severe disorders of thought such as schizophrenia.disorders of thought such as schizophrenia.

• antidepressants:antidepressants: to combat depression (*as to combat depression (*as well as panic, OCD, and social phobia).well as panic, OCD, and social phobia).

• anxiolytics: anxiolytics: to treat a wide variety of anxiety to treat a wide variety of anxiety and stress related problems and stress related problems

• pychostimulants: pychostimulants: to treat ADHD and other to treat ADHD and other disorders involving impulsivity and conductdisorders involving impulsivity and conduct

AntipsychoticsAntipsychotics

• chemical class: chemical class: neuroleptics, phenothiazinesneuroleptics, phenothiazines

• examples: examples: Thorazine, Mellaril, ProlixinThorazine, Mellaril, Prolixin

• mechanism: mechanism: blocking dopamine receptorsblocking dopamine receptors

• side effects: side effects: these drugs have many severe these drugs have many severe side effects that cause people to not want to side effects that cause people to not want to take the drugstake the drugs

• tardive dyskinesia: tardive dyskinesia: a severe irreversible side a severe irreversible side effect involving disruption of motor activity effect involving disruption of motor activity (movement), occurs with long term use(movement), occurs with long term use

1. Monoamine Oxidase Inhibitors (MAOs)1. Monoamine Oxidase Inhibitors (MAOs)

• the first group to be discoveredthe first group to be discovered

• examples:examples: Parnate, Nardil Parnate, Nardil

• mechanism:mechanism: blocks MAO, increases levels of blocks MAO, increases levels of norepinephrine and serotoninnorepinephrine and serotonin

• side effects:side effects: dry mouth, dizziness, sexual dry mouth, dizziness, sexual dysfunction, digestive problems, etc.dysfunction, digestive problems, etc.

• dietary restrictions:dietary restrictions: must avoid certain foods to must avoid certain foods to prevent high blood pressure and strokeprevent high blood pressure and stroke

3 Classes of Antidepressants3 Classes of Antidepressants

the second major group to be discoveredthe second major group to be discovered

• examples:examples: Elavil, AnafranilElavil, Anafranil

• mechanism:mechanism: llike MAOs, increases levels of llike MAOs, increases levels of norepinephrine and serotoninnorepinephrine and serotonin

• side effects:side effects: dry mouth, dizziness, sexual dry mouth, dizziness, sexual dysfunction, digestive problems, etc.dysfunction, digestive problems, etc.

• Side effects are similar to the MAOs except Side effects are similar to the MAOs except for the dietary restrictions for the dietary restrictions

2. Tricyclic Antidepressants2. Tricyclic Antidepressants

the most recent group to be discovered (1987)the most recent group to be discovered (1987)

• examples: examples: Prozac, Paxil, Zoloft Prozac, Paxil, Zoloft

• mechanism: mechanism: prevents reuptake of serotonin prevents reuptake of serotonin leaving more in synapseleaving more in synapse

• side effects: side effects: fewer than MAO or Trichyclics fewer than MAO or Trichyclics but still headache, anxiety, sexual dysfunctionbut still headache, anxiety, sexual dysfunction

• popularity: popularity: because of the less severe side because of the less severe side effects, more people are willing to take these.effects, more people are willing to take these.

3. Serotonin Reuptake Inhibitors (SSRIs)3. Serotonin Reuptake Inhibitors (SSRIs)

Lithium CarbonateLithium Carbonate• Lithium is a naturally occurring salt that is Lithium is a naturally occurring salt that is

used to treat bipolar disorder.used to treat bipolar disorder.

• Lithium helps level out the extreme highs of Lithium helps level out the extreme highs of mania and the extreme lows of depression.mania and the extreme lows of depression.

• Exact mechanism is not known but may Exact mechanism is not known but may involve NA (sodium) channels in CNS axonsinvolve NA (sodium) channels in CNS axons

• Narrow “window” of effectiveness, too little - Narrow “window” of effectiveness, too little - no effect, too much - dangerno effect, too much - danger

• Blood levels must be checked oftenBlood levels must be checked often

Two basic categoriesTwo basic categories

1 barbituratesbarbiturates:: powerful sedatives, first powerful sedatives, first anxiolytic to be developedanxiolytic to be developed

• example: example: Seconal Seconal

• mechanism: mechanism: CNS depressantCNS depressant

• side effects: side effects: sleepiness, slowed reflexes, very sleepiness, slowed reflexes, very dangerous when combined with alcoholdangerous when combined with alcohol

• tolerance and dependence are potential tolerance and dependence are potential problemsproblems

Anxiolytics (anti-anxiety) Drugs

• safer:safer: than barbiturates, highly prescribed than barbiturates, highly prescribed

• examples:examples: Valium, Xanax, Tranxene, AtivanValium, Xanax, Tranxene, Ativan

• mechanism:mechanism: binds to GABA (gamma amino binds to GABA (gamma amino butyric acid) receptors in the CNSbutyric acid) receptors in the CNS

• side effects:side effects: few and minor, some drowsiness, few and minor, some drowsiness, slowed reflexes, etc.slowed reflexes, etc.

• tolerance and dependence:tolerance and dependence: psychological and psychological and physical dependence are possible. However, physical dependence are possible. However, many experts disagree on this issuemany experts disagree on this issue

2. Benzodiazepines2. Benzodiazepines

PsychostimulantsPsychostimulants

• in children and some adults these improve in children and some adults these improve attention, help the person “settle down,” and attention, help the person “settle down,” and reduce impulsivityreduce impulsivity

• exampleexample - Ritalin - Ritalin

• mechanism - these are CNS stimulantsmechanism - these are CNS stimulants

• side effectsside effects - sedation, some long term physical - sedation, some long term physical effects effects

• tolerance or dependencetolerance or dependence - usually not a problem - usually not a problem

Other Biological TreatmentsOther Biological Treatments

• Electroconvulsive therapy (ECT)Electroconvulsive therapy (ECT)

• Psychosurgery: Psychosurgery: brain surgery brain surgery performed to change a person’s performed to change a person’s behavior and/or emotional state behavior and/or emotional state

– prefontal lobotomy

– modern psychosurgery

Electroconvulsive Therapy (ECT)Electroconvulsive Therapy (ECT)

• An electrical current is passed through the An electrical current is passed through the brain for a second or twobrain for a second or two

• This produces convulsions and temporary This produces convulsions and temporary coma. Today, muscle relaxants reduce coma. Today, muscle relaxants reduce severity of convulsionsseverity of convulsions

• Seen by most as a Seen by most as a treatment of “last treatment of “last resort” for the most severe depressionsresort” for the most severe depressions

• The mechanism by which ECT works The mechanism by which ECT works remains unknown.remains unknown.

PsychosurgeryPsychosurgery• prefrontal lobotomy: prefrontal lobotomy: “ice pick surgery” “ice pick surgery”

widely used during the first half of this widely used during the first half of this century before modern medicationscentury before modern medications

a crude operation in which axons connecting a crude operation in which axons connecting the frontal lobes with lower brain areas were the frontal lobes with lower brain areas were severed, rarely used today.severed, rarely used today.

• modern psychosurgery: modern psychosurgery: in addition to in addition to traditional methods, multi-source beams of traditional methods, multi-source beams of low energy radiation can modify brain tissue low energy radiation can modify brain tissue with pinpoint accuracywith pinpoint accuracy

DeinstitutionalizationDeinstitutionalization

• treating people with severe treating people with severe psychological disorders in the psychological disorders in the community rather than in large public community rather than in large public hospitals.hospitals.

• made possible largely by the made possible largely by the development of “anti-psychotic” drugs development of “anti-psychotic” drugs in the 1950sin the 1950s

Problems with DeinstitutionalizationProblems with Deinstitutionalization

1 Community mental-health centers are poorly Community mental-health centers are poorly funded and understaffed.funded and understaffed.

2 Ex-patients are poorly prepared to live in the Ex-patients are poorly prepared to live in the community.community.

3 Not enough housing available.Not enough housing available.4 Social stigma of having a mental disorder, Social stigma of having a mental disorder,

neighborhoods may resist these centers.neighborhoods may resist these centers.5 Large insurance companies would rather pay Large insurance companies would rather pay

for inpatient care.for inpatient care.

Types of Mental Illness PreventionTypes of Mental Illness Prevention

• primary preventionprimary prevention

• secondary preventionsecondary prevention

• tertiary preventiontertiary prevention

PreventionPrevention• Primary PreventionPrimary Prevention Improving the social Improving the social

environment so that new cases of mental environment so that new cases of mental disorders do not develop.disorders do not develop.

• Secondary PreventionSecondary Prevention identifying high identifying high risk groups and intervening before risk groups and intervening before problems become serious.problems become serious.

• Tertiary PreventionTertiary Prevention helping people adjust helping people adjust to community life after release from a to community life after release from a mental hospital.mental hospital.

Gender Differences in TreatmentGender Differences in Treatment

• Women are more likely than men to be Women are more likely than men to be in psychotherapy, possibly because is in psychotherapy, possibly because is more socially accepted for women.more socially accepted for women.

• Women receive more psychotropic Women receive more psychotropic medications than men.medications than men.

• Men are more likely to self medicate Men are more likely to self medicate with alcohol and other drugs.with alcohol and other drugs.

Cultural Differences in Cultural Differences in TreatmentTreatment

• One’s ethnic and cultural background One’s ethnic and cultural background may influence how he/she responds to may influence how he/she responds to a therapist.a therapist.

• A therapist who is more similar to the A therapist who is more similar to the client (e.g., gender, cultural group) client (e.g., gender, cultural group) may be better able to understand and may be better able to understand and relate to the problems of a particular relate to the problems of a particular client.client.