Therapy

Chapter 13

Therapy

Treating Psychological Disorders

The Psychological Therapies Psychoanalysis

Humanistic Therapies

Behavior Therapies

Cognitive Therapies

Group and Family Therapies

Therapy

Evaluating Psychotherapies Is Psychotherapy Effective?

Which Therapies Work Best?

How Do Psychotherapies Help People?

Culture and Values in Psychotherapy

Therapy

The Biomedical Therapies Drug Therapies

Brain Stimulation

Psychosurgery

Therapeutic Lifestyle Change

Preventing Psychological Disorders

Treating Psychological Disorders• In earlier times, efforts to treat psychological

disorders were often cruel and often based on irrational beliefs

• The chair on the right was once considered a more humane form of treatment.

Treatment Reformers

• Reformers pushed for gentler, more humane treatments– Constructed mental

hospitals

• Since 1950s mental hospitals have been emptied in favor of drug therapies and community-based treatments

Dorothea Dix(1802-1887)

Today’s Therapies

• Psychotherapy: treatment involving psychological techniques– Consists of interactions with a trained

therapist– Many therapists use an eclectic approach,

using a blend of therapy techniques

• Biomedical therapy: Prescribed medications or medical procedures

The Psychological Therapies

• The most influential types of psychotherapies:– Psychoanalytic– Humanistic– Behavioral– Cognitive

• Most can be used one-on-one or in groups

Psychoanalysis

• Originally developed by Freud• Today, not generally practiced as Freud did• Provides part of the foundation for treating

psychological disorders

Psychoanalysis

• Goals– Bring patients’

repressed or disowned feelings into conscious awareness

– Giving them insight into the origins of their disorder helps them take responsibility for their own growth

Techniques of Psychoanalysis

• Free association– Talking about whatever comes to mind– Can reveal unconscious blocking of anxiety-

laden material (resistance)– The psychoanalyst’s interpretation may

provide the patient with insight

• Transference: the patient may transfer to the analyst emotions linked with other relationships

Psychoanalysis

• Few U.S. therapists offer traditional psychoanalysis– Underlying theory not supported by scientific research– Interpretations cannot be proven or disproven– Can take years of several expensive sessions per

week

• Contemporary psychodynamic therapies have evolved from psychoanalysis

Psychodynamic Therapy

• Tries to help people understand their symptoms by focusing on themes across important relationships including childhood experiences and the therapist relationship– Often face-to-face– Shorter time frame than

traditional psychoanalysis

Humanistic Therapies

• Therapists aim to boost patients’ self-fulfillment by growing in self-awareness and self-acceptance

• Differences from psychoanalytic therapies– Focuses on promoting growth, not curing illness– Path to growth is taking immediate responsibility for

one’s feelings and actions– Conscious thoughts are more important than

unconscious– The present and future are more important than the past

Humanistic Therapies

• Client-centered therapy– Developed by Carl Rogers– Combines active listening with a genuine, accepting,

empathic, environment to promote clients’ growth– Includes unconditional positive regard from the

therapist

Active Listening

Hints for active listening, even among friends

1.Summarize– Repeat the other’s statements in your own

words

2.Invite clarification– “What might be an example of that?”

3.Reflect Feelings– “It sounds frustrating.”

Behavior Therapies

• Doubts the healing power of self-awareness• Applies learning principles to the elimination of

unwanted behaviors

Classical Conditioning Techniques

• Maladaptive symptoms may be examples of conditioned responses

• Treatment for bed-wetters (O.H. Mowrer)– Connect liquid-sensitive pads to an alarm– Associates urinary relaxation with waking, stops the bed-wetting

• Counterconditioning: pairs the trigger stimulus (e.g., enclosed space) with a new response (e.g., relaxation)– Exposure therapies– Aversive conditioning

Exposure Therapies

• Treat anxiety by exposing people to the things they fear and avoid

• Systematic desensitization: associates a relaxed state with gradually increasing anxiety-triggering stimuli

• Virtual reality exposure therapy: progressively exposes people to simulations of their greatest fears

Aversive Conditioning

• Associates an unpleasant state with an unwanted behavior

Operant Conditioning

• Behavior modification:– Reinforce desirable behaviors– Don’t reinforce (or even punish) undesirable

behaviors– Useful for solving specific behavior problems

• Token economy: a procedure in which people earn a token for exhibiting a desired behavior, and can later exchange the tokens for privileges or treats

Cognitive Therapies

• Behavior therapies are good for specific fears and problem behaviors

• What about range of behaviors accompanying depression or anxiety?

• Cognitive therapies teach people new, more adaptive ways of thinking and acting– Based on the assumption that thoughts

intervene between events and our emotional reactions

A Cognitive Perspective

Beck’s Therapy for Depression

• Aaron Beck and his colleagues developed cognitive therapy– Gentle questioning seeks to reveal irrational

thinking and then persuade people to remove “dark glasses” through which they view life

Beck’s Therapy for Depression

• Many students become anxious before an exam– “This exam’s going to be impossible”– “I wish I were better prepared”

• To change negative self-talk, therapists teach people to alter their thinking in stressful situations– “I’ve studied well, now it’s time to show what I know”

• Training people to “talk back” to negative thoughts can be effective at curbing depression

Cognitive-Behavioral Therapy

• An integrative therapy combines cognitive therapy (changing self-defeating thinking) with behavior therapy (changing behavior)– Shown to be effective at treating anxiety

disorders (like OCD) and depression– Albert Ellis suggested that even when

cognitive therapy works, feeling better is not enough: “You have to back it up with action, action, action.”

Group and Family Therapies

• Most therapies may also occur in small groups (except traditional psychoanalysis)

Group and Family Therapies

• Unique benefits– Relief to find that others share your problems– Receive feedback as you try out new

behaviors

• Family therapy treats the family as a system. View an individual’s unwanted behaviors as influenced by or directed at other family members

Evaluating Psychotherapies

• Is Psychotherapy Effective?

• Which Therapies Work Best?

• How Do Psychotherapies Help People?

• Culture and Values in Psychotherapy

Is Psychotherapy Effective?

• Clients’ Perceptions: Almost 90% of patients at least “fairly well satisfied”

• Criticisms of using client satisfaction as a measure of effectiveness include: – People often enter therapy in crisis, and might

have then improved without therapy

Is Psychotherapy Effective?

• Clinician’s Perceptions– Therapists tend to be aware of their own

successes and the failures of others

• To objectively evaluate psychotherapies, psychologists turn to controlled research studies

Outcome Research

• Eysenck (1952) showed with or without therapy, about two-thirds of patients show improvement with time– Research methods potentially flawed

• Today, randomized clinical trials show that psychotherapy works– Those not undergoing therapy often improve,

but those undergoing therapy are more likely to improve

Outcome Research

• NIMH Study– Experienced therapists trained in cognitive

therapy, interpersonal therapy, or drug therapy

– 239 depressed participants randomly assigned to one of those 3 or control group

– After 16 weeks, depression lifted for more than half in each of treatment groups

– Only 29% improved in control group

Outcome Research

Figure is a compilation of 475 studies

Which Therapies Work Best?

• No one type of therapy is best across the board

• Some forms work best for particular problems– Behavior conditioning for specific behavior

problems (bed-wetting, phobias, compulsions)

Therapies with Little Scientific Support

• Energy therapies

• Recovered-memory therapies

• Rebirthing therapies

• Facilitated communication

• Crisis debriefing

Clinical Decision Making What role should science play in clinical practice?

Ideal decision making is upheld by

(1) research evidence,

(2) clinical expertise,

(3) knowledge of the patient

How Do Psychotherapies Help People?

• 3 basic benefits1. Hope for demoralized people

2. A new perspective on oneself and the world

3. An empathic, trusting, caring relationship

Culture and Values in Psychotherapy

• A mismatch can occur when therapist and client have different cultural values– E.g., clients from collectivist cultures may have trouble

thinking only of their own well-being– Highly religious people prefer therapists who share their

values

• Psychotherapists’ personal beliefs and values influence their practice– Clients tend to adopt their therapists’ values – Therapists should perhaps express those values more

openly

A Consumer’s Guide to Psychotherapists

When to Seek Treatment

Adapted APA list of warning symptoms, which don’t include relationship problems:

- Feeling worthless - Withdrawing from others- Deep, lasting depression - Fears preventing daily life- Self-destructive behavior - Problems with substance abuse- Extreme mood shifts - Wanting to die or hurt self- Compulsive rituals - Sexual difficulties affecting daily life- Hearing voices or seeing things that others don’t perceive

The Biomedical Therapies

• Drug Therapies

• Brain Stimulation

• Psychosurgery

• Therapeutic Life-Style Change

Drug Therapies• Increase in use of drug therapies coincides

with an emptying of U.S. mental hospitals

Drug Therapies

• To judge the effectiveness of a new treatment, we need to compare its effectiveness to the rates of the following: – Normal recovery among untreated people– Recovery due to the placebo effect

• In double-blind (neither scientist nor subject know who is getting the real drug) studies, several types of drugs have proven useful in treating psychological disorders

Antipsychotic Drugs

• Drugs used to treat schizophrenia and other forms of severe thought disorders

• Useful for treating positive symptoms– E.g., hallucinations, paranoia

• Not as helpful in treating negative symptoms– E.g., apathy, withdrawal

• Work by blocking dopamine receptors, mimicking certain neurotransmitters.

Antipsychotic Drugs

• Powerful side effects– Sluggishness, tremors, twitches– Newer-generation antipsychotics produce

fewer side effects

• Despite drawbacks, antipsychotics can help people with schizophrenia when combined with life-skills programs and family support

Antianxiety Drugs

• Drugs used to control anxiety and agitation

• Depress central nervous system activity

• Calm anxiety as person learns to cope with fear-triggering stimuli

• Made reduce symptoms without resolving underlying problems

Antidepressant Drugs

• Used to treat depression and some anxiety disorders

• Different types work by altering the availability of various neurotransmitters

• Prozac, Zoloft, and Paxil are selective-serotonin-reuptake-inhibitors (SSRIs)

• May take up to four weeks to reach full therapeutic effect

How SSRIs Work

Using Antidepressant Drugs

• Best approach may be to use antidepressants in combination with cognitive-behavioral therapy

• In double-blind trials, placebos produced about 75% of the improvement as active drug– Some conclude that there may be little reason

to use except for the most severely depressed patients

Mood-Stabilizing Medications

• Levels the emotional highs and lows, as with bipolar disorder– Depakote, lithum

• Unclear how lithium works, but about 7 in 10 bipolar patients benefit – Risk of suicide is one-sixth of those not taking

lithium

Brain Stimulation

• Electroconvulsive Therapy (ECT)

• Alternative Neurostimulation Therapies

Electroconvulsive Therapy

• A biomedical therapy for severely depressed patients

• A brief (30-60 sec) electric current is sent through the brain of an anesthetized patient

• Can effectively treat severe depression in patients who have not responded to drug therapy

Electroconvulsive Therapy

Alternative Neurostimulation Therapies

• Vagus nerve stimulation: Stimulates vagus nerve in neck, sending signals to brain’s limbic system

• Deep-brain stimulation – Administered via implanted electrodes

• Repetitive Transcranial Magnetic Stimulation (rTMS)

rTMS

Psychosurgery

• Surgery that removes or destroys brain tissue in an effort to change behavior– Most dramatic and least-used biomedical

intervention

• Lobotomy: a psychosurgical procedure once used to calm uncontrollably emotional or violent patients– Cut the nerves connecting the frontal lobes to

the emotion-controlling centers of the inner brain

Lobotomy

• Usually decreased misery or tension

• Also produced a permanently listless, immature, uncreative personality

• No longer performedRosemary Kennedy (middle in photo) had a lobotomy for mood swings; spent rest of life in hospital, with infantile mental capacity.

Therapeutic Life-Style Change

• Everything psychological is also biological, so changing the body could change mood.

• Human brains and bodies were designed for physical activity and social engagement:– Lack of these could feed depression.

• Studies confirm that exercise reduces depression and anxiety– A useful adjunct to antidepressant drugs and

psychotherapy

Mind and Body are Connected

Comparing Therapies

Preventing Psychological Disorders

• Lifestyle change can reverse some symptoms

• Such change can also prevent some disorders by building resilience – the personal strength that helps people cope with stress and recover from adversity or trauma

Resilience

• Faced with unforeseen trauma, most adults exhibit resilience– New Yorkers after 9/11, especially those with

supportive close relationships– Holocaust survivors

• Struggling with challenging crises can lead to post-traumatic growth– Cancer survivors had a higher appreciation for life,

more meaningful relationships, increased personal strength, changed priorities

Fostering Growth and Human Flourishing

• Many psychological disorders are understandable responses to a disturbing and stressful society.

• Preventive mental health seeks to identify and wipe out conditions that cause psychological casualties.– employment/income stress, discrimination, etc.– Community Psychology/Mental Health is the effort to

create environments which support empowerment, success, well-being.