Chapter 13: Therapies

What Is Psychotherapy?

Any psychological technique Any psychological technique used to facilitate positive used to facilitate positive changes in personality, changes in personality, behavior, or adjustmentbehavior, or adjustment

Some Types of Psychotherapy

Individual: Involves only one Individual: Involves only one client and one therapistclient and one therapist

Client: Patient; the one who Client: Patient; the one who participates in psychotherapyparticipates in psychotherapyRogers used “client” to equalize Rogers used “client” to equalize therapist-client relationship and therapist-client relationship and de-emphasize doctor-patient de-emphasize doctor-patient conceptconcept

Group: Several clients Group: Several clients participate at the same timeparticipate at the same time

More Types of Psychotherapy

Insight: Goal is for clients to gain Insight: Goal is for clients to gain deeper understanding of their deeper understanding of their thoughts, emotions, and behaviors thoughts, emotions, and behaviors

Directive: Therapist provides strong Directive: Therapist provides strong guidanceguidance

Time-Limited: Any therapy that Time-Limited: Any therapy that limits number of sessionslimits number of sessions

Partial response to managed care and Partial response to managed care and to ever-increasing caseloadsto ever-increasing caseloads

Caseload: Number of clients a therapist Caseload: Number of clients a therapist actively seesactively sees

Positive Therapy

Designed to enhance Designed to enhance personal strengths rather personal strengths rather than “fix” weaknessesthan “fix” weaknesses

Origins of Therapy

Trepanning: For primitive “therapists,” Trepanning: For primitive “therapists,” refers to boring, chipping, or bashing refers to boring, chipping, or bashing holes into a patient’s head; for modern holes into a patient’s head; for modern usage, refers to any surgical procedure usage, refers to any surgical procedure in which a hole is bored into the skullin which a hole is bored into the skull

In primitive times it was unlikely the In primitive times it was unlikely the patient would survive; this may have been patient would survive; this may have been a goala goalGoal presumably to relieve pressure or rid Goal presumably to relieve pressure or rid the person of evil spiritsthe person of evil spirits

Demonology

Study of demons and people Study of demons and people beset by spiritsbeset by spirits

People were possessed, and they People were possessed, and they needed an needed an exorcism exorcism to be curedto be cured

Exorcism: Practice of driving off an Exorcism: Practice of driving off an “evil spirit”“evil spirit”

Origins of Therapy Continued

Ergotism: Psychotic-like symptoms that Ergotism: Psychotic-like symptoms that come from ergot poisoningcome from ergot poisoning

Ergot is a natural source of LSD Ergot is a natural source of LSD

Phillippe Pinel: French physician who Phillippe Pinel: French physician who initiated humane treatment of mental initiated humane treatment of mental patients in 1793patients in 1793

Created the first mental hospitalCreated the first mental hospital

Psychoanalysis: Freud

Hysteria: Physical symptoms (like Hysteria: Physical symptoms (like paralysis or numbness) occur paralysis or numbness) occur without physiological causeswithout physiological causes

Now known as Now known as somatoform disorderssomatoform disorders

Freud became convinced that Freud became convinced that hysterias were caused by deeply hysterias were caused by deeply hidden unconscious conflictshidden unconscious conflicts

Main Goal of Psychoanalysis: To Main Goal of Psychoanalysis: To resolve internal conflicts that lead resolve internal conflicts that lead to emotional sufferingto emotional suffering

Free Association

Saying whatever comes to Saying whatever comes to mind, regardless of how mind, regardless of how embarrassing it is or how embarrassing it is or how unimportant it may seemunimportant it may seem

By doing so without censorship By doing so without censorship and censure, unconscious and censure, unconscious material can emergematerial can emerge

Dream Analysis

Dreams express forbidden desires Dreams express forbidden desires and unconscious feelingsand unconscious feelings

Latent Content: Hidden, symbolic Latent Content: Hidden, symbolic meaning of dreamsmeaning of dreams

Manifest Content: Obvious, visible Manifest Content: Obvious, visible meaning of dreamsmeaning of dreams

Dream Symbols: Images in dreams Dream Symbols: Images in dreams that have personal or emotional that have personal or emotional meaningsmeanings

Psychoanalysis and Freud Concluded

Resistance: Blockage in flow of ideas; Resistance: Blockage in flow of ideas; topics the client resists thinking about topics the client resists thinking about or discussingor discussing

Resistances reveal particularly important Resistances reveal particularly important unconscious conflictsunconscious conflicts

Transference: Tendency to transfer Transference: Tendency to transfer feelings to a therapist that match those feelings to a therapist that match those the patient had for important people in the patient had for important people in his or her pasthis or her past

The patient might act like the therapist is a The patient might act like the therapist is a rejecting father, loving mother, etc.rejecting father, loving mother, etc.What Freudians aspire to in therapyWhat Freudians aspire to in therapy

Modern Psychoanalysis

Brief Psychodynamic Therapy: Based on Brief Psychodynamic Therapy: Based on psychoanalytic theory but designed to psychoanalytic theory but designed to produce insights more quickly; uses produce insights more quickly; uses direct questioning to reveal direct questioning to reveal unconscious conflictsunconscious conflictsSpontaneous Remission: Improvement Spontaneous Remission: Improvement of a psychological condition due to time of a psychological condition due to time passing withoutpassing without therapytherapy

Waiting-List Control Group

People who receive no therapy People who receive no therapy as a way to test the as a way to test the effectiveness of psychotherapyeffectiveness of psychotherapy

Compare control with Compare control with experimental group; if no experimental group; if no statistically significant statistically significant difference, then something other difference, then something other than therapy caused change or than therapy caused change or no change in conditionsno change in conditions

Humanistic Therapies

Client-Centered Therapy Client-Centered Therapy (Rogers; also known as (Rogers; also known as Person-Centered): Person-Centered): Nondirective and based on Nondirective and based on insights from conscious insights from conscious thoughts and feelings; thoughts and feelings; emphasizes accepting one’s emphasizes accepting one’s true selftrue self

Four Basic Rogerian Conditions

Effective therapists must Effective therapists must have four basic conditions:have four basic conditions:

Unconditional Positive Regard

Unshakable acceptance of Unshakable acceptance of another person, regardless of another person, regardless of what they tell the therapist or what they tell the therapist or how they feelhow they feel

Empathy

Ability to feel what another Ability to feel what another person is feeling; capacity to person is feeling; capacity to take another person’s point take another person’s point of viewof view

Authenticity

Ability of a therapist to be Ability of a therapist to be genuine and honest about his genuine and honest about his or her feelingsor her feelings

Reflection

Rephrasing or repeating Rephrasing or repeating thoughts and feelings of the thoughts and feelings of the clients’; helps clients become clients’; helps clients become aware of what they are sayingaware of what they are saying

Existential Therapy

An insight therapy that focuses on An insight therapy that focuses on problems of existence, such as meaning, problems of existence, such as meaning, choice, and responsibility; emphasizes choice, and responsibility; emphasizes making difficult choices in lifemaking difficult choices in life

Therapy focuses on death, freedom, Therapy focuses on death, freedom, isolation, and meaninglessnessisolation, and meaninglessness

Free Will: Human ability to make Free Will: Human ability to make choiceschoices

You can choose to be the person you want to You can choose to be the person you want to bebe

Confrontation

Clients are challenged to Clients are challenged to examine their values and examine their values and choiceschoices

Gestalt Therapy (Perls)

Focuses on immediate awareness to Focuses on immediate awareness to help clients rebuild thinking, feeling, help clients rebuild thinking, feeling, and acting into connected wholesand acting into connected wholes

Emphasizes integration of fragmented Emphasizes integration of fragmented experiences (filling in the gaps)experiences (filling in the gaps)

Clients are taught to accept Clients are taught to accept responsibility for their thoughts and responsibility for their thoughts and actionsactions

More directive than client-centered or More directive than client-centered or existential therapyexistential therapy

Psychotherapy at a Distance

Media Psychologists: Radio and Media Psychologists: Radio and newspaper and television psychologists; newspaper and television psychologists; often give advice, information, and social often give advice, information, and social supportsupport

Should only give general support and Should only give general support and informationinformation

Telephone Therapists: 900 number Telephone Therapists: 900 number therapiststherapists

Usually not effectiveUsually not effective

Behavior Therapy

Use of learning principles to make Use of learning principles to make constructive changes in behaviorconstructive changes in behavior

Behavior Modification: Using any Behavior Modification: Using any classical or operant conditioning classical or operant conditioning principles to directly change human principles to directly change human behavior behavior

Deep insight is often not necessaryDeep insight is often not necessary

Focus on the present; cannot change the Focus on the present; cannot change the past, and no reason to alter that which past, and no reason to alter that which has yet to occurhas yet to occur

Aversion Therapy

Conditioned Aversion: Learned dislike or Conditioned Aversion: Learned dislike or negative emotional response to a negative emotional response to a stimulusstimulus

Aversion Therapy: Associate a strong Aversion Therapy: Associate a strong aversion to an undesirable habit like aversion to an undesirable habit like smoking, overeating, or drinking alcoholsmoking, overeating, or drinking alcohol

Rapid Smoking: Prolonged smoking at a Rapid Smoking: Prolonged smoking at a rapid pace rapid pace

Designed to cause aversion to smokingDesigned to cause aversion to smoking

Desensitization

Hierarchy: Rank-ordered Hierarchy: Rank-ordered series of steps, amounts, or series of steps, amounts, or degreesdegrees

Reciprocal Inhibition: One Reciprocal Inhibition: One emotional state is used to emotional state is used to block another (e.g., block another (e.g., impossible to be anxious and impossible to be anxious and relaxed at the same time)relaxed at the same time)

Systematic Desensitization

Guided reduction in fear, Guided reduction in fear, anxiety, or aversion; attained anxiety, or aversion; attained by approaching a feared by approaching a feared stimulus gradually while stimulus gradually while maintaining relaxationmaintaining relaxation

Best used to treat phobias: Best used to treat phobias: intense, unrealistic fearsintense, unrealistic fears

Vicarious Desensitization

Model: Live or filmed person who serves Model: Live or filmed person who serves as an example for observational learningas an example for observational learningVicarious Desensitization: Reduction in Vicarious Desensitization: Reduction in fear that takes place secondhand when a fear that takes place secondhand when a client watches models perform the client watches models perform the feared behaviorfeared behaviorVirtual Reality Exposure: Presents Virtual Reality Exposure: Presents computerized fear stimuli to patients in computerized fear stimuli to patients in a controlled fashiona controlled fashion

Eye Movement Desensitization and Reprocessing (EMDR)

• Reduces fear and anxiety by Reduces fear and anxiety by holding upsetting thoughts in holding upsetting thoughts in your mind while rapidly your mind while rapidly moving your eyes from side to moving your eyes from side to sideside

Operant Conditioning

• Positive Reinforcement: Responses that Positive Reinforcement: Responses that are followed by a reward tend to occur are followed by a reward tend to occur more frequentlymore frequently

• Nonreinforcement: A response that is Nonreinforcement: A response that is not followed by a reward will occur less not followed by a reward will occur less frequentlyfrequently

• Extinction: If response is NOTExtinction: If response is NOT followed followed by reward after it has been repeated by reward after it has been repeated many times, it will go awaymany times, it will go away

Punishment

• If a response is followed by If a response is followed by discomfort or an undesirable discomfort or an undesirable effect, the response will effect, the response will decrease/be suppressed (but decrease/be suppressed (but not necessarily extinguishednot necessarily extinguished))

More Operant Principles

Shaping: Rewarding actions that are Shaping: Rewarding actions that are closer and closer approximations to a closer and closer approximations to a desired responsedesired response

Stimulus Control: Controlling responses Stimulus Control: Controlling responses in the situation in which they occurin the situation in which they occur

Time Out: Removing individual from a Time Out: Removing individual from a situation in which reinforcement occurssituation in which reinforcement occurs

Reinforcement and Tokens

Tokens: Symbolic rewards like poker Tokens: Symbolic rewards like poker chips, gold stars, or stamps that can chips, gold stars, or stamps that can be exchanged for real rewardsbe exchanged for real rewards

Can be used to reinforce positive Can be used to reinforce positive responses immediatelyresponses immediatelyEffective in psychiatric hospitals and Effective in psychiatric hospitals and sheltered care facilitiessheltered care facilities

Target Behaviors: Actions or other Target Behaviors: Actions or other behaviors a therapist seeks to behaviors a therapist seeks to changechange

Token Economy

Patients get tokens for many Patients get tokens for many socially desirable or socially desirable or productive behaviors; they productive behaviors; they can can paypay tokens for tangible tokens for tangible rewards and for undesirable rewards and for undesirable behaviorsbehaviors

Cognitive Therapy

Therapy that helps clients Therapy that helps clients change thinking patterns change thinking patterns that lead to problematic that lead to problematic behaviors or emotionsbehaviors or emotionsCognitive therapy is VERY Cognitive therapy is VERY effective in treating effective in treating depressiondepression

Cognitive Therapy for Depression

Three Major Thinking Distortions:Three Major Thinking Distortions:Selective Perception: Perceiving only Selective Perception: Perceiving only certain stimuli in a larger group of certain stimuli in a larger group of possibilitiespossibilities

Overgeneralization: Allowing Overgeneralization: Allowing upsetting events to apply to unrelated upsetting events to apply to unrelated situationssituations

All-or-Nothing Thinking: Seeing All-or-Nothing Thinking: Seeing objects and events as absolutely right objects and events as absolutely right or wrong, good or bad, and so onor wrong, good or bad, and so on

Rational Emotive Behavior Therapy (REBT)

Attempts to change irrational Attempts to change irrational beliefs that cause emotional beliefs that cause emotional problemsproblems

Theory created by Albert EllisTheory created by Albert Ellis

For example, Anya thinks, “I For example, Anya thinks, “I must be liked by everyone; if must be liked by everyone; if not, I’m a rotten person.”not, I’m a rotten person.”

Psychodrama (Moreno)

Clients actClients act out personal conflicts and out personal conflicts and feelings with others who play feelings with others who play supporting rolessupporting roles

Role Playing: Re-enacting significant life Role Playing: Re-enacting significant life eventsevents

Role Reversal: Taking the part of another Role Reversal: Taking the part of another person to learn how he or she feelsperson to learn how he or she feels

Mirror Technique: Client observes another Mirror Technique: Client observes another person re-enacting his/her behaviorperson re-enacting his/her behavior

Family Therapy

All family members work as a All family members work as a group to resolve the group to resolve the problems of each family problems of each family membermember

Tends to be brief and focuses on Tends to be brief and focuses on specific problems (e.g., specific specific problems (e.g., specific fights)fights)

Group Awareness Training

Sensitivity Groups: Increase self-Sensitivity Groups: Increase self-awareness and sensitivity to othersawareness and sensitivity to others

Encounter Groups: Emphasize honest Encounter Groups: Emphasize honest expression of feelings expression of feelings

Large-Group Awareness Training: Large-Group Awareness Training: Increases self-awareness and facilitates Increases self-awareness and facilitates constructive personal changeconstructive personal change

Therapy Placebo Effect: Improvement is Therapy Placebo Effect: Improvement is based on client’s belief that therapy will based on client’s belief that therapy will helphelp

Key Features of Psychotherapy

Therapeutic Alliance: Caring relationship Therapeutic Alliance: Caring relationship between the client and therapist; work to between the client and therapist; work to “solve” client’s problems“solve” client’s problemsTherapy offers a protected setting where Therapy offers a protected setting where emotional emotional catharsiscatharsis (release) can occur (release) can occur All the therapies offer some explanation All the therapies offer some explanation or rationale for the client’s sufferingor rationale for the client’s sufferingProvides clients with a new perspective Provides clients with a new perspective about themselves and their situations, about themselves and their situations, and a chance to practice new behaviorsand a chance to practice new behaviors

Basic Counseling Skills

Active listeningActive listening

Clarify the problemClarify the problem

Focus on feelingsFocus on feelings

Avoid giving adviceAvoid giving advice

Accept the client’s frame of Accept the client’s frame of referencereference

Basic Counseling Skills Continued

Reflect thoughts and feelingsReflect thoughts and feelings

Silence: Know when to use itSilence: Know when to use it

QuestionsQuestionsOpen: Open-ended replyOpen: Open-ended reply

Closed: Can be answered “Yes” or “No”Closed: Can be answered “Yes” or “No”

Maintain confidentialityMaintain confidentiality

Medical (Somatic) Therapies

Pharmacotherapy: Use of drugs to Pharmacotherapy: Use of drugs to alleviate emotional disturbance; alleviate emotional disturbance; three major classes:three major classes:

Anxiolytics: Like Valium; produce Anxiolytics: Like Valium; produce relaxation or reduce anxietyrelaxation or reduce anxiety

Antidepressants: Elevate mood and Antidepressants: Elevate mood and combat depressioncombat depression

Antipsychotics: Tranquilize and also Antipsychotics: Tranquilize and also reduce hallucinations and delusions in reduce hallucinations and delusions in larger dosageslarger dosages

One Potential Problem with Drug Therapy

• Clozaril (clozapine): Clozaril (clozapine): • Relieves schizophrenic Relieves schizophrenic

symptoms; however, two out symptoms; however, two out of one hundred patients may of one hundred patients may suffer from a potentially fatal suffer from a potentially fatal white blood cell diseasewhite blood cell disease

Electroconvulsive Therapy (ECT)

150 volt electric shock is 150 volt electric shock is passed through the brain for passed through the brain for about one second, inducing a about one second, inducing a convulsion convulsion

Based on belief that seizure Based on belief that seizure alleviates depression by altering alleviates depression by altering brain chemistrybrain chemistry

ECT Views

Produces only temporary improvementProduces only temporary improvement

Causes memory loss in some patientsCauses memory loss in some patients

Should only be used as a last resortShould only be used as a last resort

Should be followed by treatment with Should be followed by treatment with antidepressant medications to decrease antidepressant medications to decrease chances of relapsechances of relapse

Psychosurgery

Any surgical alteration of the brainAny surgical alteration of the brain

Prefrontal Lobotomy: Frontal lobes in Prefrontal Lobotomy: Frontal lobes in brain are surgically cut from other brain brain are surgically cut from other brain areasareas

Supposed to calm people who did not respond Supposed to calm people who did not respond to other forms of treatmentto other forms of treatment

Was not very successfulWas not very successful

Deep Lesioning: Small target areas in the Deep Lesioning: Small target areas in the brain are destroyed by using an electrodebrain are destroyed by using an electrode

Hospitalization

Mental Hospitalization: Involves placing a Mental Hospitalization: Involves placing a person in a protected, therapeutic person in a protected, therapeutic environment staffed by mental health environment staffed by mental health professionalsprofessionalsPartial Hospitalization: Patients spend Partial Hospitalization: Patients spend only their days in the hospital but go home only their days in the hospital but go home at nightat nightDeinstitutionalization: Reduced use of full-Deinstitutionalization: Reduced use of full-time commitment to mental institutionstime commitment to mental institutionsHalf-way Houses: Short-term group living Half-way Houses: Short-term group living facilities for individuals making the facilities for individuals making the transition from an institution (mental transition from an institution (mental hospital, prison, etc.) to independent hospital, prison, etc.) to independent livingliving

Community Mental Health Centers

Offer many health services like prevention, Offer many health services like prevention, education, therapy, and crisis interventioneducation, therapy, and crisis intervention

Crisis Intervention: Skilled management of a Crisis Intervention: Skilled management of a psychological emergencypsychological emergency

Paraprofessional: Individual who works in Paraprofessional: Individual who works in a near-professional capacity under a near-professional capacity under supervision of a more highly trained supervision of a more highly trained personperson

Self-Management

Covert Sensitization: Aversive imagery Covert Sensitization: Aversive imagery is used to reduce occurrence of an is used to reduce occurrence of an undesired responseundesired response

Thought Stopping: Aversive stimuli are Thought Stopping: Aversive stimuli are used to interrupt or prevent upsetting used to interrupt or prevent upsetting thoughtsthoughts

Covert Reinforcement: Using positive Covert Reinforcement: Using positive imagery to reinforce desired behaviorimagery to reinforce desired behavior

Tension Release Method: Procedure of Tension Release Method: Procedure of deep relaxationdeep relaxation

Other Therapy Options

Peer Counselor: Nonprofessional person Peer Counselor: Nonprofessional person who has learned basic counseling skillswho has learned basic counseling skills

Self-Help Group: Group of people who Self-Help Group: Group of people who share a particular type of problem and share a particular type of problem and provide mutual support to each other provide mutual support to each other (e.g., “Alcoholics Anonymous”)(e.g., “Alcoholics Anonymous”)

Evaluating a Therapist: Danger Signals

Therapist makes sexual Therapist makes sexual advances advances

Therapist makes repeated Therapist makes repeated verbal threats or is physically verbal threats or is physically aggressiveaggressive

Therapist is excessively Therapist is excessively hostile, controlling, blaming, hostile, controlling, blaming, or belittlingor belittling

More Danger Signals

Therapist talks repeatedly about his/her Therapist talks repeatedly about his/her own problemsown problems

Therapist encourages prolonged Therapist encourages prolonged dependence on him/herdependence on him/her

Therapist demands absolute trust or tells Therapist demands absolute trust or tells client not to discuss therapy with anyone client not to discuss therapy with anyone elseelse

Evaluating a Therapist: Ask During the Initial Meeting

Will the information I reveal in therapy Will the information I reveal in therapy remain confidential?remain confidential?

What risks do I face if I begin therapy?What risks do I face if I begin therapy?

How long do you expect treatment to last?How long do you expect treatment to last?

What form of treatment do you expect to What form of treatment do you expect to use?use?

Are there alternatives to therapy that Are there alternatives to therapy that might help as much or more?might help as much or more?