Chapter Outline

  1. The elements of psychotherapy: Treatments, clients, and therapists
    1. Treatments: How many types are there?
      1. Types and approaches are numerous, varied
      2. Three major categories
        1. Insight therapies, or "talk therapy" in tradition of Freud's psychoanalysis
        2. Behavior therapies, based on principles of learning and conditioning
        3. Biomedical therapies, which focus on biological interventions
    2. Clients: Who seeks therapy?
      1. Great diversity among clients
      2. Nature and severity of trouble varies from individual to individual
        1. Most common problems are anxiety, depression
        2. People often delay for years before seeking treatment
      3. Client in treatment does not necessarily have an identifiable psychological disorder
      4. People vary in willingness to seek treatment
        1. Women more likely to seek treatment than men
        2. Treatment more likely for those who have medical insurance, college education
      5. Many people who need therapy don't receive it
    3. Therapists: who provides professional treatment?
      1. Psychologists
        1. Clinical psychologists and counseling psychologists specialize in the diagnosis and treatment of psychological disorders and everyday behavioral problems
          1. Much overlap in training, skills, clientele
          2. Both must earn doctoral degree
        2. Use either insight or behavioral approaches
      2. Psychiatrists are physicians who specialize in the treatment of psychological disorders
        1. Devote more time to relatively severe disorders (e.g., schizophrenia)
        2. Have M.D. degree
        3. Tend to emphasize biomedical treatments
      3. Other mental health professionals
        1. Psychiatric social workers, psychiatric nurses often work as part of treatment team with psychologist or psychiatrist
        2. Counselors also provide therapeutic services
  2. Insight therapies (involve verbal interactions intended to enhance clients' self-knowledge and thus promote healthful changes in personality and behavior)
    1. Psychoanalysis
      1. Psychoanalysis is an insight therapy that emphasizes the recovery of unconscious conflicts, motives, and defenses through techniques such as free association, dream analysis, and transference
      2. Developed by Sigmund Freud
      3. Dominance has eroded in recent decades, but diverse array of psychoanalytic approaches continue to remain influential
      4. Probing the unconscious
        1. Free association: clients spontaneously express their thoughts and feelings exactly as they occur, with as little censorship as possible
        2. Dream analysis: the therapist interprets the symbolic meaning of the client's dreams
      5. Interpretation involves the therapist's attempt to explain the inner significance of the client's thoughts, feelings, memories, and behaviors
        1. Contrary to popular belief, analysts don't try to interpret everything
        2. Therapists generally move forward very slowly
      6. Resistance involves largely unconscious defensive maneuvers intended to hinder the progress of therapy
        1. Occurs because clients are reluctant to confront their problems
        2. May take a variety of forms
      7. Transference occurs when clients start relating to their therapist in ways that mimic critical relationships in their lives
        1. In a sense, clients transfer conflicting feeling about important people onto therapist
        2. Psychoanalysts often encourage transference as a way to bring repressed feelings, conflicts to the surface
        3. Undergoing psychoanalysis can be slow, painful process of self-examination
        4. Classical psychoanalysis, as done by Freud, is not widely practiced anymore
        5. Variations are collectively known as psychodynamic approaches (e.g., revisions devised by Jung, Adler, Klein, etc.)
    2. Client-centered therapy (an insight therapy that emphasizes providing a supportive emotional climate for clients, who play a major role in determining the pace and direction of their therapy)
      1. Stimulated by work of Carl Rogers, who took a humanistic perspective
      2. Therapeutic climate
        1. Climate is more important than process
        2. Therapist must provide three conditions
          1. Genuineness
          2. Unconditional positive regard
          3. Empathy
      3. Therapeutic process
        1. Client, therapist work together as equals
        2. Therapist's key role is clarification of client's true feelings
    3. Cognitive therapy (an insight therapy that emphasizes recognizing and changing negative thoughts and maladaptive beliefs)
      1. Exemplified by work of Aaron Beck, Albert Ellis
      2. Goals and techniques
        1. Goal is to change way clients think, to help them use more reasonable standards of evaluation
        2. Therapist is actively involved, looking for unrealistic assumptions that underlie client's negative thinking
      3. Kinship with behavior therapy
        1. Cognitive therapists often use "homework assignments" that focus on patterns of behavior
        2. A blend of "talk therapy" and behavior therapy
        3. Was originally designed for treatment with individuals, but has been adapted for use with groups
    4. Group therapy (the simultaneous treatment of several or more clients in a group)
      1. Participants' roles
        1. Therapist usually screens participants, excluding potentially disruptive people
        2. Clients and therapist are on much more equal footing with groups than with individual therapy
        3. Clients functions as therapists for each other
      2. Advantages of the group experience
        1. Can save time and money
        2. Participants often realize that their misery is not unique
        3. Provides opportunities for clients to work on social skills in safe environment
        4. Certain kinds of problems especially well suited to group treatment (e.g., drug groups, Alcoholics Anonymous)
    5. Evaluating insight therapies
      1. Hans Eysenck questioned efficacy of insight therapies
      2. Spontaneous remission: a recovery from a disorder that occurs without formal treatment
      3. Evaluating any approach to psychotherapy is complicated
        1. Especially true for insight therapies
        2. Measures of therapeutic outcome tend to be subjective
      4. Recent studies suggest that insight therapy is superior to no treatment, placebo treatment
        1. Although superiority is usually characterized as modest
        2. Differences in efficacy between professional therapy and paraprofessional interventions are often negligible
    6. Therapy and the recovered memories controversy
      1. Spurred by recent spate of reports involving recovery of repressed memories of sexual abuse, other childhood trauma
      2. Critical aspect is that there is no way to corroborate allegations of abuse
      3. Many psychologists accept repressed memories at face value
      4. Others (e.g., memory researchers) suggest that persuasive therapists may have influenced clients
      5. Debate has grown increasingly bitter
        1. Skeptics suggest that innocent families are being harmed needlessly
        2. Supporters suggest that debate will make people reluctant to report actual abuse
  3. Behavior therapies (involve the application of the principles of learning to direct efforts to change clients' maladaptive behaviors)
    1. Introduction
      1. Behaviorism has been influential since 1920s
      2. Application of behaviorism to therapy began in 1950s
    2. General principles
      1. Assumed that behavior is a product of learning
      2. Assumed that what has been learned can be unlearned
      3. Behavior therapies are close cousins of self-modification procedures (described in Chapter 4 Application)
    3. Systematic desensitization: a behavior therapy used to reduce clients' anxiety responses through counterconditioning
      1. Devised by Joseph Wolpe
      2. Involves three steps
        1. Therapist helps client build an anxiety hierarchy
        2. Therapist trains client in deep muscle relaxation
        3. Client tries to work through hierarchy, learning to remain relaxed while imagining each stimulus
      3. Desensitization to imagined stimuli generally followed by exposure to real anxiety-arousing stimuli
      4. Goal is to counter-condition new response (relaxation) to original stimulus (object of anxiety)
      5. Has been effective in eliminating specific anxieties
    4. Aversion therapy is a behavior therapy in which an aversive stimulus is paired with a stimulus that elicits an undesirable response
      1. Most controversial of behavior therapies
        1. Psychologists usually suggest it only as treatment of last resort
        2. Client has to endure unpleasant stimuli (e.g., shock, drug-induced nausea)
      2. Behaviors treated successfully include drug abuse, sexual deviance, gambling, etc.
    5. Social skills training is a behavior therapy designed to improve interpersonal skills that emphasizes shaping, modeling, and behavioral rehearsal
      1. Many psychological problems grow out of interpersonal difficulties
      2. Has yielded promising results in treatment of depression, shyness, social anxiety, even schizophrenia
      3. Can be conducted with individual clients or in groups
      4. Depends on principles of operant conditioning, observational learning
        1. Modeling- such as encouraging clients to watch socially skilled friends, colleagues
        2. In behavioral rehearsal, client practices social techniques in role-playing exercises
        3. Shaping is use by having clients gradually handle more complicated and delicate social situations
    6. Evaluating behavior therapies
      1. Ample evidence regarding effectiveness
        1. Behavior therapists have historically placed more emphasis than insight therapists on importance of measuring outcomes
        2. May be slightly better than insight therapy for certain kinds of disorders
      2. Not well suited for treatment of certain kinds of problems (e.g., vague feelings of discontent)
      3. Seem to be particularly effective in treatment of anxiety problems, phobias, sexual dysfunction, etc.
  4. Biomedical therapies are physiological interventions intended to reduce symptoms associated with psychological disorders
    1. Introduction
      1. Assume that psychological disorders are caused, at least in part, by biological malfunctions
      2. Assumption seems to have merit, particularly when applied to more severe disorders
    2. Treatment with drugs
      1. Psychopharmacotherapy involves the treatment of mental disorders with medication
      2. Therapeutic drugs fall into three major categories
        1. Antianxiety drugs: relieve tension, apprehension, and nervousness
          1. Most popular are Valium, Xanax
          2. Routinely prescribed for people with anxiety disorders
          3. Exert effects almost immediately
          4. Some potential for abuse, dependency, overdose problems, withdrawal symptoms
        2. Antipsychotic drugs are used to gradually reduce psychotic symptoms, including hyperactivity, mental confusion, hallucinations, and delusions
          1. Used primarily in treatment of schizophrenia
          2. Most popular are Thorazine, Mellaril, Haldol
          3. Vast majority of patients respond favorably, usually within 2-7 days
          4. Some problems associated with use
            1. Side effects include drowsiness, constipation, "cotton mouth"
            2. Tardive dyskinesia (a neurological disorder marked by chronic tremors and involuntary spastic movements) sometimes caused by antipsychotics
          5. Psychiatrists currently experimenting with new class of antipsychotics, called atypical antipsychotic drugs
            1. Seem to produce fewer side effects than traditional antipsychotics
            2. Appear to help a significant proportion of patients who do not respond to conventional antipsychotic medications
        3. Antidepressant drugs gradually elevate mood and help bring people out of a depression
          1. Two main classes include (e.g., Elavil) and MAO inhibitors(e.g., Nardil)
          2. Exert effects gradually, over a period of weeks
          3. Psychiatrists today are more likely to prescribe newer class of antidepressants, called selective serotonin reuptake inhibitors (e.g., Prozac)
            1. Have side effects, risks that must be weighed against benefits
            2. Patients experience withdrawal symptoms if treatment is terminated abruptly
      3. Lithium: a chemical used to control mood swings in patients with bipolar mood disorders
        1. Can prevent future episodes of mania, depression
        2. High concentrations can be toxic, fatal
      4. Evaluating drug therapies
        1. Can produce clear gains for many kinds of patients
        2. Critics have raised number of issues
          1. Often produce superficial curative effects
          2. Many drugs are over-prescribed
          3. Side effects of some drugs are worse than illnesses
        3. Overall, benefits probably outweigh any harm done
    3. Electroconvulsive therapy (ECT): a biomedical treatment in which electric shock is used to produce a cortical seizure accompanied by convulsions
      1. Clinical use peaked in 1940s and 1950s, before effective drug therapies were widely available
        1. Use declined in 1970s and 1980s
        2. But not a rare form of treatment
      2. Controversy about ECT fueled by patients' reports that treatment is dehumanizing, painful, terrifying
      3. Effectiveness of ECT
        1. Evidence open to varied interpretations
        2. Primarily recommended for treatment of depression
        3. Overall, evidence probably supports conservative use
      4. Risks associated with ECT
        1. Some short-term cognitive deficits
        2. ECT critics suggest deficits may be permanent
  5. Current Trends and Issues in Treatment
    1. Grappling with the constraints of managed care
      1. While controlling the high costs that were associated with the old fee-for-service system managed care presents new and complex ethical dilemmas for clinicians
      2. Barriers to access, pressures for a quick fix, and confidentiality issues are all sources of concern to mental health providers working in managed care systems
    2. Identifying empirically validated treatments
      1. There is growing pressure for mental health providers to find and use treatments that have been shown to be effective through controlled research studies
    3. Combining approaches to treatment
      1. Particularly likely when a treatment team from various disciplines is providing therapy
      2. Studies indicate there is merit in combining approaches
      3. Movement in psychotherapy away from loyalty to individual schools of thought, toward integrating various approaches
    4. Increasing multicultural sensitivity in treatment
      1. Underutilization of mental health services by minority group members can be a result of barriers including:
        1. Cultural barriers
        2. Language barriers
        3. Institutional barriers
      2. Increased hiring of a culturally diverse clinical staff, and cultural diversity training, is now increasing in mental health training programs and facilities.
  6. Application: Looking for a therapist
    1. When should you seek professional treatment?
      1. You have no one to lean on
      2. People you lean on indicate that they're getting tired of it
      3. You feel helpless, overwhelmed
      4. Your life is seriously disrupted by your problems
    2. Where do you find therapeutic services?
      1. Can be found in variety of settings
        1. Contrary to popular belief, most therapists are not in private practice
        2. Many therapists work in institutional settings (e.g., community mental health centers, hospitals)
      2. Configuration of services varies from one community to another
    3. Is the therapist's profession important?
      1. Researchers have not found any relationship between therapist's background and efficacy of treatment
      2. Some suggest that psychiatrists may be too quick to use drugs
    4. Is the therapist's sex important?
      1. If you feel it's important, then it is
      2. Should be aware that sexual exploitation is occasional problem in context of therapy
    5. Is therapy always expensive?
      1. Private practitioners tend to be most expensive
      2. Community mental health centers generally charge lower fees
      3. Most communities have inexpensive opportunities for psychotherapy
    6. Is the therapist's theoretical approach important?
      1. Approaches tend to be similar in terms of effectiveness, but some approaches are more effective for certain types of problems
        1. Panic disorders respond best to cognitive therapy
        2. Specific phobias are most amenable to treatment with systematic desensitization
        3. Obsessive-compulsive disorders are best treated with behavior therapy or medication
      2. There are Individual differences in therapists' effectiveness
    7. What should you look for in a prospective therapist?
      1. Personal warmth, sincere concern
      2. Empathy, understanding
      3. Self-confidence
    8. What if there isn't any progress?
      1. Should discuss these feelings with therapist
      2. Poor progress may be due to resistance
      3. Should feel free to terminate therapy after careful consideration
    9. What is therapy like?
      1. Usually a slow process
      2. You have to put work into it
      3. May not be pleasant; may have to face painful truths about yourself