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