Therapies

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Chapter 13
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Therapies Overview
Insight Therapies
What are the basic techniques of psychoanalysis, and how are they used to help patients? What are the role and the goal of the therapist in person-centered therapy? What is the major emphasis of Gestalt therapy?

Relationship Therapies
What problems commonly associated with major depression does interpersonal therapy focus on? What is the goal of family therapy? What are some advantages of group therapy?
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Therapies Overview
Behavior Therapies
How do behavior therapist modify clients problematic behavior? What behavior therapies are based on classical conditioning? How does participant modeling help people overcome their fears?

Cognitive Therapies
What is the aim of rational-emotive therapy? How does Becks cognitive therapy help people overcome depression and panic disorder?
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Therapies Overview
Biological Therapies
What are the advantages and disadvantages of using drugs to treat psychological disorders? What is electroconvulsive therapy (ECT) used for? What is psychosurgery, and for what problem is it used?

Evaluating Therapies
What therapy, if any, is most effective in treating psychological disorders?

Culturally and Gender-Sensitive Therapy

What characterizes culturally sensitive and gendersensitive therapy?
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Psychotherapy
Any type of approach that uses psychological rather than biological means to treat psychological disorders

Insight Therapies
Approaches to psychotherapy based on the notion that psychological well-being depends on selfunderstanding Of ones own thoughts, emotions, motives, behavior, and
coping mechanisms

Psychodynamic Therapies Attempt to uncover childhood experiences that are thought to

explain a patients current difficulties Psychoanalysis
Freuds first psychodynamic therapy Uses free association, dream analysis, and transference
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Psychodynamic Therapies
Free Association
A technique used to explore the unconscious by having patients reveal whatever thoughts, feelings, or images come to mind The analyst pieces together the free-flowing associations, explaining their meanings Helps the patient gain insight into troubling thoughts and
behaviors Resistance
When a patient avoids revealing certain painful or embarrassing thoughts Halting speech, forgetting appointments, or arriving late

Dream Analysis
Areas of repressed emotional concerns expressed symbolically in dreams
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Psychodynamic Therapies
Transference
An emotional reaction that occurs during psychoanalysis The patient displays feelings and attitudes toward the analyst that were present in another significant relationship

Freud believed it an essential part of therapy Patient could relive troubling experiences from the past with

Brief Psychodynamic therapy

the analyst as a parent substitute Aids in resolving any hidden conflicts

Patient and therapist agree beforehand what issues to work on rather than wait for them to emerge Therapist assumes active role and emphasizes the present rather than the past Found to be as effective as other therapies Effective with patients with out multiple psychological disorders
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Humanistic Therapies
Assumes people have the ability and freedom to lead rational lives
and make rational choices

Person-Centered Therapy
A nondirective, humanistic therapy developed by Carl Rogers The therapist creates an accepting climate and shows empathy Unconditional Positive Regard Frees clients to be themselves and releasing their natural tendency toward self-actualization Psychological disorders result when a persons natural tendency towards self-actualization is blocked by oneself or others Therapist empathizes with clients concerns and emotions Reflecting listening used to respond allowing the client to control the
direction of the sessions. Also called nondirective therapy

Rogers rejects all forms of therapy that cast the therapist as an expert who prescribes something to cure the problem
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Gestalt Therapy
Originated by Fritz Perls emphasizes the importance of clients fully experiencing, in the
present moment, their feelings, thoughts, and actions then taking responsibility for them

Goal of Gestalt therapy

Help clients achieve a more integrated self and become more authentic and self-accepting Learn to assume personal responsibility for their behavior rather than blaming society, past experiences, parents, or others.

Directive Therapy
Any type of therapy in which the therapist takes an active role in
determining the course of therapy sessions and provides answers and suggestions to the patient

Getting in touch with your feelings a major objective Those in need of therapy carry around unfinished business Empty Chair technique role plays past relationships
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Relationship Therapies

Attempt to improve patients interpersonal relationships or create new relationships to support patients efforts to address psychological problems

Interpersonal Therapy
Designed to help depressed people better understand and cope with problems relating to their interpersonal relationships Helps Identify and cope with 4 types of interpersonal problems associated with depression: 1. Unusual or Severe Responses to The Death of a Loved One 2. Interpersonal Role Disputes 3. Difficulty Adjusting to Role Transitions Divorce, career change, and retirement 4. Deficits in Interpersonal Skills Brief therapy with 12 to 16 weekly sessions Effective for severe depression and low dropout rate Longer period with out depression relapse with monthly sessions
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Family and Couples Therapy

Involves entire family Goal of helping family members reach agreement on changes that will help heal the family unit
Improve communication Create understanding Enhance harmony within the group

Dynamics of the family unit

How family members communicate How they act towards and view each other

Positively Effect Treating Disorders and Clinical Problems

Sexual dysfunctions Schizophrenia when it accompanies medication Reduces relapse by reducing criticism, hostility, or emotional overinvolvement

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Adolescent drug abuse

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Therapists working with couples pay attention to the dynamics between the two people how they communicate act toward each other, and view each other.

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Group Therapy

Several clients (7-10 usually) meet regularly with one or more therapists to resolve personal problems
Less expensive than regular therapy Provides individuals a Sense of belonging Opportunity to express feelings Get feedback from other members Give and receive help and emotional support

Self-Help Group
Usually are not led by a professional therapists Provide people who share a common problem to meet and get support Most focus on a single problem (drug abuse or depression) Alcoholics Anonymous The oldest and best known with 1.5 million members world wide Derivatives include Gamblers Anonymous, Overeaters Anonymous,
Narcotics Anonymous, Sex addicts Anonymous
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Group therapy can give individuals a sense of belonging and receive emotional opportunity to give and receive emotional support

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Behavior Therapy

Based on the idea that abnormal idea is learned

Not a sign of an underlying disorder If afraid to fly then fear of flying is the problem

applies the principles of operant and classical conditioning, or observational learning To eliminate inappropriate or maladaptive behaviors and replace them with more adaptive responses
Not change the individuals personality structure or search for the origin of the problem

Behavior Modification
Uses learning principles to eliminate inappropriate or maladaptive behaviors and replace them with more adaptive responses
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Behavior Modification Therapy Based on Operant Conditioning

Seek to control the consequences of behavior Extinction of undesirable behaviors accomplished by Terminating or withholding the reinforcement Seek to reinforce desirable behavior to increase its frequency Best done in hospitals, prisons, and schools classrooms

Token Economies
Rewards appropriate behavior with tokens Poker chips, coupons, play money, stars, stickers, etc. later exchanged for desired goods and/or privileges Weekend passes, candy, gum, TV time, etc. Undesirable behaviors can be fined a certain number of tokens
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Behavior Modification Therapy Based on Operant Conditioning

Time Out
Used to eliminate undesirable behavior by withdrawing all reinforcers for a period of time Works well with children and adolescents Children are told in advance of rules If they do undesirable behaviors they will be
removed from the situation for a period of time No more than 15 minutes In a place containing no reinforcers No toys, friends, television, books, etc. The undesirable behavior will stop if it is no longer reinforced

Also works for breaking bad habits or developing good habits Devise a reward system for desirable behaviors Reward gradual changes in the direction of the ultimate goal
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Behavior Modification Therapy Based on Classical Conditioning

Systematic Desensitization
Used to treat fears by training clients in deep muscle relaxation Then confront a hierarchy of anxiety producing situations (real or imagined) Until they remain relaxed even in the most feared situation. Highly successfully treatment for eliminating fears and phobias in a short period of time

Flooding
Used to treat phobias by exposing clients to feared object or event for an extended period of time until anxiety decreases Fear of heights may stand on roof of high building until anxiety
subsides

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Sessions do not end until patients are markedly less afraid In vivo flooding (real life) works faster up to 6 sessions
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A Possible Hierarchy of Fears

Use what you have learned about systematic desensitization to create a step-by-step approach to help someone overcome a fear of taking tests. The persons hierarchy of fears begins with reading in the syllabus that a test will be given and culminates in actually taking the test. Fill in successive steps, according to a possible hierarchy of fears, that will lead to the final step.
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Behavior Modification Therapy Based on Classical Conditioning

Exposure and Response Prevention

Exposes patients with obsessive-compulsive disorder to stimuli that trigger obsessions and compulsive rituals Touching a door knob, piece of unwashed fruit, or garbage bin Patients resist performing the compulsive rituals for progressively longer periods of time Washing hands, bathing, etc. Therapist identifies trigger thoughts, objects, or situations Typically 10 treatment sessions over 3-7 weeks bring improvement in 60-70% of patients Less relapse than those treated with drugs alone Also useful in treatment of posttraumatic stress disorder

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Behavior Modification Therapy Based on Classical Conditioning

Aversion Therapy
An aversive stimulus is paired with a painful, sickening, or otherwise aversive stimulus until the behavior becomes associated with pain or discomfort Electric shock, emetics (causes nausea and vomiting), antabuse Antabuse reacts violently with alcohol causing a person to retch

and vomit until the stomach is empty Painting fingernails with bitter tasting coating to stop nail chewing

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Participant Modeling
Appropriate response to a feared stimulus is modeled in graduated steps Client attempts to imitate the model step by step while the therapist gives encouragement and support Most phobias can be extinguished in only 3 or 4 hours
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Approaches to Therapy

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Approaches to Therapy Continued

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Cognitive Therapies
Assume maladaptive behavior can result from irrational thoughts, beliefs, and ideas Often called Cognitive-Behavioral Approach
Combine cognitive insight with methodological behavioral approach Therapists seek to change the way clients think determine effectiveness by assessing changes in the clients behavior Effective in treatment of anxiety disorders hypochondriasis psychological drug dependence pathological gambling

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Cognitive Therapies
Rational Emotive Therapy
a directive form of psychotherapy designed to challenge clients irrational beliefs about themselves and others.

Based on Ellis ABC Theory

A = activating event B = persons belief about the event C = emotional consequence that follow Ellis claims it is not the event itself that causes the emotional consequence, rather it is the persons belief about the event A does not cause C, B causes C If the belief is irrational, then the emotional consequence can be extreme distress
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The ABCs o f Rational-Emotive Therapy

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Cognitive Therapies
Rational Emotive Therapy
Ellis believes clients do not benefit from warm, supportive therapeutic approaches that do not address the irrational thoughts that underlie the problem As irrational beliefs are replaced emotional reactions become appropriate, less distressing, and lead to constructive behaviors Clients are taught they can not control demands of others but can control their emotional reactions Relaxation techniques often taught to control emotional reactions RET equally effective with systematic desensitization
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Cognitive Therapies
Becks Cognitive Therapy
Help patients stop negative thoughts as they occur and replace them with more objective or positive thoughts. Automatic thoughts cause misery of depression and anxiety: To be happy I must be liked by everyone If people disagree with me, it means they dont like me Depressed people hold a negative view of the present, past, and future experiences It has never worked and I cant make it happen Notice only negative unpleasant things Fail to recognize positive events and feelings Jump to the wrong conclusions No one likes me

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Cognitive Therapies
Becks Cognitive Therapy
Therapist identifies and challenging irrational thoughts sets up a plan and guides the client so life experiences become evidence to refute false beliefs Homework assignments given to track automatic thoughts, feelings evoked by them, and writing substitute rational thoughts Brief, lasting 10-20 sessions Extensive research demonstrates high success rate with mild to moderate depression Panic disorder Generalized Anxiety disorder Cocaine addiction, insomnia, and bulimia Negative and positive symptoms of schizophrenia Less likely to relapse than those treated with antidepressant drugs
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Becks Cognitive Therapy

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Biological Therapies
Therapy based on the assumption that psychological disorders are
symptoms of underlying physical problems Includes: drug therapy, electroconvulsive therapy, or psychosurgery Millions of people take medications for psychological problems

Drug Therapy
Antipsychotic drugs Drugs used to control severe psychotic symptoms
Delusions, hallucinations, disorganized speech and behavior

By inhibiting dopamine activity

Also known as neuroleptics Thorazine, Stelazine, Compazine, Mellaril 50% of patients have a good response Long term use may lead to tardive dyskinesia Almost continual twitching and jerking of face and tongue and squirming movements of the hands and trunk
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Biological Therapies
Antipsychotic drugs
Atypical Neuroleptics (newer drugs)
Clozapine, Risperidone, Olanzipine

Target both dopamine and serotonin Marked improvement in quality of life tardive dyskinesia is rare Treat both positive and negative effects of schizophrenia

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Antidepressant Drugs
Act as mood elevators for severely depressed people and are also
prescribed to treat some anxiety disorders 65-75% of patients report significant improvement 40-50% report complete recovery
Placebo studies demonstrate almost equal effectiveness Responses to antidepressants a combination of physiological effects on the brain and the patients confidence in effectiveness of treatment

Tricyclics first generation of antidepressants

Block reuptake of norepinephrine and serotonin into axon terminals Enhancing the action of these neurotransmitters in the synapses Side effects include Sedation, fatigue, dizziness, nervousness, dry mouth, forgetfulness, and
weight gain Weight gain #1 reason (20 or more pounds) main reason people stop taking them despite benefit
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Antidepressant Drugs
Second Generation Antidepressants
Selective serotonin reuptake inhibitors
block the reuptake of serotonin increasing availability at the brain synapses

Fewer side effects and safer in case of overdose Effective in treating Obsessive-compulsive disorder Social phobia Panic disorder Generalized anxiety disorder Binge eating Side Effects Sexual dysfunction
Returns to normal when drug is discontinued

Increase in suicide risk not substantiated

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Antidepressant Drugs
Monoamine Oxidase Inhibitors (MOA)
Block the action of an enzyme that breaks down norepinephrine and serotonin in the synapses Increase the availability of norepinephrine and serotonin Usually prescribed to patients who do not respond to other antidepressants Similar side effects to tricyclic antidepressants plus patients must avoid certain foods to reduce the risk of stroke

Lithium
A naturally occurring salt used to treat bipolar disorder Effectiveness in treating depression and bipolar is unmatched 40-60% of patients experience a recurrence Monitoring blood level necessary to prevent nervous system damage
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Antidepressant Drugs
Benzodiazepines
Valium, Librium, and Xanax Prescribed more often than any other class Effective in treating panic disorder and anxiety Xanax Works fast and has few side effects Relapse is likely if discontinued Withdrawal symptoms include intense anxiety Difficulty establishing proper dosages Help with symptoms but do not cure psychological disorders Maintenance doses are required to prevent relapse Increase in homeless population
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Unpleasant Side Effects of Drug Therapy

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Electroconvulsive Therapy
An electric current is passed through the right
hemisphere of the brain Usually reserved for severely depressed patients who are suicidal and dont respond to other treatments Highly effective for major depression Unilateral ECT used today instead of bilateral ECT Equally effective with milder cognitive side-effects Patients are given anesthesia, controlled oxygenation, and a muscle relaxant When Effective ECT
Changes the biochemical balance in the brain Cerebral blood flow in the prefrontal cortex is reduced Delta waves occur

No structural brain damage demonstrated by MRI or CT scans

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Psychosurgery
Brain surgery performed to alleviate serious psychological disorders
or unbearable chronic pain
Severe depression, anxiety, or obsessions

Lobotomy
The first surgery severing neural connections between the frontal lobes and the deeper brain centers involved in emotions Initially a tremendous contribution however treatment left patients in a severely deteriorated condition

Modern Psychosurgery
Results in less intellectual impairment Surgeons deliver electrical currents through electrodes to destroy smaller, localized areas of brain tissue Helpful with obsessive-compulsive disorder Results still not predictable and consequences are irreversible Treatment is considered experimental and an absolute last resort

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Evaluating the Therapies

Various therapeutic approaches share many similarities
Several help clients reflect on their own thoughts and/or emotions

Most therapists use a set of core techniques regardless of perspective Specific element distinguish therapeutic approaches apart Overall:
Psychotherapy is better than receiving no treatment No one type of treatment is more effective than the another Behavioral therapies show slight overall advantage Cognitive and interpersonal therapies show advantage for depression

Patients View of Effectiveness (Seligman & Consumer Reports 1995)

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Believe they benefit substantial from psychotherapy Equally satisfied with psychologist, psychiatrist, or social worker The longer a patient was in therapy the more they improved (6 months+) Patients taking Prozac or Xanax believed it helped them Psychotherapy seemed to work as well as psychotherapy plus drugs
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Culturally Sensitive Therapy

Awareness of considering cultural variable in diagnosing and treating
psychological disorders is growing APA published guidelines The meaning of symptoms, outcomes, and responses to therapy within a cultural context Cultural difference may affect the therapeutic alliance Language differences can pose problems Patients more fluent in Spanish but speak both Spanish and English may exhibit symptoms causing therapist to misdiagnose Hesitations Backtracking Delayed responses to questions Affect results on standardized tests Need to consider immigration experiences on thoughts and emotions
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Culturally Sensitive Therapy

When a therapist and client have the same racial or ethnic background, they are more likely to share cultural values and communication styles, which can facilitate the therapeutic process.

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Culturally Sensitive Therapy

Cultural models should be included with interventions
Native American Healing Circles Promote physical, mental, emotional, and spiritual well being May also include discussion, meditation, and prayer

Address group differences that can affect therapy results

African Americans are less likely to follow medication instructions Compliance increased by understanding the importance of kinship and community relationships within the culture Have the patient participate in a support group of members with the
same disorder, medication and same culture

Discuss racial perspectives prior to beginning therapy

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Gender-Sensitive Therapy
Takes into account the effects of gender on both the therapists
and the clients behavior Therapist must examine own gender-based prejudices Assuming men are more logical and women more emotional Knowledge of real differences between sexes is important Emotional expression interventions may be less effective for men due to gender-role socialization Men may see therapy as a sign of weakness or threat to masculinity Therapist should avoid creating defensiveness in male clients Avoid using research findings as a basis for stereotyping More variation within each gender than across genders Consider each man or woman as an individual Placing too much emphasis on sensitivity and misinterpret clients problems
May consider problems arise from gender-role conflict incorrectly
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Is E-therapy Right for You?

Typically involves the exchange of email messages over
a period of hours or days but can also include videoconferencing and telephone sessions. Advantages of E-therapy
Less inhibited than face-to-face sessions Less expensive Do not have to be in the same place at the same time Random schedule Live in remote areas Therapist can keep accurate records of interactions They are good at expressing their thoughts and feelings in writing.
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Is E-therapy Right for You?

Disadvantages of E-therapy
Imposters can pose as therapists No present system for regulating or licensing e-therapists Ethical problems Possible breaches of confidentiality No visual or auditory input limits possible feedback and responding to manifest symptoms.

Finding an E-therapist

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Verify credentials via a third party (licensing or certification board) Get real-world contact information (address and phone number) Verify that you will receive personal replies to messages Find out in advance how much the therapist charges.
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Review Questions
Insight Therapies
What are the basic techniques of psychoanalysis, and how are they used to help patients? What are the role and the goal of the therapist in person-centered therapy? What is the major emphasis of Gestalt therapy?

Relationship Therapies
What problems commonly associated with major depression does interpersonal therapy focus on? What is the goal of family therapy? What are some advantages of group therapy?
WWB Copyright Allyn & Bacon 2006

Review Questions
Behavior Therapies
How do behavior therapists modify clients problematic behavior? What behavior therapies are based on classical conditioning? How does participant modeling help people overcome their fears?

Cognitive Therapies
What is the aim of Rational-Emotive therapy? How does Becks cognitive therapy help people overcome depression and panic disorder?
WWB Copyright Allyn & Bacon 2006

Review Questions
Biological Therapies
What are the advantages and disadvantages of using drugs to treat psychological disorders? What is electroconvulsive therapy (ECT) used for? What is psychosurgery, and for what problems is it used?

Evaluating the Therapies

What therapy, if any, is most effective in treating psychological disorders?

Culturally and Gender Sensitive Therapy

What characterizes culturally and gender sensitive therapy?
WWB Copyright Allyn & Bacon 2006