1. Chapter 16 Therapies for Personal Change As presented by
Dr. Shannon Wright-Johnson
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2. Lecture Objectives Examine the goals of therapy
Briefly examine the historical treatment of the mentally ill
Introduce the main types of therapy interventions used and a few of techniques employed
Examine the effectiveness of treatment modalities

3. Therapy What is Therapy? What do you think therapy entails?
What theoretical orientation do you gravitate towards?
Despite differences in intervention types – all therapies are designed to change a person’s functioning in some way

4. Goals of Major Therapies
Reaching a diagnosis
Proposing a probable etiology
Making a prognosis
Treatment

5. Goals of Major Therapies
Therapy Types can be further catergorized as
Biomedical therapies
Alter brain functioning with chemical or physical interventions (e.g., ECT)
Psychotherapy
Focus on changing faulty behaviors, thoughts, perceptions, and emotions (cognitive)

6. Problems Happen to everyone at sometime in their life
Who do people typically talk to?

7. Therapists and Therapeutic Settings
Counseling psychologist
Clinical social worker
Pastoral counselor
Clinical psychologist
Psychiatrist
Psychoanalyst (MD or Ph.D)

8. Therapists and Therapeutic Settings
Patient
Used by biomedical approach
Client
Used by clinicians who think of psychological disorders as problems in living

9. Historical and Cultural Contexts
History of Western treatment
Bedlam (orig Bethlehem)
1400’s – London hospital
First pt w/psychological problem adm
mental patients chained, tortured
Mental illness
Late 18th century- concept emerged in Europe
First time seen as “sick people”
U.S. – housed but no tx
Cult of curability – environment
Madness cured via mental hygiene

10. Historical and Cultural Contexts
History of Western treatment
Rehabilitation
1900s – asylum – from stress
Overcrowded – good intentions simply became a human warehouse
Deinstitutionalization
1960s – reformers
Mainstream back into society
Increase in homelessness,
Increase in arrests

11. Historical and Cultural Contexts
Not covering in class but just remember that our culture’s cure are not the only solutions (avoid ethnocentrism)
Cultural symbols and rituals of curing
Shamanism
Ritual healing
Dissociation of consciousness
Mana

12. Therapies to be discussed
Psychodynamic
Behavior Therapy
Cognitive Therapy
Existential-Humanistic
Group Therapies
Biomedical Therapies

13. Psychodynamic Therapies
Developed by Sigmund Freud
Explores unconscious motivations and conflicts in neurotic, anxiety-ridden individuals
Before exploring techniques, let’s review some of Freud’s main tenets of how he viewed behavior

14. Psychoanalysis Breuer and Freud: Freudian Theory Structure of the Mind
The “Talking Cure”
Freudian Theory
Structure of the Mind
The Mind’s Protective Mechanisms
Stages of Psychosexual Development
If this picture is in the book, I’d like to keep it in.

15. 20th Century traditions Psychoanalytic Theory-
Mesmer, Charcot, Freud and Breuer
Discovered unconscious
Id, ego superego (structural theory)
Defense mechanisms
Psychosexual stages of development

16. Ego id The Structure of the Mind ID Libido Pleasure Principle
Primary Process Thinking id
Is the ego/id picture something you made up?

17. Ego id The Structure of the Mind ID EGO Reality Principle
“Executive of Personality”
Secondary Process Thinking id

18. Ego id The Structure of the Mind SUPEREGO Rules / Standards of Conduct
Right vs Wrong id

19. Ego id Defense Mechanisms Ego’s Battles Keep Id in Check
Anxiety results with inability to resolve inner conflicts between the unconscious, irrational impulses of the id AND the superego id

20. Ego id Defense Mechanisms
Anxiety -inner conflicts between id AND the superego
Thus 1 Goal of tx – intrapsychic harmony
Strengthen ego
Reduce demands of superego
Increase awareness of the id id

21. Ego id Defense Mechanisms Displacement - kick dog
Reaction formation – do opposite
Most important =Repression – very important in handling conflicts
messages from the unconscious that something is wrong id

22. Ego id Defense Mechanisms
Repression – very important in handling conflicts
Goals
– Bring repressed thoughts to consciousness ;
Gain insight about the relationship between current symptoms and repressed conflicts id

23. Psychodynamic Therapies
Freudian psychoanalysis
Intensive and prolonged technique for exploring unconscious motivations and conflicts
Insight therapy
Therapist guides patient toward discovering insights (increased awareness) between present symptoms and past origins
YAVIS
Takes long time

24. Psychodynamic Therapies
Main Techniques employed include:
Free association
Thoughts, wishes, physical sensations, and mental images as they occur
volunteer
Catharsis
Expressing strongly felt but usually repressed emotions

25. Psychodynamic Therapies
Resistance- understanding the role of
Barrier between unconscious and conscious(e.g., sex life,anger)
Dream analysis – “unconscious”; manifest (openly visible) and latent (hidden content)
Transference
Countertransference

26. Psychodynamic Therapies
Neo-Freudian therapies
Borne out of reaction to Freud’s theory
Kept some main tenets but added a diff twist

27. Neo-Freudian therapies
Harry Stack Sullivan
Added importance of social relationships
Need for acceptance, respect and love
“troubled interpersonal relationships” and societal pressures
Melanie Klein
Death instinct - aggression
Building blocks of how people experience the world emerge from their relations to loved and hated objects

28. Psychoanalysis Descendents: Heinz Kohut
Emphasis on self ( and how others and objects play a role in shaping our interpretation of self)
Founder of Object Relations
Object relations theory
Building blocks of how people experience the world emerge from their relations to loved and hated objects

29. Premise of Behavior Therapy
All (most) behavior is learned
Focus on observable behaviors
Abnormal behavior is learned similar to normal behaviors via conditioning and learning
Thus therapy applies principles of conditioning and reinforce to modify unwanted behavior

30. Premise of Behavior Therapy
Works best with specific behaviors
Could care less about underlying cause
Symptom substitute?
Research indicates “no”
Let’s briefly review some of the main tenets

31. Behavioral Model
Important to understanding the role of counterconditioning
Pavlov- classical conditioning (UCS,UCR,CS,)
Some Sexual disorders begin
Men and shoe example

32. Conditioning Theory Pavlov Dog, salivation, bell CSCR UCSUCR
CS UCSUCR/CR
Tone + Meat Powder -> Salivation
CS UCS UCR
Tone > Salivation
CS CR

33. Counterconditioning
New response is conditioned to replace a maladaptive response
Types of counterconditioning include:
Systematic desensitization
Implosion
Flooding
Aversion Therapy

34. Behavioral Model Watson- systematic desensitization
B.F. Skinner- science of human behavior should be based on observable events
-operant conditioning

35. Conditioning Theory
When behavior is reinforced – either through pleasure, reward, or removal of some unpleasant stimulus – it is likely to be REPEATED.
Negative consequences of a behavior through unpleasant results, pain, or loss of rewarding stimuli tend to DECREASE THE FREQUENCY of the behavior.

36. Conditioning Theory Operant Conditioning
Response that is voluntarily emitted is learned as a result of how it operates on the environment
Thorndike –Law of Effect
Learned as a result of environmental consequences that follow that behavior, either positive or negative

37. Reinforcement Punishment Conditioning Theory
by definition, the “targeted” behavior increases
Punishment
by definition, the “targeted” behavior decreases

38. OPERANT CONDITIONING: ADD REMOVE
Positive Reinforcement
Behavior increases
Negative Reinforcement
Positive Punishment
Behavior decreases
Negative Punishment

39. Behavior Therapies Thus, Behavior therapy (behavior modification)
Systematic use of principles of learning to increase or decrease the frequency of behaviors

40. Behavior Therapies Counterconditioning Systematic desensitization
Substitute a new response for a maladaptive one
Systematic desensitization
Reciprocal inhibition
Incompatible behaviors cannot occur simultaneously
Client is taught to prevent arousal of anxiety by confronting feared stimulus while relaxed

41. Behavior Therapies Systematic desensitization Gradual Steps Employed
Identify anxiety provoking stimuli via hierarchy
Deep-muscle relaxation
Desensitization – pairing of weakest stimuli (visually) with relaxation
Impotence
Stage fright
Test anxiety

42. Behavior Therapies Implosion therapy Flooding (in –vivo)
Opposite of SD
Exposes client to most anxiety-provoking stimuli through visual imagery in safe setting
Karen
Flooding (in –vivo)
Clients are exposed to stimuli most frightening to them physically rather than via imagery
More effective than SD in some cases (e.g., agoraphbia)
Key to ALL is “ EXPOSURE

43. Behavior Therapies Aversion therapy
Attractive stimulus is paired with noxious stimulus (uses counterconditioning procedures)
Cigarette smoking (rubber band around wrist), child molesters (shock tx); self-injurious behaviors (mild shock)

44. Behavior Therapies Contingency management
Changing behavior by modifying its consequences
Positive Reinforcement Strategies
Token economies (autistic child)
Extinction Strategies
Dysfunctional beh maintained by unrecognized reinforcers

45. Behavior Therapies Social-learning therapy Imitation of models
Clients observe models’ desirable behaviors being reinforced
phobias
Imitation of models
Participant modeling ( on film or in person see success w/feared stimuli)
Social-skills training
Behavioral rehearsal
Assertiveness training

46. Behavioral Model Cognitive-behavioral or social learning model
A B C’ S of EMOTIONS
A Perceptions (Activating Event – anything you can see, hear, smell, taste, or touch.)
B Self-Talk
C Feelings
Actions
Consequences

47. Cognitive Therapies Cognitive therapy
Attempts to change feelings and behaviors by changing the way a client thinks about or perceives significant life experiences

48. Cognitive Therapies Cognitive therapy
Abnormal behavior/emotional distress start with what you think
Goal – change your thought process

49. Cognitive Therapies Cognitive behavior modification Tenets
Focus on the present
We all engage in self-talk
You are what you tell yourself
You are guided by what you believe
Faulty thinking can lead to unproductive or dysfunctional behaviors
There is power in thought, how do you use your power?

50. Cognitive Therapies Cognitive behavior modification
Combines cognitive emphasis on thoughts and attitudes, and behavioral emphasis on changing performance
Unacceptable behavior modified via cognitive restructuring
Change negative self-statements into constructive coping statements
Key to process -First identify thought content
Fosters self-efficacy and + expectations about your ability to cope and deal effectively

51. Cognitive Therapies Changing false beliefs
Cognitive therapy for depression
Replace faulty patterns of thinking by substituting more effective problem solving techniques
Aaron Beck (time permitting, take BDI)
Identify warped thinking –learn more realistic ways to formulate his experiences
Maintained b/c unaware of negative automatic thoughts

52. Beck’s Cognitive Model of Depression
1.Thinking (content) becomes negative(re: self, world, future)
(past, present, future)
2.Systematic bias and distortion in info processing results
cognitive distortions and errors in reasoning

53. Cognitive Therapies Changing false beliefs Aaron Beck
Challenge basic assumptions about functioning
Evaluate evidence client has for and against accuracy of automatic thoughts
Reattribute blame to situational factors rather than to patient’s incompetence
Discuss alternative solutions to complex tasks that could lead to failure experiences

54. Cognitive Therapies Changing false beliefs
Rational-emotive therapy (RET)
Albert Ellis
1.Basis of Undesirable behavior/reactions is “irrational beliefs”
2. Beliefs are powerful in controlling our behavior
3. Goal – teach clients to recognize “shoulds, oughts, and musts

55. Cognitive Therapies Changing false beliefs
Rational-emotive therapy (RET)
Albert Ellis
4. faulty beliefs are openly and strongly disputed; very confrontational
5. Increase sense of worth

56. Humanistic Approaches
Jung and Adler-
broke from psychoanalysis and are thought of as humanistic today
Maslow-
self-actualization; hierarchy of needs
Rogers-
person-centered therapy; unconditional positive regard

57. Existential-Humanistic Therapies
Human-potential movement
Release the potential of the average human being for greater levels of performance and greater richness of experience

58. Existential-Humanistic Therapies
Client-centered therapy
Emphasizes the healthy psychological growth of the individual
Unconditional positive regard
Gestalt therapy
Focuses on the ways to unite mind and body to make a person whole

59. Group Therapies Marital and family therapy Community support groups
Couples counseling
Family therapy
Community support groups
Self-help groups

60. Biomedical Therapies Psychosurgery Prefrontal lobotomy
Electroconvulsive therapy (ECT)

61. Mood Disorders
Drug
Treatment

62. Antidepressants Do not work quickly
(2- 6 weeks to become effective)
Effective in alleviating depression, but they do not cause euphoric states

63. Antidepressants Three classes of antidepressants Tricyclics
Selective Serotonin Reuptake Inhibiots (SSRIs)
Monoamine Oxidase inhibitors (MAOIs)

64. Imipramine (Tofranil), Clomipramine (Anafranil)
TRICYCLICS
Include
Imipramine (Tofranil),
Clomipramine (Anafranil)
and Amitriptyline (Elavil)

65. TRICYCLICS Side effects include: Tachycardia Palpitations Dry mouth
Constipation
Blurred vision
Urinary retention
Tachycardia
Palpitations
Skin Rash
Memory Impairments
Impaired sexual functioning

66. Include SSRIs Fluoxetine (Prozac) Setraline (Zoloft)
Paroxetine (Paxil)

67. Also used in the treatment of OCD and eating disorders
SSRIs
Also used in the treatment of OCD and eating disorders
Increase serotonin

68. SSRIs SIDE EFFECTS: Gastrointestinal problems Decreased libido
Headaches
At least initially, may worsen sleep and anxiety problems
Can cause serious problems when combined with a tricyclic or MAOI

69. MOOD STABILIZERS Lithium treatment-of-choice for bipolar disorder
Reduces or eliminates symptoms of mania and levels out mood swings

70. LITHIUM SIDE EFFECTS Gastric distress Weight gain
Tremor (most affects the fingers)
Fatigue
Mild Cognitive impairment

71. LITHIUM
SIDE EFFECTS
Too high a dosage can cause lithium toxicity (vomiting abdominal pain, profuse diarrhea, severe tremor, and ataxia)
Can lead to seizures, coma, and/or death

72. BENZODIAZEPINES
Include
Valium
Xanax
Klnopin
Ativan

73. Used to treat anxiety symptoms such as generalized anxiety or panic
BENZODIAZEPINES
Used to treat anxiety symptoms such as generalized anxiety or panic
Enhance the activity of the neurotransmitter GABA

74. BENZODIAZEPINES SIDE EFFECTS: Motor disturbances Anteriograde amnesia
Drowsiness
Sedation
Weight gain
Apathy
Dry mough
Gastric distress
Ataxia
Motor disturbances
Anteriograde amnesia
chronic use-results in tolerance and severe withdrawal symptoms
mixing w/alcohol or other CSN depressant can be fatal

75. Drug therapy
Antipsychotic drugs
Chlorpromazine
Haloperidol
Clozapine

76. Does Therapy Work? Evaluating therapeutic effectiveness
Spontaneous-remission effect
Placebo effect
Meta-analysis

77. Today Scientific Method- Integrated Approach
1.increased sophistication of science, technology, and methodology
2. No one influence occurs in isolation