1. Introduction to Therapy and the Psychological Therapies
Module 44
Introduction to Therapy and the Psychological Therapies

2. Introduction to Therapy and the Psychological Therapies
Over the ages, a mix of treatments and methods have been attempted to treat people with psychological disorders
Treatments have ranged from harsh to gentle
Reformers Philippe Pinel (1745–1826) and Dorothea Dix (1802–1887) pushed for:
Gentler and more humane treatments
Construction of mental hospitals
Since the 1950s, drug therapies and community-based treatment programs have replaced most of the hospitals

3. THE HISTORY OF TREATMENT
Visitors to eighteenth-century mental hospitals paid to gawk at patients, as though they were viewing zoo animals. William Hogarth’s (1697–1764) painting captured one of these visits to London’s St. Mary of Bethlehem hospital (commonly called Bedlam).

4. Treating Psychological Disorders
44-1: HOW DO PSYCHOTHERAPY AND THE BIOMEDICAL THERAPIES DIFFER?
Psychotherapy
A trained therapist uses psychological techniques to assist someone seeking to overcome difficulties or achieve personal growth.
Biomedical therapy
Offers medications and other biological treatments; prescribed medications or procedures that act directly on the person’s physiology.
Eclectic approach
Approach to psychotherapy that uses techniques from various forms of therapy.

5. Psychoanalysis and Psychodynamic Therapies
44-2: WHAT ARE THE GOALS AND TECHNIQUES OF PSYCHOANALYSIS, AND HOW HAVE THEY BEEN ADAPTED IN PSYCHODYNAMIC THERAPY?
First major psychological therapy was developed by Sigmund Freud.
Psychoanalysis: Freud’s therapeutic technique. Freud believed the patient’s free associations, resistances, dreams, and transferences—and the therapist’s interpretations of them—released previously repressed feelings, allowing the patient to gain self-insight.
It helped form the foundation for treating psychological disorders, and it continues to influence modern therapists working from the psychodynamic perspective.

6. Introduction to Therapy and the Psychological Therapies Psychoanalysis and Psychodynamic Therapies
The Techniques of Psychoanalysis
Historical reconstruction of childhood experiences influencing adulthood; initially through hypnosis and later through free association.
Resistance: The blocking from consciousness of anxiety-laden material.
Interpretation: Analyst providing meanings to thoughts, dreams, resistances, and other significant behaviors and events in order to promote insight.
Transference: Occurs when the patient transfers to the analyst emotions linked with other relationships (such as love or hatred for a parent).
Resistance
In psychoanalysis, the blocking from consciousness of anxiety- laden material.
Interpretation
In psychoanalysis, the analyst’s noting supposed dream meanings, resistances, and other significant behaviors and events in order to promote insight.
Transference
In psychoanalysis, the patient’s transfer to the analyst of emotions linked with other relationships (such as love or hatred for a parent).

7. Psychoanalysis and Psychodynamic Therapies Psychodynamic Therapy
Therapy deriving from the psychoanalytic tradition; views individuals as responding to unconscious forces and childhood experiences, and seeks to enhance self-insight.
FACE-TO-FACE THERAPY In this type of therapy session, the couch has disappeared. But the influence of psychoanalytic theory may not have, especially if the therapist seeks information from the patient’s childhood and helps the patient reclaim unconscious feelings.

8. Humanistic Therapies
44-3: WHAT ARE THE BASIC THEMES OF HUMANISTIC THERAPY? WHAT ARE THE SPECIFIC GOALS AND TECHNIQUES OF ROGER’S CLIENT-CENTERED APPROACH?
Theme: Emphasis on people’s potential for self-fulfillment.
Goals: To reduce inner conflicts that interfere with natural development and growth; help clients grow in self-awareness and self-acceptance promoting personal growth.
Given that humanistic therapies aim to give clients new insights, as is the case with psychodynamic therapies, both are often referred to as insight therapies.

9. Humanistic Therapies
Strengthening communication: Rogers
Paraphrase
Invite clarification
Reflect feelings
ACTIVE LISTENING Carl Rogers (right) empathized with a client during this group therapy session.

10. Behavior Therapies
44-4: HOW DOES THE BASIC ASSUMPTION OF BEHAVIOR THERAPY DIFFER FROM THE ASSUMPTIONS OF PSYCHODYNAMIC AND HUMANISTIC THERAPIES? WHAT TECHNIQUES ARE USED IN EXPOSURE THERAPIES AND AVERSIVE CONDITIONING?
Behavior therapists (unlike those with an insight therapy approach) doubt the healing power of self-awareness, believing instead that problem behaviors are the problem
View learning principles as useful tools for eliminating problematic behaviors
Aim to replace problematic behaviors with constructive behaviors
Constructive behaviors may be learned through classical or operant conditioning

11. Behavior Therapies Classical Conditioning Techniques
This cluster of behavior therapies derives from principles developed in Ivan Pavlov’s conditioning experiments.
We learn various behaviors and emotions through classical conditioning; maladaptive symptoms are similarly examples of conditioned responses.
As well, we can unlearn responses through new conditioning. Counterconditioning uses classical conditioning to evoke new responses to stimuli that are triggering unwanted behaviors; includes exposure therapies and aversive conditioning.
Exposure Therapies
Treat anxieties by exposing people (in imagination or actual situations) to the things they fear and avoid; includes systematic desensitization and virtual reality exposure therapy.
Systematic desensitization: Associates a pleasant, relaxed state with gradually increasing, anxiety-triggering stimuli.
Exposure therapies
Behavioral techniques, such as systematic desensitization and virtual reality exposure therapy, that treat anxieties by exposing people (in imagination or actual situations) to the things they fear and avoid.
Systematic desensitization
Type of exposure therapy that associates a pleasant, relaxed state with gradually increasing anxiety-triggering stimuli. Commonly used to treat phobias.

12. Virtual Reality Exposure Therapy
Treats anxiety by progressive exposing people to creative electronic simulations of their greatest fears, such as airplane flying, spiders, or public speaking.
Within the confines of a room, virtual reality technology exposes people to vivid simulations of feared stimuli, such as walking across a rickety bridge high off the ground.

13. Behavior Therapies Classical Conditioning Techniques
Aversive Conditioning
Aversive conditioning creates a negative (aversive) response to a harmful stimulus or unwanted behavior.
Goal: Transform a positive response to a harmful stimulus to a negative response ; conditioning an aversion to something the person should avoid.
Technique: Unwanted behavior is associated with unpleasant feelings.
Ability to discriminate between aversive conditioning situation in therapy and all other situations can limit treatment effectiveness.
Often used in combination with other treatments.

14. AVERSION THERAPY FOR ALCOHOL ABUSE
Problem: Thoughts can override conditioning processes.
Therapists gave people with a history of alcohol abuse a mixed drink containing alcohol and a drug that produces severe nausea. After repeated treatments, some people developed at least a temporary conditioned aversion to alcohol. (Classical conditioning terms: US is unconditioned stimulus, UR is unconditioned response, NS is neutral stimulus, CS is conditioned stimulus, and CR is conditioned response.)

15. Behavior Therapies Operant Conditioning
44-5: WHAT IS THE MAIN PREMISE OF THERAPY BASED ON OPERANT CONDITIONING PRINCIPLES, AND WHAT ARE THE VIEWS OF ITS PROPONENTS AND CRITICS?
Behavior modification techniques derive from B. F. Skinner’s operant conditioning principle that voluntary behaviors are influenced by their consequences.
Desired behavior reinforced
Positive reinforcement used to shape behavior
Undesired behavior not reinforced, sometimes punished
Behavior shaped using positive reinforcers
Behaviors rewarded that come closer to desired behavior
In institutional settings, therapists may create a token economy

16. Behavior Therapies Operant Conditioning
Token economy:
People earn a token for exhibiting a desired behavior
Tokens can later be for privileges or treats
Have proved successful in various settings

17. Behavior Therapies Operant Conditioning
There has been both criticism and support for behavior modification techniques.
Critics express two concerns:
Token economies may produce behavior changes that disappear when rewards end.
Controlling the behavior of others is authoritarian and unethical.
Proponents argue that treatment with positive rewards is more humane than punishing people or institutionalizing them for undesired behaviors.

18. Cognitive Therapies
44-6: WHAT ARE THE GOALS AND TECHNIQUES OF COGNITIVE THERAPY AND OF COGNITIVE-BEHAVIORAL THERAPY?
Behavior therapy is more appropriate for specific fears and behaviors than for a wide assortment of behaviors or wide-ranging anxiety.
Cognitive therapies
Teaches people new, more adaptive ways of thinking.
Assumes that thoughts intervene between events and our emotional reactions.
Anxiety-provoking thoughts are usually negative.
Cognitive therapy aims to change negative thoughts to perceiving them in a new and constructive way.

19. A COGNITIVE PERSPECTIVE ON PSYCHOLOGICAL DISORDERS
The person’s emotional reactions are produced not directly by the event but by the person’s thoughts in response to the event.

20. Cognitive Therapies Beck’s Therapy for Depression
Aaron Beck (Beck et al., 1979): Changing people’s thinking can change their functioning.
Gentle questioning seeks to reveal irrational thinking.
Persuade people to change their perceptions (dark, negative, and pessimistic).
Catastrophizing: Relentless, overgeneralized, self-blaming behavior.
People trained to recognize and modify negative self-talk, and to restructure their thinking in stressful situations.
The benefits of positive self-talk are not restricted to depressed people; we all talk to ourselves and studies show the effectiveness of self-talk that is positive, not negative.

21. Cognitive Therapies
Selected Cognitive Therapy Techniques

22. Cognitive Therapies Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT) is an integrative therapy that combines cognitive therapy (changing self-defeating thinking) with behavior therapy (changing behavior).
Aims to alter the way clients act AND they way they think.
Helps people learn to replace their catastrophizing thinking with more realistic appraisals and to practice behaviors that are incompatible with their problem.
For example, those who fear social situations might learn to restrain the negative thoughts surrounding their social anxiety and practice approaching people.
A newer CBT variation, dialectical behavior therapy (DBT), helps change harmful, even suicidal, behavior patterns:
Aims to teach both acceptance and change.
Combines cognitive training with emotion regulation.

23. Group and Family Therapies Group Therapy
44-7: WHAT ARE THE AIMS AND BENEFITS OF GROUP AND FAMILY THERAPIES?
Group therapy is conducted with groups rather than individuals:
Provides benefits from group interaction
Does not provide the same degree of therapist involvement with each client
Saves therapists’ time and clients’ money
Encourages exploration of social behaviors and social skill development
Enables people to see that others share their problems
Provides feedback as clients try out new ways of behaving

24. Group and Family Therapies Family Therapy
Family therapy assumes that no person is an island:
Attempts to open up communication within the family, working with multiple family members to heal relationships and mobilize family resources
Help family members to discover and use conflict resolution strategies
Treats the family as a system
Views an individual’s unwanted behaviors as influenced by, or directed at, other family members

25. Group and Family Therapies Family Therapy
FAMILY THERAPY: This type of therapy often acts as a preventive mental health strategy.
The therapist helps family members understand how their ways of relating to one another create problems.
The treatment’s emphasis is not on changing the individuals, but on changing their relationships and interactions.

26. Group and Family Therapies Self-Help Groups
More than 100 million Americans belong to small religious, interest, or support groups
Group members support each other emotionally
Often focus on stigmatized or hard-to-discuss illnesses
Alcoholics Anonymous (AA) a successful support group:
Uses a program emulated by many other self-help groups
Reports 2.1 million members in 115,000 groups worldwide
Found to be as effective as other treatment interventions
Self-help groups provide support for those living alone, feeling isolated, addicted, bereaved, divorced, or just those seeking fellowship and growth

27. Evaluating Psychotherapies Is Psychotherapy Effective?
44-8: DOES PSYCHOTHERAPY WORK? HOW CAN WE KNOW?
We can assess psychotherapy’s effectiveness by looking at client perceptions, clinician perceptions, and outcome research.
Clients’ Perceptions
Client testimonials: Almost 90% report improvement after therapy
Critics note reasons for skepticism:
People often enter therapy in crisis
Clients believe that treatment will be effective
Clients generally speak kindly of their therapists
Clients want to believe the therapy was worth the effort

28. Evaluating Psychotherapies Is Psychotherapy Effective?
Clinicians’ Perceptions
Clients justify entering psychotherapy by emphasizing problems, and leaving by emphasizing well-being.
Therapists are most aware of failure of other therapists; the same client, finding only temporary relief, may be a “success” story in several therapists’ files.
Therapists, like the rest of us, are vulnerable to cognitive errors, such as confirmation bias and illusory correlation.

29. Evaluating Psychotherapies Is Psychotherapy Effective?
Outcome Research
Research indicates that two-thirds of those receiving treatment for disorders not involving hallucinations or delusions improved markedly.
However, research also indicates that those not undergoing treatment often improve.
Randomized clinical trials and meta-analyses provide the following conclusions:
Those undergoing psychotherapy are more likely to improve, and to improve more quickly.
Those undergoing psychotherapy also have a less chance of relapse.
Psychotherapy is cost-effective; when people seek psychological treatment, their search for other medical treatment drops.
Using meta-analyses to statistically combine the results of hundreds of randomized psychotherapy outcome studies, researchers have found that those not undergoing treatment often improve, but those undergoing psychotherapy are more likely to improve more quickly, and with less chance of relapse.

30. TREATMENT VERSUS NO TREATMENT
Number of
persons
These two normal distribution curves based on data from 475 studies show the improvement of untreated people and psychotherapy clients. The outcome for the average therapy client surpassed the outcome for 80 percent of the untreated people. (Data from Smith et al., 1980.)

31. Evaluating Psychotherapies Which Psychotherapies Work Best?
44-9: ARE SOME PSYCHOTHERAPIES MORE EFFECTIVE THAN OTHERS FOR SPECIFIC DISORDERS?
Some forms of psychotherapy work best for particular problems:
Behavior therapies: Bed-wetting, phobias, compulsions, marital problems, and sexual dysfunctions
Psychodynamic therapy: Depression and anxiety
Cognitive and cognitive-behavioral therapies: Anxiety, depression, and posttraumatic stress disorder
Therapy is most effective when problems are clear-cut
Evidence-based practice: Integration of best available research with clinicians’ expertise and patients’ characteristics, preferences, and circumstances

32. Evaluating Psychotherapies Which Psychotherapies Work Best?
Clinical Decision Making
Ideal clinical decision making can be visualized as a three-legged stool, upheld by research evidence, clinical expertise, and knowledge of the patient.

33. Evaluating Psychotherapies Evaluating Alternative Therapies
44-10: HOW DO ALTERNATIVE THERAPIES FARE UNDER SCIENTIFIC SCRUTINY?
Abnormal states often return to normal and the placebo effect can mislead effectiveness evaluation
Eye Movement Desensitization and Reprocessing (EMDR)
Some effectiveness shown
Therapy comes not from the eye movement but rather from the exposure therapy nature of the treatments (plus some placebo effect)
Light Exposure Therapy
Relief from depression symptoms for those with a seasonal pattern of major depressive disorder
Light therapy activates a brain region that influences the body’s arousal and hormones

34. How Do Psychotherapies Help People?
44-11: WHAT THREE ELEMENTS ARE SHARED BY ALL FORMS OF PSYCHOTHERAPY?
Three basic benefits for all psychotherapies
Hope for demoralized people
New perspective for oneself and the world
Empathic, trusting, caring relationship (therapeutic alliance)
A CARING RELATIONSHIP Effective counselor aboard a ship, form a bond of trust with the people they are serving.
Steve Szydlowski/KRT/Newscom

35. Evaluating Psychotherapies Culture and Values in Psychotherapy
44-12: HOW DO CULTURE AND VALUES INFLUENCE THE THERAPIST-CLIENT RELATIONSHIP?
Psychotherapists’ beliefs and values influence their practice.
Differences in cultural values can create a mismatch between therapist and client.
Many North American and European therapists reflect their culture’s individualism:
Tend to prioritize personal desires and identity
Clients may be from collectivist cultures:
More mindful of others’ expectations
APA-accredited therapy-training programs provide training in cultural sensitivity.
Highly religious clients may prefer religiously similar therapists.

36. Evaluating Psychotherapies Finding a Mental Health Professional
44-13: WHAT SHOULD A PERSON LOOK FOR WHEN SELECTING A THERAPIST?
A person seeking therapy is encouraged to ask about
Treatment approach
Values
Credentials
Fees
Perhaps the most important consideration in effective therapy is whether the potential client feels comfortable and able to establish a bond with the therapist.
See Table 15.3 for information on various types of therapists and their training.