1. Chapter 15 Psychotherapy

2. The Treatment Process, continued Treatments: How many types are there? –All psychotherapies involve “a helping relationship (the treatment) between a professional (the therapist) and another person in need of help (the client)”. –There are three main categories of therapy: 1.Insight therapies. 2.Behavior therapies. 3.Biomedical therapies.

3. The Treatment Process, continued Clients: Who seeks therapy? –Approximately 15% of Americans seek mental health services each year. –The most common problems are excessive anxiety and depression. –People seek treatment for milder problems, such as making a career decision, as well. –Women, people with medical insurance, and people with more education are all more likely to seek treatment.

4. The Treatment Process, continued Clients: Who seeks therapy?, continued –Unfortunately, many who need therapy do not receive it (see Figure 15.2). –Common barriers to seeking treatment include Lack of health insurance. The “stigma” associated with receiving mental health services.

5. Figure 15.2. Therapy utilization rates. Olfson and colleagues (2002) gathered data on the use of nonhospital outpatient mental health services in the United States in relation to various demographic variables. In regard to marital status, utilization rates are particularly high among those who are divorced or separated. The use of therapy is greater among those who have more education and, in terms of age, utilization peaks in the 35-44 age bracket. Females are more likely to pursue therapy than males are, but utilization rates are extremely low among ethnic minorities. (Data from Olfson et al., 2002)

6. The Treatment Process, continued Therapists: Who provides treatment? –Psychologists and psychiatrists are the most common providers of treatment. –However, therapy is also provided by other professionals, including Psychiatric social workers. Psychiatric nurses. Counselors.

7. The Treatment Process, continued Therapists, continued –Clinical psychologists and counseling psychologists “specialize in the diagnosis and treatment of psychological disorders and everyday behavioral problems”. –Both require a doctoral degree (Ph.D., Psy.D., or Ed.D). –Psychologists are more likely to use behavioral methods over psychoanalysis. –Psychologists also do psychological testing and conduct research.

8. The Treatment Process, continued Therapists, continued –Psychiatrists “are physicians who specialize in the treatment of psychological disorders”. –Psychiatrists focus on more severe disorders (e.g., schizophrenia). –Psychiatrists earn an M.D. and typically emphasize drug therapies (psychologists cannot prescribe medication). –Psychiatrists are also more likely to use psychoanalysis.

9. The Treatment Process, continued Therapists, continued Other mental health professionals –Psychiatric social workers work as part of a treatment “team” with a psychologists or psychiatrist. –They have a master’s degree and usually help patients integrate back into the community. –Psychiatric nurses earn a bachelor’s or master’s degree and usually work with hospitalized patients.

10. Insight Therapies, continued Insight therapies “involve verbal interactions intended to enhance clients’ self-knowledge and thus promote healthful changes in personality and behavior”. –Insight therapies include Psychoanalysis. Client-centered therapy. Positive psychology. Group therapy.

11. Insight Therapies, continued Psychoanalysis was developed by Sigmund Freud, and “emphasizes the recovery of unconscious conflicts, motives, and defenses through techniques such as free association, dream analysis and transference”. –Probing the unconscious Therapists use two techniques to probe the unconscious in an attempt to identify unresolved conflicts causing the client’s neurotic behavior.

12. Insight Therapies, continued Psychoanalysis, continued –In free association, “clients spontaneously express their thoughts and feelings exactly as they occur, with as little censorship as possible”. –In dream analysis, “the therapist interprets the symbolic meaning of the client’s dreams”. –Both techniques require the therapist to interpret the clues that these methods provide about unconscious conflicts.

13. Insight Therapies, continued Psychoanalysis, continued –Interpretation “involves the therapist’s attempts to explain the inner significance of the client’s thoughts, feelings, memories, and behaviors”. –Resistance “involves largely unconscious defensive maneuvers intended to hinder the progress of therapy”. Clients may resist by “forgetting” appointments or being hostile toward the therapist.

14. Insight Therapies, continued Psychoanalysis, continued –Transference “occurs when clients start relating to their therapists in ways that mimic critical relationships in their lives”. –Although classical psychoanalysis (as performed by Freud) is rare today, newer versions of the therapy are used and are referred to as psychodynamic approaches.

15. Insight Therapies, continued Client-centered therapy “is 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”. –This approach is rooted in the humanistic perspective and the work of Carl Rogers. –Therapists try to foster self-acceptance and personal growth in their clients. –Therapists also help clients restructure their self-concept to better correspond with reality.

16. Insight Therapies, continued Client-centered therapy, continued –Therapeutic climate Rogers believed three elements were necessary to promote positive changes in therapy: 1.Genuineness (honest communication). 2.Unconditional positive regard (therapist remains supportive, non- judgmental). 3.Empathy (therapist understands issues from client’s point of view).

17. Insight Therapies, continued Client-centered therapy, continued –Therapeutic process With this approach, the client and therapist work together almost as equals. The therapist’s key task is clarification – “reflecting the client’s statements with enhanced clarity”. The main goal of therapy is to help clients become more aware of, and comfortable with, their “genuine selves”.

18. Insight Therapies, continued Therapies inspired by positive psychology –Well-being therapy, developed by Giovanni Fava, focuses on “self-acceptance, purpose in life, autonomy, and personal growth”. –Positive psychotherapy – “ attempts to get clients to recognize their strengths, appreciate their blessings, savor positive experiences, forgive those who have wronged them, and to find meaning in their lives”. It has been successful in treating depression (see Figure 15.5).

19. Figure 15.5. Positive psychotherapy for depression. In a study of the efficacy of positive psychotherapy, it was compared to treatment as usual (clinicians delivered whatever treatment they deemed appropriate) and to treatment as usual combined with antidepressant medication. At the end of 12 weeks of treatment, symptoms of depression were measured with the widely used Hamilton Rating Scale for Depression. The mean depression scores for each group are graphed here. As you can see, the positive psychotherapy group showed less depression than the other two treatment groups, suggesting that positive psychotherapy can be an effective intervention for depression. SOURCE: Adapted from Seligman, M.E.P., Rashid,T.,& Parks, A.C.(2006). Positive psychotherapy. American Psychologist, 61, 774-778. (Figure 2, p. 784).

20. Insight Therapies, continued Group therapy “is the simultaneous treatment of several or more clients (typically five to ten people) in a group”. –Participants’ roles In group therapy, participants function like “therapists” for each other. The most important role is that of providing emotional support for fellow members of the group.

21. Insight Therapies, continued Group therapy, continued –Advantages of the group experience 1.Clients realize their problems are not unique. 2.It provides an opportunity to practice and enhance social skills. 3.Certain problems are well-suited for group therapy. In “peer self-help groups”, all members share the same kind of problem (e.g., Alcoholics Anonymous) and can provide support for each other.

22. Insight Therapies, continued Evaluating insight therapies –It is difficult to compare the effectiveness of one type of insight therapy to another because of the allegiance effect, in which researchers often find the most support for the therapeutic approach they use. –Despite this, many studies have shown insight therapy to be superior to placebo and to produce lasting effects. –Also, most people find therapy beneficial.

23. Insight Therapies, continued Evaluating insight therapies, continued Common factors that make various insight therapies effective: 1.Developing an alliance with a professional helper. 2.Emotional support and empathic understanding from the therapist. 3.The cultivation of hope, positive expectations.

24. Insight Therapies, continued Evaluating insight therapies, continued 4.Provision of a rationale for one’s problems and a method for alleviating them. 5.The opportunity to express feelings, confront problems, gain new insights, and learn new patterns of behavior.

25. Insight Therapies, continued Therapy and the recovered memories controversy –Much debate has centered around clients’ “recovery” of forgotten memories of traumatic events, including abuse by parents. –This is controversial because it is not possible to be absolutely certain whether or not the memory is real.

26. Insight Therapies, continued Therapy and recovered memories, continued –Furthermore, some recovered “memories” of abuse have been proven to be false, and people (e.g., parents) have been falsely accused of crimes they did not commit. –Psychologists are sharply divided on the issue. –Proponents argue that recovered memories are genuine and valuable.

27. Insight Therapies, continued Therapy and recovered memories, continued –Critics cite research showing that false memories can be “implanted” in experimental conditions. –Critics also argue that clients, confused about the source of their troubles, are persuaded by therapists who are overly eager to attribute problems to childhood abuse.

28. Behavior Therapies, continued Insight therapists believe that behaviors are symptoms of underlying psychological issues. In contrast, behavior therapists argue that the behaviors themselves are the problem. Thus, behavior therapies “involve the application of the principles of learning to direct efforts to change clients’ maladaptive behaviors”.

29. Behavior Therapies, continued Behavior therapy is based on two assumptions: 1.Behavior is a product of learning. 2.What has been learned can be unlearned. Clients’ vague complaints are redefined in terms of concrete, specific goals. Specific procedures are then used for specific kinds of problems to reach the goal.

30. Behavior Therapies, continued Systematic desensitization “is a behavior therapy used to reduce clients’ anxiety responses through counterconditioning”. –The goal with this technique is to break down the association between the conditioned stimulus (or the stimulus that triggers fear) and the conditioning response of anxiety (see Figure 15.7).

31. Figure 15.7. The logic underlying systematic desensitization. Behaviorists argue that many phobic responses are acquired through classical conditioning, as in the example diagrammed here. Systematic desensitization targets the conditioned associations between phobic stimuli and fear responses.

32. Behavior Therapies, continued Systematic desensitization, continued –Before beginning, the therapist helps the client build a fear hierarchy, or a list of progressively more frightening versions of the conditioned stimulus (see Figure 15.8). –Then, the client is trained in deep muscle relaxation. –Finally, the client pairs the learned relaxation with each step of the hierarchy until anxiety to the fear stimulus is reduced.

33. Figure 15.8. Example of an anxiety hierarchy. Systematic desensitization requires the construction of an anxiety hierarchy like the one shown here, which was developed for a woman with a fear of heights who had a penchant for hiking in the mountains.

34. Behavior Therapies, continued Aversion therapy “is a behavior therapy in which an aversive stimulus is paired with a stimulus that elicits an undesirable response”. –For example, as shown in Figure 15.9, an alcoholic’s desire to drink could be weakened by pairing a nausea-inducing drug with alcohol. –Aversion therapy is used with a wide range of undesirable behaviors including gambling, shoplifting, and smoking.

35. Figure 15.9. Aversion therapy. Aversion therapy uses classical conditioning to create an aversion to a stimulus that has elicited problematic behavior. For example, in the treatment of drinking problems, alcohol may be paired with a nausea-inducing drug to create a conditioned aversion to alcohol.

36. Behavior Therapies, continued Social skills training “is a behavior therapy designed to improve interpersonal skills that emphasizes shaping, modeling, and behavioral rehearsal”. –First, the client watches socially skilled people model (or demonstrate) successful interactions with others. –In behavioral rehearsal, the client practices modeled techniques through role-playing exercises – and eventually – in real life. –Shaping is used to get clients to handle gradually more demanding social situations.

37. Behavior Therapies, continued Cognitive-behavioral treatments blend verbal and behavioral interventions. Cognitive therapy “is a treatment that emphasizes recognizing and changing negative thoughts and maladaptive beliefs”. –It emerged from the work of two former psychoanalysts: Albert Ellis and Aaron Beck (this chapter will focus on the work of Aaron Beck).

38. Behavior Therapies, continued Cognitive therapy, continued –According to Beck, depression is caused by errors in thinking, and people who experience depression are more likely to 1.Blame their setbacks on personal inadequacies. 2.Focus selectively on negative events. 3.Make overly pessimistic projections about the future. 4.Draw negative conclusions about their self-worth.

39. Behavior Therapies, continued Cognitive therapy, continued –The main goal of cognitive therapy is to change the way clients think. –The therapist’s goal is to help clients detect automatic negative thoughts and to use more reasonable standards of evaluation. –The therapist primarily sets the pace and direction of treatment.

40. Behavior Therapies, continued Evaluating behavior therapies –Generally, behavior therapies are very effective. This is especially true with regard to treatment of Anxiety problems, phobias, OCD, and schizophrenia. Sexual dysfunction. Drug-related problems and eating disorders. Hyperactivity. Autism and mental retardation.

41. Biomedical Therapies, continued Biomedical therapies “are physiological interventions intended to reduce symptoms associated with psychological disorders”. Two prominent biomedical therapies are –Drug therapy. –Electroconvulsive (ECT).

42. Biomedical Therapies, continued: Treatment with drugs –Psychopharmacotherapy (or drug therapy) “is the treatment of mental disorders with medication”. –Therapeutic drugs fall into four main categories: 1.Antianxiety drugs. 2.Antipsychotic drugs. 3.Antidepressant drugs. 4.Mood stabilizers.

43. Biomedical Therapies, continued Treatment with drugs, continued Antianxiety drugs “relieve tension, apprehension, and nervousness”. –Two common antianxiety drugs are Valium and Xanax. –These drugs provide fast relief. –However there is the risk for abuse, dependency, overdose, and withdrawal effects. –Newer drugs such as Buspar act slower, with fewer sedative side effects.

44. Biomedical Therapies, continued Treatment with drugs, continued Antipsychotic drugs “are used to gradually reduce psychotic symptoms, including hyperactivity, mental confusion, hallucinations, and delusions”. –They are typically used to treat schizophrenics or other patients in a delusional state. –Common antipsychotics include Thorazine, Mellaril, and Haldol.

45. Biomedical Therapies, continued Treatment with drugs, continued –Antipsychotics work gradually (two to seven days), and reduce symptoms in about 70% of patients. –They do have unpleasant side effects, however, including Dry mouth, constipation. Drowsiness. Tremors, muscular rigidity, and impaired coordination.

46. Biomedical Therapies, continued Treatment with drugs, continued –A more serious, but rare, side effect is a condition called tardive dyskinesia, “a neurological disorder marked by chronic tremors and involuntary spastic movements”, which is irreversible. –Atypical antipsychotics are a newer class of drugs with a lower risk of these side effects (e.g., clozapine, olanzapine, & quetiapine).

47. Biomedical Therapies, continued Treatment with drugs, continued Antidepressant drugs “gradually elevate mood and help bring people out of a depression”. –The most commonly used antidepressants today are SSRIs (selective seratonin reuptake inhibitors) that work by affecting the brain chemical, seratonin (e.g., Zoloft). –SSRIs also work for some anxiety disorders.

48. Biomedical Therapies, continued Treatment with drugs, continued –Side effects of SSRIs include Weight gain. Sleep problems. Sexual dysfunction. –More recently, research has raised concern that SSRIs may possibly increase the risk for suicide, especially in adolescents.

49. Biomedical Therapies, continued Treatment with drugs, continued –The newest class of antidepressants are SNRI, which work on seratonin and norepinephrine receptors. –Preliminary data suggests they produce stronger antidepressant effects than SSRIs. –However, there may be more side effects, including elevated blood pressure.

50. Biomedical Therapies, continued Treatment with drugs, continued Mood stabilizers “are drugs used to control mood swings in patients with bipolar mood disorders”. –Lithium has long been used to treat bipolar disorder, but has dangerous side effects, including Toxicity or death at high concentrations. Kidney and thyroid gland problems. –Newer drugs (e.g., Valproate) appear to be as effective, with fewer side effects.

51. Biomedical Therapies, continued Evaluating drug therapies –Benefits Drugs provide relief for severe disorders that cannot be helped by other therapies. –Critics argue that Drugs only treat symptoms, not underlying causes of disorders. Drugs are overprescribed; people are overmedicated. Side effects may be worse than the symptoms drugs are used to treat.

52. Biomedical Therapies, continued Electroconvulsive therapy (ECT) “is a biomedical treatment in which electric shock is used to produce a cortical seizure accompanied by convulsions”. –ECT is primarily used to treat depression. –Patients are given a light anesthetic and muscle relaxers to prevent spinal fractures. –Electric current is applied for about a second, which triggers a brief seizure. –Typically, patients receive 6-12 treatments over the course of a month.

53. Biomedical Therapies, continued ECT, continued Effectiveness of ECT –Proponents of ECT claim it is very effective for depression in patients that do not respond to medication. –Opponents argue that it is not more effective than placebo and carries serious risks.

54. Biomedical Therapies, continued ECT, continued Risks associated with ECT –ECT proponents admit that memory loss and impaired attention are mild, temporary side effects of the treatment. –Critics argue that these cognitive problems are more serious and sometimes permanent.

55. Current Trends and Issues, continued Grappling with constraints of managed care –Before the 1990s, with the fee-for-service system, doctors charged patients fees for whatever services were necessary. Patients were then reimbursed through insurance or the government. –This system changed to a managed care system in the 1990s, in which people enroll in prepaid plans (typically run by HMOs) and make small copays for services.

56. Current Trends and Issues, continued Managed care, continued –Managed care was developed in an attempt to control inflation of medical costs. –However, critics assert that, in an attempt to control costs, healthcare has been rationed and access to some medically necessary services has been limited. –This is especially true in the mental health field, in which HMOs may not recognize the necessity of certain treatments.

57. Current Trends and Issues, continued Managed care, continued –In addition, critics argue that, as a result of managed care, mental health patients Are often underdiagnosed (to avoid having to prescribe costly treatments). Are not referred to mental health specialists by primary physicians. Are limited in the number of psychotherapy sessions, or length of treatment, they can have.

58. Current Trends and Issues, continued Managed care, continued –Critics also argue that managed care has created barriers to access, such as Requiring referrals from primary care physicians who don’t have appointments available for weeks or months. Rerouting patients to less expensive master’s-level counselors who may not be able to handle serious disorders. Prescribing older, less expensive drugs.

59. Current Trends and Issues, continued Blending approaches to treatment –It is becoming increasingly common for therapists to draw from various therapeutic approaches to treat a client. –Studies show that there is, indeed, merit to this idea. –Today, most therapists describe themselves as eclectic – “drawing ideas from two or more systems of therapy” (see Figure 15.15).

60. Figure 15.15. The leading approaches to therapy among psychologists. These data, from a survey of 531 psychologists who belong to the American Psychological Association’s Division of Psychotherapy, provide some indication of how common an eclectic approach to therapy has become. The findings suggest that the most widely used approaches to therapy are eclectic, psychodynamic, and cognitive- behavioral treatments. (Based on data from Norcross, Hedges, & Castle, 2002).

61. Current Trends and Issues, continued Increasing multicultural sensitivity in treatment –Minority groups are especially unlikely to seek and utilize therapy. 1.Cultural barriers –Some cultures emphasize assistance from family, clergy, etc., over mental health professionals. –Some cultures have difficulty trusting the medical (and mental health) establishment.

62. Current Trends and Issues, continued Increasing multicultural sensitivity, continued 2.Language barriers – Effective communication is critical to therapy, and cultural differences in language can act as a barrier to treatment. 3.Institutional barriers – Most therapists have only been trained to interact with white, middle-class clients and are unfamiliar with the cultural backgrounds of various ethnic groups.

63. Current Trends and Issues, continued Increasing multicultural sensitivity, continued What can be done? – Recruit and train minority therapists. – Train therapists how to work more effectively with a culturally diverse clientele. – Research how to modify current approaches so that they are more compatible with a diverse clientele.

64. Application: Looking for a Therapist, continued Where do you find therapeutic services? –Contrary to popular belief, most therapists do not operate in private practice. In fact, many work in Institutional settings (such as community mental health centers). Human service agencies. See Figure 15.16 for more information.

65. Figure 15.16. Sources of therapeutic services. Therapists work in a variety of organizational settings. Foremost among them are the five described here.

66. Application: Looking for a Therapist, continued Is the therapist’s profession or sex important? –Researchers have not found any reliable link between the therapists’ profession (e.g., psychologist versus psychiatrist) and therapeutic efficacy. –However, psychiatrists are the only mental health professionals who can prescribe medication.

67. Application: Looking for a Therapist, continued –This is a subjective matter. –Thus, if the client thinks he or she will feel more comfortable with a therapist of the same gender, then that person should find one that is the same gender. Is therapy always expensive? –Not necessarily. Costs can be reduced by Seeking treatment from providers who are not in private practice (e.g., human service agencies). Using health insurance.

68. Application: Looking for a Therapist, continued Is the therapist’s theoretical approach important? –For certain types of problems, certain theoretical approaches are a better fit. –For example, Cognitive therapy is best for panic disorders. Behavior therapy (systematic desensitization) is best for phobias. OCD is best treated with behavior therapy and medication.

69. Application: Looking for a Therapist, continued What is therapy like? –It is important to have realistic expectations about therapy. –Therapy is usually a slow process. –Therapy is hard work. –Your therapist is only a facilitator. Ultimately, you have to make changes in your behavior or personality in order to see improvement.