Therapies

Chapter Fifteen

Lecture Slides

By Glenn MeyerTrinity University

Introduction: Psychotherapy and Biomedical Therapy

Reasons for Seeking Therapy

• Psychological disorder—troubling thoughts, feelings, or behaviors that cause psychological discomfort or interfere with a person’s ability to function

• Troubled relationships—parent-child conflicts, unhappy marriage

• Life transitions—death of a loved one, dissolving marriage, adjustment to retirement

Biomedical Therapies

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Psychotherapy

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• Refers to the use of psychological techniques to treat emotional, behavioral, and interpersonal problems

• Designed to encourage understanding of problems and modify troubling feelings, behaviors,

• or relationships• Many types of psychotherapy• Assumes psychological factors play

a significant role in person’s troubling feelings, behaviors, or relationships

• Therapists are now being granted privileges to prescribe medications in some areas, but this is controversial

• Involve the use of medication, electroconvulsive therapy, or other medical treatments to treat the symptoms associated with psychological disorder

• Use psychotropic medications

• Assume symptoms of psychological disorders involve biological factors

Two Broad Forms of Therapy

Psychoanalytic TherapySigmund Freud and Psychoanalysis

• Psychoanalysis is a form of therapy developed by Sigmund Freud and is based on his theory of personality

• Repressed conflicts continue to influence a person’s thoughts and behaviors, including the dynamics of his relationships with others

• Psychoanalysis is designed to help unearth unconscious conflicts so the patient attains insight

Techniques of Psychoanalysis

to Lift Repression

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Free association—spontaneous report of all mental images, thoughts,

feelings as a way of revealing unconscious conflicts; usually done

lying on a couch

Resistance—patient’s unconscious

attempt to block revelation of

unconscious material; usually sign that patient is close to revealing painful

memory

Dream interpretation—dreams are the “royal

road to the unconscious”; interpretation often

reveals unconscious conflicts

Transference—process by which emotions originally associated with a significant person, such as a parent, are unconsciously transferred to the therapist• Seen as most

important• Therapist remains

neutral to produce optimal frustration and bring out unresolved conflicts

Traditional psychoanalysis can take years

and be very expensive

Short-Term Dynamic Therapies

Based on psychoanalytic theory, but differs because it• is typically time limited–a few months• has specific goals• involves an active, rather than neutral, role for therapist

Interpersonal Therapy (IPT)

Focuses on current rather than past relationships; interpersonal problems seen as core of psychological symptoms

Four Categories of Personal Problems

• Unresolved grief–death of significant other

• Role disputes–conflict with significant others

• Role transitions–major life changes

• Interpersonal deficits–absent or faulty social skills

Humanistic Therapy

• Humanistic perspective emphasizes human potential, self-awareness, and free-will

• Humanistic therapies focus on self-perception and individual’s conscious thoughts and perceptions

• Most important factor in personality is the individual’s conscious, subjective perception of his or her self

• Humanistic therapists see people as being innately good and motivated by the need to grow psychologically

Carl Rogers and Client-Centered Therapy• Therapy is nondirective—

therapist does not interpret thoughts, make suggestions, or pass judgment

• Therapy focuses on client’s subjective perception of self and environment

• Does not speak of “illness” or “cure”

• Therapist’s role is to create conditions that allow client to direct focus of therapy

Therapeutic conditions that promote self-awareness,

psychological growth, and self-directed change:

• Genuineness: therapist honestly and openly shares thoughts and feelings with client

• Unconditional positive regard: therapist must value, accept, and care for client

• Empathic understanding: therapist must communicate and listen actively for personal meaning

The goal is self-actualization: a realization his or her unique potentials and talents

Motivational InterviewingHelping Clients Commit to Change

• Only one or two sessions; help clients overcome reluctance to change; encourage client’s self-motivating statements

• More directive than traditional client-centered therapy

• Has been applied to marital counseling, parenting, education, business, and community and international relations

Behavior Therapy/Behavior Modification

• Uses learning principles to directly change problem behaviors

• Assumes that maladaptive behaviors are learned, just as adaptive behaviors are learned

• Basic strategy involves unlearning maladaptive behaviors and learning more adaptive behaviors instead

Techniques Based on Classical Conditioning

• Student of Watson’s – worked with conditioned emotional responses

• Developed counterconditioning, a behavior therapy technique based on classical conditioning that involves modifying behavior by conditioning a new response that is incompatible with a previously learned responses

• Also used observational learning

• Successful with Peter who was phobic to rabbits

• Rabbit presented while 3-year-old Peter had a favorite snack

• Peter observed other children playing with rabbit

Mary Cover JonesThe First Behavior

Therapist

Systematic Desensitization

• Phobic responses are reduced by pairing relaxation with mental

images or real-life situations that the person finds progressively

more fear-provoking

• Based on the principle of counterconditioning

• Patient learns a new conditioned response (relaxation) that is

incompatible with old conditioned responses of fear and anxiety

• Three basic steps

• Can be combined with observational learning

• Can be done using virtual reality – for fear of flying, specific

phobias, PTSD

• Virtual reality may be preferred over desensitization with actual

exposure

Patient learns progressive relaxation

Patient constructs anxiety hierarchy

Process of desensitization

Aversive Conditioning

• Relatively ineffective type of therapy that involves repeatedly pairing an aversive stimulus with occurrence of undesirable behaviors or thoughts

• Based in part on the Garcia effect

Example: The use of Antabuse with alcoholism

• Found not to be very effective

Techniques Based on Operant Conditioning• Uses Skinnerian principles

such as

• Shaping (useful with

patients who are mentally

disabled with autism,

mental retardation, or

schizophrenia)

• Positive and negative

reinforcement

• Extinction

Token Economy

• System for strengthening desired behaviors through positive reinforcement in a very structured environment

• Tokens or points are awarded as positive reinforcers for desirable behaviors, and are withheld or taken away for undesirable behaviors

• Tokens can be exchanged for other reinforcers

• Used for behavior modification in group settings (prisons, classrooms, hospitals)

• Has been successful with severely disturbed people

• Difficult to implement and administer

Contingency Management

Focuses on one of a small set of behaviors

Useful for outpatient substance abuse treatment

Cognitive Therapies

• Assumes that the culprit in psychological problems is

faulty or illogical patterns of thinking

• Cognitive therapists zero in on the faulty, irrational

patterns of thinking that they believe are causing

psychological problems

• Treatment techniques focus on recognizing and altering

these unhealthy thinking patterns

Albert Ellis and Rational-Emotive Therapy (RET)

• Key premise of RET is that people’s difficulties are caused by their faulty expectations and irrational beliefs

• Psychological problems are explained by the “ABC” model• Activating event (A)

occurs• Beliefs (B) about the

event… • Cause emotional

consequences (C)• Irrational beliefs lead to

self-defeating behaviors, anxiety disorders, depression, etc.

Steps in RET

• Identifying the core irrational beliefs that underlie personal distress is the first step

• Therapist then disputes the irrational beliefs• Client must admit irrational beliefs and accept fact that

they are irrational and unhealthy• Effective in

• Depression, social phobia, and certain anxiety disorders

• Overcoming self-defeating behaviors

Aaron Beck and Cognitive Therapy

• Problems due to negative cognitive bias that lead to distorted perceptions and interpretations of events

• Beck believes that depression and other psychological problems are caused by distorted thinking and unrealistic beliefs

• Therapist acts as a model and aims for a collaborative therapeutic climate

Help client learn to recognize and monitor automatic thoughts that occur without conscious

effort or control

CT therapist encourages client to

empirically test accuracy of his or her

assumptions and beliefs

CT therapist creates a therapeutic climate of

collaboration that encourages client to

contribute to the evaluation of logic and

the accuracy of automatic thoughts

Steps in Cognitive Therapy (CT)

Effective in:

Treating and preventing depression

Anxiety disorders

Borderline personality disorders

Eating disorders

Post-traumatic stress disorder

Relationship problems

Cognitive-Behavioral Therapy

• Integrates cognitive and behavioral techniques

• Based on the assumption that thoughts, moods, and behaviors are interrelated

• The hallmark of cognitive-behavioral therapy is its pragmatic approach

• May use many different therapeutic approaches

• Goal of family therapy is to alter and improve the ongoing interactions among family members

• Family therapy involves many members of immediate family and important members of the extended family

• Enhances effectiveness of individual psychotherapy

Group and Family TherapyGroup therapy

Form of psychotherapy that involves one or more

therapists working simultaneously with a small group of clients

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Family therapy Form of psychotherapy

that is based on assumption that the

family is a system and treats the family as a unit

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Advantages

• Very cost-effective

• Therapist can observe actual interactions with others

• Support and encouragement provided by the other group members

• Group members may provide one another with helpful, practical advice

Self-help groups and support groups are typically conducted by nonprofessionals

Couple Therapy

• Relationship therapy that helps with difficulties in marriage or other committed relationships

• Many different approaches: for example, behavioral couple therapy based on learning theory

• Goals

• Improving communication

• Reducing negative communication

• Increasing intimacy

Self-Help GroupsHelping Yourself by Helping Others

• Format varies (structured and unstructured)

• Many follow a 12-step approach

• 12-step attendees who find sponsors and who have a high motivation to change are more likely to stay involved in a program

• Have been shown to be very effective (equal to therapists) and cost effective

• More research needed about the reasons for effectiveness and the kinds of people and problems that benefit from this approach

Many people just seek help and support

from friends and family

Some people eventually improve

simply with the passage

of time; spontaneous

remission

Most people do not seek

help with problems

Evaluating the Effectiveness of Psychotherapy

Basic strategy for investigating effectiveness

Compare people who enter psychotherapy with a carefully selected, matched control group of people who do not receive psychotherapy

Researchers use statistical technique called meta-analysis to combine and interpret large numbers of studies

Findings• Psychotherapy is

significantly more effective than no treatment

• On average, a person who completes psychotherapy is better off than about 80 percent of those in the untreated control group

• Gains that people make as a result of psychotherapy also tend to endure long after the therapy has ended

• PET scans may show changes equivalent to drug therapies

Depression

Panic disorder, obsessive-compulsive disorder, and phobias

Cognitive therapy and

interpersonal therapy

• Insight-oriented therapies are less effective than other therapies in treating severe psychotic symptoms, such as in schizophrenia.

• General finding: no differences among the types of empirically based forms of psychotherapy

• Beware of untested psychotherapies

Cognitive, cognitive-behavioral,

and behavior therapies

Is One Form of Psychotherapy Superior?

In some cases, some therapies are more effective for different problems

What Factors Contribute to

Effective Psychotherapy?

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Therapeutic relationship characterized by mutual respect

Therapist characteristics are associated with successful therapy

Caring attitude and the ability to listen empathically

Warm, sensitive, and responsive

Sincere and genuine

Sensitivity to cultural differences

Important client characteristics

Motivated, committed to therapy, and

actively involved

Stable living situation and supportive family

members

Good match between client and specific

therapeutic technique

Personalized approach to therapy is being

facilitated by eclecticism, a pragmatic and

integrated use of diverse psychotherapy

techniques

EMDR: Can You Wave Your Fears Away?

• Developed by Francis Shapiro

• Useful for relieving anxiety and traumatic memories

• Involves visually following a moving finger while holding mental image of disturbing event, situation, or memory, but the mechanism for this being effective has not been supported

• Too much pseudoscientific trappings added to basic therapeutic principles

• No more effective than other therapies

Cultural Values and Psychotherapy

• Clients are encouraged to become more assertive, more self-sufficient, and less dependent on others in making decisions

• Problems are assumed to have an internal cause and are expected to be solved by the client alone

Western psychotherapytends to reflect European and North American cultural values

Cultural Values and PsychotherapyCollectivistic Cultures

focus on needs of group, less on internal causes, not being a burden on community

Latino cultures Click here

Native Americans: Network therapy

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• One person’s problems may be seen as a problem for entire community to resolve

• Family members, friends, and community members asked to participate in treatment or healing rituals

• Network therapy is conducted in the person’s home and can involve as many as 70 members of the individual’s community

• Interdependence over independence

• Stress the value of familismo—the importance of the extended family network

Japanese psychotherapy: Naikan therapy

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• Being self-absorbed is path to psychological suffering

• Naikan therapy: replace focus on self with a sense of gratitude and obligation

• Client is asked to meditate on how he or she failed to meet the needs of others

Value Clashes

• Western therapies focus on insight, but other cultures emphasize avoiding negative thinking

• Many cultures do not value self-disclosure

• Western values may clash with cultures that feel women should be subservient

Biomedical Therapies• Medical treatments for

symptoms of psychological disorders include medication and electroconvulsive therapy

• Past centuries, patients were whirled, soothed, drenched, restrained, and isolated—all in an attempt to alleviate symptoms of psychological disorders

• Most common biomedical therapy: Psychotropic medications—prescription drugs that alter mental functions and alleviate psychological symptoms

Antipsychotic Medications

• Effective against positive symptoms of schizophrenia

• Also referred to as neuroleptics

• Reserpine – discovered in India

• Chlorpromazine (trade name: Thorazine)

• Reduce levels of the neurotransmitter called dopamine

• Have dramatically decreased the number of patients in mental hospitals

Drawbacks of Antipsychotic Medications

• Do not cure schizophrenia

• Early antipsychotic medications ineffective with negative symptoms of schizophrenia

• Unwanted side effects

• Dry mouth, weight gain, constipation, sleepiness, and poor concentration

• Early antipsychotic medications could produce motor-related side effects caused by dopamine involvement in motor systems

• Muscle tremors, rigid movements, a shuffling gait, and a masklike facial expression

• “Thorazine shuffle”

• Long-term use can produce tardive dyskinesia, an irreversible motor disorder characterized by severe, uncontrollable facial tics and grimaces, chewing movements, and other involuntary movements of the lips, jaw, and tongue

• “Revolving door” pattern of hospitalization, discharge, and rehospitalization

The Atypical AntipsychoticsSecond Generation

• Clozapine and risperidone

• More recent: olanzapine, sertindole

• Less likely to cause movement-related dopamine side effects

• More effective in treating the negative symptoms of schizophrenia

• Lessen revolving door pattern

• Problems: weight gain, diabetes, cardiac problems

• Do not produce greater improvements than older antipsychotics

Antianxiety Medications

Antianxiety medicationsare prescribed to help people deal with the problems and symptoms associated with pathological anxiety

Non-benzodiazepine (Buspar)

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Benzodiazepines (Valium, Xanax)

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• Reduce anxiety through increasing level of GABA

• Take effect rapidly and after a week or two effectively reduce anxiety levels

• Side effects include decreased coordination, reaction time, alertness

• Physical addiction and possible life-threatening withdrawal symptoms

• Effect intensified if combined with alcohol or over-the-counter drugs like antihistamines

• Good for short-term relief

• Doesn’t effect GABA, perhaps effects dopamine or serotonin

• May take up to two or three weeks to work

• Does not reduce alertness or produce cognitive impairment

Lithium• Used to treat bipolar disorder (manic

depression), interrupt acute manic attacks, and prevent relapse

• Lithium counteracts both manic and depressive symptoms in bipolar patients

• Prevents acute manic episodes over the course of a week or two

• Lithium level problems

• Too low = manic symptoms persist

• Too high = lithium poisoning, which causes vomiting, muscle weakness, and reduced muscle coordination

• Lithium blood level must be carefully monitored

• Action: Lithium affects levels of excitatory neurotransmitter glutamate

• Stabilizes glutamate availability within a narrow, normal range, preventing both abnormal highs and abnormal lows

Antidepressant Medications

First generation—tricyclics and MAO inhibitors• Effective for about 75% of patients• Increase availability of norepinephrine and

serotonin• Can take up to six weeks before symptoms begin

to liftSide effects

• Serious physiological side effects when taken with common foods: cheese, smoked meats, and red wine

• Dangerously high blood pressure, stroke, death• Weight gain, dry mouth, dizziness, sedation

Counteract the symptoms of depression—hopelessness, guilt, dejection, suicidal thoughts, difficulty concentrating, and disruptions in sleep, energy, appetite, and sexual desire.

Antidepressant Medications

Third generation—Selective serotonin reuptake inhibitors (SSRIs)

• Fluoxetine—Prozac, Zoloft, and Paxil

• Effect the availability of a single neurotransmitter: serotonin

• Milder side effects • Prozac’s: headaches,

nervousness, difficulty sleeping, loss of appetite, and sexual dysfunction

Dual-action antidepressants: Serzone and Remeron

• Affect serotonin levelsDual-reuptake inhibitors: Effexorand Cymbalta

• Affect levels of both serotonin and norepinephrine

Dopamine-norepinephrine inhibitor: Wellbutrin

Second generation• Trazodone and

bupropion• No more

effective than first generation

• Same side effects

Comparing Psychotherapy and Antidepressant Medication

Results

• PET scans revealed that patients in both groups showed a trend toward more normalized brain functioning

• Similar changes in patients with panic disorder, post-traumatic stress disorder, obsessive compulsive disorder, phobias, and other anxiety disorders after psychotherapy treatment

PET scan study: Depressed individuals showed increased activity in the prefrontal cortex, caudate nucleus, and thalamus

Two groups in study; each group was assigned to either Paxil or interpersonal

therapy

Electroconvulsive Therapy (Electroshock therapy or shock therapy)

• Involves brief burst of electric current to induce a seizure in the brain

• Commonly used to treat depression• Occasionally used to treat mania, schizophrenia• Used after other forms of treatment have failed to help • Antidepressive effects can be short-lived• Half of patients relapse within six months• Not known exactly how it relieves the symptoms of

depression• May have cognitive side effects such as memory loss• Controversial because of its early overuse and punitive

appearance

New and Experimental Treatments

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Vagus nerve stimulation (VNS)

Implantation of a device into left chest wall

Uses brief, intermittent electrical stimulation to left vagus nerve

Runs through the neck and connects to the brain stem

Deep brain stimulation (DBS)

Uses electrodes surgically implanted

in the brain

Transcranialmagnetic

stimulation (TMS) Stimulation of certain regions of brain with

magnetic pulses

B. F. Skinner and the Search for “Order in Behavior”

1. Strengthen your commitment to change.

Think about the reasons you want to change.

2. Therapy is a collaborative effort.

You must actively participate. Therapist can’t do all the work.

3. Don’t confuse catharsis with change.

Emotional release alone doesn’t fix the problem.

4. Don’t confuse insight with change.

Insight doesn’t automatically translate into healthier behavior and attitudes.

5. Don’t expect your therapist to make decisions for you.

You need to decide what to do with the therapist helping you explore decision making.

6. Expect therapy to challenge how you think and act.

Therapy can be a painful magnifying glass on your life.

What to Expect in Psychotherapy