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Chapter 16 Introduction to Therapy and Psychological Therapies Treating Psychological Disorders    

In psychotherapy a trained therapist uses psychological techniques to assist someone seeking either to overcome difficulties or to achieve personal growth therapist may explore a clients early relationships encourage the client to adopt new ways of thinking or coach the client in replacing old behaviors with new ones bio medical therapy offers medications and other biological treatments Some therapists combine techniques and many psychotherapists describe their approach as eclectic using a blend of therapies

Psychanalysis and Psychodynamic Therapies   

The first major psychological therapy with Sigmund Freud psychoanalysis Psychoanalysis is the theory of personality that attributes thoughts and actions to unconscious motives and conflicts Freud believed the patients free associations resistances dreams and transferences and the therapist interpretations of them released previously repressed feelings allowing the patient to gain self insight

The Goal of Psychoanalysis    

Freud believed that in therapy people could achieve healthier less anxious living by releasing the energy they had previously devoted to it ego and superego conflicts he believes that there are threatening things we repress so we disavow or deny them psychoanalysis was his method of helping people bring these repressed feelings into conscious awareness he helped them reclaim their unconscious thoughts and feelings by giving them insight into the origins of their disorders

The Techniques of Psychoanalysis        

psychoanalytic theory emphasizes the power of childhood experiences to mold the adult after discarding hypnosis as an unreliable excavator Freud turned free Association Do the analyst mental blocks indicate resistance they hint that anxiety lurks an you are defending against sensitive material the analyst will note your resistance and then provide insight into its meaning if offered at the right moment this interpretation if you're not wanting to talk about whatever may illuminate the underlying wishes feelings and conflicts you are avoiding over such many sessions your relationship pattern surface and your interaction with your therapist you may find yourself experiencing strong positive or negative feelings for your analyst the analyst may suggest that you are transferring feelings such as dependency or love or anger that you experienced in earlier relationships with family members or other important people

Psychodynamic Therapy

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Psychodynamic therapist don't talk much about the id ego superego conflicts instead they try to help people understand their current symptoms by focusing on important relationships including childhood experiences and therapist client relationship Shapiro noted with such patients who are estranged from themselves therapists use psychodynamic techniques exploring past relationship troubles may help clients understand the origin of their current difficulties without embracing all of Freud's theory psychodynamic therapists aimed to help people gain insight into unconscious dynamics that arise from their life experiences

Humanistic Therapies               

The humanistic perspective emphasizes people's innate potential for self fulfillment they attempt to reduce inner conflicts that interfere with natural development and growth humanistic therapies are often referred to as insight therapies Humanistic therapists aimed to boost people self fulfillment by helping them grow and self awareness and self acceptance promoting growth not curing illness is the therapy focus conscious thoughts are more important than the unconscious the present and future are more important than the past All of these themes are present in the widely used humanistic technique that Carl Rogers developed and called the client centred therapy in this nondirective therapy the client leads the discussion the therapist listens without judging or interpreting and refrains from directing the client towards certain insights Rogers encouraged therapist to foster growth by exhibiting acceptance genuineness and empathy Rogers believed that hearing was active listening the therapist echoes restates and seeks clarification of what the person expresses and acknowledges those expressed feelings He said the therapist's most important contribution is to accept and understand the client given a nonjudgmental grace-filled environment that provides unconditional positive regard people may accept even their worst traits and feel valued as a whole How can we improve communication in our own relationships by listening more actively? Rogers inspired three hints may help: 1. paraphrase 2 invite clarification 3. reflect feelings

Behaviour Therapies  

Behavior therapies doubt the healing power of self awareness rather than delving deeply below the surface looking for inner causes behavior therapists assume the problem behaviors are the problem

Classical Conditioning Techniques

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One cluster of behavior therapies derives from principles developed in Ivan pavlov's early 20th century conditioning experiments O.H Mowrer develop a successful conditioning therapy for chronic bedwetter's using a liquid sensitive pad connected to an alarm in three out of four cases the treatment has been effective and success boosted the child self image Counterconditioning such as exposure therapy pairs the trigger stimulus with a new response that is incompatible with fear

Exposure Therapies          

Joseph wolpe refined Joneses counterconditioning technique into the exposure therapies used today these therapies in a variety of ways try to change people's reactions by repeatedly exposing them to stimuli that trigger unwanted reactions with repeated exposure to what they normally avoid or escape people adapt One exposure therapy used to treat phobias is systematic desensitisation You cannot simultaneously be anxious and relaxed therefore if you can repeatedly relax when facing anxiety provoking stimuli then you can gradually eliminate your anxiety next therapist would train you in taprogressive relaxation you would learn to release tension in one muscle group after another until you achieve a comfortable complete relaxation The therapist will then move to the next item in your anxiety hierarchy again using relaxation techniques to desensitize you to each imagined situation after several sessions you move to actual situations and practice what you've only imagined before if an anxiety arising situation is too expensive difficult or embarrassing to recreate the therapist may recommend virtual reality exposure therapy you would don a head mounted display unit that projects a 3 dimensional virtual world the lifelike scenes which shift as your head turns would be tailored to your particular fear

Aversive Conditioning     

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And exposure therapy enables a more relaxed positive response to an upsetting harmless stimulus it helps you accept what you should do aversive conditioning creates a negative response to a harmful stimulus it helps you to learn what you should not do it associates the unwanted behavior with unpleasant feelings to treat nail biting the therapist may suggest painting the fingernails with a nasty tasting polish Does aversive conditioning also transform humans reactions to alcohol? in one classic study 685 hospital patients with alcohol use disorder completed an aversion therapy program over the next year they returned for several booster treatments that paired alcohol with sickness at the end of that year 63% were not drinking alcohol but after three years only 33% were alcohol free

Operant Conditioning

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Consequences strongly influence our voluntary behavior knowing this basic principle of operant conditioning behavior therapists can practice behavior modification they reinforce behaviors they consider desirable and they failed to reinforce or sometimes punish behaviors they consider undesirable using operant conditioning to solve specific behavior problems has raised hopes for some seemingly hopeless cases An institutional settings therapist may create a token economy when people display desired behavior such as getting out of bed washing dressing eating talking coherently cleaning up their rooms or playing cooperatively they receive a token or plastic coin later they can exchange that coin for rewards such as candy TV time day trips Behavior modification critics expressed two concerns 1. how durable are the behaviors? 2. is it right for one human to control another's behavior?

Cognitive Therapies    

Cognitive therapies assume that our thinking colours our feelings between an event in our response lies the mind self blaming and overgeneralized explanations of bad events feed depression cognitive therapies aimed to help people change their mind with new more constructive ways of perceiving and interpreting events

Beck’s Therapy for Depressions       

Beck realize that changing peoples automatic negative thoughts could be therapeutic his cognitive therapy assumes that changing peoples thinking can change their functioning he found that often people with depression reported dreams the negative themes of loss rejection and abandonment and those thoughts extended into their waking thoughts with cognitive therapy back in his colleague sought to reverse clients negativity about themselves their situations and their futures with this technique gentle questioning seeks to reveal a rational thinking and then to persuade people to remove the dark glasses which they view life To change such negative self talk therapists have offered stress inoculation training: teaching people to restructure their thinking in stressful situations after learning to talk back to negative thoughts depression prone teenagers, children, and college students have shown a greatly reduced rate of future depression

Aim of Technique Technique Reveal beliefs

Therapists’ Directives

Question your interpretations

Explore your beliefs, revealing faulty assumptions such as “I must be liked by everyone.”

Rank thoughts and

Gain perspective by ranking your thoughts and emotions from mildly

emotions Test beliefs Examine consequences

Change beliefs

to extremely upsetting. Explore difficult situations, assessing possible consequences and challenging faulty reasoning.

Decatastrophize thinking

Work through the actual worst-case consequences of the situation you face (it is often not as bad as imagined). Then determine how to cope with the real situation you face.

Take appropriate responsibility

Challenge total self-blame and negative thinking, noting aspects for which you may be truly responsible, as well as aspects that aren’t your responsibility.

Resist extremes

Develop new ways of thinking and feeling to replace maladaptive habits. For example, change from thinking “I am a total failure” to “I got a failing grade on that paper, and I can make these changes to succeed next time.”

TABLE 16.1Selected Cognitive Therapy Techniques  

the findings of nearly three dozen sports psychology studies show that self talk can enhance the learning of athletic skills for example novice basketball players may be trained to think focus an follow through swimmers to think high elbows and tennis players to think look at the ball

Cognitive-Behavioral Therapy   

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Cognitive behavioral therapy takes a combined approach to depression and other disorders this widely practiced integrative therapy aims to alter not only the way people think but also the way they act it seeks to make people aware of their irrational negative thinking and replace it with new ways of thinking and like other behavior therapies it trains people to practice the more positive approach in everyday settings anxiety depressive disorders and bipolar disorder share a common problem: emotion regulation an effective CBT program for these emotional disorders trains people both to replace their catastrophizing thinking with more realistic appraisals and as homework to practice behaviors that are incompatible with their problem CBT affectively treats people with obsessive compulsive disorder in one classic study people learn to prevent their compulsive behaviors by re labeling their obsessive thoughts feeling the urge to wash their hands again they would tell themselves I'm having a compulsive urge they would explain to themselves that the handwashing urge was a result of their brains abnormal activity then instead of giving in they would spend 15 minutes in an enjoyable alternative behavior by the end of the study most participants symptoms had diminished and their PET scans revealed normalized brain activity

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even on line CBT quizzes and exercises have helped alleviate insomnia depression anxiety A newer CBT variation “dialectical behavior therapy” helps change harmful and even suicidal behavior patterns dialectical means opposing Ann this therapy attempts to make peace between two opposing forces acceptance and change therapist also received training and social skills an in mindfulness meditation which helps alleviate depression

Group Therapy 

Group therapy does not provide the same degree of therapist involvement with each client however it offers other benefits: - it saves therapist time and clients money - it offers a social laboratory for exploring social behaviors and developing social skills - it enables people to see that other show their problems - it provides feedback as clients try out new ways of behaving

Family Therapy   

One special type of group interaction, family therapy , assumes that no person is an island we live in grow in relation to others especially our families family therapists tend to view families as systems in which each person's actions trigger reactions from others therapists are often successful in helping family members identify their roles within the family social system improve communication and discover new ways of preventing or resolving conflicts

Self Help Groups 

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More than 100,000,000 Americans have belonged to small religious interest or support groups that meet regularly with nine in 10 reporting that group members support each other emotionally one analysis of online support and self-help groups reported that most focus on stigmatized or hard to discuss illnesses aids patients were 250 times more likely than hypertension patients to be in support groups studies of 12 step programs such as AA have found that they help reduce alcohol use disorder at rates comparable to other treatment interventions the more meetings AA members attend the greater their alcohol abstinence

Evaluating Psychotherapies Clients Perspective   

If clients testimonials were the only measuring stick we could strongly affirm psychotherapy's effectiveness almost 90% reported feeling fairly well satisfied among those who recalled feeling fair or very poor when beginning therapy nine and ten were now feeling very good, good, or at least so so

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As earlier chapters document we are prone to selective and biased recall and to making judgments that confirm our beliefs psychologists call this effort justification

Clinicians Perceptions   

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If clinicians perceptions were proof of therapy's effectiveness we would have even more reason to celebrate the problem is that clients justify entering psychotherapy by emphasizing their unhappiness and justify leaving it by emphasizing their well being therapist treasure compliments from clients as they say goodbye or later expressed their gratitude but they hear little from clients who experience only temporary relief and seek out new therapists for the recurring problems thus therapists are more aware of the failures of other therapists Moreover therapists like the rest of us are vulnerable to cognitive errors such as confirmation bias and illusory correlation Hans Eysenck launched a spirited debate when he summarized 24 studies of psychotherapy outcomes he found that 2/3 of those receiving psychotherapy for disorders not involving hallucinations or delusions improved markedly he also reported similar improvement among untreated persons such as those who were on waiting list for treatment later research revealed shortcomings in his analysis hey sample was small compared with hundreds available today the best of these are randomized clinical trials which researchers randomly assign people on a waiting list of therapy or to no therapy A glimpse of psychotherapies overall effectiveness can then be provided by means of meta analysis S statistical procedure that combines the conclusions of a large number of different studies it gives us the bottom line result of lots of studies it shows that the average therapy client ends up better off than 80% of untreated individuals on waiting lists the claim is modest by definition about 50% of untreated people are also better off than average untreated people Dozens of subsequent summaries have now examined psychotherapy's effectiveness their verdict echoes the earlier results: those not undergoing therapy often improve but those undergoing therapy are more likely to improve and to improve more quickly and with less risk of relapse people exhibit a more stable and outgoing personality after therapy and some people experience sudden symptom reductions between their treatment sessions for depression or anxiety Psychotherapy can also be cost effective studies show that when people seek psychological treatment their search for other medical treatment drops by 16%

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boosting employees psychological well being can lower medical costs improve work efficiency and diminish absenteeism but note that the claim that psychotherapy on average is somewhat effective refers to no one therapy in particular

What Psychotherapies Work Best?       

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The early statistical summaries and surveys did not find that one type of psychotherapy in general is superior later studies have similarly found little connection between clients outcomes and their clinicians experience training supervision and licensing one general finding emerges from the studies: the more specific the problem the greater the hope that psychotherapy might solve it those who experience phobias or panic, who are unassertive, or who are frustrated by sexual performance problems can hope for improvement those with less focus problems such as depression and anxiety usually benefit in the short term but often relapse later there's often an overlapping or comorbidity of disordersevidence based practice Nevertheless some forms of therapy do get prizes for effectively treating particular problems: - cognitive and cognitive behavioral therapies: anxiety post traumatic stress disorder insomnia depression - behavioral conditioning therapies: bed wetting, phobias, compulsions, marital problems and sexual dysfunctions - psychodynamic therapy: depression and anxiety - nondirective counseling: mild to moderate depression Evidence based practice which has been endorsed by the American psychological Association and others therapist using this approach integrate the best available research with clinical expertise and with patient preferences and characteristics after rigorous evaluation clinicians apply therapies suited to their own skill and their patients unique situations increasingl...