Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                
SlideShare a Scribd company logo

learning objectives 16 16.1 Who seeks therapy and what are the goa.docx

•Download as DOCX, PDF•
•
C
croysierkathey

learning objectives 16 16.1 Who seeks therapy and what are the goals of therapy? 16.2 How is the success of psychotherapy measured? 16.3 What are some of the factors that must be considered to provide optimal treatment? 16.4 What psychological approaches are used to treat abnormal behavior? 16.5 What roles do social values and culture play in psychotherapy? 16.6 What biological approaches to treating abnormal behavior are available? Most of us have experienced a time or situation when we were dramatically helped by talking things over with a relative or friend. Most therapists, like all good listeners, rely on receptiveness, warmth, and empathy and take a nonjudgmental approach to the problems their clients present. But there is more to therapy than just giving someone an opportunity to talk. Therapists also introduce into the relationship psychological interventions that are designed to promote new understandings, behaviors, or both on the client’s part. The fact that these interventions are deliberately planned and systematically guided by certain theoretical preconceptions is what distinguishes professional therapy from more informal helping relationships. An Overview of Treatment The belief that people with psychological problems can change—can learn more adaptive ways of perceiving, evaluating, and behaving—is the conviction underlying all psychotherapy. Achieving these changes is by no means easy. Sometimes a person’s view of the world and her or his self-concept are distorted because of pathological early relationships that have been reinforced by years of negative life experiences. In other instances, environmental factors such as an unsatisfying job, an unhappy relationship, or financial stresses must be the focus of attention in addition to psychotherapy. Because change can be hard, people sometimes find it easier to bear their present problems than to challenge themselves to chart a different life course. Therapy also takes time. Even a highly skilled and experienced therapist cannot undo a person’s entire past history and, within a short time, prepare him or her to cope adequately with difficult life situations. Therapy offers no magical transformations. Nevertheless, it holds promise even for the most severe mental disorders. Moreover, contrary to common opinion, psychotherapy can be less expensive in the long run than alternative modes of intervention (Dobson et al., 2008; Gabbard et al., 1997). Numerous therapeutic approaches exist, ranging from psychoanalysis to Zen meditation. However, the era of managed care has prompted new and increasingly stringent demands that the efficacy of treatments be empirically demonstrated. This chapter will explore some of the most widely accepted psychological and biological treatment approaches in use today. Although we recognize that different groups of mental health professionals often have their own preferences with respect to the use of the terms client and patient, in this chapter we use ...

1 of 85
learning objectives 16 16.1 Who seeks therapy and what are the goals of therapy? 16.2 How is the success of psychotherapy measured? 16.3 What are some of the factors that must be considered to provide optimal treatment? 16.4 What psychological approaches are used to treat abnormal behavior? 16.5 What roles do social values and culture play in psychotherapy? 16.6 What biological approaches to treating abnormal behavior are available? Most of us have experienced a time or situation when we were dramatically helped by talking things over with a relative or friend. Most therapists, like all good listeners, rely on receptiveness, warmth, and empathy and take a nonjudgmental approach to the problems their clients present. But there is more to therapy than just giving someone an opportunity to talk. Therapists also introduce into the relationship psychological interventions that are designed to promote new understandings, behaviors, or both on the client’s part. The fact that these interventions are deliberately planned and systematically guided by certain theoretical preconceptions is what distinguishes professional therapy from more informal helping relationships. An Overview of Treatment The belief that people with psychological problems can change—can learn more adaptive ways of perceiving, evaluating, and behaving—is the conviction underlying all psychotherapy. Achieving these changes is by no means easy. Sometimes a person’s view of the world and her or his self-concept are distorted because of pathological early relationships that have been reinforced by years of negative life experiences. In other instances, environmental factors such as an unsatisfying job, an unhappy relationship, or financial stresses must be the focus of attention in addition to psychotherapy. Because change can be hard, people sometimes find it easier to bear their present problems than to challenge themselves to chart a different life course. Therapy also takes time. Even a highly skilled and experienced therapist cannot undo a person’s entire past history and, within
a short time, prepare him or her to cope adequately with difficult life situations. Therapy offers no magical transformations. Nevertheless, it holds promise even for the most severe mental disorders. Moreover, contrary to common opinion, psychotherapy can be less expensive in the long run than alternative modes of intervention (Dobson et al., 2008; Gabbard et al., 1997). Numerous therapeutic approaches exist, ranging from psychoanalysis to Zen meditation. However, the era of managed care has prompted new and increasingly stringent demands that the efficacy of treatments be empirically demonstrated. This chapter will explore some of the most widely accepted psychological and biological treatment approaches in use today. Although we recognize that different groups of mental health professionals often have their own preferences with respect to the use of the terms client and patient, in this chapter we use the terms interchangeably. Why Do People Seek Therapy? People who seek therapy vary widely in their problems and in their motivations to solve them. Below we explore a few such motivations. STRESSFUL CURRENT LIFE CIRCUMSTANCES Perhaps the most obvious candidates for psychological treatment are people experiencing sudden and highly stressful situations such as a divorce or unemployment— people who feel so overwhelmed by a crisis that they cannot manage on their own. These people often feel quite vulnerable and tend to be open to psychological treatment because they are motivated to alter their present intolerable mental states. In such situations, clients may gain considerably—and in a brief time—from the perspective provided by their therapists. PEOPLE WITH LONG-STANDING PROBLEMS Other people entering therapy have experienced long-term psychological distress and have lengthy histories of maladjustment. They may have had interpersonal problems such as an inability to be comfortable with intimacy, or they may have felt susceptible to low moods that are difficult for them to shake. Chronic unhappiness and the inability to feel confident and secure may finally prompt them to seek outside help. These people seek
psychological assistance out of dissatisfaction and despair. They may enter treatment with a high degree of motivation, but as therapy proceeds, their persistent patterns of maladaptive behavior may generate resistance with which a therapist must contend. For example, a narcissistic client who expects to be praised by his or her therapist may become disenchanted and hostile when such ego “strokes” are not forthcoming. RELUCTANT CLIENTS Some people enter therapy by a more indirect route. Perhaps they had consulted a physician for their headaches or stomach pains, only to be told that nothing was physically wrong with them. After they are referred to a therapist, they may at first resist the idea that their physical symptoms are emotionally based. Motivation to enter treatment differs widely among psychotherapy clients. Reluctant clients may come from many situations—for example, a person with a substance abuse problem whose spouse threatens “either therapy or divorce,” or a suspected felon whose attorney advises that things will go better at trial if it can be announced that the suspect has “entered therapy.” A substantial number of angry parents bring their children to therapists with demands that their child’s “problematic behavior,” which they view as independent of the family context, be “fixed.” These parents may be surprised and reluctant to recognize their own roles in shaping their child’s behavior patterns. In general, males are more reluctant to seek help of any kind when they are experiencing problems than females are. In the case of depression, far more men than women say that they would never consider seeing a therapist; when men are depressed they are even reluctant to seek informal help from their friends. Moreover, when men do seek professional help, they tend to ask fewer questions than women do (see Addis & Mahalik, 2003). Why should this be? One answer is that men are less able than women to recognize and label feelings of distress and to identify these feelings as emotional problems. In addition, men who subscribe to masculine stereotypes emphasizing self-reliance and lack of emotionality also tend to experience more gender-role conflict
when they consider traditional counseling, with its focus on emotions and emotional disclosure. For a man who prides himself on being emotionally stoic, seeking help for a problem like depression may present a major threat to his self-esteem. Seeking help also requires giving up some control and may run counter to the ideology that “a real man helps himself.” How can men be encouraged to seek help when they have difficulties? Part of the solution may be to develop new treatment approaches that provide a better fit for men who see little value in talking about their problems. An example here might be the use of virtual reality therapy to treat soldiers with posttraumatic stress disorder (PTSD; see Chapter 5). Another strategy is to use more creative approaches to encourage men to seek help and support. For example, television commercials for erectile dysfunction use professional basketball players and football coaches to encourage men with similar problems to “step up to the plate” and talk to their doctors. Making men more aware of other “masculine men” who have been “man enough” to go for help when they needed it may be an important step toward educating those whose adherence to masculine gender roles makes it difficult for them to acknowledge and seek help for their problems. PEOPLE WHO SEEK PERSONAL GROWTH A final group of people who enter therapy have problems that would be considered relatively normal. That is, they appear to have achieved success, have financial stability, have generally accepting and loving families, and have accomplished many of their life goals. They enter therapy not out of personal despair or impossible interpersonal involvements but out of a sense that they have not lived up to their own expectations and realized their own potential. These people, partly because their problems are more manageable than the problems of others, may make substantial gains in personal growth. Psychotherapy, however, is not just for people who have clearly defined problems, high levels of motivation, and an ability to gain insight into their behavior. Psychotherapeutic interventions have been applied to a wide variety of chronic
problems. Even severely disturbed clients with psychosis may profit from a therapeutic relationship that takes into account their level of functioning and maintains therapeutic subgoals that are within their capabilities (e.g., Kendler, 1999; Valmaggia et al., 2008). It should be clear from these brief descriptions that there is no typical client. Neither is there a model therapy. No currently used form of therapy is applicable to all types of clients, and all of the standard therapies can document some successes. Most authorities agree that client variables such as motivation to change and severity of symptoms are exceedingly important to the outcome of therapy (Clarkin & Levy, 2004). As we will see, the various therapies have relatively greater success when a therapist takes the characteristics of a particular client into account in determining treatment approaches. Who Provides Psychotherapeutic Services? Members of many different professions have traditionally provided advice and counsel to individuals in emotional distress. Physicians, in addition to caring for their patients’ physical problems, often become trusted advisers in emotional matters as well. Many physicians are trained to recognize psychological problems that are beyond their expertise and to refer patients to psychological specialists or to psychiatrists. Another professional group that deals extensively with emotional problems is the clergy. A minister, priest, or rabbi is frequently the first professional to encounter a person experiencing an emotional crisis. Although some clergy are trained mental health counselors, most limit their counseling to religious matters and spiritual support and do not attempt to provide psychotherapy. Rather, like general-practice physicians, they are trained to recognize problems that require professional management and to refer seriously disturbed people to mental health specialists. Often the first person that someone experiencing an emotional crisis will talk to is a trusted member of his or her religious community. The three types of mental health professionals who most often administer psychological treatment in mental health settings are clinical psychologists,
psychiatrists, and psychiatric social workers. In addition to their being able to provide psychotherapy, the medical training and licensure qualifications of psychiatrists enable them to prescribe psychoactive medications and also to administer other forms of medical treatment such as electroconvulsive therapy. In some states, appropriately supervised psychologists and other clinical specialists may prescribe medications if they have received additional training. Although mental health professionals differ with respect to their training and approach to treatment, generally, psychiatrists differ from psychologists insofar as they treat mental disorders using biological approaches (e.g., medications), whereas psychologists treat patients’ problems by examining and in some cases changing their patients’ behaviors and thought patterns. In a clinic or hospital (as opposed to an individual practice), a wide range of treatment approaches may be used. These range from the use of medications, to individual or group psychotherapy, to home, school, or job visits aimed at modifying adverse conditions in a client’s life—for example, helping a teacher become more understanding and supportive of a child-client’s needs. Often the latter is as important as treatment directed toward modifying the client’s personality, behavior, or both. This willingness to use a variety of procedures is reflected in the frequent use of a team approach to assessment and treatment, particularly in group practice and institutional settings. This approach ideally involves the coordinated efforts of medical, psychological, social work, and other mental health personnel working together as the needs of each case warrant. Also of key importance is the current practice of providing treatment facilities in the community. Instead of considering maladjustment to be an individual’s private misery, which in the past often required confinement in a distant mental hospital, this approach integrates family and community resources in a total treatment approach. The Therapeutic Relationship The therapeutic relationship evolves out of what both client and therapist bring to the therapeutic situation. The outcome of psychotherapy normally depends on
whether the client and therapist are successful in achieving a productive working alliance. The client’s major contribution is his or her motivation. Clients who are pessimistic about their chances of recovery or who are ambivalent about dealing with their problems and symptoms respond less well to treatment (e.g., Mussell et al., 2000). The establishment of an effective working alliance between client and therapist is seen by most investigators and practitioners as essential to psychotherapeutic gain. Our experiences as therapists affirm this basic observation, as does the research literature. In a very real sense, the relationship with the therapist is therapeutic in its own right. Studies of the therapeutic relationship show that how well patients do over the course of therapy is predicted by the ability of their therapist to form a strong alliance with them (Baldwin et al., 2007). Although definitions of the therapeutic alliance vary, its key elements are (1) a sense of working collaboratively on the problem, (2) agreement between patient and therapist about the goals and tasks of therapy, and (3) an affective bond between patient and therapist (see Constantino et al., 2001; Martin et al., 2000). Clear communication is also important. This is no doubt facilitated by the degree of shared experience in the backgrounds of client and therapist. Almost as important as motivation is a client’s expectation of receiving help. This expectancy is often sufficient in itself to bring about substantial improvement, perhaps because patients who expect therapy to be effective engage more in the process (Meyer et al., 2002). Just as a placebo often lessens pain for someone who believes it will do so, a person who expects to be helped by therapy is likely to be helped, almost regardless of the particular methods used by a therapist. The downside of this fact is that if a therapy or therapist fails for whatever reason to inspire client confidence, the effectiveness of treatment is likely to be compromised. What are some of the key elements of an effective therapeutic alliance between client and therapist? To the art of therapy, a therapist brings a variety of professional skills and methods intended to help people see themselves and
their situations more objectively—that is, to gain a different perspective. Besides helping provide a new perspective, most therapy situations also offer a client a safe setting in which he or she is encouraged to practice new ways of feeling and acting, gradually developing both the courage and the ability to take responsibility for acting in more effective and satisfying ways. To bring about such changes, an effective psychotherapist must help the client give up old and dysfunctional behavior patterns and replace them with new, functional ones. Because clients will present varying challenges in this regard, the therapist must be flexible enough to use a variety of interactive styles. in review • Why do people seek therapy? • What kinds of professionals provide help to people in psychological distress? In what kinds of settings does treatment occur? • What factors are important in determining how well patients do in therapy? Measuring Success in Psychotherapy Evaluating treatment success is not always as easy as it might seem (Hill & Lambert, 2004). Attempts at estimating clients’ gains in therapy generally depend on one or more of the following sources of information: (1) a therapist’s impression of changes that have occurred, (2) a client’s reports of change, (3) reports from the client’s family or friends, (4) comparison of pretreatment and posttreatment scores on personality tests or other instruments designed to measure relevant facets of psychological functioning, and (5) measures of change in selected overt behaviors. Unfortunately, each of these sources has its own limitations. A therapist may not be the best judge of a client’s progress because any therapist is likely to be biased in favor of seeing himself or herself as competent and successful (after all, therapists are only human). In addition, the therapist typically has only a limited observational sample (the client’s in-session behavior) from which to make judgments of overall change. Furthermore, therapists can inflate improvement averages by deliberately or subtly encouraging difficult clients to discontinue therapy. The problem of how to deal with early dropouts from treatment further complicates many studies of therapy outcomes. Should
these patients be excluded from analyses of outcome? (After all, they have received little or none of the therapy being evaluated.) Or should they be included and counted as treatment failures? These issues have been at the heart of much debate and discussion. Also, a client is not necessarily a reliable source of information on therapeutic outcomes. Not only may clients want to believe for various personal reasons that they are getting better, but in an attempt to please the therapist they may report that they are being helped. In addition, because therapy often requires a considerable investment of time, money, and sometimes emotional distress, the idea that it has been useless is a dissonant one. Relatives of the client may also be inclined to “see” the improvement they had hoped for, although they often seem to be more realistic than either the therapist or the client in their evaluations of outcome. Clinical ratings by an outside, independent observer are sometimes used in research on psychotherapy outcomes to evaluate the progress of a client; these ratings may be more objective than ratings made by those directly involved in the therapy. Another widely used objective measure of client change is performance on various psychological tests. A client evaluated in this way takes a battery of tests before and after therapy, and the differences in scores are assumed to reflect progress, or lack of progress, or occasionally even deterioration. However, some of the changes that such tests show may be artifactual, as with regression to the mean, wherein very high (or very low) scores tend on repeated measurement to drift toward the average of their own distributions, yielding a false impression that some real change has been documented. Also, the particular tests selected are likely to focus on the theoretical predictions of the therapist or researcher. Thus they are not necessarily valid predictors of the changes, if any, that the therapy actually induces or of how the client will behave in real life. And without follow-up assessment, they provide little information on how enduring any change is likely to be. Objectifying and Quantifying Change Generalized terms such as recovery, marked improvement, and
moderate improvement, which were often used in outcome research in the past, are open to considerable differences in interpretation. Today the emphasis is on using more quantitative methods of measuring change. For example, the Beck Depression Inventory (a self-report measure of depression severity) and the Hamilton Rating Scale for Depression (a set of rating scales used by clinicians to measure the same thing) both yield summary scores and have become almost standard in the pre- and post-therapy assessment of depression. Changes in preselected and specifically denoted behaviors that are systematically monitored, such as how many times a client with obsessions about contamination washes his or her hands, are often highly valid measures of outcome. Such techniques, including client self-monitoring, have been widely and effectively used, mainly by behavioral and cognitive-behavioral therapists. research CLOSE-UP: Regression to the Mean This reflects the statistical tendency for extreme scores (e.g., very high or very low scores) on a given measure to look less extreme at a second assessment (as occurs in a repeated- measures design). Because of this statistical artifact, people whose scores are farthest away from the group mean to begin with (e.g., people who have the highest anxiety scores or the lowest scores on self-esteem) will tend to score closer to the group mean at the second assessment, even if no real clinical change has occurred. In research settings, functional magnetic resonance imaging (fMRI) can be used to examine brain activity before and after treatment. For example, Nakao and colleagues (2005) studied 10 outpatients with obsessive-compulsive disorder (OCD). At the start of the study, all the patients received a brain scan while they were engaged in a task that required them to think about words (e.g., sweat, urine, feces) that triggered their obsessions and compulsions. Patients were then treated for 12 weeks either with the SSRI (selective serotonin reuptake inhibitor) fluvoxamine (Luvox) or with behavior therapy. At the end of this treatment period, the brain scanning was repeated. The results showed that, before
treatment, certain areas of the brain thought to be involved in OCD (e.g., a brain region in the frontal lobe called the orbitofrontal cortex) were activated during the symptom- provocation task. However, after therapy, these same regions showed much less activation when the patients were challenged to think about the provocative trigger words. In subsequent research these scientists have also shown that, after 12 weeks of behavior therapy, patients with OCD again show changes in several brain regions that are implicated in this disorder (Nabeyama et al., 2008). Research of this type suggests that physiological changes may indeed accompany the clinical gains that occur in psychotherapy (see Siegle et al., 2012). It is important to keep in mind, however, that changes on rating scales (or on MRI scans) do not necessarily tell us how well the patient is functioning in everyday life (Kazdin, 2008). Would Change Occur Anyway? What happens to disturbed people who do not obtain formal treatment? In view of the many ways in which people can help each other, it is not surprising that improvement often occurs without professional intervention. Moreover, some forms of psychopathology such as depressive episodes or brief psychotic disorder sometimes run a fairly short course with or without treatment. In other instances, disturbed people improve over time for reasons that are not apparent. Even if many emotionally disturbed persons tend to improve over time without psychotherapy, psychotherapy can often accelerate improvement or bring about desired behavior change that might not otherwise occur. Most researchers today would agree that psychotherapy is more effective than no treatment (see Shadish et al., 2000), and indeed the pertinent evidence, widely cited throughout this entire text, confirms this strongly. The chances of an average client benefiting significantly from psychological treatment are, overall, impressive (Lambert & Ogles, 2004). Research suggests that about 50 percent of patients show clinically significant change after 21 therapy sessions. After 40 sessions, about 75 percent of patients have improved (Lambert et al., 2001). But why do patients improve?
Remarkably, we know very little about the mechanisms through which therapeutic change occurs, or about the “active ingredients” of effective therapy (Kazdin, 2008; Hayes et al., 2011). We do know that progress in therapy is not always smooth and linear, however. Sudden gains can occur between one therapy session and another (Tang & DeRubeis, 1999; Tang et al., 2002). These clinical leaps appear to be triggered by cognitive changes or by psychodynamic insights that patients experience in certain critical sessions. Researchers are now actively exploring how such factors as therapist adherence (how well a therapist delivers a particular type of therapy) and therapist competence (how skillfully the therapist administers the therapy) impact how well the patient does (see Webb et al., 2010). For patients receiving cognitive therapy for depression, therapist competence has been shown to be a predictor of better clinical outcome, as might be expected (Strunk et al., 2010). Can Therapy Be Harmful? The outcomes of psychotherapy are not invariably either neutral (no effect) or positive. Some clients are actually harmed by their encounters with psychotherapists (see The World Around Us box). According to one estimate, somewhere between 5 and 10 percent of clients deteriorate during treatment (Lambert & Ogles, 2004). Patients suffering from borderline personality disorder and from OCD typically have higher rates of negative treatment outcomes than do patients with other problems (Mohr, 1995). Problems in the therapeutic alliance account for some instances of treatment failure. For example, a mismatch of therapist and client personality characteristics may produce deteriorating outcomes. Our impression, supported by some evidence (see Beutler et al., 2004; Castonguay et al., 2010), is that certain therapists, probably for reasons of personality or lack of interpersonal skills, just do not do well with certain types of client problems. In light of these intangible factors, it is ethically required of all therapists (1) to monitor their work with various types of clients to discover any such deficiencies and (2) to refer to other therapists those clients with whom they may be ill-equipped to
work (American Psychological Association, 2002). Unfortunately, clinicians are often quite bad at recognizing when their clients are not doing well (Whipple & Lambert, 2011). To address this problem, research-based measures to assess clinical deterioration are now being developed. If clinicians are willing to use these in their routine clinical practice, they will be able to be warned when their clients are not progressing in an expected manner. A major hurdle, however, is implementation. We would not be surprised to learn that the worst therapists are the ones most reluctant to use such patient-monitoring methods. the WORLD around us: When Therapy Harms There are many ways in which therapy can be detrimental. For example, a particular therapy might make certain symptoms worse, make a person more concerned about the symptoms they do have, or make the client excessively dependent on the therapist in order to function. Encounters with some therapists or forms of therapy may also make a person less willing to seek therapy in the future. Lilienfeld (2007) has developed a list of therapies that have potentially harmful consequences. One example is “rebirthing” therapy for children with attachment problems. This approach, which involves therapists wrapping children in blankets, sitting on them, and squeezing them in an attempt to mirror the birth process, has resulted in several children dying of suffocation. Another problematic technique is facilitated communication, which is based on the premise that children with autism can communicate if they have the assistance of a facilitator who helps the child communicate using a computer keyboard. Facilitated communication has been linked to dozens of child sexual abuse allegations against the parents of children with autism. This has exposed these families to a great deal of needless emotional pain and suffering because studies show that the communications in facilitated communication do not come from the children themselves. Rather, they are unknowingly generated by the facilitators themselves as they guide the child’s hands over the keyboard. All practicing clinicians and
therapists owe it to their clients (and to the families of their clients) to educate themselves about research on potentially harmful treatments. They should also monitor their own behavior and adhere to high ethical standards of practice. In this way they can minimize the likelihood that they will cause damage to the people who come to them seeking help. A special case of therapeutic harm concerns what are called boundary violations. This is when the therapist behaves in ways that exploit the trust of the patient or engages in behavior that is highly inappropriate (e.g., taking the patient to dinner, giving the patient gifts). One case involved a patient who had been treated by a psychiatrist for 10 years. During this time the patient gave the therapist gifts of a refrigerator and a dining table and six chairs. She also sold him her Waterford crystal, her china, and a silver service. The silver had an appraised value of $1,600. However, it was purchased by the psychiatrist for only $200. The psychiatrist also sold the patient two of his boats, without her even having seen them (Norris et al., 2003). A sexual relationship between the patient and the therapist represents perhaps the most obvious and extreme example of a serious boundary violation. This is highly unethical conduct. Given the frequently intense and intimate quality of therapeutic relationships, it is not surprising that sexual attraction arises. However, it is the therapist’s professional responsibility to maintain the appropriate boundaries at all times. When exploitive and unprofessional behavior on the part of therapists does occur, it results in great harm to patients (Norris et al., 2003). Anyone seeking therapy needs to be sufficiently aware enough to determine that the therapist she or he has chosen is committed to high ethical and professional standards. For the vast majority of therapists, this is indeed the case. in review What approaches can be used to evaluate treatment success? What are the advantages and limitations of these approaches? Do people who receive psychological treatment always show a clinical benefit? What is a boundary violation? Give three examples. What Therapeutic Approaches Should Be Used?
Before optimal treatment can be provided, a number of important decisions must be made. In the sections below we consider some of the factors that are important. Evidence-Based Treatment When a pharmaceutical company develops a new drug, it must obtain approval of the drug from the federal Food and Drug Administration (FDA) before that drug can be marketed. This involves, among other things, demonstrating through research on human subjects that the drug has efficacy— that is, the drug does what it is supposed to do in curing or relieving some target condition. These tests, using voluntary and informed patients as subjects, are called randomized clinical trials (RCTs) or, more simply, efficacy trials. Although these trials may become quite elaborate, the basic design is one of randomly assigning (e.g., by the flip of a coin) half the patients to the supposedly “active” drug and the other half to a visually identical but physiologically inactive placebo. Usually, neither the patient nor the prescriber is informed which is to be administered; that information is recorded in code by a third party. This double-blind procedure (see Chapter 1) is an effort to ensure that expectations on the part of the patient and prescriber play no role in the study. After a predetermined treatment interval, the code is broken and the active-drug or placebo status of all subjects is revealed. If subjects on the active drug have improved in health significantly more than subjects on the placebo, the investigator has evidence of the drug’s efficacy. Obviously, the same design could be modified to compare the efficacy of two or more active drugs, with the option of adding a placebo condition. Thousands of such studies are in progress daily across the country. They usually take place in academic medical settings, and many are financially supported by the pharmaceutical industry. Investigators of psychotherapy outcomes have attempted to apply this research design to their own field of inquiry, with necessary modifications (see Chambless & Ollendick, 2001). A source of persistent frustration has been the difficulty of creating a placebo condition that will appear credible to patients. Most
such research has thus adopted the strategy of either comparing two or more purportedly “active” therapies or using a no- treatment (“wait list”) control of the same duration as the active-drug treatment. However, withholding treatment from patients in need (even temporarily) by placing them on a wait list sometimes raises ethical concerns. Another problem is that therapists, even those with the same theoretical orientations, often differ markedly in the manner in which they deliver therapy. (In contrast, pills of the same chemical compound and dosage do not vary.) To test a given therapy, it therefore becomes necessary to develop a treatment manual to specify just how the therapy under examination will be delivered. Therapists in the research trial are then trained (and monitored) to make sure that their therapy sessions do not deviate significantly from the procedures outlined in the manual (e.g., see Blum et al., 2008). Efforts to “manualize” therapy represent one way that researchers have tried to minimize the variability in patients’ clinical outcomes that might result from characteristics of the therapist themselves (such as personal charisma). Although manualized therapies originated principally to standardize psychosocial treatments to fit the RCT paradigm, some therapists recommend extending their use to routine clinical practice after efficacy for particular disorders has been established (e.g., see Wilson, 1998). Practicing clinicians, however, vary in their attitudes toward treatment manuals (Addis & Krasnow, 2000). Efficacy, or RCT, studies of psychosocial treatments are increasingly common. These time- limited studies typically focus on patients who have a single DSM diagnosis (patients with comorbid diagnoses are sometimes excluded) and involve two or more treatment or control (e.g., wait list) conditions, where at least one of the treatment conditions is psychosocial (another could be some biological therapy, such as a particular drug). Client- participants are randomly assigned to these conditions, whose effects, if any, are evaluated systematically with a common battery of assessment instruments, usually administered both
before and after treatment. Efficacy studies of the outcomes of specific psychosocial treatment procedures are considered the most rigorous type of evaluation researchers have for establishing that a given therapy “works” for clients with a given diagnosis. Treatments that meet this standard are often described as evidence based or empirically supported. Medication or Psychotherapy? Advances in psychopharmacology have allowed many people who would otherwise need hospitalization to remain with their families and function in the community. These advances have also reduced the time patients need to spend in the hospital and have made restraints and locked wards largely relics of the past. In short, medication has led to a much more favorable hospital climate for patients and staff alike. Nevertheless, certain issues arise in the use of psychotropic drugs. Aside from possible unwanted side effects, there is the complexity of matching drug and drug dosage to the needs of the specific patient. It is also sometimes necessary for patients to change medication in the course of treatment. In addition, the use of medications in isolation from other treatment methods may not be ideal for some disorders because drugs themselves generally do not cure disorders. Nonetheless, there is now a national trend toward greater use of psychiatric medications at the expense of psychotherapy. This may be problematic because, as many investigators have pointed out, drugs tend to alleviate symptoms by inducing biochemical changes, not by helping the individual understand and change the personal or situational factors that may be creating or reinforcing maladaptive behaviors. Moreover, when drugs are discontinued, patients may be at risk of relapsing (Dobson et al., 2008). For many disorders, a variety of evidence-based forms of psychotherapy may produce more long-lasting benefits than medications alone unless the medications are continued indefinitely. Combined Treatments The integration of medication and psychotherapy remains common in clinical practice, particularly for disorders such as schizophrenia and bipolar disorder (Olfson & Marcus, 2010). Such integrated
approaches are also appreciated and regarded as essential by the patients themselves. The integrative approach is a good example of the biopsychosocial perspective that best describes current thinking about mental disorders and that is reflected throughout this book. Medications can be combined with a broad range of psychological approaches. In some cases, they can help patients benefit more fully from psychotherapy. For example, patients with social anxiety disorder who receive exposure therapy do much better if they are given an oral dose of D-cycloserine before each session. D-cycloserine is an antibiotic used in the treatment of tuberculosis. When taken alone, it has no effect on anxiety. However, D-cycloserine activates a receptor that is critical in facilitating extinction of anxiety. By making the receptor work better, the therapeutic benefits of exposure training are enhanced in people taking D-cycloserine versus placebo (Guastella et al., 2008; Hofman et al., 2006). Typically, psychosocial interventions are combined with psychiatric medications. This may be especially beneficial for patients with severe disorders (see Gabbard & Kay, 2001). Keller and colleagues (2000) compared the outcomes of 519 depressed patients who were treated with an antidepressant (nefazodone), with psychotherapy (cognitive-behavioral), or with a combination of both of these treatments. In the medication- alone condition, 55 percent of patients did well. In the psychotherapy-alone condition, 52 percent of patients responded to treatment. However, patients for whom the two treatments were combined did even better, with an overall positive response rate of 85 percent. Quite possibly, combined treatment is effective because medications and psychotherapy may target different symptoms and work at different rates. As Hollon and Fawcett (1995) have noted, “Pharmaco-therapy appears to provide rapid, reliable relief from acute distress, and psychotherapy appears to provide broad and enduring change, with combined treatment retaining the specific benefits of each” (p. 1232). It is important to note that combined treatments are not always superior to single treatments. Adding psychiatric
medications does not generally improve the clinical efficacy of psychosocial treatments for anxiety disorders, for example. However, for people suffering from chronic or recurrent depression, combined treatments often result in better clinical outcomes (Aaronson et al., 2007). in review What are the advantages and drawbacks of using a manualized therapy? What does it mean to describe a treatment as evidence based? For what kinds of disorders is combination therapy superior? Psychosocial Approaches To Treatment People are fascinated by psychotherapy. As practicing therapists, we are often asked about the work that we do and the kinds of patients we see. In this section, we try to give you a sense of the different clinical approaches that therapists sometimes use. Although we have discussed treatment in the earlier chapters in the context of specific disorders, our goal here is to provide you with a better sense of the different therapeutic approaches, illustrating them with case studies whenever possible. Behavior Therapy Behavior therapy is a direct and active treatment that recognizes the importance of behavior, acknowledges the role of learning, and includes thorough assessment and evaluation. Instead of exploring past traumatic events or inner conflicts, behavior therapists focus on the presenting problem—the problem or symptom that is causing the patient great distress. A major assumption of behavior therapy is that abnormal behavior is acquired in the same way as normal behavior—that is, by learning. A variety of behavioral techniques have therefore been developed to help patients “unlearn” maladaptive behaviors by one means or another. EXPOSURE THERAPY As you know, a behavior therapy technique that is widely used in the treatment of anxiety disorders is exposure (see Chapter 6). If anxiety is learned, then, from the behavior therapy perspective, it can be unlearned. This is accomplished through guided exposure to anxiety-provoking stimuli. During exposure therapy, the patient or client is confronted with the fear-producing stimulus in a therapeutic manner. This can be accomplished in a very controlled, slow, and gradual way, as in systematic
desensitization, or in a more extreme manner, as in flooding, in which the patient directly confronts the feared stimulus at full strength. (An example is a housebound patient with agoraphobia being accompanied outdoors by the therapist.) Moreover, the form of the exposure can be real (also known as in vivo exposure) or imaginary (imaginal exposure). The rationale behind systematic desensitization is quite simple: Find a behavior that is incompatible with being anxious (such as being relaxed or experiencing something pleasant) and repeatedly pair this with the stimulus that provokes anxiety in the patient. Because it is difficult if not impossible to feel both pleasant and anxious at the same time, systematic desensitization is aimed at teaching a person, while in the presence (real or imagined) of the anxiety-producing stimulus, to relax or behave in some other way that is inconsistent with anxiety. It may therefore be considered a type of counterconditioning procedure. The term systematic refers to the carefully graduated manner in which the person is exposed to the feared stimulus. The prototype of systematic desensitization is the classic experiment of Mary Cover Jones (1924), in which she successfully eliminated a small boy’s fears of a white rabbit and other furry animals. She began by bringing the rabbit just inside the door at the far end of the room while the boy, Peter, was eating. On successive days, the rabbit was gradually brought closer until Peter could pat it with one hand while eating with the other. Joseph Wolpe (1958; Rachman & Hodgson, 1980) elaborated on the procedure developed by Jones and coined the phrase systematic desensitization to refer to it. On the assumption that most anxiety-based patterns are, fundamentally, conditioned responses, Wolpe worked out a way to train a client to remain calm and relaxed in situations that formerly produced anxiety. Wolpe’s approach is elegant in its simplicity, and his method is equally straightforward. Exposure therapy involves confronting anxiety-provoking situations. It can be done in vivo (in real life) or in thoughts or imagination. In vivo is preferable whenever practically possible. A client is first taught to enter a
state of relaxation, typically by progressive concentration on relaxing various muscle groups. Meanwhile, patient and therapist collaborate in constructing an anxiety hierarchy that consists of imagined scenes graded as to their capacity to elicit anxiety. For example, for a dog-phobic patient, a low-anxiety step might be imagining a small dog in the distance being walked on a leash by its owner. In contrast, a high-anxiety step might be imagining a large and exuberant dog running toward the patient. Therapy sessions consist of the patient’s repeatedly imagining, under conditions of deep relaxation, the scenes in the hierarchy, beginning with low-anxiety images and gradually working toward those in the more extreme ranges. Treatment continues until all items in the hierarchy can be imagined without notable discomfort, at which point the client’s real-life difficulties typically have shown substantial improvement. Imaginal procedures have some limitations, an obvious one being that not everybody is capable of vividly imagining the required scenes. In an influential early study of clients with agoraphobia, Emmelkamp and Wessels (1975) conclude that prolonged exposure in vivo is superior to imaginal exposure. Since then, therapists have sought to use in vivo exposure whenever practical, encouraging clients to confront anxiety- provoking situations directly. As practicing clinicians, we sometimes receive requests from behavior therapists using electronic mailing lists for instructions on making concoctions that look like vomit. In these cases the therapist is treating someone who has a vomiting phobia and has a need for something that looks realistic for an in vivo exposure. Of course, in vivo exposure is not possible for all stimuli. In addition, occasionally a client is so fearful that he or she cannot be induced to confront the anxiety-arousing situation directly. Imaginal procedures are therefore a vital part of the therapeutic exposure repertoire. An important development in behavior therapy is the use of virtual reality to help patients overcome their fears and phobias (Rothbaum, Hodges, et al., 2000). Such approaches are obviously needed when the source of the
patient’s anxiety is something that is not easily reproduced in real life, such as flying. Overall, the outcome record for exposure treatments is impressive (Barlow et al., 2007; Emmelkamp, 2004). It is also encouraging that the results from virtual reality exposure are comparable to the results obtained from in vivo exposure (Powers & Emmelkamp, 2008). AVERSION THERAPY Aversion therapy involves modifying undesirable behavior by the old-fashioned method of punishment. Probably the most commonly used aversive stimuli today are drugs that have noxious effects, such as Antabuse, which induces nausea and vomiting when a person who has taken it ingests alcohol. In another variant, the client is instructed to wear a substantial elastic band on the wrist and to “snap” it when temptation arises, thus administering self- punishment. In the past, painful electric shock was commonly employed in programs that paired it with the occurrence of the undesirable behavior, a practice that certainly contributed to aversion therapy’s negative image among some segments of the public. Although aversive conditioning has been used to treat a wide range of mal-adaptive behaviors including smoking, drinking, overeating, drug dependence, gambling, sexual deviance, and bizarre psychotic behavior, interest in this approach has declined as other treatment options have become available (see Emmelkamp, 2004). MODELING As the name implies, in modeling the client learns new skills by imitating another person, such as a parent or therapist, who performs the behavior to be acquired. A younger client may be exposed to behaviors or roles in peers who act as assistants to the therapist and then be encouraged to imitate and practice the desired new responses. For example, modeling may be used to promote the learning of simple skills such as self-feeding for a child with profound mental retardation or more complex skills such as being more effective in social situations for a shy, withdrawn adolescent. In work with children especially, effective decision making and problem solving may be modeled when the therapist “thinks out loud” about everyday choices that present
themselves in the course of therapy (Kendall, 1990; Kendall & Braswell, 1985). Modeling and imitation are adjunctive aspects of various forms of behavior therapy as well as other types of therapy. For example, in an early classic work, Bandura (1964) found that live modeling of fearlessness, combined with instruction and guided exposure, was the most effective treatment for snake phobia, resulting in the elimination of phobic reactions in over 90 percent of the cases treated. The photographs taken during the treatment of spider phobia (see Chapter 6) provide a graphic example of a similar approach. SYSTEMATIC USE OF REINFORCEMENT Systematic programs that use reinforcement to suppress (extinguish) unwanted behavior or to elicit and maintain desired behavior have achieved notable success. Often called contingency management programs, these approaches are often used in institutional settings, although this is not always the case. Suppressing problematic behavior may be as simple as removing the reinforcements that support it, provided, of course, that they can be identified. Sometimes identification is relatively easy, as in the following case. In other instances, it may require extremely careful and detailed observation and analysis for the therapist to learn what is maintaining the maladaptive behavior. Showing Off in Class Billy, a 6-year-old first grader, was brought to a psychological clinic by his parents because he hated school and because his teacher had told them that his showing off was disrupting the class and making him unpopular. It became apparent in observing Billy and his parents during the initial interview that both his mother and his father were noncritical and approving of everything Billy did. After further assessment, a three-phase program of therapy was undertaken: (1) Billy’s parents were helped to discriminate between showing-off behavior and appropriate behavior on Billy’s part. (2) They were instructed to ignore Billy when he engaged in showing-off behavior while continuing to show their approval of appropriate behavior. (3) Billy’s teacher was also instructed to ignore Billy, insofar as it was feasible, when he engaged in
showing-off behavior and to devote her attention at those times to children who were behaving more appropriately. Although Billy’s showing off in class increased during the first few days of this behavior therapy program, it diminished markedly after his parents and teacher no longer reinforced it. As his maladaptive behavior diminished, he was better accepted by his classmates. This helped reinforce more appropriate behavior patterns and changed Billy’s negative attitude toward school. Billy’s was a case in which unwanted behavior was eliminated by eliminating its reinforcers. On other occasions, therapy is administered to establish desired behaviors that are missing. Examples of such approaches are response shaping and use of token economies. In response shaping, positive reinforcement is used to establish, by gradual approximation, a response that is actively resisted or is not initially in an individual’s behavioral repertoire. This technique has been used extensively in working with children’s behavior problems (Kazdin, 2007). For example, a child who refuses to speak in front of others (selective mutism) may be first rewarded (with praise or a more tangible treat) for making any sound. Later, only complete words, and later again only strings of words, would be rewarded. TOKEN ECONOMIES Years ago, when behavior therapy was in its infancy, token economies based on the principles of operant conditioning were developed for use with chronic psychiatric inpatients. When they behaved appropriately on the hospital ward, patients earned tokens that they could later use to receive rewards or privileges (Paul, 1982; Paul & Lentz, 1977). Token economies have been used to establish adaptive behaviors ranging from elementary responses such as eating and making one’s bed to the daily performance of responsible hospital jobs. In the latter instance, the token economy resembles the outside world, where an individual is paid for his or her work in tokens (money) that can later be exchanged for desired objects and activities. Although sometimes the subject of criticism and controversy, token economies remain a relevant treatment approach for the seriously mentally ill and those with
developmental disabilities (see Higgins et al., 2001; Le Blanc et al., 2000). Similar reinforcement-based methods are now being used to treat substance abuse. In one study, people being treated for cocaine dependence were rewarded with vouchers worth 25 cents if their urine tests came back negative (see Higgins, Wong, et al., 2000). Patients could then ask a staff member to purchase for them items from the community with the vouchers they had accumulated. Patients who received the incentive vouchers based on their abstinence from cocaine had better clinical outcomes than a comparison group of patients who also received vouchers but whose vouchers were not contingent on their abstinent behavior. EVALUATING BEHAVIOR THERAPY Compared with some other forms of therapy, behavior therapy has some distinct advantages. Behavior therapy usually achieves results in a short period of time because it is generally directed to specific symptoms, leading to faster relief of a client’s distress and to lower costs. The methods to be used are also clearly delineated, and the results can be readily evaluated. Overall, the outcomes achieved with behavior therapy compare very favorably with those of other approaches (Emmelkamp, 2004; Nathan & Gorman, 2007). As with other approaches, behavior therapy works better with certain kinds of problems than with others. Generally, the more pervasive and vaguely defined the client’s problem, the less likely behavior therapy is to be useful. For example, it appears to be only rarely employed to treat complex personality disorders, although dialectical behavior therapy (see Chapter 10) for patients with borderline personality disorder is an exception (Crits-Christoph & Barber, 2007). On the other hand, behavioral techniques remain central to the treatment of anxiety disorders (Barlow et al., 2007; Franklin & Foa, 2007). Because behavioral treatments are often quite straightforward, behavior therapy can be used with psychotic patients (Kopelowicz et al., 2007). Recent research also shows that behavior therapy is an effective treatment for the vocal and motor tics that are found in people with Tourette’s syndrome (Wilhelm et al., 2012). This is
welcome news because the alternative treatment approach involves the use of antipsychotic medications. A recent development in the treatment of depression is a brief and structured form of therapy called behavioral activation (see Chapter 7). In this treatment the patient and the therapist work together to help the patient find ways to become more active and engaged with life. The patient is encouraged to engage in activities that will help improve mood and lead to better ways of coping with specific life problems. Although this sounds quite simple, it is not always that easy to accomplish. However, evidence to date suggests that this form of therapy is very beneficial for patients and can lead to enduring change (Dimidjian et al., 2011; Dobson et al., 2008). Cognitive and Cognitive-Behavioral Therapy The early behavior therapists focused on observable behavior and regarded the inner thoughts of their clients as unimportant. However, starting in the 1970s, a number of behavior therapists began to reappraise the importance of “private events”—thoughts, perceptions, evaluations, and self-statements—and started to see them as processes that mediated the effects of objective stimulus conditions to determine behavior and emotions (Borkovec, 1985; Mahoney & Arnkoff, 1978). Cognitive and cognitive- behavioral therapy (terms for the most part used interchangeably) stem from both cognitive psychology (with its emphasis on the effects of thoughts on behavior) and behaviorism (with its rigorous methodology and performance- oriented focus). No single set of techniques defines cognitively oriented treatment approaches. However, two main themes are important: (1) the conviction that cognitive processes influence emotion, motivation, and behavior; and (2) the use of cognitive and behavior-change techniques in a pragmatic (hypothesis- testing) manner. In the following discussion, we briefly describe the rational emotive behavior therapy of Albert Ellis and then focus in more detail on the cognitive therapy approach of Aaron Beck. RATIONAL EMOTIVE BEHAVIOR THERAPY The first form of behaviorally oriented cognitive therapy was
developed by Albert Ellis and called rational emotive behavior therapy (REBT) (see Ellis & Dryden, 1997). REBT attempts to change a client’s maladaptive thought processes, on which maladaptive emotional responses, and thus behavior, are presumed to depend. Ellis posited that a well-functioning individual behaves rationally and in tune with empirical reality. Unfortunately, however, many of us have learned unrealistic beliefs and perfectionistic values that cause us to expect too much of ourselves, leading us to behave irrationally and then to feel that we are worthless failures. For example, a person may continually think, “I should be able to win everyone’s love and approval” or “I should be thoroughly adequate and competent in everything I do.” Such unrealistic assumptions and self- demands inevitably spell problems. The task of REBT is to restructure an individual’s belief system and self-evaluation, especially with respect to the irrational “shoulds,” “oughts,” and “musts” that are preventing the individual from having a more positive sense of self-worth and an emotionally satisfying, fulfilling life. Several methods are used. One method is to dispute a person’s false beliefs through rational confrontation (“Why should your failure to get the promotion you wanted mean that you are worthless?”). REBT therapists also use behaviorally oriented techniques. For example, homework assignments might be given to encourage clients to have new experiences and to break negative chains of behavior. Although the techniques differ dramatically, the philosophy underlying REBT has something in common with that underlying humanistic therapy (discussed later) because both take a clear stand on personal worth and human values. Rational emotive behavior therapy aims to increase an individual’s feelings of self-worth and clear the way for self-actualization by removing the false beliefs that have been stumbling blocks to personal growth. BECK’S COGNITIVE THERAPY Beck’s cognitive therapy approach was originally developed for the treatment of depression and later for anxiety disorders. Now, however, this form of treatment is used for a broad range of conditions,
including eating disorders and obesity, personality disorders, substance abuse, and even schizophrenia (Beck, 2005; Beck & Rector, 2005; Hollon & Beck, 2004). The cognitive model is basically an information-processing model of psychopathology. A fundamental assumption of the cognitive model is that problems result from biased processing of external events or internal stimuli. These biases distort the way that a person makes sense of the experiences that she or he has in the world, leading to cognitive errors. According to the cognitive model, how we think about situations is closely linked to our emotional responses to them. If this young man is having automatic thoughts such as, “I’ll never get to play. I’m such a loser,” he is likely to be more emotionally distressed about waiting on the sideline than if he has a thought such as, “There’s a lot I can learn from watching how this game is going.” But why do people make cognitive errors at all? According to Beck (2005), underlying these biases is a relatively stable set of cognitive structures or schemas that contain dysfunctional beliefs. When these schemas become activated (by external or internal triggers), they bias how people process information. In the case of depression, people become inclined to make negatively biased interpretations of themselves, their world, and their future. In the initial phase of cognitive therapy, clients are made aware of the connection between their patterns of thinking and their emotional responses. They are first taught simply to identify their own automatic thoughts (such as, “This event is a total disaster”) and to keep records of their thought content and their emotional reactions (see Wright et al., 2006). With the therapist’s help, they then identify the logical errors in their thinking and learn to challenge the validity of these automatic thoughts. The errors in the logic behind their thinking lead them (1) to perceive the world selectively as harmful while ignoring evidence to the contrary; (2) to overgeneralize on the basis of limited examples—for example, seeing themselves as totally worthless because they were laid off from work; (3) to magnify the significance of undesirable events—for example, seeing the
job loss as the end of the world for them; and (4) to engage in absolutistic thinking—for example, exaggerating the importance of someone’s mildly critical comment and perceiving it as proof of their instant descent from goodness to worthlessness. In the case study below, the therapist describes some of these errors in thinking to a depressed patient. Cognitive Therapy THERAPIST: You have described many instances today where your interpretations led to particular feelings. You remember when you were crying a little while ago and I asked you what was going through your mind? You told me that you thought that I considered you pathetic and that I wouldn’t want to see you for therapy. I said you were reading my mind and putting negative thoughts in my mind that were not, in fact, correct. You were making an arbitrary inference, or jumping to conclusions without evidence. This is what often happens when one is depressed. One tends to put the most negative interpretations on things, even sometimes when the evidence is contrary, and this makes one even more depressed. Do you recognize what I mean? PATIENT: You mean even my thoughts are wrong? THERAPIST: No, not your thoughts in general, and I am not talking about right and wrong. As I was explaining before, interpretations are not facts. They can be more or less accurate, but they cannot be right or wrong. What I mean is that some of your interpretations, in particular those relating to yourself, are biased negatively. The thoughts you attributed to me could have been accurate. But there were also many other conclusions you could have reached that might have been less depressing for you, in that they would reflect less badly on you. For example, you could have thought that since I was spending time with you, that meant I was interested and that I wanted to try and help. If this had been your conclusion, how do you think that you would have felt? Do you think that you would have felt like crying? PATIENT: Well, I guess I might have felt less depressed, more hopeful. THERAPIST: Good. That’s the point I was trying to make. We feel what we think. Unfortunately, these biased interpretations tend to occur automatically. They just pop
into one’s head and one believes them. What you and I will do in therapy is to try and catch these thoughts and examine them. Together we will look at the evidence and correct the biases to make the thoughts more realistic. Does this sound all right with you? PATIENT: Yes. Source: From I-M. Blackburn and K. M. Davidson. (1990). Cognitive therapy for depression and anxiety: A practitioner’s guide (pp. 106–7). Copyright © 1995 Blackwell Science. Much of the content of the therapy sessions and homework assignments is analogous to experiments in which a therapist and a client apply learning principles to alter the client’s biased and dysfunctional cognitions and continuously evaluate the effects that these changes have on subsequent thoughts, feelings, and overt behavior. It is important to note, however, that in Beck’s cognitive therapy, clients do not change their beliefs by debate and confrontation as is common in REBT. Rather, they are encouraged to gather information about themselves. For example, a young man who believes that he will be rejected by any attractive woman he approaches would be led to a searching analysis of the reasons why he holds this belief. The client might then be assigned the task of “testing” this dysfunctional “hypothesis” by actually approaching seemingly appropriate women whom he admires. The results of the “test” would then be discussed with the cognitive therapist, and any cognitive “errors” that may have interfered with a skillful performance would be identified and corrected. In addition, the client is encouraged to discover the faulty assumptions or dysfunctional schemas that may be leading to problem behaviors and self-defeating tendencies (Young et al., 2008). These generally become evident over the course of therapy as the client and the therapist examine the themes of the client’s automatic thoughts. Because these dysfunctional schemas are seen as making the person vulnerable (e.g., to depression), this phase of treatment is considered essential in ensuring resistance to relapse when the client faces stressful life events in the future. That is, if the underlying cognitive vulnerability factors are not changed, the client may show only short-term
improvement and will still be subject to recurrent depression. For disorders other than depression, the general approach is quite similar. However, the nature of the patient’s automatic thoughts and underlying beliefs is obviously quite different across disorders. In panic disorder, for example, the focus is on identifying the automatic thoughts about feared bodily sensations and on teaching the client to “decatastrophize” the experience of panic (Craske & Barlow, 2008). In bulimia nervosa, the cognitive approach centers on the person’s overvalued ideas about body weight and shape, which are often fueled by low self-esteem and fears of being unattractive. In addition, faulty cognitions about which foods are “safe” and which are “dangerous” are explored (Fairburn et al., 2008; Wilson, 2005). EVALUATING COGNITIVE-BEHAVIORAL THERAPIES In spite of the widespread attention that Ellis’s REBT has enjoyed, it has been less well assimilated into the mainstream than Beck’s cognitive therapy (David et al., 2005). Nonetheless, REBT is still very much alive and well. In general, this approach may be most useful in helping basically healthy people to cope better with everyday stress and perhaps in preventing them from developing full-blown anxiety or depressive disorders (Haaga & Davison, 1989, 1992). With respect to controlled research studies with carefully diagnosed clinical populations, REBT appears to be inferior to exposure- based therapies in the treatment of anxiety disorders such as agoraphobia, social phobia (Haaga & Davison, 1989, 1992), and probably obsessive-compulsive disorder (Franklin & Foa, 1998). In contrast, the efficacy of Beck’s cognitive treatment methods has been well documented. Research suggests that these approaches are extremely beneficial in alleviating many different types of disorders (see Hollon & Beck, 2004). For all but the most severe cases of depression (e.g., psychotic depression), cognitive-behavioral therapy is at least comparable to drug treatment. It also offers long-term advantages, especially with regard to the prevention of relapse (Craighead et al., 2007). Cognitive therapy also produces dramatic results in
the treatment of panic disorder and generalized anxiety disorder (Hollon & Beck, 2004), and cognitive-behavioral therapy is now the treatment of choice for bulimia (Wilson, 2010; Wilson & Fairburn, 2007). Finally, cognitive approaches have promise in the treatment of conduct disorder in children (Kazdin, 2007), substance abuse (Beck et al., 1993), and certain personality disorders (Beck et al., 1990; Linehan, 1993). The combined use of cognitive and behavior therapy approaches is now quite routine. Some disagreement remains about whether the effects of cognitive treatments are actually the result of cognitive changes as the cognitive theorists propose (Hollon & Beck, 2004; Jacobson et al., 1996). At least for depression and panic disorder, it does appear that cognitive change is the best predictor of long-term outcome, just as cognitive theory maintains (Hollon et al., 1990). Exactly what the “active ingredients” of cognitive treatments really are, however, remains a source of debate and research (e.g., Garratt et al., 2007; Teasdale et al., 2001). Humanistic-Experiential Therapies The humanistic-experiential therapies emerged as significant treatment approaches after World War II. In a society dominated by self-interest, mechanization, computerization, mass deception, and mindless bureaucracy, proponents of the humanisticexperiential therapies see psychopathology as stemming in many cases from problems of alienation, depersonalization, loneliness, and a failure to find meaning and genuine fulfilment. Problems of this sort, it is held, are not likely to be solved either by delving into forgotten memories or by correcting specific maladaptive behaviors. The humanistic- experiential therapies are based on the assumption that people have both the freedom and the responsibility to control their own behavior—that they can reflect on their problems, make choices, and take positive action. Humanistic- experiential therapists feel that a client must take most of the responsibility for the direction and success of therapy, with the therapist serving merely as counselor, guide, and facilitator. Although humanistic-experiential therapies differ in their details, their
central focus is always expanding a client’s “awareness.” CLIENT-CENTERED THERAPY The client-centered (person- centered) therapy of Carl Rogers (1902–1987) focuses on the natural power of the organism to heal itself (Rogers, 1951, 1961). Rogers saw therapy as a process of removing the constraints and restrictions that grow out of unrealistic demands that people tend to place on themselves when they believe, as a condition of self-worth, that they should not have certain kinds of feelings such as hostility. By denying that they do in fact have such feelings, they become unaware of their actual “gut” reactions. As they lose touch with their own genuine experience, the result is lowered integration, impaired personal relationships, and various forms of maladjustment. The primary objective of Rogerian therapy is to resolve this incongruence— to help clients become able to accept and be themselves. To this end, client-centered therapists establish a psychological climate in which clients can feel unconditionally accepted, understood, and valued as people. Within this context, the therapist employs nondirective techniques such as empathic reflecting, or restatement of the client’s descriptions of life difficulties. If all goes well, clients begin to feel free, for perhaps the first time, to explore their real feelings and thoughts and to accept hates and angers and ugly feelings as parts of themselves. As their self-concept becomes more congruent with their actual experience, they become more self-accepting and more open to new experiences and new perspectives; in short, they become better-integrated people. In contrast to most other forms of therapy, the client-centered therapist does not give answers, interpret what a client says, probe for unconscious conflicts, or even steer the client toward certain topics. Rather, he or she simply listens attentively and acceptingly to what the client wants to talk about, interrupting only to restate in different words what the client is saying. Such restatements, devoid of any judgment or interpretation by the therapist, help the client to clarify further the feelings and ideas that he or she is exploring—really to look at them and acknowledge them. The
following excerpt from a therapist’s second interview with a young woman will serve to illustrate these techniques of reflection and clarification. Client-Centered Therapy JENNY: I was thinking about how I always try to make people around me feel at ease. It’s so important for me to make things go along smoothly. THERAPIST: In other words, you are always trying to make other people feel better and to do all you can to keep things on an even keel and going well. JENNY: Yes. That’s right. I mean, it’s not because I am such a kind person and all I want to see is other people being happy. I think the reason I do it is probably because that has always been the role that has felt the easiest for me to play. It’s the role I played at home. I didn’t stand up for my own convictions. And now I’m at the point where I don’t really know whether I have any convictions to stand up for. THERAPIST: So you feel this is a role you have been playing for a long time, smoothing out frictions and avoiding saying anything that might be challenging in any way. JENNY: I think that’s right. THERAPIST: And so now you aren’t sure if you even have any genuine opinions or reactions of your own. Is that right? JENNY: That’s it. Or maybe I haven’t really been honest with myself and let myself even consider what I really think about things. I’ve just been playing a sort of a false role—being a people-pleaser. Whatever I felt other people needed me to be, that’s who I was. And in the process I just got lost. Pure client-centered psychotherapy, as originally practiced, is rarely used today in North America, although it is still relatively popular in Europe. Motivational interviewing is a new form of therapy that is based on this empathic style. MOTIVATIONAL INTERVIEWING People tend to be ambivalent about making changes in their lives. They want to change, but they also don’t want to change. Motivational interviewing (MI; see Hettema, Steele, & Miller, 2005) is a brief form of therapy that can be delivered in one or two sessions. It was developed as a way to help people resolve their ambivalence about change and make a commitment to treatment (Miller, 1983). At its center is a supportive and empathic style
of relating to the client that has its origins in the work of Carl Rogers. However, MI differs from client-centered counseling because it also employs a more direct approach that explores the client’s own reasons for wanting to change. The therapist encourages this “change talk” by asking the client to discuss his or her desire, ability, reasons, and need for change. These are reflected back by the therapist, thus exposing the client to periodic summaries of his or her own motivational statements and thoughts about change. The result is that clients can develop and strengthen their commitment to change in an active, accepting, and supportive atmosphere. Motivational interviewing is most often used in the areas of substance abuse and addiction. When added to the beginning of a treatment program, it appears to benefit patients, perhaps because it facilitates patients’ staying in treatment and following the treatment plan. Hettema and colleagues’ (2005) meta-analysis of the MI literature has also shown that MI has a large effect when it is used with ethnic minorities. In one alcoholism-treatment trial, Native American participants did better if they received four sessions of MI than if they received 12 sessions of cognitive-behavior therapy or else participated in a 12-step program (Villanueva et al., 2003). Quite possibly, the supportive and nonconfrontational style of MI may be more congruent with the typical and culturally sanctioned communication style of Native Americans and thus represent a culturally appropriate intervention. The collaborative and nonconfrontational style of MI may also make it acceptable to adolescents. Even a very small number of sessions of MI can promote behavior change in adolescents who use drugs and alcohol (Jensen et al., 2011). GESTALT THERAPY In German, the term gestalt means “whole,” and gestalt therapy emphasizes the unity of mind and body—placing strong emphasis on the need to integrate thought, feeling, and action. Gestalt therapy was developed by Frederick (Fritz) Perls (1969) as a means of teaching clients to recognize the bodily processes and emotions they had been blocking off from awareness. As with the client-
centered and humanistic approaches, the main goal of gestalt therapy is to increase the individual’s self-awareness and self- acceptance. Motivational interviewing is a brief intervention that helps people resolve their ambivalence about making change. It is often used in the treatment of substance abuse and addiction. Although gestalt therapy is commonly used in a group setting, the emphasis is on one person at a time, with whom a therapist works intensively, trying to help identify aspects of the individual’s self or world that are not being acknowledged in awareness. The individual may be asked to act out fantasies concerning feelings and conflicts or to represent one side of a conflict while sitting in one chair and then switch chairs to take the part of the adversary. Often the therapist or other group members will ask such questions as, “What are you aware of in your body now?” and “What does it feel like in your gut when you think of that?” In Perls’s approach to therapy, a good deal of attention is also paid to dreams, but with an emphasis very different from that of classical psychoanalysis. In gestalt theory, all elements of a dream, including seemingly inconsequential, impersonal objects, are considered to be representations of unacknowledged aspects of the dreamer’s self. The therapist urges the client to suspend normal critical judgment, to “be” the object in the dream, and then to report on the experience. This is illustrated in the following case study. Gestalt Therapy A college professor was preoccupied with his academic promotion and tenure and found himself unable to experience any joy. He sought the assistance of a friend who was a gestalt therapist. She asked him to conjure up a daydream rather than a dream. The daydream that emerged spontaneously was one of skiing. The therapist asked him to be the mountain, and he began to experience how warm he was when he was at his base. As he got closer to the top, what looked so beautiful was also very cold and frozen. The therapist asked the professor to be the snow, and he experienced how hard and icy he could be near the top. But near the bottom, people ran over him easily and wore him out. When the session was finished, the professor
did not feel like crying or shouting; he felt like skiing. So he went, leaving articles and books behind. In the sparkle of the snow and sun, he realized that joy in living emerges through deeds and not through words. In his rush to succeed, he had committed one of the cardinal sins against himself—the sin of not being active. Source: Adapted from Prochaska & Norcross, 2003, p. 183. EVALUATING HUMANISTIC-EXPERIENTIAL THERAPIES Many of the humanistic-experiential concepts—the uniqueness of each individual, the importance of therapist genuineness, the satisfaction that comes from realizing one’s potential, the importance of the search for meaning and fulfilment, and the human capacity for choice and self- direction—have had a major impact on our contemporary views of both human nature and the nature of good psychotherapy. However, humanistic-experiential therapies have been criticized for their lack of agreed-upon therapeutic procedures and their vagueness about what is supposed to happen between client and therapist. In response, proponents of such approaches argue against reducing people to abstractions, which can diminish their perceived worth and deny their uniqueness. Because people are so different, they argue, we should expect different techniques to be appropriate for different cases. Controlled research on the outcomes achieved by many forms of humanistic-existential therapy was lacking in the past. However, research in this area is now on the increase. There is evidence to suggest that these treatment approaches are helpful for patients with a variety of problems including depression, anxiety, trauma, and marital difficulties (Elliot et al., 2004). And, as we have already noted, motivational interviewing is now established as an effective method for promoting behavior change in people with substance abuse problems (Ball et al., 2007; Jensen et al., 2011). Psychodynamic Therapies Psychodynamic therapy is a broad treatment approach that focuses on individual personality dynamics, usually from a psychoanalytic or some psychoanalytically derived perspective. Psychoanalytic therapy is the oldest form of psychological
therapy and began with Sigmund Freud. The therapy is mainly practiced in two basic forms: classical psychoanalysis and psychoanalytically oriented psychotherapy. As developed by Freud and his immediate followers, classical psychoanalysis is an intensive (at least three sessions per week), long-term procedure for uncovering repressed memories, thoughts, fears, and conflicts presumably stemming from problems in early psychosexual development—and helping individuals come to terms with them in light of the realities of adult life. For example, excessive orderliness and a grim and humorless focus on rigorous self-control would probably be viewed as deriving from difficulties in early toilet training. In psychoanalytically oriented psychotherapy, the treatment and the ideas guiding it may depart substantially from the principles and procedures laid out by orthodox Freudian theory, yet the therapy is still loosely based on psychoanalytic concepts. For example, many psychoanalytically oriented therapists schedule less frequent sessions (e.g., once per week) and sit face-to-face with the client instead of having the latter recline on a couch with the analyst out of sight behind him or her. Likewise, the relatively passive stance of the analyst (primarily listening to the client’s “free associations” and rarely offering “interpretations”) is replaced with an active conversational style in which the therapist attempts to clarify distortions and gaps in the client’s construction of the origins and consequences of his or her problems, thus challenging client “defenses” as they present themselves. It is widely believed that this more direct approach significantly shortens total treatment time. We will first examine Freud’s original treatment methods, in part because of their historical significance and enormous influence; we will then look briefly at some of the contemporary modifications of psychodynamic therapy, which for the most part focus on interpersonal processes. Before we do so, however, let’s consider the case of Karen. Psychodynamic Therapy Karen was about to be terminated from her nursing program if her problems were not resolved. She had always been a competent
student who seemed to get along well with peers and patients. Now, since the beginning of her rotation on 3 South, a surgical ward, she was plagued by headaches and dizzy spells. Of more serious consequence were the two medical errors she had made when dispensing medications to patients. She realized that these errors could have proved fatal, and she was as concerned as her nursing faculty about why such problems had begun in this final year of her education. Karen knew she had many negative feelings toward the head nurse on 3 South, but she did not believe these feelings could account for her current dilemma. She entered psychotherapy. After a few weeks of psychotherapy, the therapist realized that one of Karen’s important conflicts revolved around the death of her father when she was 12 years old. Karen had just gone to live with her father after being with her mother for 7 years. She remembered how upset she was when her father had a heart attack and had to be rushed to the hospital. For a while it looked as though her father was going to pull through, and Karen began enjoying her daily visits to see him. During one of these visits, her father clutched his chest in obvious pain and told Karen to get a nurse. She remembered how helpless she felt when she could not find a nurse, although she did not recall why this was so difficult. Her search seemed endless, and by the time she finally found a nurse, her father was dead. The therapist asked Karen the name of the ward on which her father had died. She paused and thought, and then she blurted out, “3 South.” She cried at length as she told how confused she was and how angry she felt toward the nurses on the ward for not being more readily available, although she thought they might have been involved with another emergency. After weeping and shaking and expressing her resentment, Karen felt calm and relaxed for the first time in months. Her symptoms disappeared, and her problems in the nursing program were relieved. Source: Adapted from Prochaska & Norcross, 2003, p. 28. In classical (Freudian) psychoanalysis the technique of free association may be used to explore the contents of the preconscious. FREUDIAN
PSYCHOANALYSIS Psychoanalysis is a system of therapy that evolved over a period of years during Freud’s long career. Psychoanalysis is not easy to describe, and the problem is complicated by the fact that many people have inaccurate conceptions of it based on cartoons and other forms of caricature. The best way to begin our discussion is to describe the four basic techniques of this form of therapy: (1) free association, (2) analysis of dreams, (3) analysis of resistance, and (4) analysis of transference. Then we will note some of the most important changes that have taken place in psychodynamic therapy since Freud’s time. Free Association The basic rule of free association (see Chapter 2) is that an individual must say whatever comes into her or his mind regardless of how personal, painful, or seemingly irrelevant it may be. Usually a client lies in a relaxed position on a couch and gives a running account of all the thoughts, feelings, and desires that come to mind as one idea leads to another. The therapist normally takes a position behind the client so as not to disrupt the free flow of associations in any way. Although such a running account of whatever comes into one’s mind may seem random, Freud did not view it as such; rather, he believed that associations are determined just like other events. The purpose of free association is to explore thoroughly the contents of the preconscious—that part of the mind considered subject to conscious attention but largely ignored. Analytic interpretation involves a therapist’s tying together a client’s often disconnected ideas, beliefs, and actions into a meaningful explanation to help the client gain insight into the relationship between his or her maladaptive behavior and the repressed (unconscious) events and fantasies that drive it. Analysis of Dreams Another important, related procedure for uncovering unconscious material is the analysis of dreams. When a person is asleep, repressive defenses are said to be lowered, and forbidden desires and feelings may find an outlet in dreams. For this reason, dreams have been referred to as the “royal road to the unconscious.” Some motives, however, are so unacceptable
to an individual that even in dreams they are not revealed openly but are expressed in disguised or symbolic form. Thus a dream has two kinds of content: (1) manifest content, which is the dream as it appears to the dreamer, and (2) latent content, which consists of the actual motives that are seeking expression but are so painful or unacceptable that they are disguised. It is a therapist’s task, in conjunction with the associations of the patient, to uncover these disguised meanings by studying the images that appear in the manifest content of a client’s dream and in the client’s associations to them. For example, a client’s dream of being engulfed in a tidal wave may be interpreted by a therapist as indicating that the client feels in danger of being overwhelmed by inadequately repressed fears or hostilities. Analysis of Resistance During the process of free association or of associating to dreams, an individual may evidence resistance—an unwillingness or inability to talk about certain thoughts, motives, or experiences. For example, a client may be talking about an important childhood experience and then suddenly switch topics, perhaps stating, “It really isn’t that important” or “It is too absurd to discuss.” Resistance may also be evidenced by the client’s giving a too-glib interpretation of some association, or coming late to an appointment, or even “forgetting” an appointment altogether. Because resistance prevents painful and threatening material from entering awareness, its sources must be sought if an individual is to face the problem and learn to deal with it in a realistic manner (Horner, 2005). Analysis of Transference As client and therapist interact, the relationship between them may become complex and emotionally involved. Often people carry over, and unconsciously apply to their therapist, attitudes and feelings that they had in their relations with a parent or other person close to them in the past, a process known as transference. Thus clients may react to their analyst as they did to that earlier person and feel the same love, hostility, or rejection that they felt long ago. If the analyst is operating according to the prescribed role of maintaining an impersonal stance of detached
attention, the often affect-laden reactions of the client can be interpreted, it is held, as a type of projection—inappropriate to the present situation yet highly revealing of central issues in the client’s life. For example, should the client vehemently (but inaccurately) condemn the therapist for a lack of caring and attention to the client’s needs, this would be seen as a “transference” to the therapist of attitudes acquired (possibly on valid grounds) in childhood interactions with parents or other key individuals. In helping the client to understand and acknowledge the transference relationship, a therapist may provide the client with insight into the meaning of his or her reactions to others. In doing so, the therapist may also introduce a corrective emotional experience by refusing to engage the person on the basis of his or her unwarranted assumptions about the nature of the therapeutic relationship. If the client expects rejection and criticism, for example, the therapist is careful to maintain a neutral manner. Or contrarily, the therapist may express positive emotions at a point where the client feels particularly vulnerable, thereby encouraging the client to reframe and rethink her or his view of the situation. In this way it may be possible for the client to recognize these assumptions and to “work through” the conflict in feelings about the real parent or perhaps to overcome feelings of hostility and self- devaluation that stem from the earlier parental rejection. In essence, the negative effects of an undesirable early relationship are counteracted by working through a similar emotional conflict with the therapist in a therapeutic setting. A person’s reliving of a pathogenic past relationship in a sense recreates the neurosis in real life, and therefore this experience is often referred to as a transference neurosis. It is not possible here to consider at length the complexities of transference relationships, but a client’s attitudes toward his or her therapist usually do not follow such simple patterns as our examples suggest. Often the client is ambivalent—distrusting the therapist and feeling hostile toward him or her as a symbol of authority, but at the same time seeking acceptance and love. In addition,
the problems of transference are not confined to the client, for the therapist may also have a mixture of feelings toward the client. This countertransference, wherein the therapist reacts in accord with the client’s transferred attributions rather than objectively, must be recognized and handled properly by the therapist. For this reason, it is considered important that therapists have a thorough understanding of their own motives, conflicts, and “weak spots”; in fact, all psychoanalysts undergo psychoanalysis themselves before they begin independent practice. The resolution of the transference neurosis is said to be the key element in effecting a psychoanalytic “cure.” Such resolution can occur only if an analyst successfully avoids the pitfalls of countertransference. That is, the analyst needs to keep track of his or her own transference or reaction to a client’s behavior. Failure to do so risks merely repeating, in the therapy relationship, the typical relationship difficulties characterizing the client’s adult life. Analysis of transference and the phenomenon of countertransference are also part of most psychodynamic derivatives of classical psychoanalysis, to which we now turn. Psychodynamic Therapy Since Freud The original version of psychoanalysis is practiced only rarely today. Arduous and costly in time, money, and emotional commitment, it may take several years before all major issues in the client’s life have been satisfactorily resolved. In light of these heavy demands, psychoanalytic or psychodynamic therapists have worked out modifications in procedure designed to shorten the time and expense required. A good review of some of these approaches can be found in Prochaska and Norcross (2003). Object Relations, Attachment-Based Approaches, and Self-Psychology The most extensive revisions of classical psychoanalytic theory undertaken within recent decades have been related to the object-relations perspective (in psychoanalytic jargon, “objects” are other people) and, to a lesser extent, the attachment and self-psychology perspectives (see Prochaska & Norcross, 2003). Whether or not psychotherapy investigators and clinicians use the term object
relations (or attachment or self-psychology) to denote their approach, increasing numbers of them describe procedures that focus on interpersonal relationship issues, particularly as they play themselves out in the client–therapist relationship. Interpersonally oriented psychodynamic therapists vary considerably in their time focus: whether they concentrate on remote events of the past, on current interpersonal situations and impasses (including those of the therapy itself), or on some balance of the two. Most seek to expose, bring to awareness, and modify the effects of the remote developmental sources of the difficulties the client is currently experiencing. These therapies generally retain, then, the classical psychoanalytic goal of understanding the present in terms of the past. What they ignore are the psychoanalytic notions of staged libidinal energy transformations and of entirely internal (and impersonal) drives that are channeled into psychopathological symptom formation. EVALUATING PSYCHODYNAMIC THERAPIES The practice of classical psychoanalysis is routinely criticized by outsiders for being relatively time consuming and expensive; for being based on a questionable, stultified, and sometimes cult-like approach to human nature; for neglecting a client’s immediate problems in the search for unconscious conflicts in the remote past; and for there being no adequate proof of its general effectiveness. Concerning this, we note that there have been no rigorous, controlled outcome studies of classical psychoanalysis. This is understandable, given the intensive and long-term nature of the treatment and the methodological difficulties inherent in testing such an approach. Nonetheless, there are some hints that this treatment approach has some value (Gabbard et al., 2002). Psychoanalysts also argue that manualized treatments unduly limit treatment for a disorder. They note that simply because a treatment cannot be standardized does not mean that it is invalid or unhelpful. Whether the clinical benefits justify the time and expense of psychoanalysis, however, remains uncertain. In contrast, there is much more research on some of the newer psychodynamically
oriented approaches. There are signs that psychodynamic approaches may be helpful in the treatment of depression, panic disorder, PTSD, and substance abuse disorders (Gibbons et al., 2008). Recent research also supports the idea that increases in insight (“insight” is a key construct in psychodynamic theory and involves cognitive and emotional understanding of inner conflicts) must occur before there is long-term clinical change (Johansson et al., 2010). Psychoanalytically oriented treatments are also showing promise in the treatment of borderline personality disorder. One example is transference-focused psychotherapy, or TFP. Developed by Kernberg and colleagues, this treatment approach uses such techniques as clarification, confrontation, and interpretation to help the patient understand and correct the distortions that occur in his or her perception of other people, including the therapist. In a clinical trial, patients with borderline personality disorder who received TFP did as well as those who were assigned to receive dialectical behavior therapy (Clarkin et al., 2007). A recent meta-analysis provides further support for the idea that long-term psychodynamic psychotherapy (50 sessions or more) may be more beneficial than less intensive forms of treatment for patients with complex mental disorders (Leichsenring & Rabung, 2011). Findings such as these are creating renewed interest in psychodynamic forms of psychotherapy and energizing the field of treatment research. Couple and Family Therapy Many problems that therapists deal with concern distressed relationships. A common example is couple or marital distress. Here, the maladaptive behavior exists between the partners in the relationship. Extending the focus even further, a family systems approach reflects the assumption that the within-family behavior of any particular family member is subject to the influence of the behaviors and communication patterns of other family members. It is, in other words, the product of a “system” that may be amenable to both understanding and change. Addressing problems deriving from the in-place system thus requires therapeutic techniques that focus on relationships as much as, or more than, on individuals.
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx
learning objectives 16 16.1 Who seeks therapy and what are the goa.docx

More Related Content

learning objectives 16 16.1 Who seeks therapy and what are the goa.docx

  • 1. learning objectives 16 16.1 Who seeks therapy and what are the goals of therapy? 16.2 How is the success of psychotherapy measured? 16.3 What are some of the factors that must be considered to provide optimal treatment? 16.4 What psychological approaches are used to treat abnormal behavior? 16.5 What roles do social values and culture play in psychotherapy? 16.6 What biological approaches to treating abnormal behavior are available? Most of us have experienced a time or situation when we were dramatically helped by talking things over with a relative or friend. Most therapists, like all good listeners, rely on receptiveness, warmth, and empathy and take a nonjudgmental approach to the problems their clients present. But there is more to therapy than just giving someone an opportunity to talk. Therapists also introduce into the relationship psychological interventions that are designed to promote new understandings, behaviors, or both on the client’s part. The fact that these interventions are deliberately planned and systematically guided by certain theoretical preconceptions is what distinguishes professional therapy from more informal helping relationships. An Overview of Treatment The belief that people with psychological problems can change—can learn more adaptive ways of perceiving, evaluating, and behaving—is the conviction underlying all psychotherapy. Achieving these changes is by no means easy. Sometimes a person’s view of the world and her or his self-concept are distorted because of pathological early relationships that have been reinforced by years of negative life experiences. In other instances, environmental factors such as an unsatisfying job, an unhappy relationship, or financial stresses must be the focus of attention in addition to psychotherapy. Because change can be hard, people sometimes find it easier to bear their present problems than to challenge themselves to chart a different life course. Therapy also takes time. Even a highly skilled and experienced therapist cannot undo a person’s entire past history and, within
  • 2. a short time, prepare him or her to cope adequately with difficult life situations. Therapy offers no magical transformations. Nevertheless, it holds promise even for the most severe mental disorders. Moreover, contrary to common opinion, psychotherapy can be less expensive in the long run than alternative modes of intervention (Dobson et al., 2008; Gabbard et al., 1997). Numerous therapeutic approaches exist, ranging from psychoanalysis to Zen meditation. However, the era of managed care has prompted new and increasingly stringent demands that the efficacy of treatments be empirically demonstrated. This chapter will explore some of the most widely accepted psychological and biological treatment approaches in use today. Although we recognize that different groups of mental health professionals often have their own preferences with respect to the use of the terms client and patient, in this chapter we use the terms interchangeably. Why Do People Seek Therapy? People who seek therapy vary widely in their problems and in their motivations to solve them. Below we explore a few such motivations. STRESSFUL CURRENT LIFE CIRCUMSTANCES Perhaps the most obvious candidates for psychological treatment are people experiencing sudden and highly stressful situations such as a divorce or unemployment— people who feel so overwhelmed by a crisis that they cannot manage on their own. These people often feel quite vulnerable and tend to be open to psychological treatment because they are motivated to alter their present intolerable mental states. In such situations, clients may gain considerably—and in a brief time—from the perspective provided by their therapists. PEOPLE WITH LONG-STANDING PROBLEMS Other people entering therapy have experienced long-term psychological distress and have lengthy histories of maladjustment. They may have had interpersonal problems such as an inability to be comfortable with intimacy, or they may have felt susceptible to low moods that are difficult for them to shake. Chronic unhappiness and the inability to feel confident and secure may finally prompt them to seek outside help. These people seek
  • 3. psychological assistance out of dissatisfaction and despair. They may enter treatment with a high degree of motivation, but as therapy proceeds, their persistent patterns of maladaptive behavior may generate resistance with which a therapist must contend. For example, a narcissistic client who expects to be praised by his or her therapist may become disenchanted and hostile when such ego “strokes” are not forthcoming. RELUCTANT CLIENTS Some people enter therapy by a more indirect route. Perhaps they had consulted a physician for their headaches or stomach pains, only to be told that nothing was physically wrong with them. After they are referred to a therapist, they may at first resist the idea that their physical symptoms are emotionally based. Motivation to enter treatment differs widely among psychotherapy clients. Reluctant clients may come from many situations—for example, a person with a substance abuse problem whose spouse threatens “either therapy or divorce,” or a suspected felon whose attorney advises that things will go better at trial if it can be announced that the suspect has “entered therapy.” A substantial number of angry parents bring their children to therapists with demands that their child’s “problematic behavior,” which they view as independent of the family context, be “fixed.” These parents may be surprised and reluctant to recognize their own roles in shaping their child’s behavior patterns. In general, males are more reluctant to seek help of any kind when they are experiencing problems than females are. In the case of depression, far more men than women say that they would never consider seeing a therapist; when men are depressed they are even reluctant to seek informal help from their friends. Moreover, when men do seek professional help, they tend to ask fewer questions than women do (see Addis & Mahalik, 2003). Why should this be? One answer is that men are less able than women to recognize and label feelings of distress and to identify these feelings as emotional problems. In addition, men who subscribe to masculine stereotypes emphasizing self-reliance and lack of emotionality also tend to experience more gender-role conflict
  • 4. when they consider traditional counseling, with its focus on emotions and emotional disclosure. For a man who prides himself on being emotionally stoic, seeking help for a problem like depression may present a major threat to his self-esteem. Seeking help also requires giving up some control and may run counter to the ideology that “a real man helps himself.” How can men be encouraged to seek help when they have difficulties? Part of the solution may be to develop new treatment approaches that provide a better fit for men who see little value in talking about their problems. An example here might be the use of virtual reality therapy to treat soldiers with posttraumatic stress disorder (PTSD; see Chapter 5). Another strategy is to use more creative approaches to encourage men to seek help and support. For example, television commercials for erectile dysfunction use professional basketball players and football coaches to encourage men with similar problems to “step up to the plate” and talk to their doctors. Making men more aware of other “masculine men” who have been “man enough” to go for help when they needed it may be an important step toward educating those whose adherence to masculine gender roles makes it difficult for them to acknowledge and seek help for their problems. PEOPLE WHO SEEK PERSONAL GROWTH A final group of people who enter therapy have problems that would be considered relatively normal. That is, they appear to have achieved success, have financial stability, have generally accepting and loving families, and have accomplished many of their life goals. They enter therapy not out of personal despair or impossible interpersonal involvements but out of a sense that they have not lived up to their own expectations and realized their own potential. These people, partly because their problems are more manageable than the problems of others, may make substantial gains in personal growth. Psychotherapy, however, is not just for people who have clearly defined problems, high levels of motivation, and an ability to gain insight into their behavior. Psychotherapeutic interventions have been applied to a wide variety of chronic
  • 5. problems. Even severely disturbed clients with psychosis may profit from a therapeutic relationship that takes into account their level of functioning and maintains therapeutic subgoals that are within their capabilities (e.g., Kendler, 1999; Valmaggia et al., 2008). It should be clear from these brief descriptions that there is no typical client. Neither is there a model therapy. No currently used form of therapy is applicable to all types of clients, and all of the standard therapies can document some successes. Most authorities agree that client variables such as motivation to change and severity of symptoms are exceedingly important to the outcome of therapy (Clarkin & Levy, 2004). As we will see, the various therapies have relatively greater success when a therapist takes the characteristics of a particular client into account in determining treatment approaches. Who Provides Psychotherapeutic Services? Members of many different professions have traditionally provided advice and counsel to individuals in emotional distress. Physicians, in addition to caring for their patients’ physical problems, often become trusted advisers in emotional matters as well. Many physicians are trained to recognize psychological problems that are beyond their expertise and to refer patients to psychological specialists or to psychiatrists. Another professional group that deals extensively with emotional problems is the clergy. A minister, priest, or rabbi is frequently the first professional to encounter a person experiencing an emotional crisis. Although some clergy are trained mental health counselors, most limit their counseling to religious matters and spiritual support and do not attempt to provide psychotherapy. Rather, like general-practice physicians, they are trained to recognize problems that require professional management and to refer seriously disturbed people to mental health specialists. Often the first person that someone experiencing an emotional crisis will talk to is a trusted member of his or her religious community. The three types of mental health professionals who most often administer psychological treatment in mental health settings are clinical psychologists,
  • 6. psychiatrists, and psychiatric social workers. In addition to their being able to provide psychotherapy, the medical training and licensure qualifications of psychiatrists enable them to prescribe psychoactive medications and also to administer other forms of medical treatment such as electroconvulsive therapy. In some states, appropriately supervised psychologists and other clinical specialists may prescribe medications if they have received additional training. Although mental health professionals differ with respect to their training and approach to treatment, generally, psychiatrists differ from psychologists insofar as they treat mental disorders using biological approaches (e.g., medications), whereas psychologists treat patients’ problems by examining and in some cases changing their patients’ behaviors and thought patterns. In a clinic or hospital (as opposed to an individual practice), a wide range of treatment approaches may be used. These range from the use of medications, to individual or group psychotherapy, to home, school, or job visits aimed at modifying adverse conditions in a client’s life—for example, helping a teacher become more understanding and supportive of a child-client’s needs. Often the latter is as important as treatment directed toward modifying the client’s personality, behavior, or both. This willingness to use a variety of procedures is reflected in the frequent use of a team approach to assessment and treatment, particularly in group practice and institutional settings. This approach ideally involves the coordinated efforts of medical, psychological, social work, and other mental health personnel working together as the needs of each case warrant. Also of key importance is the current practice of providing treatment facilities in the community. Instead of considering maladjustment to be an individual’s private misery, which in the past often required confinement in a distant mental hospital, this approach integrates family and community resources in a total treatment approach. The Therapeutic Relationship The therapeutic relationship evolves out of what both client and therapist bring to the therapeutic situation. The outcome of psychotherapy normally depends on
  • 7. whether the client and therapist are successful in achieving a productive working alliance. The client’s major contribution is his or her motivation. Clients who are pessimistic about their chances of recovery or who are ambivalent about dealing with their problems and symptoms respond less well to treatment (e.g., Mussell et al., 2000). The establishment of an effective working alliance between client and therapist is seen by most investigators and practitioners as essential to psychotherapeutic gain. Our experiences as therapists affirm this basic observation, as does the research literature. In a very real sense, the relationship with the therapist is therapeutic in its own right. Studies of the therapeutic relationship show that how well patients do over the course of therapy is predicted by the ability of their therapist to form a strong alliance with them (Baldwin et al., 2007). Although definitions of the therapeutic alliance vary, its key elements are (1) a sense of working collaboratively on the problem, (2) agreement between patient and therapist about the goals and tasks of therapy, and (3) an affective bond between patient and therapist (see Constantino et al., 2001; Martin et al., 2000). Clear communication is also important. This is no doubt facilitated by the degree of shared experience in the backgrounds of client and therapist. Almost as important as motivation is a client’s expectation of receiving help. This expectancy is often sufficient in itself to bring about substantial improvement, perhaps because patients who expect therapy to be effective engage more in the process (Meyer et al., 2002). Just as a placebo often lessens pain for someone who believes it will do so, a person who expects to be helped by therapy is likely to be helped, almost regardless of the particular methods used by a therapist. The downside of this fact is that if a therapy or therapist fails for whatever reason to inspire client confidence, the effectiveness of treatment is likely to be compromised. What are some of the key elements of an effective therapeutic alliance between client and therapist? To the art of therapy, a therapist brings a variety of professional skills and methods intended to help people see themselves and
  • 8. their situations more objectively—that is, to gain a different perspective. Besides helping provide a new perspective, most therapy situations also offer a client a safe setting in which he or she is encouraged to practice new ways of feeling and acting, gradually developing both the courage and the ability to take responsibility for acting in more effective and satisfying ways. To bring about such changes, an effective psychotherapist must help the client give up old and dysfunctional behavior patterns and replace them with new, functional ones. Because clients will present varying challenges in this regard, the therapist must be flexible enough to use a variety of interactive styles. in review • Why do people seek therapy? • What kinds of professionals provide help to people in psychological distress? In what kinds of settings does treatment occur? • What factors are important in determining how well patients do in therapy? Measuring Success in Psychotherapy Evaluating treatment success is not always as easy as it might seem (Hill & Lambert, 2004). Attempts at estimating clients’ gains in therapy generally depend on one or more of the following sources of information: (1) a therapist’s impression of changes that have occurred, (2) a client’s reports of change, (3) reports from the client’s family or friends, (4) comparison of pretreatment and posttreatment scores on personality tests or other instruments designed to measure relevant facets of psychological functioning, and (5) measures of change in selected overt behaviors. Unfortunately, each of these sources has its own limitations. A therapist may not be the best judge of a client’s progress because any therapist is likely to be biased in favor of seeing himself or herself as competent and successful (after all, therapists are only human). In addition, the therapist typically has only a limited observational sample (the client’s in-session behavior) from which to make judgments of overall change. Furthermore, therapists can inflate improvement averages by deliberately or subtly encouraging difficult clients to discontinue therapy. The problem of how to deal with early dropouts from treatment further complicates many studies of therapy outcomes. Should
  • 9. these patients be excluded from analyses of outcome? (After all, they have received little or none of the therapy being evaluated.) Or should they be included and counted as treatment failures? These issues have been at the heart of much debate and discussion. Also, a client is not necessarily a reliable source of information on therapeutic outcomes. Not only may clients want to believe for various personal reasons that they are getting better, but in an attempt to please the therapist they may report that they are being helped. In addition, because therapy often requires a considerable investment of time, money, and sometimes emotional distress, the idea that it has been useless is a dissonant one. Relatives of the client may also be inclined to “see” the improvement they had hoped for, although they often seem to be more realistic than either the therapist or the client in their evaluations of outcome. Clinical ratings by an outside, independent observer are sometimes used in research on psychotherapy outcomes to evaluate the progress of a client; these ratings may be more objective than ratings made by those directly involved in the therapy. Another widely used objective measure of client change is performance on various psychological tests. A client evaluated in this way takes a battery of tests before and after therapy, and the differences in scores are assumed to reflect progress, or lack of progress, or occasionally even deterioration. However, some of the changes that such tests show may be artifactual, as with regression to the mean, wherein very high (or very low) scores tend on repeated measurement to drift toward the average of their own distributions, yielding a false impression that some real change has been documented. Also, the particular tests selected are likely to focus on the theoretical predictions of the therapist or researcher. Thus they are not necessarily valid predictors of the changes, if any, that the therapy actually induces or of how the client will behave in real life. And without follow-up assessment, they provide little information on how enduring any change is likely to be. Objectifying and Quantifying Change Generalized terms such as recovery, marked improvement, and
  • 10. moderate improvement, which were often used in outcome research in the past, are open to considerable differences in interpretation. Today the emphasis is on using more quantitative methods of measuring change. For example, the Beck Depression Inventory (a self-report measure of depression severity) and the Hamilton Rating Scale for Depression (a set of rating scales used by clinicians to measure the same thing) both yield summary scores and have become almost standard in the pre- and post-therapy assessment of depression. Changes in preselected and specifically denoted behaviors that are systematically monitored, such as how many times a client with obsessions about contamination washes his or her hands, are often highly valid measures of outcome. Such techniques, including client self-monitoring, have been widely and effectively used, mainly by behavioral and cognitive-behavioral therapists. research CLOSE-UP: Regression to the Mean This reflects the statistical tendency for extreme scores (e.g., very high or very low scores) on a given measure to look less extreme at a second assessment (as occurs in a repeated- measures design). Because of this statistical artifact, people whose scores are farthest away from the group mean to begin with (e.g., people who have the highest anxiety scores or the lowest scores on self-esteem) will tend to score closer to the group mean at the second assessment, even if no real clinical change has occurred. In research settings, functional magnetic resonance imaging (fMRI) can be used to examine brain activity before and after treatment. For example, Nakao and colleagues (2005) studied 10 outpatients with obsessive-compulsive disorder (OCD). At the start of the study, all the patients received a brain scan while they were engaged in a task that required them to think about words (e.g., sweat, urine, feces) that triggered their obsessions and compulsions. Patients were then treated for 12 weeks either with the SSRI (selective serotonin reuptake inhibitor) fluvoxamine (Luvox) or with behavior therapy. At the end of this treatment period, the brain scanning was repeated. The results showed that, before
  • 11. treatment, certain areas of the brain thought to be involved in OCD (e.g., a brain region in the frontal lobe called the orbitofrontal cortex) were activated during the symptom- provocation task. However, after therapy, these same regions showed much less activation when the patients were challenged to think about the provocative trigger words. In subsequent research these scientists have also shown that, after 12 weeks of behavior therapy, patients with OCD again show changes in several brain regions that are implicated in this disorder (Nabeyama et al., 2008). Research of this type suggests that physiological changes may indeed accompany the clinical gains that occur in psychotherapy (see Siegle et al., 2012). It is important to keep in mind, however, that changes on rating scales (or on MRI scans) do not necessarily tell us how well the patient is functioning in everyday life (Kazdin, 2008). Would Change Occur Anyway? What happens to disturbed people who do not obtain formal treatment? In view of the many ways in which people can help each other, it is not surprising that improvement often occurs without professional intervention. Moreover, some forms of psychopathology such as depressive episodes or brief psychotic disorder sometimes run a fairly short course with or without treatment. In other instances, disturbed people improve over time for reasons that are not apparent. Even if many emotionally disturbed persons tend to improve over time without psychotherapy, psychotherapy can often accelerate improvement or bring about desired behavior change that might not otherwise occur. Most researchers today would agree that psychotherapy is more effective than no treatment (see Shadish et al., 2000), and indeed the pertinent evidence, widely cited throughout this entire text, confirms this strongly. The chances of an average client benefiting significantly from psychological treatment are, overall, impressive (Lambert & Ogles, 2004). Research suggests that about 50 percent of patients show clinically significant change after 21 therapy sessions. After 40 sessions, about 75 percent of patients have improved (Lambert et al., 2001). But why do patients improve?
  • 12. Remarkably, we know very little about the mechanisms through which therapeutic change occurs, or about the “active ingredients” of effective therapy (Kazdin, 2008; Hayes et al., 2011). We do know that progress in therapy is not always smooth and linear, however. Sudden gains can occur between one therapy session and another (Tang & DeRubeis, 1999; Tang et al., 2002). These clinical leaps appear to be triggered by cognitive changes or by psychodynamic insights that patients experience in certain critical sessions. Researchers are now actively exploring how such factors as therapist adherence (how well a therapist delivers a particular type of therapy) and therapist competence (how skillfully the therapist administers the therapy) impact how well the patient does (see Webb et al., 2010). For patients receiving cognitive therapy for depression, therapist competence has been shown to be a predictor of better clinical outcome, as might be expected (Strunk et al., 2010). Can Therapy Be Harmful? The outcomes of psychotherapy are not invariably either neutral (no effect) or positive. Some clients are actually harmed by their encounters with psychotherapists (see The World Around Us box). According to one estimate, somewhere between 5 and 10 percent of clients deteriorate during treatment (Lambert & Ogles, 2004). Patients suffering from borderline personality disorder and from OCD typically have higher rates of negative treatment outcomes than do patients with other problems (Mohr, 1995). Problems in the therapeutic alliance account for some instances of treatment failure. For example, a mismatch of therapist and client personality characteristics may produce deteriorating outcomes. Our impression, supported by some evidence (see Beutler et al., 2004; Castonguay et al., 2010), is that certain therapists, probably for reasons of personality or lack of interpersonal skills, just do not do well with certain types of client problems. In light of these intangible factors, it is ethically required of all therapists (1) to monitor their work with various types of clients to discover any such deficiencies and (2) to refer to other therapists those clients with whom they may be ill-equipped to
  • 13. work (American Psychological Association, 2002). Unfortunately, clinicians are often quite bad at recognizing when their clients are not doing well (Whipple & Lambert, 2011). To address this problem, research-based measures to assess clinical deterioration are now being developed. If clinicians are willing to use these in their routine clinical practice, they will be able to be warned when their clients are not progressing in an expected manner. A major hurdle, however, is implementation. We would not be surprised to learn that the worst therapists are the ones most reluctant to use such patient-monitoring methods. the WORLD around us: When Therapy Harms There are many ways in which therapy can be detrimental. For example, a particular therapy might make certain symptoms worse, make a person more concerned about the symptoms they do have, or make the client excessively dependent on the therapist in order to function. Encounters with some therapists or forms of therapy may also make a person less willing to seek therapy in the future. Lilienfeld (2007) has developed a list of therapies that have potentially harmful consequences. One example is “rebirthing” therapy for children with attachment problems. This approach, which involves therapists wrapping children in blankets, sitting on them, and squeezing them in an attempt to mirror the birth process, has resulted in several children dying of suffocation. Another problematic technique is facilitated communication, which is based on the premise that children with autism can communicate if they have the assistance of a facilitator who helps the child communicate using a computer keyboard. Facilitated communication has been linked to dozens of child sexual abuse allegations against the parents of children with autism. This has exposed these families to a great deal of needless emotional pain and suffering because studies show that the communications in facilitated communication do not come from the children themselves. Rather, they are unknowingly generated by the facilitators themselves as they guide the child’s hands over the keyboard. All practicing clinicians and
  • 14. therapists owe it to their clients (and to the families of their clients) to educate themselves about research on potentially harmful treatments. They should also monitor their own behavior and adhere to high ethical standards of practice. In this way they can minimize the likelihood that they will cause damage to the people who come to them seeking help. A special case of therapeutic harm concerns what are called boundary violations. This is when the therapist behaves in ways that exploit the trust of the patient or engages in behavior that is highly inappropriate (e.g., taking the patient to dinner, giving the patient gifts). One case involved a patient who had been treated by a psychiatrist for 10 years. During this time the patient gave the therapist gifts of a refrigerator and a dining table and six chairs. She also sold him her Waterford crystal, her china, and a silver service. The silver had an appraised value of $1,600. However, it was purchased by the psychiatrist for only $200. The psychiatrist also sold the patient two of his boats, without her even having seen them (Norris et al., 2003). A sexual relationship between the patient and the therapist represents perhaps the most obvious and extreme example of a serious boundary violation. This is highly unethical conduct. Given the frequently intense and intimate quality of therapeutic relationships, it is not surprising that sexual attraction arises. However, it is the therapist’s professional responsibility to maintain the appropriate boundaries at all times. When exploitive and unprofessional behavior on the part of therapists does occur, it results in great harm to patients (Norris et al., 2003). Anyone seeking therapy needs to be sufficiently aware enough to determine that the therapist she or he has chosen is committed to high ethical and professional standards. For the vast majority of therapists, this is indeed the case. in review What approaches can be used to evaluate treatment success? What are the advantages and limitations of these approaches? Do people who receive psychological treatment always show a clinical benefit? What is a boundary violation? Give three examples. What Therapeutic Approaches Should Be Used?
  • 15. Before optimal treatment can be provided, a number of important decisions must be made. In the sections below we consider some of the factors that are important. Evidence-Based Treatment When a pharmaceutical company develops a new drug, it must obtain approval of the drug from the federal Food and Drug Administration (FDA) before that drug can be marketed. This involves, among other things, demonstrating through research on human subjects that the drug has efficacy— that is, the drug does what it is supposed to do in curing or relieving some target condition. These tests, using voluntary and informed patients as subjects, are called randomized clinical trials (RCTs) or, more simply, efficacy trials. Although these trials may become quite elaborate, the basic design is one of randomly assigning (e.g., by the flip of a coin) half the patients to the supposedly “active” drug and the other half to a visually identical but physiologically inactive placebo. Usually, neither the patient nor the prescriber is informed which is to be administered; that information is recorded in code by a third party. This double-blind procedure (see Chapter 1) is an effort to ensure that expectations on the part of the patient and prescriber play no role in the study. After a predetermined treatment interval, the code is broken and the active-drug or placebo status of all subjects is revealed. If subjects on the active drug have improved in health significantly more than subjects on the placebo, the investigator has evidence of the drug’s efficacy. Obviously, the same design could be modified to compare the efficacy of two or more active drugs, with the option of adding a placebo condition. Thousands of such studies are in progress daily across the country. They usually take place in academic medical settings, and many are financially supported by the pharmaceutical industry. Investigators of psychotherapy outcomes have attempted to apply this research design to their own field of inquiry, with necessary modifications (see Chambless & Ollendick, 2001). A source of persistent frustration has been the difficulty of creating a placebo condition that will appear credible to patients. Most
  • 16. such research has thus adopted the strategy of either comparing two or more purportedly “active” therapies or using a no- treatment (“wait list”) control of the same duration as the active-drug treatment. However, withholding treatment from patients in need (even temporarily) by placing them on a wait list sometimes raises ethical concerns. Another problem is that therapists, even those with the same theoretical orientations, often differ markedly in the manner in which they deliver therapy. (In contrast, pills of the same chemical compound and dosage do not vary.) To test a given therapy, it therefore becomes necessary to develop a treatment manual to specify just how the therapy under examination will be delivered. Therapists in the research trial are then trained (and monitored) to make sure that their therapy sessions do not deviate significantly from the procedures outlined in the manual (e.g., see Blum et al., 2008). Efforts to “manualize” therapy represent one way that researchers have tried to minimize the variability in patients’ clinical outcomes that might result from characteristics of the therapist themselves (such as personal charisma). Although manualized therapies originated principally to standardize psychosocial treatments to fit the RCT paradigm, some therapists recommend extending their use to routine clinical practice after efficacy for particular disorders has been established (e.g., see Wilson, 1998). Practicing clinicians, however, vary in their attitudes toward treatment manuals (Addis & Krasnow, 2000). Efficacy, or RCT, studies of psychosocial treatments are increasingly common. These time- limited studies typically focus on patients who have a single DSM diagnosis (patients with comorbid diagnoses are sometimes excluded) and involve two or more treatment or control (e.g., wait list) conditions, where at least one of the treatment conditions is psychosocial (another could be some biological therapy, such as a particular drug). Client- participants are randomly assigned to these conditions, whose effects, if any, are evaluated systematically with a common battery of assessment instruments, usually administered both
  • 17. before and after treatment. Efficacy studies of the outcomes of specific psychosocial treatment procedures are considered the most rigorous type of evaluation researchers have for establishing that a given therapy “works” for clients with a given diagnosis. Treatments that meet this standard are often described as evidence based or empirically supported. Medication or Psychotherapy? Advances in psychopharmacology have allowed many people who would otherwise need hospitalization to remain with their families and function in the community. These advances have also reduced the time patients need to spend in the hospital and have made restraints and locked wards largely relics of the past. In short, medication has led to a much more favorable hospital climate for patients and staff alike. Nevertheless, certain issues arise in the use of psychotropic drugs. Aside from possible unwanted side effects, there is the complexity of matching drug and drug dosage to the needs of the specific patient. It is also sometimes necessary for patients to change medication in the course of treatment. In addition, the use of medications in isolation from other treatment methods may not be ideal for some disorders because drugs themselves generally do not cure disorders. Nonetheless, there is now a national trend toward greater use of psychiatric medications at the expense of psychotherapy. This may be problematic because, as many investigators have pointed out, drugs tend to alleviate symptoms by inducing biochemical changes, not by helping the individual understand and change the personal or situational factors that may be creating or reinforcing maladaptive behaviors. Moreover, when drugs are discontinued, patients may be at risk of relapsing (Dobson et al., 2008). For many disorders, a variety of evidence-based forms of psychotherapy may produce more long-lasting benefits than medications alone unless the medications are continued indefinitely. Combined Treatments The integration of medication and psychotherapy remains common in clinical practice, particularly for disorders such as schizophrenia and bipolar disorder (Olfson & Marcus, 2010). Such integrated
  • 18. approaches are also appreciated and regarded as essential by the patients themselves. The integrative approach is a good example of the biopsychosocial perspective that best describes current thinking about mental disorders and that is reflected throughout this book. Medications can be combined with a broad range of psychological approaches. In some cases, they can help patients benefit more fully from psychotherapy. For example, patients with social anxiety disorder who receive exposure therapy do much better if they are given an oral dose of D-cycloserine before each session. D-cycloserine is an antibiotic used in the treatment of tuberculosis. When taken alone, it has no effect on anxiety. However, D-cycloserine activates a receptor that is critical in facilitating extinction of anxiety. By making the receptor work better, the therapeutic benefits of exposure training are enhanced in people taking D-cycloserine versus placebo (Guastella et al., 2008; Hofman et al., 2006). Typically, psychosocial interventions are combined with psychiatric medications. This may be especially beneficial for patients with severe disorders (see Gabbard & Kay, 2001). Keller and colleagues (2000) compared the outcomes of 519 depressed patients who were treated with an antidepressant (nefazodone), with psychotherapy (cognitive-behavioral), or with a combination of both of these treatments. In the medication- alone condition, 55 percent of patients did well. In the psychotherapy-alone condition, 52 percent of patients responded to treatment. However, patients for whom the two treatments were combined did even better, with an overall positive response rate of 85 percent. Quite possibly, combined treatment is effective because medications and psychotherapy may target different symptoms and work at different rates. As Hollon and Fawcett (1995) have noted, “Pharmaco-therapy appears to provide rapid, reliable relief from acute distress, and psychotherapy appears to provide broad and enduring change, with combined treatment retaining the specific benefits of each” (p. 1232). It is important to note that combined treatments are not always superior to single treatments. Adding psychiatric
  • 19. medications does not generally improve the clinical efficacy of psychosocial treatments for anxiety disorders, for example. However, for people suffering from chronic or recurrent depression, combined treatments often result in better clinical outcomes (Aaronson et al., 2007). in review What are the advantages and drawbacks of using a manualized therapy? What does it mean to describe a treatment as evidence based? For what kinds of disorders is combination therapy superior? Psychosocial Approaches To Treatment People are fascinated by psychotherapy. As practicing therapists, we are often asked about the work that we do and the kinds of patients we see. In this section, we try to give you a sense of the different clinical approaches that therapists sometimes use. Although we have discussed treatment in the earlier chapters in the context of specific disorders, our goal here is to provide you with a better sense of the different therapeutic approaches, illustrating them with case studies whenever possible. Behavior Therapy Behavior therapy is a direct and active treatment that recognizes the importance of behavior, acknowledges the role of learning, and includes thorough assessment and evaluation. Instead of exploring past traumatic events or inner conflicts, behavior therapists focus on the presenting problem—the problem or symptom that is causing the patient great distress. A major assumption of behavior therapy is that abnormal behavior is acquired in the same way as normal behavior—that is, by learning. A variety of behavioral techniques have therefore been developed to help patients “unlearn” maladaptive behaviors by one means or another. EXPOSURE THERAPY As you know, a behavior therapy technique that is widely used in the treatment of anxiety disorders is exposure (see Chapter 6). If anxiety is learned, then, from the behavior therapy perspective, it can be unlearned. This is accomplished through guided exposure to anxiety-provoking stimuli. During exposure therapy, the patient or client is confronted with the fear-producing stimulus in a therapeutic manner. This can be accomplished in a very controlled, slow, and gradual way, as in systematic
  • 20. desensitization, or in a more extreme manner, as in flooding, in which the patient directly confronts the feared stimulus at full strength. (An example is a housebound patient with agoraphobia being accompanied outdoors by the therapist.) Moreover, the form of the exposure can be real (also known as in vivo exposure) or imaginary (imaginal exposure). The rationale behind systematic desensitization is quite simple: Find a behavior that is incompatible with being anxious (such as being relaxed or experiencing something pleasant) and repeatedly pair this with the stimulus that provokes anxiety in the patient. Because it is difficult if not impossible to feel both pleasant and anxious at the same time, systematic desensitization is aimed at teaching a person, while in the presence (real or imagined) of the anxiety-producing stimulus, to relax or behave in some other way that is inconsistent with anxiety. It may therefore be considered a type of counterconditioning procedure. The term systematic refers to the carefully graduated manner in which the person is exposed to the feared stimulus. The prototype of systematic desensitization is the classic experiment of Mary Cover Jones (1924), in which she successfully eliminated a small boy’s fears of a white rabbit and other furry animals. She began by bringing the rabbit just inside the door at the far end of the room while the boy, Peter, was eating. On successive days, the rabbit was gradually brought closer until Peter could pat it with one hand while eating with the other. Joseph Wolpe (1958; Rachman & Hodgson, 1980) elaborated on the procedure developed by Jones and coined the phrase systematic desensitization to refer to it. On the assumption that most anxiety-based patterns are, fundamentally, conditioned responses, Wolpe worked out a way to train a client to remain calm and relaxed in situations that formerly produced anxiety. Wolpe’s approach is elegant in its simplicity, and his method is equally straightforward. Exposure therapy involves confronting anxiety-provoking situations. It can be done in vivo (in real life) or in thoughts or imagination. In vivo is preferable whenever practically possible. A client is first taught to enter a
  • 21. state of relaxation, typically by progressive concentration on relaxing various muscle groups. Meanwhile, patient and therapist collaborate in constructing an anxiety hierarchy that consists of imagined scenes graded as to their capacity to elicit anxiety. For example, for a dog-phobic patient, a low-anxiety step might be imagining a small dog in the distance being walked on a leash by its owner. In contrast, a high-anxiety step might be imagining a large and exuberant dog running toward the patient. Therapy sessions consist of the patient’s repeatedly imagining, under conditions of deep relaxation, the scenes in the hierarchy, beginning with low-anxiety images and gradually working toward those in the more extreme ranges. Treatment continues until all items in the hierarchy can be imagined without notable discomfort, at which point the client’s real-life difficulties typically have shown substantial improvement. Imaginal procedures have some limitations, an obvious one being that not everybody is capable of vividly imagining the required scenes. In an influential early study of clients with agoraphobia, Emmelkamp and Wessels (1975) conclude that prolonged exposure in vivo is superior to imaginal exposure. Since then, therapists have sought to use in vivo exposure whenever practical, encouraging clients to confront anxiety- provoking situations directly. As practicing clinicians, we sometimes receive requests from behavior therapists using electronic mailing lists for instructions on making concoctions that look like vomit. In these cases the therapist is treating someone who has a vomiting phobia and has a need for something that looks realistic for an in vivo exposure. Of course, in vivo exposure is not possible for all stimuli. In addition, occasionally a client is so fearful that he or she cannot be induced to confront the anxiety-arousing situation directly. Imaginal procedures are therefore a vital part of the therapeutic exposure repertoire. An important development in behavior therapy is the use of virtual reality to help patients overcome their fears and phobias (Rothbaum, Hodges, et al., 2000). Such approaches are obviously needed when the source of the
  • 22. patient’s anxiety is something that is not easily reproduced in real life, such as flying. Overall, the outcome record for exposure treatments is impressive (Barlow et al., 2007; Emmelkamp, 2004). It is also encouraging that the results from virtual reality exposure are comparable to the results obtained from in vivo exposure (Powers & Emmelkamp, 2008). AVERSION THERAPY Aversion therapy involves modifying undesirable behavior by the old-fashioned method of punishment. Probably the most commonly used aversive stimuli today are drugs that have noxious effects, such as Antabuse, which induces nausea and vomiting when a person who has taken it ingests alcohol. In another variant, the client is instructed to wear a substantial elastic band on the wrist and to “snap” it when temptation arises, thus administering self- punishment. In the past, painful electric shock was commonly employed in programs that paired it with the occurrence of the undesirable behavior, a practice that certainly contributed to aversion therapy’s negative image among some segments of the public. Although aversive conditioning has been used to treat a wide range of mal-adaptive behaviors including smoking, drinking, overeating, drug dependence, gambling, sexual deviance, and bizarre psychotic behavior, interest in this approach has declined as other treatment options have become available (see Emmelkamp, 2004). MODELING As the name implies, in modeling the client learns new skills by imitating another person, such as a parent or therapist, who performs the behavior to be acquired. A younger client may be exposed to behaviors or roles in peers who act as assistants to the therapist and then be encouraged to imitate and practice the desired new responses. For example, modeling may be used to promote the learning of simple skills such as self-feeding for a child with profound mental retardation or more complex skills such as being more effective in social situations for a shy, withdrawn adolescent. In work with children especially, effective decision making and problem solving may be modeled when the therapist “thinks out loud” about everyday choices that present
  • 23. themselves in the course of therapy (Kendall, 1990; Kendall & Braswell, 1985). Modeling and imitation are adjunctive aspects of various forms of behavior therapy as well as other types of therapy. For example, in an early classic work, Bandura (1964) found that live modeling of fearlessness, combined with instruction and guided exposure, was the most effective treatment for snake phobia, resulting in the elimination of phobic reactions in over 90 percent of the cases treated. The photographs taken during the treatment of spider phobia (see Chapter 6) provide a graphic example of a similar approach. SYSTEMATIC USE OF REINFORCEMENT Systematic programs that use reinforcement to suppress (extinguish) unwanted behavior or to elicit and maintain desired behavior have achieved notable success. Often called contingency management programs, these approaches are often used in institutional settings, although this is not always the case. Suppressing problematic behavior may be as simple as removing the reinforcements that support it, provided, of course, that they can be identified. Sometimes identification is relatively easy, as in the following case. In other instances, it may require extremely careful and detailed observation and analysis for the therapist to learn what is maintaining the maladaptive behavior. Showing Off in Class Billy, a 6-year-old first grader, was brought to a psychological clinic by his parents because he hated school and because his teacher had told them that his showing off was disrupting the class and making him unpopular. It became apparent in observing Billy and his parents during the initial interview that both his mother and his father were noncritical and approving of everything Billy did. After further assessment, a three-phase program of therapy was undertaken: (1) Billy’s parents were helped to discriminate between showing-off behavior and appropriate behavior on Billy’s part. (2) They were instructed to ignore Billy when he engaged in showing-off behavior while continuing to show their approval of appropriate behavior. (3) Billy’s teacher was also instructed to ignore Billy, insofar as it was feasible, when he engaged in
  • 24. showing-off behavior and to devote her attention at those times to children who were behaving more appropriately. Although Billy’s showing off in class increased during the first few days of this behavior therapy program, it diminished markedly after his parents and teacher no longer reinforced it. As his maladaptive behavior diminished, he was better accepted by his classmates. This helped reinforce more appropriate behavior patterns and changed Billy’s negative attitude toward school. Billy’s was a case in which unwanted behavior was eliminated by eliminating its reinforcers. On other occasions, therapy is administered to establish desired behaviors that are missing. Examples of such approaches are response shaping and use of token economies. In response shaping, positive reinforcement is used to establish, by gradual approximation, a response that is actively resisted or is not initially in an individual’s behavioral repertoire. This technique has been used extensively in working with children’s behavior problems (Kazdin, 2007). For example, a child who refuses to speak in front of others (selective mutism) may be first rewarded (with praise or a more tangible treat) for making any sound. Later, only complete words, and later again only strings of words, would be rewarded. TOKEN ECONOMIES Years ago, when behavior therapy was in its infancy, token economies based on the principles of operant conditioning were developed for use with chronic psychiatric inpatients. When they behaved appropriately on the hospital ward, patients earned tokens that they could later use to receive rewards or privileges (Paul, 1982; Paul & Lentz, 1977). Token economies have been used to establish adaptive behaviors ranging from elementary responses such as eating and making one’s bed to the daily performance of responsible hospital jobs. In the latter instance, the token economy resembles the outside world, where an individual is paid for his or her work in tokens (money) that can later be exchanged for desired objects and activities. Although sometimes the subject of criticism and controversy, token economies remain a relevant treatment approach for the seriously mentally ill and those with
  • 25. developmental disabilities (see Higgins et al., 2001; Le Blanc et al., 2000). Similar reinforcement-based methods are now being used to treat substance abuse. In one study, people being treated for cocaine dependence were rewarded with vouchers worth 25 cents if their urine tests came back negative (see Higgins, Wong, et al., 2000). Patients could then ask a staff member to purchase for them items from the community with the vouchers they had accumulated. Patients who received the incentive vouchers based on their abstinence from cocaine had better clinical outcomes than a comparison group of patients who also received vouchers but whose vouchers were not contingent on their abstinent behavior. EVALUATING BEHAVIOR THERAPY Compared with some other forms of therapy, behavior therapy has some distinct advantages. Behavior therapy usually achieves results in a short period of time because it is generally directed to specific symptoms, leading to faster relief of a client’s distress and to lower costs. The methods to be used are also clearly delineated, and the results can be readily evaluated. Overall, the outcomes achieved with behavior therapy compare very favorably with those of other approaches (Emmelkamp, 2004; Nathan & Gorman, 2007). As with other approaches, behavior therapy works better with certain kinds of problems than with others. Generally, the more pervasive and vaguely defined the client’s problem, the less likely behavior therapy is to be useful. For example, it appears to be only rarely employed to treat complex personality disorders, although dialectical behavior therapy (see Chapter 10) for patients with borderline personality disorder is an exception (Crits-Christoph & Barber, 2007). On the other hand, behavioral techniques remain central to the treatment of anxiety disorders (Barlow et al., 2007; Franklin & Foa, 2007). Because behavioral treatments are often quite straightforward, behavior therapy can be used with psychotic patients (Kopelowicz et al., 2007). Recent research also shows that behavior therapy is an effective treatment for the vocal and motor tics that are found in people with Tourette’s syndrome (Wilhelm et al., 2012). This is
  • 26. welcome news because the alternative treatment approach involves the use of antipsychotic medications. A recent development in the treatment of depression is a brief and structured form of therapy called behavioral activation (see Chapter 7). In this treatment the patient and the therapist work together to help the patient find ways to become more active and engaged with life. The patient is encouraged to engage in activities that will help improve mood and lead to better ways of coping with specific life problems. Although this sounds quite simple, it is not always that easy to accomplish. However, evidence to date suggests that this form of therapy is very beneficial for patients and can lead to enduring change (Dimidjian et al., 2011; Dobson et al., 2008). Cognitive and Cognitive-Behavioral Therapy The early behavior therapists focused on observable behavior and regarded the inner thoughts of their clients as unimportant. However, starting in the 1970s, a number of behavior therapists began to reappraise the importance of “private events”—thoughts, perceptions, evaluations, and self-statements—and started to see them as processes that mediated the effects of objective stimulus conditions to determine behavior and emotions (Borkovec, 1985; Mahoney & Arnkoff, 1978). Cognitive and cognitive- behavioral therapy (terms for the most part used interchangeably) stem from both cognitive psychology (with its emphasis on the effects of thoughts on behavior) and behaviorism (with its rigorous methodology and performance- oriented focus). No single set of techniques defines cognitively oriented treatment approaches. However, two main themes are important: (1) the conviction that cognitive processes influence emotion, motivation, and behavior; and (2) the use of cognitive and behavior-change techniques in a pragmatic (hypothesis- testing) manner. In the following discussion, we briefly describe the rational emotive behavior therapy of Albert Ellis and then focus in more detail on the cognitive therapy approach of Aaron Beck. RATIONAL EMOTIVE BEHAVIOR THERAPY The first form of behaviorally oriented cognitive therapy was
  • 27. developed by Albert Ellis and called rational emotive behavior therapy (REBT) (see Ellis & Dryden, 1997). REBT attempts to change a client’s maladaptive thought processes, on which maladaptive emotional responses, and thus behavior, are presumed to depend. Ellis posited that a well-functioning individual behaves rationally and in tune with empirical reality. Unfortunately, however, many of us have learned unrealistic beliefs and perfectionistic values that cause us to expect too much of ourselves, leading us to behave irrationally and then to feel that we are worthless failures. For example, a person may continually think, “I should be able to win everyone’s love and approval” or “I should be thoroughly adequate and competent in everything I do.” Such unrealistic assumptions and self- demands inevitably spell problems. The task of REBT is to restructure an individual’s belief system and self-evaluation, especially with respect to the irrational “shoulds,” “oughts,” and “musts” that are preventing the individual from having a more positive sense of self-worth and an emotionally satisfying, fulfilling life. Several methods are used. One method is to dispute a person’s false beliefs through rational confrontation (“Why should your failure to get the promotion you wanted mean that you are worthless?”). REBT therapists also use behaviorally oriented techniques. For example, homework assignments might be given to encourage clients to have new experiences and to break negative chains of behavior. Although the techniques differ dramatically, the philosophy underlying REBT has something in common with that underlying humanistic therapy (discussed later) because both take a clear stand on personal worth and human values. Rational emotive behavior therapy aims to increase an individual’s feelings of self-worth and clear the way for self-actualization by removing the false beliefs that have been stumbling blocks to personal growth. BECK’S COGNITIVE THERAPY Beck’s cognitive therapy approach was originally developed for the treatment of depression and later for anxiety disorders. Now, however, this form of treatment is used for a broad range of conditions,
  • 28. including eating disorders and obesity, personality disorders, substance abuse, and even schizophrenia (Beck, 2005; Beck & Rector, 2005; Hollon & Beck, 2004). The cognitive model is basically an information-processing model of psychopathology. A fundamental assumption of the cognitive model is that problems result from biased processing of external events or internal stimuli. These biases distort the way that a person makes sense of the experiences that she or he has in the world, leading to cognitive errors. According to the cognitive model, how we think about situations is closely linked to our emotional responses to them. If this young man is having automatic thoughts such as, “I’ll never get to play. I’m such a loser,” he is likely to be more emotionally distressed about waiting on the sideline than if he has a thought such as, “There’s a lot I can learn from watching how this game is going.” But why do people make cognitive errors at all? According to Beck (2005), underlying these biases is a relatively stable set of cognitive structures or schemas that contain dysfunctional beliefs. When these schemas become activated (by external or internal triggers), they bias how people process information. In the case of depression, people become inclined to make negatively biased interpretations of themselves, their world, and their future. In the initial phase of cognitive therapy, clients are made aware of the connection between their patterns of thinking and their emotional responses. They are first taught simply to identify their own automatic thoughts (such as, “This event is a total disaster”) and to keep records of their thought content and their emotional reactions (see Wright et al., 2006). With the therapist’s help, they then identify the logical errors in their thinking and learn to challenge the validity of these automatic thoughts. The errors in the logic behind their thinking lead them (1) to perceive the world selectively as harmful while ignoring evidence to the contrary; (2) to overgeneralize on the basis of limited examples—for example, seeing themselves as totally worthless because they were laid off from work; (3) to magnify the significance of undesirable events—for example, seeing the
  • 29. job loss as the end of the world for them; and (4) to engage in absolutistic thinking—for example, exaggerating the importance of someone’s mildly critical comment and perceiving it as proof of their instant descent from goodness to worthlessness. In the case study below, the therapist describes some of these errors in thinking to a depressed patient. Cognitive Therapy THERAPIST: You have described many instances today where your interpretations led to particular feelings. You remember when you were crying a little while ago and I asked you what was going through your mind? You told me that you thought that I considered you pathetic and that I wouldn’t want to see you for therapy. I said you were reading my mind and putting negative thoughts in my mind that were not, in fact, correct. You were making an arbitrary inference, or jumping to conclusions without evidence. This is what often happens when one is depressed. One tends to put the most negative interpretations on things, even sometimes when the evidence is contrary, and this makes one even more depressed. Do you recognize what I mean? PATIENT: You mean even my thoughts are wrong? THERAPIST: No, not your thoughts in general, and I am not talking about right and wrong. As I was explaining before, interpretations are not facts. They can be more or less accurate, but they cannot be right or wrong. What I mean is that some of your interpretations, in particular those relating to yourself, are biased negatively. The thoughts you attributed to me could have been accurate. But there were also many other conclusions you could have reached that might have been less depressing for you, in that they would reflect less badly on you. For example, you could have thought that since I was spending time with you, that meant I was interested and that I wanted to try and help. If this had been your conclusion, how do you think that you would have felt? Do you think that you would have felt like crying? PATIENT: Well, I guess I might have felt less depressed, more hopeful. THERAPIST: Good. That’s the point I was trying to make. We feel what we think. Unfortunately, these biased interpretations tend to occur automatically. They just pop
  • 30. into one’s head and one believes them. What you and I will do in therapy is to try and catch these thoughts and examine them. Together we will look at the evidence and correct the biases to make the thoughts more realistic. Does this sound all right with you? PATIENT: Yes. Source: From I-M. Blackburn and K. M. Davidson. (1990). Cognitive therapy for depression and anxiety: A practitioner’s guide (pp. 106–7). Copyright © 1995 Blackwell Science. Much of the content of the therapy sessions and homework assignments is analogous to experiments in which a therapist and a client apply learning principles to alter the client’s biased and dysfunctional cognitions and continuously evaluate the effects that these changes have on subsequent thoughts, feelings, and overt behavior. It is important to note, however, that in Beck’s cognitive therapy, clients do not change their beliefs by debate and confrontation as is common in REBT. Rather, they are encouraged to gather information about themselves. For example, a young man who believes that he will be rejected by any attractive woman he approaches would be led to a searching analysis of the reasons why he holds this belief. The client might then be assigned the task of “testing” this dysfunctional “hypothesis” by actually approaching seemingly appropriate women whom he admires. The results of the “test” would then be discussed with the cognitive therapist, and any cognitive “errors” that may have interfered with a skillful performance would be identified and corrected. In addition, the client is encouraged to discover the faulty assumptions or dysfunctional schemas that may be leading to problem behaviors and self-defeating tendencies (Young et al., 2008). These generally become evident over the course of therapy as the client and the therapist examine the themes of the client’s automatic thoughts. Because these dysfunctional schemas are seen as making the person vulnerable (e.g., to depression), this phase of treatment is considered essential in ensuring resistance to relapse when the client faces stressful life events in the future. That is, if the underlying cognitive vulnerability factors are not changed, the client may show only short-term
  • 31. improvement and will still be subject to recurrent depression. For disorders other than depression, the general approach is quite similar. However, the nature of the patient’s automatic thoughts and underlying beliefs is obviously quite different across disorders. In panic disorder, for example, the focus is on identifying the automatic thoughts about feared bodily sensations and on teaching the client to “decatastrophize” the experience of panic (Craske & Barlow, 2008). In bulimia nervosa, the cognitive approach centers on the person’s overvalued ideas about body weight and shape, which are often fueled by low self-esteem and fears of being unattractive. In addition, faulty cognitions about which foods are “safe” and which are “dangerous” are explored (Fairburn et al., 2008; Wilson, 2005). EVALUATING COGNITIVE-BEHAVIORAL THERAPIES In spite of the widespread attention that Ellis’s REBT has enjoyed, it has been less well assimilated into the mainstream than Beck’s cognitive therapy (David et al., 2005). Nonetheless, REBT is still very much alive and well. In general, this approach may be most useful in helping basically healthy people to cope better with everyday stress and perhaps in preventing them from developing full-blown anxiety or depressive disorders (Haaga & Davison, 1989, 1992). With respect to controlled research studies with carefully diagnosed clinical populations, REBT appears to be inferior to exposure- based therapies in the treatment of anxiety disorders such as agoraphobia, social phobia (Haaga & Davison, 1989, 1992), and probably obsessive-compulsive disorder (Franklin & Foa, 1998). In contrast, the efficacy of Beck’s cognitive treatment methods has been well documented. Research suggests that these approaches are extremely beneficial in alleviating many different types of disorders (see Hollon & Beck, 2004). For all but the most severe cases of depression (e.g., psychotic depression), cognitive-behavioral therapy is at least comparable to drug treatment. It also offers long-term advantages, especially with regard to the prevention of relapse (Craighead et al., 2007). Cognitive therapy also produces dramatic results in
  • 32. the treatment of panic disorder and generalized anxiety disorder (Hollon & Beck, 2004), and cognitive-behavioral therapy is now the treatment of choice for bulimia (Wilson, 2010; Wilson & Fairburn, 2007). Finally, cognitive approaches have promise in the treatment of conduct disorder in children (Kazdin, 2007), substance abuse (Beck et al., 1993), and certain personality disorders (Beck et al., 1990; Linehan, 1993). The combined use of cognitive and behavior therapy approaches is now quite routine. Some disagreement remains about whether the effects of cognitive treatments are actually the result of cognitive changes as the cognitive theorists propose (Hollon & Beck, 2004; Jacobson et al., 1996). At least for depression and panic disorder, it does appear that cognitive change is the best predictor of long-term outcome, just as cognitive theory maintains (Hollon et al., 1990). Exactly what the “active ingredients” of cognitive treatments really are, however, remains a source of debate and research (e.g., Garratt et al., 2007; Teasdale et al., 2001). Humanistic-Experiential Therapies The humanistic-experiential therapies emerged as significant treatment approaches after World War II. In a society dominated by self-interest, mechanization, computerization, mass deception, and mindless bureaucracy, proponents of the humanisticexperiential therapies see psychopathology as stemming in many cases from problems of alienation, depersonalization, loneliness, and a failure to find meaning and genuine fulfilment. Problems of this sort, it is held, are not likely to be solved either by delving into forgotten memories or by correcting specific maladaptive behaviors. The humanistic- experiential therapies are based on the assumption that people have both the freedom and the responsibility to control their own behavior—that they can reflect on their problems, make choices, and take positive action. Humanistic- experiential therapists feel that a client must take most of the responsibility for the direction and success of therapy, with the therapist serving merely as counselor, guide, and facilitator. Although humanistic-experiential therapies differ in their details, their
  • 33. central focus is always expanding a client’s “awareness.” CLIENT-CENTERED THERAPY The client-centered (person- centered) therapy of Carl Rogers (1902–1987) focuses on the natural power of the organism to heal itself (Rogers, 1951, 1961). Rogers saw therapy as a process of removing the constraints and restrictions that grow out of unrealistic demands that people tend to place on themselves when they believe, as a condition of self-worth, that they should not have certain kinds of feelings such as hostility. By denying that they do in fact have such feelings, they become unaware of their actual “gut” reactions. As they lose touch with their own genuine experience, the result is lowered integration, impaired personal relationships, and various forms of maladjustment. The primary objective of Rogerian therapy is to resolve this incongruence— to help clients become able to accept and be themselves. To this end, client-centered therapists establish a psychological climate in which clients can feel unconditionally accepted, understood, and valued as people. Within this context, the therapist employs nondirective techniques such as empathic reflecting, or restatement of the client’s descriptions of life difficulties. If all goes well, clients begin to feel free, for perhaps the first time, to explore their real feelings and thoughts and to accept hates and angers and ugly feelings as parts of themselves. As their self-concept becomes more congruent with their actual experience, they become more self-accepting and more open to new experiences and new perspectives; in short, they become better-integrated people. In contrast to most other forms of therapy, the client-centered therapist does not give answers, interpret what a client says, probe for unconscious conflicts, or even steer the client toward certain topics. Rather, he or she simply listens attentively and acceptingly to what the client wants to talk about, interrupting only to restate in different words what the client is saying. Such restatements, devoid of any judgment or interpretation by the therapist, help the client to clarify further the feelings and ideas that he or she is exploring—really to look at them and acknowledge them. The
  • 34. following excerpt from a therapist’s second interview with a young woman will serve to illustrate these techniques of reflection and clarification. Client-Centered Therapy JENNY: I was thinking about how I always try to make people around me feel at ease. It’s so important for me to make things go along smoothly. THERAPIST: In other words, you are always trying to make other people feel better and to do all you can to keep things on an even keel and going well. JENNY: Yes. That’s right. I mean, it’s not because I am such a kind person and all I want to see is other people being happy. I think the reason I do it is probably because that has always been the role that has felt the easiest for me to play. It’s the role I played at home. I didn’t stand up for my own convictions. And now I’m at the point where I don’t really know whether I have any convictions to stand up for. THERAPIST: So you feel this is a role you have been playing for a long time, smoothing out frictions and avoiding saying anything that might be challenging in any way. JENNY: I think that’s right. THERAPIST: And so now you aren’t sure if you even have any genuine opinions or reactions of your own. Is that right? JENNY: That’s it. Or maybe I haven’t really been honest with myself and let myself even consider what I really think about things. I’ve just been playing a sort of a false role—being a people-pleaser. Whatever I felt other people needed me to be, that’s who I was. And in the process I just got lost. Pure client-centered psychotherapy, as originally practiced, is rarely used today in North America, although it is still relatively popular in Europe. Motivational interviewing is a new form of therapy that is based on this empathic style. MOTIVATIONAL INTERVIEWING People tend to be ambivalent about making changes in their lives. They want to change, but they also don’t want to change. Motivational interviewing (MI; see Hettema, Steele, & Miller, 2005) is a brief form of therapy that can be delivered in one or two sessions. It was developed as a way to help people resolve their ambivalence about change and make a commitment to treatment (Miller, 1983). At its center is a supportive and empathic style
  • 35. of relating to the client that has its origins in the work of Carl Rogers. However, MI differs from client-centered counseling because it also employs a more direct approach that explores the client’s own reasons for wanting to change. The therapist encourages this “change talk” by asking the client to discuss his or her desire, ability, reasons, and need for change. These are reflected back by the therapist, thus exposing the client to periodic summaries of his or her own motivational statements and thoughts about change. The result is that clients can develop and strengthen their commitment to change in an active, accepting, and supportive atmosphere. Motivational interviewing is most often used in the areas of substance abuse and addiction. When added to the beginning of a treatment program, it appears to benefit patients, perhaps because it facilitates patients’ staying in treatment and following the treatment plan. Hettema and colleagues’ (2005) meta-analysis of the MI literature has also shown that MI has a large effect when it is used with ethnic minorities. In one alcoholism-treatment trial, Native American participants did better if they received four sessions of MI than if they received 12 sessions of cognitive-behavior therapy or else participated in a 12-step program (Villanueva et al., 2003). Quite possibly, the supportive and nonconfrontational style of MI may be more congruent with the typical and culturally sanctioned communication style of Native Americans and thus represent a culturally appropriate intervention. The collaborative and nonconfrontational style of MI may also make it acceptable to adolescents. Even a very small number of sessions of MI can promote behavior change in adolescents who use drugs and alcohol (Jensen et al., 2011). GESTALT THERAPY In German, the term gestalt means “whole,” and gestalt therapy emphasizes the unity of mind and body—placing strong emphasis on the need to integrate thought, feeling, and action. Gestalt therapy was developed by Frederick (Fritz) Perls (1969) as a means of teaching clients to recognize the bodily processes and emotions they had been blocking off from awareness. As with the client-
  • 36. centered and humanistic approaches, the main goal of gestalt therapy is to increase the individual’s self-awareness and self- acceptance. Motivational interviewing is a brief intervention that helps people resolve their ambivalence about making change. It is often used in the treatment of substance abuse and addiction. Although gestalt therapy is commonly used in a group setting, the emphasis is on one person at a time, with whom a therapist works intensively, trying to help identify aspects of the individual’s self or world that are not being acknowledged in awareness. The individual may be asked to act out fantasies concerning feelings and conflicts or to represent one side of a conflict while sitting in one chair and then switch chairs to take the part of the adversary. Often the therapist or other group members will ask such questions as, “What are you aware of in your body now?” and “What does it feel like in your gut when you think of that?” In Perls’s approach to therapy, a good deal of attention is also paid to dreams, but with an emphasis very different from that of classical psychoanalysis. In gestalt theory, all elements of a dream, including seemingly inconsequential, impersonal objects, are considered to be representations of unacknowledged aspects of the dreamer’s self. The therapist urges the client to suspend normal critical judgment, to “be” the object in the dream, and then to report on the experience. This is illustrated in the following case study. Gestalt Therapy A college professor was preoccupied with his academic promotion and tenure and found himself unable to experience any joy. He sought the assistance of a friend who was a gestalt therapist. She asked him to conjure up a daydream rather than a dream. The daydream that emerged spontaneously was one of skiing. The therapist asked him to be the mountain, and he began to experience how warm he was when he was at his base. As he got closer to the top, what looked so beautiful was also very cold and frozen. The therapist asked the professor to be the snow, and he experienced how hard and icy he could be near the top. But near the bottom, people ran over him easily and wore him out. When the session was finished, the professor
  • 37. did not feel like crying or shouting; he felt like skiing. So he went, leaving articles and books behind. In the sparkle of the snow and sun, he realized that joy in living emerges through deeds and not through words. In his rush to succeed, he had committed one of the cardinal sins against himself—the sin of not being active. Source: Adapted from Prochaska & Norcross, 2003, p. 183. EVALUATING HUMANISTIC-EXPERIENTIAL THERAPIES Many of the humanistic-experiential concepts—the uniqueness of each individual, the importance of therapist genuineness, the satisfaction that comes from realizing one’s potential, the importance of the search for meaning and fulfilment, and the human capacity for choice and self- direction—have had a major impact on our contemporary views of both human nature and the nature of good psychotherapy. However, humanistic-experiential therapies have been criticized for their lack of agreed-upon therapeutic procedures and their vagueness about what is supposed to happen between client and therapist. In response, proponents of such approaches argue against reducing people to abstractions, which can diminish their perceived worth and deny their uniqueness. Because people are so different, they argue, we should expect different techniques to be appropriate for different cases. Controlled research on the outcomes achieved by many forms of humanistic-existential therapy was lacking in the past. However, research in this area is now on the increase. There is evidence to suggest that these treatment approaches are helpful for patients with a variety of problems including depression, anxiety, trauma, and marital difficulties (Elliot et al., 2004). And, as we have already noted, motivational interviewing is now established as an effective method for promoting behavior change in people with substance abuse problems (Ball et al., 2007; Jensen et al., 2011). Psychodynamic Therapies Psychodynamic therapy is a broad treatment approach that focuses on individual personality dynamics, usually from a psychoanalytic or some psychoanalytically derived perspective. Psychoanalytic therapy is the oldest form of psychological
  • 38. therapy and began with Sigmund Freud. The therapy is mainly practiced in two basic forms: classical psychoanalysis and psychoanalytically oriented psychotherapy. As developed by Freud and his immediate followers, classical psychoanalysis is an intensive (at least three sessions per week), long-term procedure for uncovering repressed memories, thoughts, fears, and conflicts presumably stemming from problems in early psychosexual development—and helping individuals come to terms with them in light of the realities of adult life. For example, excessive orderliness and a grim and humorless focus on rigorous self-control would probably be viewed as deriving from difficulties in early toilet training. In psychoanalytically oriented psychotherapy, the treatment and the ideas guiding it may depart substantially from the principles and procedures laid out by orthodox Freudian theory, yet the therapy is still loosely based on psychoanalytic concepts. For example, many psychoanalytically oriented therapists schedule less frequent sessions (e.g., once per week) and sit face-to-face with the client instead of having the latter recline on a couch with the analyst out of sight behind him or her. Likewise, the relatively passive stance of the analyst (primarily listening to the client’s “free associations” and rarely offering “interpretations”) is replaced with an active conversational style in which the therapist attempts to clarify distortions and gaps in the client’s construction of the origins and consequences of his or her problems, thus challenging client “defenses” as they present themselves. It is widely believed that this more direct approach significantly shortens total treatment time. We will first examine Freud’s original treatment methods, in part because of their historical significance and enormous influence; we will then look briefly at some of the contemporary modifications of psychodynamic therapy, which for the most part focus on interpersonal processes. Before we do so, however, let’s consider the case of Karen. Psychodynamic Therapy Karen was about to be terminated from her nursing program if her problems were not resolved. She had always been a competent
  • 39. student who seemed to get along well with peers and patients. Now, since the beginning of her rotation on 3 South, a surgical ward, she was plagued by headaches and dizzy spells. Of more serious consequence were the two medical errors she had made when dispensing medications to patients. She realized that these errors could have proved fatal, and she was as concerned as her nursing faculty about why such problems had begun in this final year of her education. Karen knew she had many negative feelings toward the head nurse on 3 South, but she did not believe these feelings could account for her current dilemma. She entered psychotherapy. After a few weeks of psychotherapy, the therapist realized that one of Karen’s important conflicts revolved around the death of her father when she was 12 years old. Karen had just gone to live with her father after being with her mother for 7 years. She remembered how upset she was when her father had a heart attack and had to be rushed to the hospital. For a while it looked as though her father was going to pull through, and Karen began enjoying her daily visits to see him. During one of these visits, her father clutched his chest in obvious pain and told Karen to get a nurse. She remembered how helpless she felt when she could not find a nurse, although she did not recall why this was so difficult. Her search seemed endless, and by the time she finally found a nurse, her father was dead. The therapist asked Karen the name of the ward on which her father had died. She paused and thought, and then she blurted out, “3 South.” She cried at length as she told how confused she was and how angry she felt toward the nurses on the ward for not being more readily available, although she thought they might have been involved with another emergency. After weeping and shaking and expressing her resentment, Karen felt calm and relaxed for the first time in months. Her symptoms disappeared, and her problems in the nursing program were relieved. Source: Adapted from Prochaska & Norcross, 2003, p. 28. In classical (Freudian) psychoanalysis the technique of free association may be used to explore the contents of the preconscious. FREUDIAN
  • 40. PSYCHOANALYSIS Psychoanalysis is a system of therapy that evolved over a period of years during Freud’s long career. Psychoanalysis is not easy to describe, and the problem is complicated by the fact that many people have inaccurate conceptions of it based on cartoons and other forms of caricature. The best way to begin our discussion is to describe the four basic techniques of this form of therapy: (1) free association, (2) analysis of dreams, (3) analysis of resistance, and (4) analysis of transference. Then we will note some of the most important changes that have taken place in psychodynamic therapy since Freud’s time. Free Association The basic rule of free association (see Chapter 2) is that an individual must say whatever comes into her or his mind regardless of how personal, painful, or seemingly irrelevant it may be. Usually a client lies in a relaxed position on a couch and gives a running account of all the thoughts, feelings, and desires that come to mind as one idea leads to another. The therapist normally takes a position behind the client so as not to disrupt the free flow of associations in any way. Although such a running account of whatever comes into one’s mind may seem random, Freud did not view it as such; rather, he believed that associations are determined just like other events. The purpose of free association is to explore thoroughly the contents of the preconscious—that part of the mind considered subject to conscious attention but largely ignored. Analytic interpretation involves a therapist’s tying together a client’s often disconnected ideas, beliefs, and actions into a meaningful explanation to help the client gain insight into the relationship between his or her maladaptive behavior and the repressed (unconscious) events and fantasies that drive it. Analysis of Dreams Another important, related procedure for uncovering unconscious material is the analysis of dreams. When a person is asleep, repressive defenses are said to be lowered, and forbidden desires and feelings may find an outlet in dreams. For this reason, dreams have been referred to as the “royal road to the unconscious.” Some motives, however, are so unacceptable
  • 41. to an individual that even in dreams they are not revealed openly but are expressed in disguised or symbolic form. Thus a dream has two kinds of content: (1) manifest content, which is the dream as it appears to the dreamer, and (2) latent content, which consists of the actual motives that are seeking expression but are so painful or unacceptable that they are disguised. It is a therapist’s task, in conjunction with the associations of the patient, to uncover these disguised meanings by studying the images that appear in the manifest content of a client’s dream and in the client’s associations to them. For example, a client’s dream of being engulfed in a tidal wave may be interpreted by a therapist as indicating that the client feels in danger of being overwhelmed by inadequately repressed fears or hostilities. Analysis of Resistance During the process of free association or of associating to dreams, an individual may evidence resistance—an unwillingness or inability to talk about certain thoughts, motives, or experiences. For example, a client may be talking about an important childhood experience and then suddenly switch topics, perhaps stating, “It really isn’t that important” or “It is too absurd to discuss.” Resistance may also be evidenced by the client’s giving a too-glib interpretation of some association, or coming late to an appointment, or even “forgetting” an appointment altogether. Because resistance prevents painful and threatening material from entering awareness, its sources must be sought if an individual is to face the problem and learn to deal with it in a realistic manner (Horner, 2005). Analysis of Transference As client and therapist interact, the relationship between them may become complex and emotionally involved. Often people carry over, and unconsciously apply to their therapist, attitudes and feelings that they had in their relations with a parent or other person close to them in the past, a process known as transference. Thus clients may react to their analyst as they did to that earlier person and feel the same love, hostility, or rejection that they felt long ago. If the analyst is operating according to the prescribed role of maintaining an impersonal stance of detached
  • 42. attention, the often affect-laden reactions of the client can be interpreted, it is held, as a type of projection—inappropriate to the present situation yet highly revealing of central issues in the client’s life. For example, should the client vehemently (but inaccurately) condemn the therapist for a lack of caring and attention to the client’s needs, this would be seen as a “transference” to the therapist of attitudes acquired (possibly on valid grounds) in childhood interactions with parents or other key individuals. In helping the client to understand and acknowledge the transference relationship, a therapist may provide the client with insight into the meaning of his or her reactions to others. In doing so, the therapist may also introduce a corrective emotional experience by refusing to engage the person on the basis of his or her unwarranted assumptions about the nature of the therapeutic relationship. If the client expects rejection and criticism, for example, the therapist is careful to maintain a neutral manner. Or contrarily, the therapist may express positive emotions at a point where the client feels particularly vulnerable, thereby encouraging the client to reframe and rethink her or his view of the situation. In this way it may be possible for the client to recognize these assumptions and to “work through” the conflict in feelings about the real parent or perhaps to overcome feelings of hostility and self- devaluation that stem from the earlier parental rejection. In essence, the negative effects of an undesirable early relationship are counteracted by working through a similar emotional conflict with the therapist in a therapeutic setting. A person’s reliving of a pathogenic past relationship in a sense recreates the neurosis in real life, and therefore this experience is often referred to as a transference neurosis. It is not possible here to consider at length the complexities of transference relationships, but a client’s attitudes toward his or her therapist usually do not follow such simple patterns as our examples suggest. Often the client is ambivalent—distrusting the therapist and feeling hostile toward him or her as a symbol of authority, but at the same time seeking acceptance and love. In addition,
  • 43. the problems of transference are not confined to the client, for the therapist may also have a mixture of feelings toward the client. This countertransference, wherein the therapist reacts in accord with the client’s transferred attributions rather than objectively, must be recognized and handled properly by the therapist. For this reason, it is considered important that therapists have a thorough understanding of their own motives, conflicts, and “weak spots”; in fact, all psychoanalysts undergo psychoanalysis themselves before they begin independent practice. The resolution of the transference neurosis is said to be the key element in effecting a psychoanalytic “cure.” Such resolution can occur only if an analyst successfully avoids the pitfalls of countertransference. That is, the analyst needs to keep track of his or her own transference or reaction to a client’s behavior. Failure to do so risks merely repeating, in the therapy relationship, the typical relationship difficulties characterizing the client’s adult life. Analysis of transference and the phenomenon of countertransference are also part of most psychodynamic derivatives of classical psychoanalysis, to which we now turn. Psychodynamic Therapy Since Freud The original version of psychoanalysis is practiced only rarely today. Arduous and costly in time, money, and emotional commitment, it may take several years before all major issues in the client’s life have been satisfactorily resolved. In light of these heavy demands, psychoanalytic or psychodynamic therapists have worked out modifications in procedure designed to shorten the time and expense required. A good review of some of these approaches can be found in Prochaska and Norcross (2003). Object Relations, Attachment-Based Approaches, and Self-Psychology The most extensive revisions of classical psychoanalytic theory undertaken within recent decades have been related to the object-relations perspective (in psychoanalytic jargon, “objects” are other people) and, to a lesser extent, the attachment and self-psychology perspectives (see Prochaska & Norcross, 2003). Whether or not psychotherapy investigators and clinicians use the term object
  • 44. relations (or attachment or self-psychology) to denote their approach, increasing numbers of them describe procedures that focus on interpersonal relationship issues, particularly as they play themselves out in the client–therapist relationship. Interpersonally oriented psychodynamic therapists vary considerably in their time focus: whether they concentrate on remote events of the past, on current interpersonal situations and impasses (including those of the therapy itself), or on some balance of the two. Most seek to expose, bring to awareness, and modify the effects of the remote developmental sources of the difficulties the client is currently experiencing. These therapies generally retain, then, the classical psychoanalytic goal of understanding the present in terms of the past. What they ignore are the psychoanalytic notions of staged libidinal energy transformations and of entirely internal (and impersonal) drives that are channeled into psychopathological symptom formation. EVALUATING PSYCHODYNAMIC THERAPIES The practice of classical psychoanalysis is routinely criticized by outsiders for being relatively time consuming and expensive; for being based on a questionable, stultified, and sometimes cult-like approach to human nature; for neglecting a client’s immediate problems in the search for unconscious conflicts in the remote past; and for there being no adequate proof of its general effectiveness. Concerning this, we note that there have been no rigorous, controlled outcome studies of classical psychoanalysis. This is understandable, given the intensive and long-term nature of the treatment and the methodological difficulties inherent in testing such an approach. Nonetheless, there are some hints that this treatment approach has some value (Gabbard et al., 2002). Psychoanalysts also argue that manualized treatments unduly limit treatment for a disorder. They note that simply because a treatment cannot be standardized does not mean that it is invalid or unhelpful. Whether the clinical benefits justify the time and expense of psychoanalysis, however, remains uncertain. In contrast, there is much more research on some of the newer psychodynamically
  • 45. oriented approaches. There are signs that psychodynamic approaches may be helpful in the treatment of depression, panic disorder, PTSD, and substance abuse disorders (Gibbons et al., 2008). Recent research also supports the idea that increases in insight (“insight” is a key construct in psychodynamic theory and involves cognitive and emotional understanding of inner conflicts) must occur before there is long-term clinical change (Johansson et al., 2010). Psychoanalytically oriented treatments are also showing promise in the treatment of borderline personality disorder. One example is transference-focused psychotherapy, or TFP. Developed by Kernberg and colleagues, this treatment approach uses such techniques as clarification, confrontation, and interpretation to help the patient understand and correct the distortions that occur in his or her perception of other people, including the therapist. In a clinical trial, patients with borderline personality disorder who received TFP did as well as those who were assigned to receive dialectical behavior therapy (Clarkin et al., 2007). A recent meta-analysis provides further support for the idea that long-term psychodynamic psychotherapy (50 sessions or more) may be more beneficial than less intensive forms of treatment for patients with complex mental disorders (Leichsenring & Rabung, 2011). Findings such as these are creating renewed interest in psychodynamic forms of psychotherapy and energizing the field of treatment research. Couple and Family Therapy Many problems that therapists deal with concern distressed relationships. A common example is couple or marital distress. Here, the maladaptive behavior exists between the partners in the relationship. Extending the focus even further, a family systems approach reflects the assumption that the within-family behavior of any particular family member is subject to the influence of the behaviors and communication patterns of other family members. It is, in other words, the product of a “system” that may be amenable to both understanding and change. Addressing problems deriving from the in-place system thus requires therapeutic techniques that focus on relationships as much as, or more than, on individuals.