Enduring Issues in Therapies

Therapies13

Enduring Issues in Therapies

Insight Therapies • Psychoanalysis • Client-Centered Therapy • Gestalt Therapy • Recent Developments Behavior Therapies • Therapies Based on

Classical Conditioning

• Therapies Based on Operant Conditioning

• Therapies Based on Modeling Cognitive Therapies • Stress-Inoculation Therapy • Rational–Emotive Therapy • Beck’s Cognitive Therapy Group Therapies • Family Therapy

• Couple Therapy • Self-Help Groups Effectiveness of Psychotherapy • Which Type of Therapy Is

Best for Which Disorder? Biological Treatments • Drug Therapies • Electroconvulsive Therapy • Psychosurgery

Institutionalization and Its Alternatives • Deinstitutionalization • Alternative Forms of

Treatment • Prevention Client Diversity and Treatment • Gender and Treatment • Culture and Treatment

O V E R V I E W

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For most new mothers, giving birth results in an instant bondand feelings of immediate and unconditional love for theirnew baby. Many describe motherhood as the happiest time in their lives and cannot imagine a life without their children. However, for some, another reaction occurs—one of sadness and apathy, and withdrawal from the world around them. Brooke Shields, the well-known actress and model, was one of these women.

In Down Came the Rain: My Journey Through Postpartum Depression, Shields (2006) writes that she had always dreamed of being a mother. Although she and her husband, Chris Henchy, initially had trouble conceiving, Shields eventually became pregnant through in vitro fertilization and gave birth to a daugh- ter in 2003. Just as her attempt at conceiving wasn’t without effort, easing into life as a mother wasn’t effortless, either.

Almost immediately after returning home from the hospital, Shields began to experience symptoms of postpartum depres- sion. Once referred to as the “baby blues,” postpartum depres- sion has recently come to be considered a very legitimate type of depression. Symptoms range from anxiety and tearfulness to feelings of extreme detachment and even being suicidal. Shields notes that her “baby blues” rapidly gave way to full- blown depression, including thoughts of self-harm and frighten- ing visions of harm coming to her baby. In addition to the birth of her child, Shields was also coping with the recent death of her father, as well as the ongoing struggle of coping with the suicide of a close friend 2 years prior. Doctors note that postpartum depression can be exacerbated by events such as these.

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As Shields’s mental health began to decline, she felt more anxious and panicky. She felt sadness greater than she’d ever experienced, and began thinking that it would never go away. She felt completely detached from the baby she had gone through so much to have. This detachment depressed her fur- ther. It became a vicious cycle, and she suffered tremendously throughout it. It didn’t occur to Shields that she might have post- partum depression until she heard someone comment on the shame and depression associated with the disease. It finally hit home and Shields sought help.

As with nearly all forms of depression, there was no quick and easy solution. Treatment requires patience, help from a doctor, a supportive family, and often medication. Shields began treatment and gradually began to feel better. She eventually was able to feel the love that mothers speak of when referring to their children. She bonded with her baby and became tuned in to the child’s needs instinctively. With her doctor’s guidance, she began to wean herself off the medication. She also sought healing through writing the book that detailed her experience, and in 2006, she and her husband conceived again, adding another child to their family.

Having learned about a wide range of psychological disor- ders in Chapter 12, “Psychological Disorders,” you are probably curious about the kinds of treatments available for them. Brooke Shields’s treatment for depression, a combination of medication and psychotherapy, exemplifies the help that is available. This chapter describes a variety of treatments that mental health professionals provide.

ENDURING ISSUES IN THERAPIES The underlying assumption behind therapy for psychological disorders is the belief that people are capable of changing (stability–change). Throughout this chapter are many opportunities to think about whether people suffering from psychological disorders can change significantly and whether they can change without intervention. In the discussion of biological treatments for psychological disorders we again encounter the issue of mind–body. Finally, the enduring issue of diversity–universality will arise when we discuss the challenges therapists face when treating people from cultures other than their own.

INSIGHT THERAPIES What do insight therapies have in common?

Although the details of various insight therapies differ, their common goal is to give peo- ple a better awareness and understanding of their feelings, motivations, and actions in the hope that this will lead to better adjustment (Huprich, 2009; Messer & McWilliams, 2007; Person, Cooper, & Gabbard, 2005). In this section, we consider three major insight thera- pies: psychoanalysis, client-centered therapy, and Gestalt therapy.

insight therapies A variety of individual psychotherapies designed to give people a better awareness and understanding of their feelings, motivations, and actions in the hope that this will help them to adjust.

L E A R N I N G O B J E C T I V E S • Describe the common goal of all insight

therapies. Compare and contrast psychoanalysis, client-centered therapy, and Gestalt therapy.

• Explain how short-term psychodynamic therapy and virtual therapy differ from the more traditional forms of insight therapy.

psychotherapy The use of psychological techniques to treat personality and behavior disorders.

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Psychoanalysis How does “free association” in psychoanalysis help a person to become aware of hidden feelings?

Psychoanalysis is designed to bring hidden feelings and motives to conscious awareness so that the person can deal with them more effectively.

In Freudian psychoanalysis, the client is instructed to talk about whatever comes to mind. This process is called free association. Freud believed that the resulting “stream of consciousness” would provide insight into the person’s unconscious mind. During the early stages of psychoanalysis, the analyst remains impassive, mostly silent, and out of the person’s sight. The analyst’s silence serves as a “blank screen” onto which the person projects uncon- scious thoughts and feelings.

Eventually, clients may test their analyst by talking about desires and fantasies that they have never revealed to anyone else. When clients discover that their analyst is not shocked or disgusted by their revelations, they are reassured and transfer to their analyst feelings they have toward authority figures from their childhood. This process is known as transference. It is said to be positive transference when the person feels good about the analyst.

As people continue to expose their innermost feelings, they begin to feel increasingly vulnerable. Threatened by their analyst’s silence and by their own thoughts, clients may feel cheated and perhaps accuse their analyst of being a money grabber. Or they may suspect that their analyst is really disgusted by their disclosures or is laughing at them behind their backs. This negative transference is thought to be a crucial step in psychoanalysis, for it pre- sumably reveals negative feelings toward authority figures and resistance to uncovering repressed emotions.

As therapy progresses, the analyst takes a more active role and begins to interpret or suggest alternative meanings for clients’ feelings, memories, and actions. The goal of interpretation is to help people to gain insight—to become aware of what was formerly outside their awareness. As what was unconscious becomes conscious, clients may come to see how their childhood experi- ences have determined how they currently feel and act. By working through old conflicts, clients have a chance to review and revise the feelings and beliefs that underlie their problems. In the example of a therapy session that follows, the woman discovers a link between her current behaviors and childhood fears regarding her mother, which she has transferred to the analyst.

Therapist: (summarizing and restating) It sounds as if you would like to let loose with me, but you are afraid of what my response would be.

Patient: I get so excited by what is hap- pening here. I feel I’m being held back by needing to be nice. I’d like to blast loose sometimes, but I don’t dare.

Therapist: Because you fear my reaction? Patient: The worst thing would be that

you wouldn’t like me. You wouldn’t speak to me friendly; you wouldn’t smile; you’d feel you can’t treat me and dis- charge me from treatment. But I know this isn’t so; I know it.

Therapist: Where do you think these atti- tudes come from?

Patient: When I was 9 years old, I read a lot about great men in his- tory. I’d quote them and be dramatic, I’d want a sword at my side; I’d dress like an Indian. Mother would scold

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free association A psychoanalytic technique that encourages the person to talk without inhibition about whatever thoughts or fantasies come to mind.

transference The client’s carrying over to the analyst feelings held toward childhood authority figures.

The consulting room where Freud met his clients. Note the position of Freud’s chair at the head of the couch. In order to encourage free association, the psychoanalyst has to function as a blank screen onto which the client can project his or her feelings. To accomplish this, Freud believed, the psycho- analyst has to stay out of sight of the client.

insight Awareness of previously unconscious feelings and memories and how they influence present feelings and behavior.

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me, “Don’t frown; don’t talk so much. Sit on your hands,” over and over again. I did all kinds of things. I was a naughty child. She told me I’d be hurt. Then, at 14, I fell off a horse and broke my back. I had to be in bed. Mother told me that day not to go riding. I’d get hurt because the ground was frozen. I was a stubborn, self-willed child. Then I went against her will and suffered an accident that changed my life: a fractured back. Her attitude was, “I told you so.” I was put in a cast and kept in bed for months.

Therapist: You were punished, so to speak, by this accident. Patient: But I gained attention and love from Mother for the first time. I

felt so good. I’m ashamed to tell you this: Before I healed, I opened the cast and tried to walk, to make myself sick again so I could stay in bed longer.

Therapist: How does that connect with your impulse to be sick now and stay in bed so much?

Patient: Oh. . . . (pause) Therapist: What do you think? Patient: Oh, my God, how infantile, how ungrownup (pause). It must be so. I want

people to love me and feel sorry for me. Oh, my God. How completely child- ish. It is, is that. My mother must have ignored me when I was little, and I wanted so to be loved.

Therapist: So that it may have been threatening to go back to being self-willed and unloved after you got out of the cast (interpretation).

Patient: It did. My life changed. I became meek and controlled. I couldn’t get angry or stubborn afterward.

Therapist: Perhaps if you go back to being stubborn with me, you would be returning to how you were before, that is, active, stubborn, but unloved.

Patient: (excitedly) And, therefore, losing your love. I need you, but after all, you aren’t going to reject me. But the pattern is so established now that the threat of the loss of love is too overwhelming with everybody, and I’ve got to keep myself from acting selfish or angry (Wolberg, 1977, pp. 560–561).

Only a handful of people who seek therapy go into traditional psychoanalysis, as this woman did. As Freud recognized, analysis requires great motivation to change and an abil- ity to deal rationally with whatever the analysis uncovers. Moreover, traditional analysis may take 5 years or longer, with three, sometimes five, sessions a week. Few can afford this kind of treatment, and fewer possess the verbal and analytical skills necessary to discuss thoughts and feelings in this detailed way. And many want more immediate help for their problems. For those with severe disorders, psychoanalysis is ineffective.

Since Freud’s invention around the turn of the 20th century, psychodynamic personal- ity theory has changed significantly. Many of these changes have led to modified psychoan- alytic techniques as well as to different therapeutic approaches (McCullough & Magill, 2009; Monti & Sabbadini, 2005). Freud felt that to understand the present we must under- stand the past, but most neo-Freudians encourage clients to cope directly with current problems in addition to addressing unresolved conflicts from the past. Neo-Freudians also favor face-to-face discussions, and most take an active role in analysis by interpreting their client’s statements freely and suggesting discussion topics.

Client-Centered Therapy Why did Carl Rogers call his approach to therapy “client centered”?

Carl Rogers, the founder of client-centered (or person-centered) therapy, took pieces of the neo-Freudians’ views and revised them into a radically different approach to therapy. According to Rogers, the goal of therapy is to help people to become fully functioning, to open them up to all of their experiences and to all of themselves. Such inner awareness is a form of insight, but for Rogers, insight into current feelings was more important than insight into unconscious wishes with roots in the distant past. Rogers called his approach to

Source: © The New Yorker Collection, 1989, Danny Shanahan from cartoonbank.com. All Rights Reserved.

client-centered (or person-centered) therapy Nondirectional form of therapy developed by Carl Rogers that calls for unconditional positive regard of the client by the therapist with the goal of helping the client become fully functioning.

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therapy client centered because he placed the responsibility for change on the person with the problem. Rogers believed that people’s defensive- ness, anxiety, and other signs of discomfort stem from their experiences of conditional positive regard. They have learned that love and accep- tance are contingent on conforming to what other people want them to be. By contrast, the cardinal rule in person-centered therapy is for the thera- pist to express unconditional positive regard—that is, to show true acceptance of clients no matter what they may say or do (Bozarth, 2007). Rogers felt that this was a crucial first step toward clients’ self-acceptance.

Rogerian therapists try to understand things from the clients’ point of view. They are emphati- cally nondirective. They do not suggest reasons for a client’s feelings or how they might better handle a difficult situation. Instead, they try to reflect clients’ statements, sometimes asking questions or

hinting at feelings that clients have not articulated. Rogers felt that when therapists provide an atmosphere of openness and genuine respect, clients can find themselves, as portrayed in the following session.

Client: I guess I do have problems at school . . . . You see, I’m chairman of the Sci- ence Department, so you can imagine what kind of a department it is.

Therapist: You sort of feel that if you’re in something that it can’t be too good. Is that . . .

Client: Well, it’s not that I . . . It’s just that I’m . . . I don’t think that I could run it. Therapist: You don’t have any confidence in yourself? Client: No confidence, no confidence in myself. I never had any confidence in

myself. I—like I told you—like when even when I was a kid I didn’t feel I was capable and I always wanted to get back with the intellectual group.

Therapist: This has been a long-term thing, then. It’s gone on a long time. Client: Yeah, the feeling is—even though I know it isn’t, it’s the feeling that I have

that—that I haven’t got it, that—that—that—people will find out that I’m dumb or—or . . .

Therapist: Masquerade. Client: Superficial, I’m just superficial. There’s nothing below the surface. Just

superficial generalities, that … Therapist: There’s nothing really deep and meaningful to you (Hersher, 1970,

pp. 29–32).

Rogers wanted to discover those processes in client-centered therapy that were associated with positive results. Rogers’s interest in the process of therapy resulted in important and lasting contributions to the field; research has shown that a therapist’s emphasis on empathy, warmth, and understanding increase success, no matter what therapeutic approach is used (Bike, Norcross, & Schatz, 2009; Kirschenbaum & Jourdan, 2005).

Gestalt Therapy How is Gestalt therapy different from psychoanalysis?

Gestalt therapy is largely an outgrowth of the work of Frederick (Fritz) Perls at the Esalen Institute in California. By emphasizing the present and encouraging face-to-face confrontations, Gestalt therapy attempts to help people become more

Carl Rogers (far right) leading a group ther- apy session. Rogers was the founder of client-centered therapy.

Gestalt therapy An insight therapy that emphasizes the wholeness of the personality and attempts to reawaken people to their emotions and sensations in the present.

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genuine in their daily interactions. The therapist is active and directive, and the emphasis is on the whole person. (The term Gestalt means “whole.”) The therapist’s role is to “fill in the holes in the personality to make the person whole and complete again” (Perls, 1969, p. 2).

Gestalt therapists use various techniques to try to make people aware of their feelings. For example, they tell people to “own their feelings” by talking in an active, rather than a passive way: “I feel angry when he’s around” instead of “He makes me feel angry when he’s around.” They also ask people to speak to a part of themselves that they imagine to be sit- ting next to them in an empty chair. This empty-chair technique and others are illustrated in the following excerpt:

Therapist: Try to describe just what you are aware of at each moment as fully as possi- ble. For instance, what are you aware of now?

Client: I’m aware of wanting to tell you about my problem, and also a sense of shame—yes, I feel very ashamed right now.

Therapist: Okay. I would like you to develop a dialogue with your feeling of shame. Put your shame in the empty chair over here (indicates chair), and talk to it.

Client: Are you serious? I haven’t even told you about my problem yet. Therapist: That can wait—I’m perfectly serious, and I want to know what you have to

say to your shame. Client: (awkward and hesitant at first, but then becoming looser and more involved)

Shame, I hate you. I wish you would leave me—you drive me crazy, always reminding me that I have a problem, that I’m perverse, different, shameful— even ugly. Why don’t you leave me alone?

Therapist: Okay, now go to the empty chair, take the role of shame, and answer your- self back.

Client: (moves to the empty chair) I am your constant companion—and I don’t want to leave you. I would feel lonely without you, and I don’t hate you. I pity you, and I pity your attempts to shake me loose, because you are doomed to failure.

Therapist: Okay, now go back to your original chair and answer back. Client: (once again as himself) How do you know I’m doomed to failure?

(spontaneously shifts chairs now, no longer needing direction from the ther- apist; answers himself back, once again in the role of shame) I know that you’re doomed to failure because I want you to fail and because I control your life. You can’t make a single move without me. For all you know, you were born with me. You can hardly remember a single moment when you were without me, totally unafraid that I would spring up and suddenly remind you of your loathsomeness (Shaffer, 1978, pp. 92–93).

In this way, the client becomes more aware of conflicting inner feelings and, with insight, can become more genuine. Psychoanalysis, client-centered therapy, and Gestalt therapy differ in technique, but all use talk to help people become more aware of their feelings and conflicts, and all involve fairly substantial amounts of time. More recent developments in therapy seek to limit the amount of time people spend in therapy.

Recent Developments What are some recent developments in insight therapies?

Although Freud, Rogers, and Perls originated the three major forms of insight therapy, oth- ers have developed hundreds of variations on this theme. Most involve a therapist who is far more active and emotionally engaged with clients than traditional psychoanalysts thought fit. These therapists give clients direct guidance and feedback, commenting on what they are told rather than just neutral listening.

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Another general trend in recent years is toward shorter-term “dynamic therapy.” For most people, this usually means meeting once a week for a fixed period. In fact, short- term psychodynamic therapy is increasingly popular among both clients and mental health professionals (Abbass, Joffres, & Ogrodniczuk, 2008; McCullough & Magill, 2009). Insight remains the goal, but the course of treatment is usually limited—for example, to 25 sessions. With the trend to a time-limited framework, insight therapies have become more problem- or symptom-oriented, with greater focus on the person’s current life situ- ation and relationships. Although contemporary insight therapists do not discount child- hood experiences, they view people as being less at the mercy of early childhood events than Freud did.

Perhaps the most dramatic and controversial change in insight therapies is virtual therapy. For a hundred years or so, people who wanted to see a therapist have literally gone to see a therapist—they have traveled to the therapist’s office, sat down, and talked through their problems. In recent years, however, some people have started connecting with their therapists by telephone (S. Williams, 2000). Others pay their visits via cyberspace. The delivery of health care over the Internet or through other electronic means is part of a rapidly expanding field known as telehealth.

Although most therapists believe that online therapy is no substitute for face-to- face interactions (Almer, 2000; Rabasca, 2000c), evidence suggests that telehealth may provide cost-effective opportunities for delivery of some mental health services (J. E. Barnett & Scheetz, 2003). Telehealth is a particularly appealing alternative for people who live in remote or rural areas (Hassija & Gray, 2009; Stamm, 2003). For example, a university-based telehealth system in Kentucky provides psychological services to rural schools (Thomas Miller et al., 2003), and video-conferencing therapy has been used suc- cessfully to treat posttraumatic stress disorder in rural Wyoming (Hassija & Gray, 2009). Clearly, research is needed to determine under what, if any, circumstances vir- tual therapy is effective, as such services are likely to proliferate in the future (Melnyk, 2008; Zur, 2007).

Even more notable than the trend toward short-term and virtual therapy has been the proliferation of behavior therapies during the past few decades. In this next section, we examine several types.

CHECK YOUR UNDERSTANDING

1. ____________ therapies focus on giving people clearer understanding of their feelings, motives, and actions.

2. ____________ ____________ is a technique in psychoanalysis whereby the client lets thoughts flow without interruption or inhibition.

3. The process called ____________ involves having clients project their feelings toward authority figures onto their therapist.

4. Rogerian therapists show that they value and accept their clients by providing them with ____________ ____________ regard.

5. Indicate whether the following statements are true (T) or false (F): a. _____ Psychoanalysis is based on the belief that problems are symptoms of inner

conflicts dating back to childhood. b. _____ Rogers’s interest in the process of therapy was one avenue of exploration that

did not prove very fruitful. c. _____ In Gestalt therapy, the therapist is active and directive. d. _____ Gestalt therapy emphasizes the client’s problems in the present.

Answers:1. Insight.2. Free association.3. transference.4. unconditional positive.a.(T). b. (F).c. (T).d. (T).short-term psychodynamic therapy Insight

therapy that is time limited and focused on trying to help clients correct the immediate problems in their lives.

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BEHAVIOR THERAPIES What do behaviorists believe should be the focus of psychotherapy?

Behavior therapies sharply contrast with insight-oriented approaches. They are focused on changing behavior, rather than on discovering insights into thoughts and feelings. Behavior therapies are based on the belief that all behavior, both normal and abnormal, is learned (D. Richards, 2007). People suffering from hypochondriasis learn that they get attention when they are sick; people with paranoid personalities learn to be suspicious of others. Behavior therapists also assume that maladaptive behaviors are the problem, not symptoms of deeper underlying causes. If behavior therapists can teach people to behave in more appropriate ways, they believe that they have cured the problem. The therapist does not need to know exactly how or why a client learned to behave abnormally in the first place. The job of the therapist is simply to teach the person new, more satisfying ways of behaving on the basis of scientifically studied principles of learning, such as classical condi- tioning, operant conditioning, and modeling (Zinbarg & Griffith, 2008).

Therapies Based on Classical Conditioning How can classical conditioning be used as the basis of treatment?

Classical conditioning involves the repeated pairing of a neutral stimulus with one that evokes a certain reflex response. Eventually, the formerly neutral stimulus alone comes to elicit the same response. The approach is one of learned stimulus-response associations. Several variations on classical conditioning have been used to treat psychological problems.

Desensitization, Extinction, and Flooding Systematic desensitization, a method for gradually reducing fear and anxiety, is one of the oldest behavior therapy techniques (Wolpe, 1990). The method works by gradually associating a new response (relaxation) with anxiety-causing stimuli. For example, an aspiring politician might seek therapy because he is

L E A R N I N G O B J E C T I V E S • Explain the statement that “Behavior

therapies sharply contrast with insight- oriented approaches.”

• Describe the processes of desensitization, extinction, flooding, aversive conditioning, behavior contracting, token economies, and modeling.

APPLY YOUR UNDERSTANDING

1. Consider the following scenario: The client lies on a couch, and the therapist sits out of sight. The therapist gets to know the client’s problems through free association and then encourages the client to “work through” his or her problems. What kind of therapy is this?

a. psychoanalysis b. client-centered therapy c. Gestalt therapy d. rational–emotive therapy

2. Which of the following choices illustrates client-centered therapy with a depressed person?

a. The client is encouraged to give up her depression by interacting with a group of people in an encounter group.

b. The therapist tells the client that his depression is self-defeating and gives the client “assignments” to develop self-esteem and enjoy life.

c. The therapist encourages the client to say anything that comes into her head, to express her innermost fantasies, and to talk about critical childhood events.

d. The therapist offers the client her unconditional positive regard and, once this open atmosphere is established, tries to help the client discover why she feels depressed.

Answers:1. a.2. d.

behavior therapies Therapeutic approaches that are based on the belief that all behavior, normal and abnormal, is learned, and that the objective of therapy is to teach people new, more satisfying ways of behaving.

systematic desensitization A behavioral technique for reducing a person’s fear and anxiety by gradually associating a new response (relaxation) with stimuli that have been causing the fear and anxiety.

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anxious about speaking to crowds. The therapist explores the kinds of crowds that are most threatening: Is an audience of 500 worse than one of 50? Is it harder to speak to men than it is to women? Is there more anx- iety facing strangers than a roomful of friends? From this information the therapist develops a hierarchy of fears—a list of situations from the least to the most anxiety provoking. The therapist then teaches tech- niques for relaxation, both mentally and physically. Once the client has mastered deep relaxation, she or he begins work at the bottom of the hierarchy of fears. The person is told to relax while imagining the least threat- ening situation on the list, then the next most threaten- ing, and so on, until the most fear-arousing one is reached and the client can still remain calm.

Numerous studies show that systematic desensiti- zation helps many people overcome their fears and phobias (Hazel, 2005; D. W. McNeil & Zvolensky, 2000). The key to success may not be the learning of a new conditioned relaxation response, but rather the extinction of the old fear response through mere expo-

sure. Recall that in classical conditioning, extinction occurs when the learned, conditioned stimulus is repeatedly presented without the unconditioned stimulus following it. Thus, if a person repeatedly imagines a frightening situation without encountering danger, the associated fear should gradually decline. Desensitization is most effective when clients gradually confront their fears in the real world rather than merely in their imaginations.

The technique of flooding is a less familiar and more frightening desensitization method. It involves full-intensity exposure to a feared stimulus for a prolonged period of time (Moulds & Nixon, 2006; Wolpe, 1990). Someone with a fear of snakes might be forced to handle dozens of snakes. Though flooding may seem unnecessarily harsh, remember how debilitating many untreated anxiety disorders can be.

Aversive Conditioning Another classical conditioning technique is aversive condi- tioning, in which pain and discomfort are associated with the behavior that the client wants to unlearn. Aversive conditioning has been used with limited success to treat alco- holism, obesity, smoking, and some psychosexual disorders. For example, the taste and smell of alcohol are sometimes paired with drug-induced nausea and vomiting. Before long, clients feel sick just seeing a bottle of liquor. A follow-up study of nearly 800 people who completed alcohol-aversion treatment found that 63% had maintained continuous abstinence for at least 12 months (Sharon Johnson, 2003; Wiens & Menustik, 1983). The long-term effectiveness of this technique has been questioned; if punishment no longer follows, the undesired behavior may reemerge. Aversive conditioning is a controversial technique because of its unpleasant nature.

Therapies Based on Operant Conditioning How could “behavior contracting” change an undesirable behavior?

In operant conditioning, a person learns to behave a certain way because that behavior is reinforced. One therapy based on the principle of reinforcement is called behavior con- tracting. The therapist and the client agree on behavioral goals and on the reinforcement that the client will receive when he or she reaches those goals. These goals and reinforce- ments are often written in a contract that “legally” binds both the client and the therapist. A contract to help a person stop smoking might read: “For each day that I smoke fewer than 20 cigarettes, I will earn 30 minutes of time to go bowling. For each day that I exceed the goal, I will lose 30 minutes from the time that I have accumulated.”

The clients in these photographs are over- coming a simple phobia: fear of snakes. After practicing a technique of deep relaxation, clients in desensitization therapy work from the bottom of their hierarchy of fears up to the situation that provokes the greatest fear or anxiety. Here, clients progress from han- dling rubber snakes (top left) to viewing live snakes through a window (top center) and finally to handling live snakes. This procedure can also be conducted vicariously in the ther- apist’s office, where clients combine relax- ation techniques with imagining anxiety-provoking scenes.

aversive conditioning Behavioral therapy techniques aimed at eliminating undesirable behavior patterns by teaching the person to associate them with pain and discomfort.

behavior contracting Form of operant conditioning therapy in which the client and therapist set behavioral goals and agree on reinforcements that the client will receive on reaching those goals.

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Another therapy based on operant conditioning is called the token economy. Token economies are usually used in schools and hospitals, where controlled conditions are most feasible (Boniecki & Moore, 2003; Comaty, Stasio, & Advokat, 2001). People are rewarded with tokens or points for appropriate behaviors, which can be exchanged for desired items and privileges. In a mental hospital, for example, improved grooming habits might earn points that can be used to purchase special foods or weekend passes. The positive changes in behavior, however, do not always generalize to everyday life outside the hospital or clinic, where adaptive behavior is not always reinforced and maladaptive behavior is not always punished.

token economy An operant conditioning therapy in which people earn tokens (reinforcers) for desired behaviors and exchange them for desired items or privileges.

CHECK YOUR UNDERSTANDING

1. The therapeutic use of rewards to encourage desired behavior is based on a form of learning called ____________ ____________.

2. When client and therapist agree on a written set of behavioral goals, as well as a specific schedule of reinforcement when each goal is met, they are using a technique called ____________ ____________.

3. Some therapy involves learning desired behaviors by watching others perform those actions, which is also known as ____________.

4. A ____________ ____________ is an operant conditioning technique whereby people earn some tangible item for desired behavior, which can then be exchanged for more basic rewards and privileges.

5. The technique of ____________ involves intense and prolonged exposure to something feared.

Answers:1. operant conditioning.2. behavior contracting.3. modeling.4. token economy. 5. flooding.

APPLY YOUR UNDERSTANDING

1. Maria is in an alcoholism treatment program in which she must take a pill every morning. If she drinks alcohol during the day, she immediately feels nauseous. This treatment is an example of

a. transference. b. flooding. c. aversive conditioning. d. desensitization.

2. Robert is about to start a new job in a tall building; and he is deathly afraid of riding in elevators. He sees a therapist who first teaches him how to relax. Once he has mastered that skill, the therapist asks him to relax while imagining that he is entering the office building. Once he can do that without feeling anxious, the therapist asks him to relax while imagining standing in front of the elevator doors, and so on until Robert can completely relax while imagining riding in elevators. This therapeutic technique is known as

a. transference. b. desensitization. c. behavior contracting. d. flooding. Answers:1. c.2. b.

modeling A behavior therapy in which the person learns desired behaviors by watching others perform those behaviors.

Therapies Based on Modeling What are some therapeutic uses of modeling?

Modeling—learning a behavior by watching someone else perform it—can also be used to treat problem behaviors. In a now classic demonstration of modeling, Albert Bandura and colleagues helped people to overcome a snake phobia by showing films in which

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models gradually moved closer and closer to snakes (Bandura, Blanchard, & Ritter, 1969). Modeling techniques have also been successfully used as part of job training pro- grams (P. J. Taylor, Russ-Eft, & Chan, 2005) and have been used extensively with people with mental retardation to teach job and independent living skills (Cannella-Malone et al., 2006; Farr, 2008).

COGNITIVE THERAPIES How can people overcome irrational and self-defeating beliefs?

Cognitive therapies are based on the belief that if people can change their distorted ideas about themselves and the world, they can also change their problem behaviors and make their lives more enjoyable (Bleijenberg, Prins, & Bazelmans, 2003). A cognitive therapist’s goal is to identify erroneous ways of thinking and to correct them. Three popular forms of cognitive therapy are stress-inoculation therapy, rational–emotive therapy, and Aaron Beck’s cognitive approach.

Stress-Inoculation Therapy How can self-talk help us deal with difficult situations?

As we go about our lives, we talk to ourselves constantly—proposing courses of action, commenting on our performance, expressing wishes, and so on. Stress-inoculation ther- apy makes use of this self-talk to help people cope with stressful situations. The client is taught to suppress any negative, anxiety-evoking thoughts and to replace them with pos- itive, “coping” thoughts. A student facing anxiety with an exam may think, “Another test; I’m so nervous. I’m sure I won’t know the answers. If only I’d studied more. If I don’t get through this course, I’ll never graduate!” This pattern of thought is dysfunctional because it only makes anxiety worse. With the help of a cognitive therapist, the student learns a new pattern of self-talk: “I studied hard, and I know the material well. I looked at the textbook last night and reviewed my notes. I should be able to do well. If some ques- tions are hard, they won’t all be, and even if it’s tough, my whole grade doesn’t depend on just one test.” Then the person tries the new strategy in a real situation, ideally one of only moderate stress (like a short quiz). Finally, the person is ready to use the strategy in a more stressful situation, like a final exam (Sheehy & Horan, 2004). Stress-inoculation therapy works by turning the client’s thought patterns into a kind of vaccine against stress-induced anxiety.

Rational–Emotive Therapy What irrational beliefs do many people hold?

Another type of cognitive therapy, rational–emotive therapy (RET), developed by Albert Ellis (1973, 2001), is based on the view that most people in need of therapy hold a set of irrational and self-defeating beliefs (Macavei, 2005; Overholser, 2003). They believe that they should be competent at everything, always treated fairly, quick to find solutions to every problem, and so forth. Such beliefs involve absolutes—“musts” and “shoulds”— and make no room for mistakes. When people with such irrational beliefs come up against real-life struggles, they often experience excessive psychological distress.

Rational–emotive therapists confront such dysfunctional beliefs vigorously, using a variety of techniques, including persuasion, challenge, commands, and theoretical argu- ments (A. Ellis & MacLaren, 1998). Studies have shown that RET often enables people to

L E A R N I N G O B J E C T I V E S • Describe the common beliefs that

underlie all cognitive therapies. • Compare and contrast stress-inoculation

therapy, rational–emotive therapy, and Beck’s cognitive therapy.

cognitive therapies Psychotherapies that emphasize changing clients’ perceptions of their life situation as a way of modifying their behavior.

stress-inoculation therapy A type of cognitive therapy that trains clients to cope with stressful situations by learning a more useful pattern of self-talk.

According to cognitive therapists, the confi- dence this person is showing stems from the positive thoughts she has about herself. Stress-inoculation therapy helps replace negative, anxiety-evoking thoughts with con- fident self-talk.

rational–emotive therapy (RET) A directive cognitive therapy based on the idea that clients’ psychological distress is caused by irrational and self-defeating beliefs and that the therapist’s job is to challenge such dysfunctional beliefs.

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reinterpret negative beliefs and experiences more positively, decreasing the likelihood of depression (Blatt, Zuroff, Quinlan, & Pilkonis, 1996; Bruder et al., 1997).

Beck’s Cognitive Therapy How can cognitive therapy be used to combat depression?

One of the most important and promising forms of cognitive therapy for treating depres- sion is known simply as cognitive therapy (J. Cahill et al., 2003). Sometimes it is referred to as “Beck’s cognitive therapy,” after developer Aaron Beck (1967), to distinguish between the broader category of cognitive therapies.

Beck believes that depression results from inappropriately self-critical patterns of thought. Self-critical people have unrealistic expectations, magnify failures, make sweeping negative generalizations based on little evidence, notice only negative feedback from the outside world, and interpret anything less than total success as failure. Although Beck’s assumptions about the cause of depression are very similar to those underlying RET, the style of treatment differs considerably. Cognitive therapists are much less challenging and confrontational than rational–emotive therapists (Dozois, Frewen, & Covin, 2006). Instead, they try to help clients examine each dysfunctional thought in a supportive, but objectively scientific manner (“Are you sure your whole life will be totally ruined if you break up with Frank? What is your evidence for that? Didn’t you once tell me how happy you were before you met him?”). Like RET, Beck’s cognitive therapy tries to lead the person to more realistic and flexible ways of thinking. Watch on MyPsychLab

CHECK YOUR UNDERSTANDING

1. Developing new ways of thinking that lead to more adaptive behavior lies at the heart of all ____________ therapies.

2. An important form of cognitive therapy used to combat depression was developed by Aaron ____________.

3. The immediate focus in cognitive therapies is to help clients change their behaviors. Is this statement true (T) or false (F)?

Answers:1. cognitive.2. Beck.3. (F).

APPLY YOUR UNDERSTANDING

1. Larry has difficulty following his boss’s directions. Whenever his boss asks him to do something, Larry panics. Larry enters a stress-inoculation program. Which is most likely to be the first step in this program?

a. Have Larry volunteer to do a task for his boss. b. Show Larry a film in which employees are asked to do tasks and they perform well. c. Ask Larry what he says to himself when his boss asks him to perform a task. d. Ask Larry how he felt when he was a child and his mother asked him to do something.

2. Sarah rushes a sorority but isn’t invited to join. She has great difficulty accepting this fact and as a consequence she becomes deeply depressed. She sees a therapist who vigorously challenges and confronts her in an effort to show her that her depression comes from an irrational, self-defeating belief that she must be liked and accepted by everyone. This therapist is most likely engaging in

a. rational–emotive therapy. b. stress-inoculation therapy. c. flooding. d. desensitization therapy.

Answers:1. c.2. a. cognitive therapy Therapy that depends on identifying and changing inappropriately negative and self-critical patterns of thought.

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GROUP THERAPIES What are some advantages of group therapies?

Some therapists believe that treating several people simultaneously is preferable to individ- ual treatment. Group therapy allows both client and therapist to see how the person acts around others. If a person is painfully anxious and tongue-tied, chronically self-critical, or hostile, these tendencies show up quickly in a group.

Group therapies have the other advantage of social support—a feeling that one is not the only person in the world with problems. Group members can help one another learn useful new behaviors, like how to disagree without antagonizing others. Group interactions can lead people toward insights into their own behavior, such as why they

are defensive or feel compelled to complain constantly. Because group therapy consists of several clients “sharing” a therapist, it is less expensive than individual therapy (Fejr, 2003; N. Morrison, 2001).

There are many kinds of group therapy. Some groups follow the general outlines of the therapies we have already mentioned. Others are oriented toward a specific goal, such as stopping smoking or drinking. Others may have a more open-ended goal—for example, a happier family or romantic relationship.

Family Therapy Who is the client in family therapy?

Family therapy is one form of group therapy (Lebow, 2006; Snow, Crethar, & Robey, 2005). Family therapists believe that if one person in the family is having problems, it’s a signal that the entire family needs assistance. Therefore, it would be a mistake to treat a client without attempting to meet the person’s parents, spouse, or children. Family therapists do not try to reshape the personalities of family members (Gurman & Kniskern, 1991), rather, they attempt to improve communica- tion, encourage empathy, share responsibilities, and reduce family conflict. To achieve these goals, all family members must believe that they will benefit from behavioral changes.

Although family therapy is appropriate when there are problems between husband and wife or parents and children, it is increasingly used when only one family member has a clear psychological disorder (Keitner, Archambault, Ryan, & Miller, 2003; Mueser, 2006). The goal of treatment in these circumstances is to help mentally healthy members of the family cope more effectively with the impact of the disorder on the family unit, which in turn, helps the troubled person. Family therapy is also called for when a person’s progress in individual therapy is slowed by the family (often because other family members have trouble adjusting to that person’s improvement).

Couple Therapy What are some techniques used in couple therapy?

Another form of group therapy is couple therapy, which is designed to assist partners who are having relationship difficulties. Previously termed marital therapy, the term “couple therapy” is considered more appropriate today because it captures the broad range of part- ners who may seek help (Lebow, 2006; Sheras & Koch-Sheras, 2006).

group therapy Type of psychotherapy in which clients meet regularly to interact and help one another achieve insight into their feelings and behavior.

L E A R N I N G O B J E C T I V E S • Describe the potential advantages of group

therapy compared to individual therapy. • Compare and contrast family therapy,

couple therapy, and self-help groups.

Group therapy can help to identify problems that a person has when interacting with other people. The group also offers social support, helping people to feel less alone with their problems.

family therapy A form of group therapy that sees the family as at least partly responsible for the individual’s problems and that seeks to change all family members’ behaviors to the benefit of the family unit as well as the troubled individual.

couple therapy A form of group therapy intended to help troubled partners improve their problems of communication and interaction.

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Most couple therapists concentrate on improving patterns of communication and mutual expectations. In empathy training, each member of the couple is taught to share inner feelings and to listen to and understand the partner’s feelings before responding. This tech- nique requires more time spent listening, grasping what is really being said, and less time in self-defensive rebuttal. Other couple therapists use behavioral techniques, such as helping a couple develop a schedule for exchanging specific caring actions, like helping with chores or making time to share a special meal together. This approach may not sound romantic, but proponents say it can break a cycle of dissatisfaction and hostility in a relationship, and hence, it is an important step in the right direction (N. B. Epstein, 2004). Couple therapy for both partners is generally more effective than therapy for just one (Fraser & Solovey, 2007; Susan Johnson, 2003).

Self-Help Groups Why are self-help groups so popular?

An estimated 57 million Americans suffer some kind of psychological problem (Kessler, Chiu, Demler, & Walters, 2005). Since individual treatment can be expensive, more and more people faced with life crises are turning to low-cost self-help groups. Most groups are small, local gatherings of people who share a common problem and who provide mutual support. Alcoholics Anonymous is perhaps the best-known self-help group, but self-help groups are available for virtually every life problem.

Do these self-help groups work? In many cases, they apparently do. Alcoholics Anony- mous has developed a reputation for helping people cope with alcoholism. Most group mem- bers express strong support for their groups, and studies have demonstrated that they can indeed be effective (Galanter, Hayden, Castañeda, & Franco, 2005; Kurtz, 2004; McKellar, Stewart, & Humphreys, 2003).

Such groups also help to prevent more serious psychological disorders by reaching out to people who are near the limits of their ability to cope with stress. The social support they offer is particularly important in an age when divorce, geographic mobility, and other factors have reduced the ability of the family to comfort people. A list of some self-help organiza- tions is included in “Applying Psychology: How to Find Help.”

CHECK YOUR UNDERSTANDING

1. Which of the following is an advantage of group therapy? a. The client has the experience of interacting with other people in a therapeutic setting. b. It often reveals a client’s problems more quickly than individual therapy. c. It can be cheaper than individual therapy. d. All of the above.

Answers:1. d.

APPLY YOUR UNDERSTANDING

1. You are talking to a clinical psychologist who explains that, in her view, it is a mistake to try to treat a client’s problems in a vacuum. Quite often, well-adjusted members of a family can help the client cope more effectively. Other times, the client’s progress is slowed due to other people in the family. She is most likely a

a. self-help therapist. b. family therapist. c. proximity therapist. d. social-attribution therapist.

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How to Find Help

The attitude that seeking help for psy-chological problems is a sign of“weakness” is very common in our society. But the fact is that millions of peo- ple, including students, are helped by psy- chological counseling and therapy every year. Therapy is a common, useful aid in coping with daily life.

College is a time of stress and anxiety for many people. The competition for grades, the exposure to many different kinds of people with unfamiliar views, the tension of relating to peers all can take a psychological toll, especially for students away from home for the first time. Most colleges and univer- sities have their own counseling services, and many are as sophisticated as the best clinics in the country. Most communities also have mental health programs. As an aid to a potential search for the right counseling service, we include here a list of some of the available resources for people who seek the advice of a mental health professional. Many of these services have national offices that can provide local branch information and the appropriate people to contact.

FOR ALCOHOL AND DRUG ABUSE

National Clearinghouse for Alcohol and Drug Information

Rockville, MD (800) 729-6686

General Service Board Alcoholics Anonymous, Inc. New York, NY (212) 870-3400

FOR FRIENDS OR RELATIVES OF THOSE WITH AN ALCOHOL PROBLEM

Al-Anon Family Groups Virginia Beach, VA (888) 4alanon (meeting information) (757) 563-1600 (personal assistance) Web site: www.al-anon.alateen.org

National Association for Children of Alcoholics

Rockville, MD (301) 468-0985

FOR DEPRESSION AND SUICIDE Mental Health Counseling Hotline New York, NY (212) 734-5876

Heartbeat (for survivors of suicides) Colorado Springs, CO (719) 596-2575

FOR SEXUAL AND SEX-RELATED PROBLEMS

Sex Information and Education Coun- cil of the United States (SIECUS)

New York, NY (212) 819-9770

National Organization for Women Legislative Office Washington, DC (202) 331-0066

FOR PHYSICAL ABUSE Child Abuse Listening and Mediation

(CALM) Santa Barbara, CA (805) 965-2376

FOR HELP IN SELECTING A THERAPIST

National Mental Health Consumer Self-Help Clearinghouse

(215) 751-1810

FOR GENERAL INFORMATION ON MENTAL HEALTH AND COUNSELING

The National Alliance for the Mentally Ill Arlington, VA (703) 524-7600

The National Mental Health Association

Alexandria, VA (703) 684-7722

The American Psychiatric Association Washington, DC (703) 907-7300

The American Psychological Association Washington, DC (202) 336-5500

The National Institute of Mental Health Rockville, MD (301) 443-4513

Answers:1. b.2. d.

2. Imagine that you believe most problems between partners arise because they don’t share their inner feelings and they don’t truly listen to and try to understand each other. You meet with them together and teach them to spend more time listening to the other person and trying to understand what the other person is really saying. Your beliefs are closest to which of the following kinds of therapists?

a. Gestalt therapists. b. rational–emotive therapists. c. family therapists. d. couple therapists.

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L E A R N I N G O B J E C T I V E S • Summarize the research evidence that

psychotherapy is, in fact, more effective than no therapy at all. Briefly describe the five major results of the Consumer Reports study.

• Describe the common features shared by all forms of psychotherapy that may account for the fact that there is little or no overall difference in their effectiveness. Explain the statement that “Some kinds of psychotherapy seem to be particularly appropriate for certain people and problems”; include examples.

EFFECTIVENESS OF PSYCHOTHERAPY How much better off is a person who receives psychotherapy than one who gets no treatment at all?

We have noted that some psychotherapies are generally effective, but how much better are they than no treatment at all? Researchers have found that roughly twice as many people (two-thirds) improve with formal therapy than with no treatment at all (Borkovec & Costello, 1993; M. J. Lambert, 2001). Furthermore, many people who do not receive formal therapy get therapeutic help from friends, clergy, physicians, and teachers. Thus, the recov- ery rate for people who receive no therapeutic help at all is quite possibly even less than one-third. Other studies concur on psychotherapy’s effectiveness (Hartmann & Zepf, 2003; M. J. Lambert & Archer, 2006; Leichsenring & Leibing, 2003), although its value appears to be related to a number of other factors. For instance, psychotherapy works best for rela- tively mild psychological problems (Kopta, Howard, Lowry, & Beutler, 1994) and seems to provide the greatest benefits to people who really want to change such as Brooke Shields (Orlinsky & Howard, 1994).

Finally, one very extensive study designed to eval- uate the effectiveness of psychotherapy was reported by Consumer Reports. Largely under the direction of psychologist Martin E. P. Seligman (1995), this investi- gation surveyed 180,000 Consumer Reports subscribers on everything from automobiles to mental health. Approximately 7,000 people from the total sample responded to the mental health section of the ques- tionnaire that assessed satisfaction and improvement in people who had received psychotherapy, with the following results.

First, the vast majority of respondents reported significant overall improvement after therapy (Seligman, 1995). Second, there was no difference in the overall improvement score among people who had received therapy alone and those who had com- bined psychotherapy with medication. Third, no differences were found between the various forms of psychotherapy. Fourth, no differences in effectiveness were indicated between psychologists, psychiatrists, and social workers, although mar- riage counselors were seen as less effective. Fifth, people who received long-term therapy reported more improvement than those who received short-term therapy. This last result, one of the most striking findings of the study, is illustrated in Figure 13–1. Though the Consumer Reports study lacked the scientific rigor of more traditional inves- tigations designed to assess psychotherapeutic efficacy (Jacobson & Christensen, 1996; Seligman, 1995, 1996), it does provides broad support for the idea that psychotherapy works.

Which Type of Therapy Is Best for Which Disorder? An important question is whether some forms of psychotherapy are more effective than others (Lyddon & Jones, 2001). Is behavior therapy, for example, more effective than insight therapy? In general, the answer seems to be “not much” (J. A. Carter, 2006; Hanna, 2002; Wampold et al., 1997). Most of the benefits of treatment seem to come from being in some kind of therapy, regardless of the particular type.

As we have seen, the various forms of psychotherapy are based on very different views about what causes mental disorders and, at least on the surface, approach the treatment of mental disorders in different ways. Why, then, is there no difference in their effectiveness? To answer this question, some psychologists have focused their attention on what the various

Survey Results

The text states that the Consumer Reports study lacked the scientificrigor of more traditional investigations. Think about the followingquestions: • How were the respondents selected? How does that compare to the

way in which scientific surveys select respondents (see Chapter 1, “The Science of Psychology”)?

• How did the study determine whether the respondents had improved? • How would a psychologist conduct a more scientific study of the effec-

tiveness of psychotherapy? What variables would need to be defined? How would the participants be chosen? What ethical issues might need to be considered?

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forms of psychotherapy have in common, rather than emphasizing their differences (J. A. Carter, 2006; A. H. Roberts, Kewman, Mercer, & Hovell, 1993):

1. All forms of psychotherapy provide people with an explanation for their problems. Along with this explanation often comes a new perspective, providing people with specific actions to help them cope more effectively.

2. Most forms of psychotherapy offer people hope. Because most people who seek therapy have low self-esteem and feel demoralized and depressed, hope and the expectation for improvement increase their feelings of self-worth.

3. All major types of psychotherapy engage the client in a therapeutic alliance with a therapist. Although their therapeutic approaches may differ, effective therapists are warm, empathetic, and caring people who understand the importance of establishing a strong emotional bond with their clients that is built on mutual respect and understanding (Norcross, 2002; Wampold, 2001).

Together, these nonspecific factors common to all forms of psychotherapy appear to help explain why most people who receive any form of therapy show some benefits, com- pared with those who receive none at all (D. N. Klein et al., 2003).

Some kinds of psychotherapy seem to be particularly appropriate for certain people and problems. Insight therapy, for example, though reasonably effective with a wide range of mental disorders (de Maat, de Jonghe, Schoevers, & Dekker, 2009), seems to be best suited to people seeking profound self-understanding, relief of inner conflict and anxiety, or better relationships with others. It has also been found to improve the basic life skills of people suffering from schizophrenia (Maxine Sigman & Hassan, 2006). Behavior therapy is apparently most appropriate for treating specific anxieties or other well-defined behavioral problems, such as sexual dysfunctions. Couple therapy is generally more effective than individual counseling for the treatment of drug abuse (Fals-Stewart & Lam, 2008; Liddle & Rowe, 2002).

Figure 13–1 Duration of therapy and improvement. One of the most dramatic results of the Consumer Reports (1995) study on the effective- ness of psychotherapy was the strong relation- ship between reported improvement and the duration of therapy. Source: Adapted from “The Effectiveness of Psychotherapy: The Consumer Reports Study” by M. E. P. Seligman, American Psychologist, 50 (1995), pp. 965–974. Copyright © 1995 by American Psychological Association.

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BIOLOGICAL TREATMENTS What are biological treatments, and who can provide them?

Biological treatments—a group of approaches including medication, electroconvulsive therapy, and psychosurgery—may be used to treat psychological disorders in addition to, or instead of, psychotherapy. Clients and therapists opt for biological treatments for several reasons. First, some people are too agitated, disoriented, or unresponsive to be helped by psychotherapy. Second, biological treatment is virtually always used for disorders with a strong biological component. Third, biological treatment is often used for people who are dangerous to themselves and to others.

Traditionally, the only mental health professionals licensed to offer biological treat- ments were psychiatrists, who are physicians. However, some states now permit specially trained psychologists to prescribe drugs. Therapists without such training often work with physicians who prescribe medication for their clients. In many cases where biological treat- ments are used, psychotherapy is also recommended; medication and psychotherapy used

CHECK YOUR UNDERSTANDING

1. There is a trend among psychotherapists to combine treatment techniques in what is called ____________.

2. Most researchers agree that psychotherapy helps about ____________ ____________ of the people treated.

3. Psychotherapy works best for relatively ____________ disorders, as compared with ____________ ones.

Answers:1. eclecticism.2. two-thirds.3. mild, severe.

APPLY YOUR UNDERSTANDING

1. Your friend is experiencing anxiety attacks, but doesn’t want to see a therapist because “they don’t do any good.” Which of the following replies most accurately reflects what you have learned about the effectiveness of therapy?

a. “You’re right. Psychotherapy is no better than no treatment at all.” b. “Actually, even just initiating therapy has a beneficial effect compared with doing

nothing.” c. “You’re at least twice as likely to improve if you see a therapist than if you don’t.” d. “Therapy could help you, but you’d have to stick with it for at least a year before it

has any effect.”

2. John is suffering from moderate depression. Which of the following therapies is most likely to help him?

a. insight therapy b. cognitive therapy c. behavioral contracting d. group therapy

Answers:1. c.2. b.

L E A R N I N G O B J E C T I V E S • Explain why some clients and

therapists opt for biological treatment instead of psychotherapy.

• Describe the major antipsychotic and antidepressant drugs including their significant side effects.

• Describe electroconvulsive therapy and psychosurgery, their effectiveness in treating specific disorders, and their potential side effects. Explain why these are “last resort treatments” that are normally used only other treatments have failed.

eclecticism Psychotherapeutic approach that recognizes the value of a broad treatment package over a rigid commitment to one particular form of therapy.

biological treatments A group of approaches, including medication, electroconvulsive therapy, and psychosurgery, that are sometimes used to treat psychological disorders in conjunction with, or instead of, psychotherapy.

Cognitive therapies have been shown to be effective treatments for depression (Ham- dan-Mansour, Puskar, & Bandak, 2009; Leahy, 2004) and anxiety disorders (M. A. Stanley et al., 2009), and even show some promise in reducing suicide (Wenzel, Brown, & Beck, 2009). In addition, cognitive therapies have been used effectively to treat people with per- sonality disorders by helping them change their core beliefs and reducing their automatic acceptance of negative thoughts (McMain & Pos, 2007; S. Palmer et al., 2006; Tarrier, Taylor, & Gooding, 2008). The trend in psychotherapy is toward eclecticism—that is, toward recognition of the value of a broad treatment package, rather than commitment to a single form of therapy (J. A. Carter, 2006; Slife & Reber, 2001).

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together generally are more effective for treating major depression and for preventing a recurrence than either treatment used alone (M. B. Keller et al., 2000; Manber et al., 2008).

Drug Therapies What are some of the drugs used to treat psychological disorders?

Medication is frequently and effectively used to treat a number of psychological problems. (See Table 13–1.) In fact, Prozac, a drug used to treat depression, today is one of the best selling of all prescribed medications. Two major reasons for the widespread use of drug therapies today are the development of several very effective psychoactive medications and the fact that drug therapies can cost less than psychotherapy. Critics suggest, however, that another reason is our society’s “pill mentality,” or belief that we can take a medicine to fix any problem.

Antipsychotic Drugs Before the mid-1950s, drugs were not widely used to treat psy- chological disorders, because the only available sedatives induced sleep as well as calm. Then the major tranquilizers reserpine and the phenothiazines were introduced. In addition to alleviating anxiety and aggression, both drugs reduce psychotic symptoms, such as hal- lucinations and delusions; for that reason, they are called antipsychotic drugs. Antipsy- chotic drugs are prescribed primarily for very severe psychological disorders, particularly schizophrenia. They are very effective for treating schizophrenia’s “positive symptoms,” like hallucinations, but less effective for the “negative symptoms,” like social withdrawal. The most widely prescribed antipsychotic drugs are known as neuroleptics, which work by blocking the brain’s receptors for dopamine, a major neurotransmitter (Leuner & Müller, 2006; Oltmanns & Emery, 2006). The success of antipsychotic drugs in treating schizophre- nia supports the notion that schizophrenia is linked in some way to an excess of this neuro- transmitter in the brain. (See Chapter 12, “Psychological Disorders.”)

Antipsychotic medications sometimes have dramatic effects. People with schizophre- nia who take them can go from being perpetually frightened, angry, confused, and plagued by auditory and visual hallucinations to being totally free of such symptoms. These drugs do not cure schizophrenia; they only alleviate the symptoms while the person is taking the

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Table 13–1 MAJOR TYPES OF PSYCHOACTIVE MEDICATIONS

Therapeutic Use Chemical Structure Trade Name*

Antipsychotics Phenothiazines Thorazine, Therazine, Olanzapine, Risperdal, Clozapine

Antidepressants Tricyclics Elavil MAO inhibitors Nardil SSRIs Paxil, Prozac, Zoloft SNRI Effexor

Psychostimulants Amphetamines Dexedrine Other Ritalin, Adderall

Antiseizure Carbamazepine Tegretol Antianxiety Benzodiazepines Valium Sedatives Barbiturates Antipanic Tricyclics Tofranil Antiobsessional Tricyclics Anafranil

*The chemical structures and especially the trade names listed in this table are representative examples, rather than an exhaustive list, of the many kinds of medications available for the specific therapeutic use.

Source: Klerman et al., 1994 (adapted and updated).antipsychotic drugs Drugs used to treat very severe psychological disorders, particularly schizophrenia.

Explore Drugs Commonly Used to Treat Psychiatric Disor- ders at www.mypsychlab.com

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drug (Oltmanns & Emery, 2006; P. Thomas et al., 2009). Moreover, antipsychotic drugs can have a number of undesirable side effects (H.-Y. Lane et al., 2006., Roh, Ahn, & Nam, 2006). Blurred vision, weight gain, and constipation are among the common complaints, as are temporary neurological impairments such as muscular rigidity or tremors. A very serious potential side effect is tardive dyskinesia, a permanent disturbance of motor control, partic- ularly of the face (uncontrollable smacking of the lips, for instance), which can be only par- tially alleviated with other drugs (Chong, Tay, Subramaniam, Pek, & Machin, 2009; Eberhard, Lindström, & Levander, 2006). In addition, some of the antipsychotic medica- tions that are effective with adults are not as well tolerated by children who experience an increased risk for many of the side effects described above (Kumra et al., 2008). Another problem is that antipsychotics are of little value in treating the problems of social adjust- ment that people with schizophrenia face outside an institutional setting. Because many discharged people fail to take their medications, relapse is common. However, the relapse rate can be reduced if drug therapy is effectively combined with psychotherapy.

Mind–Body Combining Drugs and Psychotherapy For some disorders a combination of drugs and psychotherapy works better than either approach used independently. This underscores the fact that the relationship between mind and body is highly complex. The causes of depression have not yet been fully determined, but they will probably be found to include a mixture of genetic predisposi- tion, chemical changes in the brain, and life situation (see Chapter 12, “Psychological Disorders”). ■

Antidepressant Drugs A second group of drugs, known as antidepressants, is used to combat depression like that experienced by Brooke Shields. Until the end of the 1980s, there were only two main types of antidepressant drugs: monoamine oxidase inhibitors (MAO inhibitors) and tricyclics. Both drugs work by increasing the concentration of the neuro- transmitters serotonin and norepinephrine in the brain (McKim, 2007; A. V. Terry, Bucca- fusco, & Wilson, 2008). Both are effective for most people with serious depression, but both produce a number of serious and troublesome side effects.

In 1988, Prozac (fluoxetine) came onto the market. This drug works by reducing the uptake of serotonin in the nervous system, thus increasing the amount of serotonin active in the brain at any given moment. (See Figure 13–2.) For this reason, Prozac is part of a group of psychoactive drugs known as selective serotonin reuptake inhibitors (SSRIs). (See Chapter 2, “The Biological Basis of Behavior.”) Today, a number of second-generation SSRIs are available to treat depression, including Paxil (paroxetine), Zoloft (sertraline), and Effexor (venlafaxine HCl). For many people, correcting the imbalance in these chemicals in the brain reduces their symptoms of depression and also relieves the associated symptoms of anxiety. More- over, because these drugs have fewer side effects than do MAO inhibitors or tricyclics (Nemeroff & Schatzberg, 2002), they have been heralded in the popular media as “wonder drugs” for the treatment of depression.

Today, antidepressant drugs are not only used to treat depression, but also have shown promise in treating general- ized anxiety disorder, panic disorder, obsessive–compulsive dis- order, social phobia, and posttraumatic stress disorder (M. H. Pollack & Simon, 2009; Ralat, 2006). Antidepressant drugs

Figure 13–2 How do the SSRIs work? Antidepressants like Prozac, Paxil, and Zoloft belong to a class of drugs called SSRIs (selec- tive serotonin reuptake inhibitors). These drugs reduce the symptoms of depression by blocking the reabsorption (or reuptake) of serotonin in the synaptic space between neurons. The increased availability of serotonin to bind to receptor sites on the receiving neuron is thought to be responsible for the ability of these drugs to relieve the symptoms of depression.

Terminal button

Dendrite or cell body

Synaptic space

Synaptic vesicles release serotonin into

synaptic space

SSRIs block the reuptake of excess serotonin

Normal path for serotonin

reuptake

Serotonin in receptor site of

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like the SSRIs do not work for everyone, however. At least a quarter of the patients with major depressive disorder do not respond to antidepressant drugs (Shelton & Hollon, 2000). Moreover, for some patients, these drugs produce unpleasant side effects, including nausea, weight gain, insomnia, headaches, anxiety, and impaired sexual functioning (Demyttenaere & Jaspers, 2008). They can also cause severe withdrawal symptoms in patients who abruptly stop taking them (Kotzalidis et al., 2007).

Lithium Bipolar disorder is frequently treated with lithium carbonate. Lithium is not a drug, but a naturally occurring salt that is generally quite effective in treating bipolar disor- der (Gnanadesikan, Freeman, & Gelenberg, 2003) and in reducing the incidence of suicide in bipolar patients (Grandjean & Aubry, 2009). We do not know exactly how lithium works, but recent studies with mice indicate that it may act to stabilize the levels of specific neuro- transmitters (Dixon & Hokin, 1998) or alter the receptivity of specific synapses (G. Chen & Manji, 2006). Unfortunately, some people with bipolar disorder stop taking lithium when their symptoms improve—against the advice of their physicians; this leads to a relatively high relapse rate (Gershon & Soares, 1997; M. Pope & Scott, 2003).

Other Medications Several other medications can be used to alleviate the symptoms of various psychological problems. (See Table 13–1.) Psychostimulants heighten alertness and arousal. Some psychostimulants, such as Ritalin, are commonly used to treat children with attention-deficit hyperactivity disorder (Ghuman, Arnold, & Anthony, 2008). In these cases, they have a calming, rather than stimulating effect. Some professionals worry that psychostimulants are being overused, especially with young children (S. Rose, 2008). Antianxiety medications, such as Valium, are commonly prescribed as well. Quickly produc- ing a sense of calm and mild euphoria, they are often used to reduce general tension and stress. Because they are potentially addictive, however, they must be used with caution. Sedatives produce both calm and drowsiness, and are used to treat agitation or to induce sleep. These drugs, too, can become addictive.

Electroconvulsive Therapy How is modern electroconvulsive therapy different from that of the past?

Electroconvulsive therapy (ECT) is most often used for cases of prolonged and severe depression that do not respond to other forms of treatment (Birkenhaeger, Pluijms, & Lucius, 2003; Tess & Smetana, 2009). The technique involves briefly passing a mild electric current through the brain or, more recently, through only one of its hemispheres (S. G. Thomas & Kellner, 2003). Treatment normally consists of 10 or fewer sessions of ECT.

No one knows exactly why ECT works, but its effectiveness has been clearly demon- strated. In addition, the fatality rate for ECT is markedly lower than for people taking anti- depressant drugs (Henry, Alexander, & Sener, 1995). Still, ECT has many critics and its use remains controversial (Krystal, Holsinger, Weiner, & Coffey, 2000; Shorter & Healy, 2007). Side effects include brief confusion, disorientation, and memory impairment, though research suggests that unilateral ECT produces fewer side effects and is only slightly less effective than the traditional method (Bajbouj et al., 2006). In view of the side effects, ECT is usually considered a “last-resort” treatment after all other methods have failed.

Psychosurgery What is psychosurgery, and how is it used today?

Psychosurgery refers to brain surgery performed to change a person’s behavior and emo- tional state. This is a drastic step, especially because the effects of psychosurgery are diffi- cult to predict. In a prefrontal lobotomy, the frontal lobes of the brain are severed from the deeper centers beneath them. The assumption is that in extremely disturbed people, the

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electroconvulsive therapy (ECT) Biological therapy in which a mild electrical current is passed through the brain for a short period, often producing convulsions and temporary coma; used to treat severe, prolonged depression.

psychosurgery Brain surgery performed to change a person’s behavior and emotional state; a biological therapy rarely