15.4 behavior therapy psychodynamic therapy 15.5 cognitive …chapter+15.pdf · 2015-03-19 · 15.2...

Chapter Overview

15.1 Mental Health Practitioners and SettingsPsychiatristsCounseling and Clinical Psychologists

Counseling PsychologistsClinical Psychologists

Master’s-Level TherapistsSettings for Mental Health PractitionersThe Role of Psychotherapy

CONCEPT LEARNING CHECK 15.1 Comparing the Roles and Settings of Mental Health Practitioners

15.2 Psychodynamic TherapyTechniques of Psychodynamic TherapyTypes of Psychodynamic Therapy

Psychoanalysis

Short-Term Psychodynamic Therapy

CONCEPT LEARNING CHECK 15.2 Understanding Psychodynamic Therapies

15.3 Humanistic TherapyCarl Rogers and Client-Centered Therapy

CONCEPT LEARNING CHECK 15.3 Describing the Elements of Humanistic Therapy

15.4 Behavior TherapyClassic Conditioning TechniquesOperant Conditioning Techniques

CONCEPT LEARNING CHECK 15.4 Designing a Behavioral Treatment Plan

15.5 Cognitive TherapiesAaron Beck and Cognitive TherapyAlbert Ellis and Rational Emotive Therapy

Chapter Overview

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Learning Objectives

Therapies for Psychological Disorders15

CONCEPT LEARNING CHECK 15.5 Comparing Cognitive Therapies

15.6 Family Systems and Group TherapySystems ApproachesGroup Therapy

CONCEPT LEARNING CHECK 15.6 Describing an Eclectic Systems Approach

15.7 Biomedical TherapiesDrug Treatments

Antidepressant DrugsAntianxiety Drugs

Mood-Stabilizing DrugsAntipsychotic Drugs

Medical ProceduresElectroconvulsive TherapyOther Medical Procedures

CONCEPT LEARNING CHECK 15.7 Explaining the Use of Medications for Psychological Conditions

15.8 Evaluating Therapies for Psychological DisordersEffectiveness of Therapies for Psychological DisordersEffectiveness of Different Therapies

Common Factors That Increase EffectivenessCulture, Cultural Values, and Psychotherapy

CRITICAL THINKING APPLICATIONSummary of Multiple Influences on Therapies for Psychological Disorders

CONCEPT LEARNING CHECK 15.8 Summarizing the Factors of Effective Psychotherapy

15.1 Compare and contrast the roles of psychiatrists, counseling psychologists, and clinical psychologists.

Discuss the settings used by mental health practitioners.

15.2 Define psychodynamic therapy.

Illustrate the techniques used in psychodynamic therapy.

Compare and contrast traditional psychoanalytic therapy and short-term psychodynamic therapy.

15.3 Describe the role of genuineness, acceptance, and empathy in client-centered approaches.

15.4 Explain the ways in which behavioral therapies attempt to change maladaptive associations, discourage maladaptive behaviors, or encourage more adaptive ones.

Compare and contrast classical conditioning and operant conditioning.

15.5 Discuss Beck’s cognitive therapy and Ellis’s rational emotive therapy as they relate to cognitive therapy.

15.6 Illustrate how family systems therapy focuses on how individuals function in their relationships through communication patterns.

15.7 Explain the focus on changing physiological problems that lead to psychological conditions in biomedical therapies.

Compare and contrast the major classes of antidepressant drugs, the major drug treatments for anxiety, and antipsychotic medications.

Discuss other nondrug medical treatments for psychological conditions.

15.8 Describe how clinical trials test treatments for psychological conditions.

Discuss types of research that have provided evidence of the efficacy of treatments for psychological disorders.

I must have looked terrified. There I was, staring out the window at the wing of the airplane, doing my best to interpret the signals and noises around me. I always chose the window seat over the

wing. It is the safest part of the airliner, or so I was told, and it had the added benefit of being a front-row seat to all the commotion on the ever-wobbling wings. Every sound, every noise, every bump was a prelude to disaster—or so I imagined. This time was going to be different. In the palm of my hand was the miracle pill that would rescue me from my anxiety. I had recently received a prescription for a medication to help me with my phobia of flying.

Even as a psychology student, I always thought “fear of flying” was an odd term. It really was not the flying that scared me—it was the potential to suddenly not be flying that was the problem. On the plane, my brain would go into overtime analyzing hints of possible problems. I would scrutinize the flight attendants’ faces for any sign of nervousness, analyze the whirr and flailing of little flaps on the wing as they went up and down, and usually could convince myself, briefly, that it was some sort of visual warning to the other planes to stay way. My anxiety usually got the best of me.

I took the pill wondering how in the world something so small could help with such great anxiety. I expected it to make me feel dopey or sleepy like Xanax or Valium might. But it did not. In fact, it did not do anything at all. The next moment, as the engine started, I noticed that I was searching my body for anxiety. None was there. It was as if my brain had signaled, “cue stomach for anxiety,” and my stomach simply refused to obey. Something was different. But would it last?

The etiology , or cause, of a disorder informs the disorder’s treatment. Tension headaches, for example, are caused by inflammation. Reducing the inflammation with aspirin can be a good treatment. Because there are multiple influences on the creation of psychological conditions, there are many ways to intervene. Treatments can be behavioral, biological, sociocultural, or a mix of all of these. In this chapter, we will describe the professionals who use these techniques as well as many treatments that mental health practitioners employ to help those with psychological conditions. By the end of the chapter, you will have learned how each of these treatments is used, and you may realize that it took more than that one tiny pill to get me through the flight.

15.1 Mental Health Practitioners and Settings There are various kinds of mental health practitioners who help clients in a variety of settings.

Compare and contrast the roles of psychiatrists, counseling psychologists, and clinical psychologists.

Discuss the settings used by mental health practitioners.

Etiology Cause of a disorder.

Generally, when people experience a lot of stress, a significant event, depression, or other symptoms, they employ their own ways of coping. Often things get better. Sometimes they do not. When regular coping mechanisms offer little relief, or a new, objective approach is desired, people often seek professional help. How do people decide to get help? To what settings and what kind of person do they turn?

Naturally, some people are uneasy about seeking treatment the first time. People new to therapy sometimes think that the professional will think they are weak. Others seeking treatment wonder if they will be in therapy forever. These are common and understand-able concerns. Unfortunately, such concerns can delay help. The median delay for seeking treatment is about 6 years for bipolar disorder, 8 years for depression, and up to 10 years for panic disorders (Wang et al., 2005). Fortunately, many do seek treatment, and in the United States, about 15% of the population seek mental health treatment, mostly for depression and anxiety (Narrow, Regier, Rae, Manderscheid, & Locke, 1993).

Often people will say that they are going to a therapist, counselor, or a psychotherapist, which could refer to any number of mental health practitioners with various approaches to mental health concerns. There are many kinds of mental health professionals. In this section, we will discuss three: psychiatrists, counseling psychologists, and clinical psychologists.

PsychiatristsPsychiatry is a branch of medicine that treats mental and behavioral conditions. The first 2 years of medical training focus on the biomedical clinical sciences, followed by training in clinical specialties. Students earn professional doctoral degrees such as doctor of medicine (MD) or doctor of osteopathic medicine (DO). After medical school, those interested in psychiatry practice as psychiatric residents for another 4 years of in-depth training. Psychiatrists spend the majority of their time treating severe psychological condi-tions and may prescribe psychotropic mediation or order and interpret laboratory tests.

Counseling and Clinical PsychologistsIt can be confusing that some psychologists call themselves counseling psychologists while others are known as clinical psychologists. After all, counseling and clinical psychologists often do similar tasks and may even work together. A peek into the history of these two fields reveals their similarities and differences.

Counseling PsychologistsA counseling psychologist is a mental health professional who helps people experi-encing difficulty adjusting to life stressors to achieve greater well-being. Counsel comes from the Latin consulere, which means to consult or seek advice. Historically, counseling psychologists delivered occupational advice to help people choose careers best suited to their abilities and interests. Since then, counseling psychologists have expanded their role by providing psychotherapy. Many counseling psychologists focus on everyday people by helping them adjust to changes in their lives.

Clinical PsychologistsClinical psychologists are mental health practitioners who research, evaluate, and treat psychological conditions. Clinical gets its name from Greek kline, which means bed, as in recline, since most medical clinical work was done at the bedside. Historically, clinical psychologists have focused on psychopathology. Clinical psychologists began by provid-ing testing services and added psychotherapy, previously practiced only by psychiatrists, to their portfolio.

Clinical psychology training programs vary in their emphasis on the different roles of clinical psychologists. Clinical training programs can be based on a scientist-practi-tioner model, a practitioner-scholar model, or a clinical researcher model. The scientist- practitioner model, also called the Boulder model, is a balanced program in which students learn clinical skills as well as research skills. However, not everyone who is interested in clinical psychology wants to generate new research. Some are interested only in treatment. An alternative model for clinical psychologists is a program that focuses more on treatment than on generating research. This model emphasizes work with clients

Psychiatry A branch of medicine that treats mental and behavioral conditions.

Counseling psychologist A mental health professional who helps people experienc-ing difficulty adjusting to life stressors to achieve greater well-being.

Clinical psychologist A mental health practitioner who researches, evaluates, and treats psychological conditions.

Scientist-practitioner model Also called the Boulder model, a balanced program in which psychologists learn about clinical skills as well as research skills.

15.1 Mental Health Practitioners and Settings 581

Recently, some psychologists with advanced training in psychopharmacology, treatment of psychological conditions using medication, have been licensed to prescribe medicine. New Mexico granted properly trained psychologists prescriptive authority in 2002, and Louisiana followed by granting medical psychologists prescriptive authority.

Master’s-Level TherapistsSo far we have discussed mental health practitioners at the doctoral level. However, there are also many mental health practitioners who are trained at the master’s level. These include social workers, pastoral counselors, licensed professional counselors, and mar-riage and family therapists.

Settings for Mental Health PractitionersMental health practitioners work in many settings. Some work in modern mental hospi-tals, medical centers that treat psychological conditions. Many more work in outpatient settings, which are outside of hospitals.

Mental hospitals have come a long way since their beginning. The first mental hospi-tals, called asylums, opened in Europe around 850. The Bethlem Royal Hospital in London FIGURE 15-2, for example, was an early mental hospital for those suffering from mental con-ditions. It also housed the poor and people being punished for crimes. Those hospitalized were sometimes subjected to torture and deprivation. It would not be until the late 1700s when more humane mental hospitals would be built (Porter, 2003).

and shifts the focus from generating new research to understanding, synthesizing, and applying existing research. The practitioner-scholar model, otherwise known as the Vail model, along with a professional doctorate in psychology (doctor of psychology, or PsyD) is well suited for individuals who want to focus on treatment. Still others who are interested in psychology focus on generating new research and less on working directly with clients. Research is the basis of the clinical researcher model, a training program that emphasizes clinical psychology research over direct work with clients FIGURE 15-1.

In addition to coursework, doctoral students in psychology undertake 2 to 3 years of supervised training and complete scholarly work such as a dissertation in PhD programs or an extensive literature review in PsyD programs.

Practitioner-scholar model Also called the Vail model, a program in which psy-chologists emphasize clinical training over generating new research in order to under-stand, synthesize, and apply existing research.

Clinical researcher model A type of psychology program that emphasizes clinical psy-chology research over direct work with clients.

Psychopharmacology Treatment of psychological conditions using medication.

Mental hospital A medical center that treats psychologi-cal conditions.

Outpatient Treatment set-tings that are outside of a hospital.

A psychiatrist’s work with clients may include writing prescriptions to treat psychological conditions.

FIGURE 15-2 The first Bethlem Royal Hospital was built in the 14th century. Known as “Bedlam,” this was the first hospital specializing in the treatment of psychiatric conditions.

FIGURE 15-1 Types of psychological training programs.

Practitioner-scholarmodel

• more clinical work

Scientist-practitionermodel

• balance of clinical work and research

• more research

Clinical researchermodel

ResearchClinical

582 CHAPTER 15 Therapies for Psychological Disorders

By the mid-19th century, there were many state-funded mental hospitals in the United States. Led in part by Dorothea Dix FIGURE 15-3 and others, the new facili-ties were established to provide more humane treatment to those suffering from psychological conditions (Gollaher, 1995). By the mid-1950s, however, large state facilities fell into disrepair from lack of funding, which resulted in too many patients and too few well-trained staff members. Mental hospitals again became notorious for poor treatment. In reaction to the poorly funded large hospitals, many patients were discharged from the hospitals and a community-based system was established for those suffering from psychological conditions. Community mental health services include housing with oversight by either full- or part-time mental health professions in assisted-living facilities or half-way houses. Deinstitutionalization is the process of replacing inpatient psychiatric care with community outpatient services. While offering more freedom for clients and costing less than care in large hospitals, dein-stitutionalization released many people with severe conditions, few work skills, and limited access to the level of care required for their condition. Many former patients became homeless or ended up in prison FIGURE 15-4. The inpatient population plum-meted from 555,000 in the mid-1950s to around 70,000 by 2000 FIGURE 15-5 as the imprisoned and homeless populations grew.

The Role of PsychotherapyPsychotherapy, or talk therapy, has probably been around as long as lan-guage itself and is often misunderstood. In therapy, many believe, the cure comes from complaining. It is understandable that people who have never been in therapy may be unaware of the therapeutic process or of the variety of procedures used in the different styles of psychotherapy. Theories of personality explain the nature of humans, and, in many cases, offer ways to treat psychological conditions. An understanding of the sources and motiva-tion of behavior leads to therapeutic insight, which is central to therapies such as psychodynamic, humanistic, and systems approaches, while it is less important to behavioral and cognitive approaches. Psychotherapies that use insight as part of treatment are referred to as insight therapies. In the next sections, we will discuss therapy treatments from five established therapies: psychodynamic, humanistic, behavioral, cognitive, and systems approaches.

Before we begin, a note about terminology: You will recall that there are several different kinds of mental health care practitioners—psychiatrists, clinical psychologists, and counseling psychologists, to name a few. There are also many terms for those who receive services. Some mental health practitioners call the people with whom they work clients, some call them patients, and others use the term consumer. In this chapter, we will use the terms therapist and client or patient as general terms for those who provide and those who receive therapeutic services.

FIGURE 15-3 Dorothea Dix (1802–1887) was a leader in promoting ethical treatment for those in psychiatric hospitals. She was responsible for the founding of dozens of mental institutions in the United States.

FIGURE 15-4 As the population in mental hospitals declined through deinstitutionalization, the prison population increased dramatically.Source: Data from Harcourt, B. E. An institutionalization effect: The impact of mental hospitalization and imprisonment on homicide in the United States, 1934–2001 (March 1, 2007). Journal of Legal Studies, Vol. 40, 2011; University of Chicago Law & Economics, Olin Working Paper No. 335; University of Chicago, Public Law Working Paper No. 155. Available at SSRN: http://ssrn.com/abstract=970341

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Even in the mid-1940s in the United States, patients in mental hospitals were subjected to inadequate conditions.

Deinstitutionalization The process of replacing inpatient psychiatric care with community outpatient services.

Insight An understanding of the motivation of behavior.

Insight therapies A family of psychotherapies that focus on the unconscious motivations of behavior.

15.1 Mental Health Practitioners and Settings 583

15.2 Psychodynamic Therapy Psychodynamic treatments are based on settling unconscious conflicts that are created in childhood.

Define psychodynamic therapy.

Illustrate the techniques used in psychodynamic therapy.

Compare and contrast traditional psychoanalytic therapy and short-term psychodynamic therapy.

Modern psychotherapy emerged from the personality theories and treatments of Sigmund Freud (1856–1939) FIGURE 15- 6 . Earlier physicians had relied on other devices and tech-niques, including hypnosis and even machines designed to rock patients into passivity FIGURE 15- 7 to treat psychological conditions. Psychodynamic therapies are a family of treatments that have at their core the exploration of unconscious internal conflict. They use insight to bring about therapeutic change.

According to Freud, unresolved unconscious conflicts from childhood cause difficul-ties in adulthood. These difficulties include unhealthy defense mechanisms, anxiety, and problematic ways of guarding against the wishes of the id. Unhealthy defense mechanisms need to be dismantled because they are not successful at reducing anxiety and they cause problems in everyday life. For example, a person may sabotage healthy relationships because he or she feels unlovable, all at the unconscious level.

In order to be healthy, clients must come to understand their unconscious conflicts and gain the ability to make informed, mature decisions about fears and desires created in the formative childhood years. Insight into these internal workings requires an emo-tional appreciation and not simply a cognitive understanding. After all, someone can intellectually understand an unconscious conflict but not really appreciate its potentially overwhelming emotional force.

Techniques of Psychodynamic Therapy Psychodynamic techniques use several tools to help clients bring unconscious conflicts into awareness and gain insight, including interpretation, analysis of dreams, transfer-ence, and resistance, as well as free association.

FIGURE 15- 5 In 1955 the first antipsychotic medications were in wide use. By 1955, the number of patients in mental hospitals had been reduced remarkably. Source: Data from Deinstitutionalization—Special Reports|The New Asylums|FRONTLINE|PBS, Out of the shadows: Confronting America’s mental illness crisis by E. F. Torrey, M.D. (New York: John Wiley & Sons, 1997).

1955: First antipsychotic drugs

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FIGURE 15- 6 Dr. Sigmund Freud in 1885.

Psychodynamic therapies A family of psychotherapies that have at their core the exploration of intrapsychic conflict and the role of insight to bring about therapeutic change.

Comparing the Roles and Settings of Mental Health Practitioners CONCEPT LEARNING CHECK 15. 1

1. Compare some of the results, both positive and negative, of deinstitutionalization.

2. Compare and contrast the roles of psychiatrists, counseling psychologists, and clinical psychologists.


In order to explore the unconscious and discover what is causing the symptoms in consciousness, the therapist must find a way to bring unconscious processes into consciousness. Free association is one way to explore the unconscious. Free association is a psychodynamic therapy technique that reveals unconscious conflicts by interpreting spontaneous responses to given words. Free association provides evidence about unconscious conflicts that can be interpreted by the therapist.

Evidence of unconscious conflicts can also be revealed through dream analysis—the interpretation of dreams. According to the psychodynamic theory of dreams, dreams contain both a surface or manifest content, as well as a deeper unconscious or latent content. Through therapy, the latent content can be revealed.

A goal of psychodynamic therapy is to bring into awareness problematic intrapsychic conflicts. Awareness allows the client to work through unresolved conflicts in a more adaptive way. Since the conflicts are unconscious, the therapist must take care to reveal them in a way that is useful or helpful to the client. Because the therapist is trained in psychodynamic techniques and is not entangled in the intrapsychic conflicts of the client, the therapist can see patterns in the evidence, or material revealed by the client. Using the material gathered, the therapist may develop an understanding of the landscape of the client’s unconscious world. Making carefully timed interpretations, or explanations of the client’s unconscious motivations, in order to improve psychological functioning is an important part of therapy. Interpretations can help clients to understand their own unconscious worlds.

But the therapist’s work is more complex than simply revealing the interpretation. If it is revealed too quickly or in the wrong way, the client may reject it. A client may reject an interpretation no matter how it is revealed. Interpretations, especially con-troversial ones, can be met with unconscious or conscious resistance. Resistance is a client’s employment of a defense mechanism during therapy. Defense mechanisms are unconscious arrangements that the ego uses to satisfy id instincts indirectly. In fact, the closer to the conflict, the greater the resistance can be. Resistance can show up in subtle ways. Coming late to a session or revealing important information so late in a session that there is little time to actually address it are all examples of resistance because they block the therapeutic process.

Sometimes, unconsciously, clients will act out the kinds of relationships they have in their lives and shift the fears or wishes of past important relationships into the thera-peutic relationship. This shift is called transference. Analysis of transference provides the therapist with additional material for interpretation. Interpreting transference gives the client insight into his or her relationships. One way the therapist can encourage transference is to be as neutral as possible so that he or she can use the therapeutic relationship itself as a tool to help the client. For example, a few years ago, I needed to rebook a client for a later appointment in the same week. About 2 weeks before the event, I let my client know about the change. He responded angrily, “You are just like my dad. You are never there when I need you.” I knew that he was not really upset with me but with his father. The unconscious feelings about being disappointed by

FIGURE 15-7 The Darwin-Coxe machine was used to swing patients until they were quiet.

Free association A psycho-analytic therapy technique that reveals intrapsychic conflicts by interpreting spontaneous responses to given words.

Dream analysis A psy-choanalytic technique that reveals intrapsychic conflicts through interpretations of dreams.

Manifest content In the psychoanalytic theory, the dream as the dreamer reports it.

Interpretation A psychoana-lytic technique in which a therapist will reveal explana-tions of the client’s uncon-cious motivations in order to improve psychological functioning.

Latent content In the psychoanalytic theory, the true, underlying, undisguised meaning of a dream.

Resistance In psychoanaly-sis, a client’s employment of a defense mechanism during therapy.

Defense mechanism Unconscious arrangements that the ego uses to satisfy id instincts indirectly.

Transference In psycho-analysis, a type of displace-ment in which the client will unconsciously act out rela-tionships with the therapist.

15.2 Psychodynamic Therapy 585

important people in his life bubbled to the surface, and we had a chance to discuss that in the session.

Types of Psychodynamic Therapy There are several categories of psychodynamic therapies. We will discuss two: classical psychoanalysis and short-term psychodynamic therapy.

Psychoanalysis Although not broadly practiced, classical psychoanalysis is performed in much the same way as Freud developed it. Psychoanalytic therapy, or psychoanalysis , is based on Freud’s traditional approach to psychotherapy. The client lies on a comfortable couch while the therapist sits out of view and encourages free association FIGURE 15- 8 . This creates a com-fortable environment in which free association can take place without the client having to look at the therapist directly. Much like it is easier to tell someone something while looking down, relaxing on a sofa in an inviting environment with only your thoughts is a better environment for psychotherapy, according to the psychoanalytic approach. Psychoanalysis is intense, with hour-long sessions taking place three to five times a week for years. Psychoanalysis is prohibitively expensive and time consuming for most people. However, it does have a track record of helping those with complex psychological condi-tions ( Leichsenring & Rabung, 2008 ).

Short-Term Psychodynamic Therapy Short-term psychodynamic therapy is a type of solution-focused psychoanalytic treat-ment rooted in Freud’s classical psychoanalysis. The client–therapist relationship is much more casual in short-term psychodynamic therapy. While still exploring intrapsychic dynamics, the therapist and client sit face to face in chairs FIGURE 15- 9 . Psychodynamic therapy is much more goal oriented, lasting from 12 to 50 weekly sessions. Short-term psychodynamic therapy is more active and directive than psychoanalysis, with the goal of figuring out a client’s current problems rather than restructuring his or her personal-ity. Because of its duration, short-term psychodynamic therapy is much more affordable but not necessarily appropriate for in-depth personality change as might be required, for personality disorders, for example ( Knekt et al., 2008 ).

The couch of Sigmund Freud.

FIGURE 15- 8 In classic psychoanalysis, the therapist is out of view of the client.

FIGURE 15- 9 In short-term psychodynamic therapy, client and therapist sit face to face in a more casual and goal-oriented approach.

Psychoanalysis A type of therapy based on Freud’s theory of personality.

Short-term psychodynamic therapy A type of solution-focused psychoanalytic treatment.

Understanding Psychodynamic Therapies CONCEPT LEARNING CHECK 15. 2

1. Psychoanalytic therapy is considered an insight-oriented therapy. What kind of insight does this therapy provide?

2. Compare and contrast traditional psychoanalytic therapy and short-term psychodynamic therapy.


15.3 Humanistic TherapyHumanistic therapy focuses on the therapeutic environment to release an individual’s ability to improve his or her own life.

Describe the role of genuineness, acceptance, and empathy in client-centered approaches.

As a personality theory, humanism is based on the idea that all humans have an actualizing tendency, that is, an instinctual desire to be the best possible version of themselves. As such, therapies based on the humanistic perspective attempt to activate this natural actualizing tendency by fostering self-acceptance and self-awareness. Human-istic therapies do this by encouraging clients to understand and be accountable for their own behavior and use the therapeutic relationship to lead the client toward therapeutic change. For example, client-centered therapy, a humanistic psychotherapy based on a nondirective, genuine, and accepting environment, features humanistic therapeutic techniques.

Carl Rogers and Client-Centered TherapyCarl Rogers FIGURE 15-10 established client-centered therapy based on humanistic personality theory. In nondirective client-centered therapy, the therapist’s major role is to clarify and to provide the proper therapeutic environment, working as an equal with the client. Client-centered therapists create the environment for therapeutic change by providing feedback to the client, with minimal advice giving, instruction, or interpretation. An important part of client-centered therapy is active listening, a communication method in which the listener responds in ways that demonstrate understanding of what another person says. Using these techniques, the therapist helps clients deeply explore their emotions and approaches to life. The therapeutic relationship leads the client toward personality change. Client-centered approaches are powered by the active ingredients of genuineness, acceptance, and empathy (Rogers, 1989).

Genuineness refers to authenticity in the relationship. In client-centered therapy, the therapist is encouraged to behave in exactly the way she or he feels, revealing his or her inner experiences to the client. In that way, client-centered therapy encourages therapists to be transparent in their relationships with their clients. In order to be genuine, the therapist is encouraged to focus more on the “here and now” rather than past experi-ence (the “there and then”). As clients sense genuineness in the therapist, they will offer more genuineness themselves. Genuineness encourages clients to become more aware of their experiences and to become better able to know and express what is going on in the moment. Instead of recalling and discussing past feelings, humanistic therapies explore emotions in real time as they occur.

Acceptance, or communication of respect, is also important for client-centered therapy. Rogers suggests that the client is more likely to be able to change if the therapist grants the client the respect that all humans should receive. This respect should be communicated as unconditional positive regard, or a sense of respect and love that is not linked to specific behaviors and does not have to be earned. Respect from the therapist will increase self-respect and self-acceptance in the client and, according to Rogers, lead to greater self-understanding.

Empathy refers to the therapist’s attempt to understand the client’s inner world. The client-centered approach is rooted in the idea of phenomenology, which emphasizes each individual’s unique perspective. Phenomenology is the idea that in order to understand someone, it is important to understand what it feels like to be that person and to see the world from his or her perspective.

By exposing clients to an atmosphere of genuineness, acceptance, and empa-thy, the therapeutic environment helps clients to understand hidden aspects of themselves, relate more directly to others, better tolerate the nuances of situa-tions, and emphasize conscious over unconscious processes. The relationship encourages clients to focus on growth and to appreciate and be accountable for their own behavior. FIGURE 15-10 Dr. Carl Rogers.

Humanism A theoretical orientation that emphasizes growth, potential, and self-actualization.

Actualizing tendency According to the humanists, the instinctual desire to be the best version of yourself possible.

Client-centered therapy A humanistic psychotherapy based on a nondirective, genuine, and accepting envi-ronment.

Active listening A com-munication method in which the listener responds in ways that demonstrate understanding of what another person says.

Genuineness According to the client-centered approach, authenticity in a relationship.

Acceptance Communi cation of respect.

Unconditional positive regard According to Rogers, a sense of respect and love that is not linked to specific behaviors.

Empathy An attempt to understand the client’s inner world.

Phenomenology The idea that, in order to understand a person, it is important to understand the world from that person’s perspective; also known as phenomeno-logical approach.

15.3 Humanistic Therapy 587

15.4 Behavior Therapy Behavioral therapies attempt to modify clients’ maladaptive actions.

Explain the ways in which behavioral therapies attempt to change maladaptive associations, discourage maladaptive behaviors, or encourage more adaptive ones.

Compare and contrast classical conditioning and operant conditioning.

Behavior therapies use learning theory to change behavior. Behavior therapies for psy-chological conditions assume that psychological disorders are the result of maladaptive behavior patterns: Change the behaviors and you can change the emotions, too. Behav-ioral therapists question the role of insight in producing change. Symptoms, behavioral therapists believe, are not a sign of the problem—they are the only problem. On the other hand, insight-oriented therapists believe that if you just get rid of a symptom, it will return in another way, in what is called symptom substitution . Symptom substitution is like a game of whack-a-mole, with new symptoms emerging if the root cause of the condition is not found. Behaviorists disagree, arguing that knowing why you do something does not necessarily stop the behavior. Knowing that you should not eat three cupcakes a day might not stop you from doing it. So behavior therapies focus on current symptoms by discouraging maladaptive behaviors and encouraging constructive ones.

Sometimes behavior therapy will treat a specific sign related to the complaint. Lack of social skills, for example, can lead to nervousness and, in extreme cases, social isola-tion. Since social skills are attained through learning, according to behaviorists, behavior therapy uses social skills training to increase social ease. Social skills training is a type of behavior therapy intended to improve interaction with others, and it has been used to treat many issues, including social anxiety ( Spence, Donovan, & Brechman-Toussaint, 2000 ) and autism ( Leaf, Dotson, Oppenheim-Leaf, Sherman, & Sheldon, 2011 ).

More often, behavioral therapies are used as a way to change associations, discourage maladaptive behaviors, or encourage more adaptive ones. Behavioral therapists use clas-sical conditioning and operant conditioning techniques to achieve therapeutic change.

Classical Conditioning Techniques Classical conditioning focuses on the basic physiological responses to various experiences, also known as stimuli. Classical conditioning is a type of associative learning in which two things are paired together. Sometimes people make maladaptive or accidental asso-ciations that lead to problematic behaviors or reactions. Behavioral therapists attempt to decouple these associations by using counterconditioning , a behavioral technique in which a response to a stimulus is replaced by a new response. Classical conditioning techniques attempt to extinguish behaviors in various ways. The bell-and-pad treatment FIGURE 15- 11 is a classical conditioning treatment used to treat nighttime bedwetting. A moisture sensor in the bed (pad) is activated by bedwetting. When the moisture sensor is activated, an alarm (bell) awakens the person. An association of relaxation of the bladder with waking up prevents bedwetting. Having a full bladder (a conditioned stimulus) triggers waking up (a conditioned response) since the sensation has been linked to the bell that would awaken you FIGURE 15- 12 . Bell-and-pad treatments have been shown to be very effective, with few people needing additional treatments ( Gim, Lillystone, & Caldwell, 2009 ).

Many therapies have been influenced by client-centered approaches, including positive psychotherapy, which helps clients recognize strengths and relish positive expe-riences ( Joseph & Linley, 2006 ). Positive psychotherapy is an applied version of positive psychology , a branch of psychology that studies human strengths.

Positive psychology A branch of psychology that studies human strengths.

Behavior therapy A family of therapies that use learning theory to change behavior.

Symptom substitution The emergence of a replace-ment symptom of a psycho-logical condition if the root cause is not resolved.

Social skills training A type of behavior therapy intended to improve interaction with others.

Classical conditioning Learning in which a neutral stimulus becomes associ-ated with an unlearned stimulus and the response it automatically elicits.

Counterconditioning A behavioral technique in which a response to a stimu-lus is replaced by a new response.

Bell-and-pad treatment A classical conditioning treat-ment used to treat nighttime bedwetting.

Describing the Elements of Humanistic Therapy CONCEPT LEARNING CHECK 15. 3

1. Humanistic therapists seem to focus more on the therapeutic environment than the actual psychotherapy. Why do you suppose the client-centered approach focuses so much on the environment?

The bell-and-pad treatment can be an effective behavioral treatment for bedwetting.


Anxiety can be countered by using relaxation as a substitute. Since anxiety is produced by the sympathetic nervous system, which prepares the body to fight, flee, or freeze, and relaxation by the parasympathetic nervous system that conserves the bodily functions and energy, these two states cannot exist at the same time. Mary Cover Jones (1924) developed exposure therapy. This behavior therapy technique involves repeat-edly presenting the client with a distressing object in order to reduce anxiety. Repetitive exposure leads to less anxiety and reduces the fear response over time (Deacon & Abramowitz, 2004). A common type of exposure therapy is systematic desensitization, in which a client practices relaxation while facing progressively more fear-inducing stimuli.

Systematic desensitization has three components:

1. Constructing a hierarchy of fears such as the one in TABLE 15-1

2. Training the client in progressive relaxation

3. Alternately exposing the client through the fear hierarchy and relaxing until the fear response is extinguished so that it no longer occurs.

Exposure therapies, including systematic desensitization, can be done en vivo, meaning actual exposure to the thing that causes anxiety; using imagination, in which the person will create a mental image of the feared object; or by using computers, as

FIGURE 15-12 Classical conditioning helps to associate a full bladder with waking up.

Unconditionedstimulus

Full bladder

UnconditionedresponseSleep Conditioned

stimulusBell

Conditionedstimulus

Full bladder

Conditionedresponse

Awaken

Unconditionedstimulus

Full bladder UnconditionedresponseAwaken

Before During After

Anticipated Distress Level Description

100 Strapping yourself into the airplane seat

90 Finding your seat on the airplane

80 Boarding the airplane

70 Waiting at the gate for your flight

60 Finding your gate

50 Arriving at the airport

TABLE 15-1 Hierarchy of Fears for Flying

Exposure therapy A behav-ior therapy technique that involves repeatedly present-ing the client with a distress-ing object in order to reduce anxiety.

Systematic desensitization Treatment for phobia in which a client practices relaxation during progres-sively more fear-inducing stimuli.

En vivo A type of exposure therapy in which the actual feared object is used.

FIGURE 15-11 A bell-and-pad device uses classical conditioning techniques as a treatment for bedwetting.

Alarm unit on night stand

Cord connectsalarm unit to mat

Mat sits under fitted sheet

Blanket

Top sheet

Fitted sheet

Waterproofsheet

15.4 Behavior Therapy 589

15.5 Cognitive Therapies Cognitive therapies attempt to modify clients’ maladaptive thoughts.

Discuss Beck’s cognitive therapy and Ellis’s rational emotive therapy as they relate to cognitive therapy.

Cognitive therapy is a type of treatment emphasizing the link between thoughts and emotions. Cognitive therapies suggest that thoughts are the etiology, or cause, of psy-chological conditions. The goal of cognitive therapy is to understand these maladaptive thinking patterns and develop healthier ways of thinking: change the way you think and you can change the way you feel. While this may sound like using the power of positive thinking, it is not the same thing. Therapists use specific techniques to recognize patterns of maladaptive thoughts and apply intervention strategies to reshape ways of thinking. The two most common types of cognitive therapy are Beck’s cognitive therapy and Ellis’s rational emotive therapy.

in virtual reality exposure therapy FIGURE 15- 13 . Virtual reality exposure therapy is a behavior therapy technique involving the repetitive presentation of a simulated dis-tressing object or situation in order to reduce anxiety. Virtual reality therapy has been used for posttraumatic stress disorder and for flight anxiety ( Krijn, Emmelkamp, Olafsson, & Biemond, 2004 ).

Aversive conditioning involves pairing an unpleas-ant stimulus with an undesired behavior in order to reduce the target behavior. Painting an unpleasant-tasting liquid on the fingernails of people who bite their nails to reduce the nail biting, for example ( Vargas & Adesso, 1976 ), is using aversive conditioning. Although aversive conditioning has been shown to be beneficial in the short run, its use has been limited because of the availability of more effective treatments such as operant conditioning techniques ( Nakatani et al., 2009 ).

Operant Conditioning Techniques Operant conditioning involves training emitted behaviors to make them more likely to occur again. Techniques seek to increase the occurrence of certain behaviors and reduce the occurrence of others. Operant techniques include positive reinforcement , or a consequence that creates a pleasant state, making behavior more likely to occur again, of adaptive behaviors and nonreinforcement and sometimes punishment of behaviors that are maladaptive, or undesired. Often, desired or adaptive behaviors are encouraged through shaping , in which a part of a behavior is reinforced initially, and then increas-ing the goal to more complex behaviors later on. Sometimes what is called a token economy is used for reinforcement. In this type of behavior therapy, involving positive reinforcement of specific behaviors, tokens or points can be swapped for privileges or other reinforcements. Painting a bad-tasting

liquid on the fingernails can be an example of aversive conditioning.

Designing a Behavioral Treatment Plan CONCEPT LEARNING CHECK 15. 4

1. Create a systematic desensitization behavioral treatment plan for a person who has a fear of flying.

Cognitive and rational emotive therapists may ask clients to fill out forms in order to analyze their thoughts.

FIGURE 15- 13 Virtual reality exposure therapy is a form of behavior therapy in which the soldier is subjected to simulations of the event that caused the PTSD symptoms.


Albert Ellis and Rational Emotive Therapy Like Beck, Albert Ellis was also trained as a psychoanalyst, but Ellis’s approach to cognitive therapy is different from Beck’s. Ellis’s rational emotive therapy is a type of active and directive therapy that emphasizes the link between thoughts and emotions.

Ellis rejected the notion that the past is important to a person’s current condition. In fact, he believed that you affect your future more than the past affects you. Your cur-rent problems are based on the idea that you teach yourself false notions of yourself, the world, or other people over and over again ( Ellis, 2001 ). How do we do this? Ellis says that we use self-talk to focus on irrational or unrealistic expectations, leading to unwanted feelings. Statements like “I am worthless” are illogical overgeneralizations associated with anxiety and depression. Ellis also emphasizes the importance of action. Like cognitive therapy, rational emotive therapy involves homework in which clients practice their new ways of thinking.

Aaron Beck and Cognitive Therapy Aaron Beck, who was trained as a psychoanalyst, noticed that his clients’ language changed over the course of therapy ( Beck, Rush, Shaw, & Emery, 1987 ). Reflecting on this observation, he wondered if a therapist could change clients’ thoughts more directly using language. As in all forms of cognitive therapy, the basis of Beck’s model is that psychological conditions, like depression, result from thoughts. People who are depressed tend to have a pessimistic explanatory style, and when bad things occur, they tend to blame themselves. They are also more likely to discount positive events ( Beck et al., 1987 ). In therapy, the goal is to identify any negative self-talk and examine it fully. Rather than just thinking positively, the therapist encourages clients to notice and test their maladaptive or distorted beliefs through questioning techniques and homework. Cognitive behavior therapy is a type of treatment that emphasizes the link between thoughts, emotions, and behavior. In therapy, a cognitive therapist will give clients tools that can help them address distortions in their thinking. TABLE 15- 2 gives examples of common cognitive distortions.

All or nothing thinking Seeing things in inflexible extremes such asgood or bad

Overgeneralization Seeing one negative event as an ongoing pattern

Disqualifying the positive Filtering out the positive aspects of a situation

Jumping to conclusions Assuming something negative without enough evidence

Magnification or minimization Amplifying the significance of somethingnegative or lessening the significance of something positive

Emotional reasoning An assumption that negative emotions mean that negative things are really happening

Labeling Instead of describing a mistake you negatively brand yourself as “loser” or an “idiot”

TABLE 15-2 Examples of Maladaptive Beliefs in Cognitive Therapy

Virtual reality exposure therapy A behavioral therapy technique that involves the repetitive presentation of a simulated distressing object or situation in order to reduce anxiety.

Aversive conditioning A behavioral technique that pairs an unpleasant stimulus with an undesired behavior in order to reduce the target behavior.

Shaping Reinforcing part of a behavior initially and then increasing the goal to more complex behaviors.

Cognitive therapy A type of treatment that emphasizes the link between thoughts and emotions; also known as cognitive behavior therapy.

Rational emotive therapy A type of active and directive therapy that emphasizes the link between thoughts and emotions.

Comparing Cognitive Therapies CONCEPT LEARNING CHECK 15. 5

1. Compare and contrast the cognitive therapy approaches of Aaron Beck and Albert Ellis.

15.5 Cognitive Therapies 591

15.6 Family Systems and Group TherapyFamily systems and group therapy focus on how individuals function in their relationships to evaluate and improve communication and interpersonal connections.

Illustrate how family systems therapy focuses on how individuals function in their relationships through communication patterns.

Some psychotherapies focus on the individual in treatment. Other therapies take into account the relationships that people have in their lives. For example, family systems and group therapy approaches both recognize the influence of other people in an indi-vidual’s life.

Systems ApproachesFamily therapy is a type of psychotherapy that treats the immediate social system, the family, to improve individuals’ psychological functioning. Family therapy, also known as family system therapy or couples therapy, is an approach to psychotherapy that attempts to change the way individuals in a group (such as a family or couple) relate to each other (Becvar, 1998). Systems approaches emphasize the importance of relationships.

No psychological condition is an individual issue, according to this approach. Sys-tems approaches suggest that even when an individual has a psychological condition, something in his or her system is involved in establishing, maintaining, or exacerbating the current psychological state. Systems therapists recognize this and use the system as an important intervention point in treatment. Families, couples, and friends may participate in the therapy session. Systems approaches also note that people will often play roles in certain social structures, such as being first born in a family.

The systems approach is eclectic, meaning it integrates a broad range of intervention strategies and therapies, including psychodynamic, humanistic, behavioral, and cogni-tive ones. Systems approaches also utilize communication skills training and relationship education in an effort to open up the lines of communication. Rather than examining intra-psychic conflicts or assigning blame in the system, the intervention focuses on patterns of communication, exploring the ways of communication within the system. Sometimes the

intervention involves examining intergen-erational patterns, using genograms or family trees to understand common roles that people play in the system.

Group TherapyGroup therapy can use some of the same intervention techniques as family sys-tems approaches, except the clients in the group have similar concerns. Group

therapy is a technique that treats multiple clients in a collective setting, often under the direction of one or several therapists (Yalom & Leszcz, 2005). One type of group therapy is the support group, in which members meet without a therapist to provide social support for each other.

Group therapy has both strengths and weaknesses. It is much less expensive than individual therapy since the members share the cost of the therapist. In addition, the group experience can reveal patterns of problematic relationships that may not show themselves in individual settings. However, while members of the group do save money because they share therapist, they compete for the therapist’s time. Confidentiality is harder to control in group settings as well. Groups are helpful for some concerns but not appropriate for all conditions.

Family and couples therapy attempt to change the way that individuals in a group relate to one another.

Primary theoretical orientations for psychologists.Source: Adapted from Norcross, J. C., Hedges, M., & Castle, P. H. (2002). Psychologists conducting psychotherapy in 2001: A study of the Division 29 membership. Psychotherapy: Theory, Research, Practice, Training, 39(1), 97–102. doi:10.1037/0033-3204.39.1.97

Humanistic(6%)Eclectic (36%) Psychodynamic (29%) Cognitive behavioral

(19%)Other (10%)

Familysystems

(3%)

Primary Theoretical Orientations for Psychologists

Both therapy and support groups treat clients in a collective setting.


15.7 Biomedical Therapies Biomedical therapies focus on changing physiological problems that lead to psychological conditions using drug treatments as well as surgical interventions.

Explain the focus on changing physiological problems that lead to psychological conditions in biomedical therapies.

Compare and contrast the major classes of antidepressant drugs, the major drug treatments for anxiety, and antipsychotic medications.

Discuss other nondrug medical treatments for psychological conditions.

Psychotherapy is not the only technique used to help with psychological conditions. Biomedical therapies are a family of therapies that use surgery, medication, or other physiological interventions for the treatment of psychological conditions. In this section, we will focus on drug treatments, including medications for depression, bipolar and anxiety disorders, and psychosis; as well as more invasive medical procedures such as electroconvulsive therapy, transcranial magnetic stimulation, and deep brain stimulation.

Drug Treatments Psychotropic medications are drugs used to treat psychological conditions. Most bio-medical therapies are pharmaceutical or drug treatments. Psychopharmacologists are researchers and practitioners who study and often prescribe psychiatric medications. Psy-chopharmacologists include physicians, nurse practitioners, doctors of nursing practice, pharmacists, medical psychologists, and prescribing psychologists with extensive knowl-edge of medicines that treat psychological conditions. Psychopharmacologists assume that psychological conditions are, in part, the result of physiological problems, including neurotransmitter abnormalities. Neurotransmitters are chemical messengers that transmit information from one neuron to another. Drug treatments have reduced patients’ hos-pitalizations and relieved their suffering from the symptoms of psychological disorders.

All prescription medications undergo extensive review in the United States by the Food and Drug Administration (FDA). In order for a medication to be approved for use, its developers have to provide evidence that the medication is both safe and effective. “Safe” does not mean that the medication is without risk. In general, a medication is considered “safe” if the benefits of the medicine outweigh the risks. For example, some medications have significant or dangerous adverse effects such as nausea or seizures. Similarly, “effective” does not mean that the medication cures or removes all symptoms of the condition. A medication is considered “effective” if the medication’s treatment effects outperform a placebo , a substance without an active ingredient. In fact, many placebos can have treatment effects as well as side effects. When a placebo helps a condition, it is considered to be a placebo effect , a treatment result in response to a physiologically ineffective treatment. People have reported side effects such as nausea, sweating, rash, and fever, while using placebos ( Hróbjartsson & Norup, 2003 ).

After a medication has been approved by the FDA to be used as a treatment for a con-dition, the developer of the medication is granted a patent for the medication. Medicines normally have both a generic name (often related to the molecule or how it works) as well as a brand name that is used in marketing the medication. Brand names are usually written with the first letter capitalized, while the generic name is lowercase. For example, if you have been to the supermarket in search of something to help your headache, you may have chosen Tylenol ® (a brand name) or a supermarket version of acetaminophen (generic). Once the patent for the medication runs out, other companies can produce

Describing an Eclectic Systems Approach CONCEPT LEARNING CHECK 15. 6

1. The systems approach is eclectic, meaning it integrates a broad range of intervention strategies, including psychodynamic, humanistic, behavioral and cognitive ones. Illustrate how a group therapy approach can be combined with a humanistic approach.

Family therapy A type of psychotherapy that treats the immediate social system, i.e., the family, to improve individuals’ psychological functioning.

Eclectic approach A therapy technique that integrates ideas from several theories.

Genogram Family tree.

Group therapy A psycho-therapeutic technique that treats multiple clients in a collective setting.

Support group A type of group therapy in which members meet without a therapist to provide social support.

Biomedical therapies A family of therapies that focuses on surgery, medication, or other physi-ological interventions for the treatment of psychological conditions.

Psychotropic medication A drug used to treat psycho-logical conditions.

Psychopharmacologists Researchers and practi-tioners who study and often prescribe psychiatric medications.

Placebo A substance without an active ingredient.

Placebo effect Treatment result in response to a physiologically ineffective treatment.

15.7 Biomedical Therapies 593

generic versions of the medication. While these generic medications are usually much less expensive because their manufacturers do not have to recoup any development costs for the medication, they contain the same active ingredients as the brand-name medica-tion. Some brand-name medications also contain inactive ingredients that might help them work better, but in general, generic medications are quite similar to brand-name medications (Howland, 2009).

Antidepressant DrugsAn antidepressant medication is a type of drug used to reduce the symptoms of depres-sive mood disorders. There are dozens of different antidepressants on the market today. They are all designed to affect neurotransmitters, the chemical messengers in the brain. The monoamine hypothesis of depression is the theory that depression is related to problems in a family of neurotransmitters called monoamines (Preston, O’Neal, & Talaga, 2010). The monoamines include serotonin (abbreviated 5-HT), norepinephrine (NE), and dopamine (DA). Some theories suggest that excessive reuptake of monoamines is a problem related to the symptoms of depression. This means that the transport proteins reabsorb the monoamines too aggressively and take too many of the monoamines out of the synaptic gap, leaving too few of the monoamines to bind to the receptor site and deliver the message that the next neuron should fire. Other biomedical theories of depres-sion suggest that neurons are not releasing enough monoamines, so the “fire” message is not delivered as quickly as it should be. Another theory suggests that the enzyme responsible for cleaning up the synaptic gap, monoamine oxidase (MAO), is overac-tive. Overactive MAO metabolizes, or breaks down, the monoamines too quickly. This leaves too few monoamines available to bind with neurons to deliver the “fire” message. A different theory suggests that the receptor site that receives the neurotransmitter is abnormal in some way and needs extra stimulation in order to send the message to the receiving neuron. In all of these theories, monoamine malfunction results in symptoms of depression.

Whatever the case, increasing the availability or efficiency of monoamines does reduce the symptoms of depression. Two out of three people who are depressed will benefit from antidepressant medications (Gitlin, 2002). While many medications are indicated for treatment of depression, these medications can also be used to treat other conditions. Prozac, for example, is useful in alleviating the symptoms of both depression and anxiety (Stahl, 2008). Because medications can treat more than one condition, medications are categorized into functional classes according to what they do rather than the specific conditions that they treat. Functional classes that have an antidepressant effect include monoamine oxidase inhibitors (MAOIs), selec-tive serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs).

Monoamine Oxidase InhibitorsSome of the oldest medications for use in depression are monoamine oxidase inhibitors, or MAOIs. As the name suggests, MAOIs TABLE 15-3 work by preventing the enzyme monoamine oxidase from doing its job of metabolizing, or destroying, the family of neurotransmitters known as monoamines: serotonin, norepinephrine, and dopamine (Preston et al., 2010). MAOIs typically take about 4 to 6 weeks to start working and have side effects including dizziness, diarrhea, insomnia, and weight gain (Stahl, 2009). One notable side effect of MAOIs is what some call the “cheese effect,” or hypertensive crisis. Because MAO helps to regulate blood pressure, destroying MAO makes it dif-ficult to control blood pressure under certain situations. One of these situations occurs when you ingest tyrine, a naturally occurring substance in many foods TABLE 15-4 and

Antidepressant medication A type of drug used to reduce the symptoms of depressive mood disorders.

phenelzine (Nardil)tranylcypromine (Parnate)selegiline (Emsam)

TABLE 15-3 Commonly Prescribed Monoamine Oxidase Inhibitors (MAOIs)

A pepperoni pizza can be a problematic choice for those on MAOIs.


medicines. Ingesting too much tyrine from, for example, eating pepperoni pizza and taking cough medicine if you are not feeling well can lead to a sudden spike of your blood pressure, giving you a terrible headache or even a stroke. Because many people need to stay on MAOIs for several years, adherence to a tyrine-free diet can be challeng-ing. For this reason, MAOIs are not usually the first medicine that prescribers choose, even though they decrease symptoms in up to 75% of patients with depression (Stein, Kupfer, & Schatzberg, 2005).

Selective Serotonin Reuptake InhibitorsAnother way to keep monoamines in the synaptic gap is to prevent them from being reabsorbed. That is what SSRIs do. Selective serotonin reuptake inhibitors (SSRIs) TABLE 15-5 are a class of medications that increase the efficiency of serotonin binding in the nervous system. Like their name suggests, SSRIs work by blocking the reabsorption of the neurotransmitter serotonin to the presynaptic neurons FIGURE 15-14. Doing this causes

Source: Adapted from Gardner, Shulman, Walker, & Tailor (1996).

Selective serotonin reuptake inhibitor (SSRI) A class of medications that increase the efficiency of serotonin binding in the nervous system.

All tap beers

Matured or aged cheese

Casseroles made with aged cheeses

Fermented or dry sausage like pepperoni, salami, or summer sausage

Improperly stored meat, fish, or poultry

Fava or broad bean pods

Soy sauce or other soybean condiments

TABLE 15-4 Foods to Avoid with Monoamine Oxidase Inhibitors (MAOIs)


SSRIs are well tolerated, meaning that people do not have as many side effects on SSRIs as they might on other medications. Fewer side effects increases the likelihood that clients who are depressed will take them. In addition, SSRIs are not toxic in overdose and are available as generics, which makes them less expensive than some of the newer drugs. Side effects of SSRIs include high rates of sexual dysfunction, decreased appetite, nausea, diarrhea, insomnia, and headaches.

Vilazodone (Viibryd) is a new SSRI that works on both the presynaptic and post-synaptic neurons. You will recall that the monoamine hypothesis of depression suggests that problems of depression can happen both upstream (on the sending neuron) as well as downstream (on the receiving neuron). Vilazodone targets serotonin by blocking reabsorption (like an SSRI) and by antagonizing, or stimulating, the receiving neuron by pretending to be a type of serotonin. Vilazodone has a lower rate of sexual dysfunction than SSRIs (de Paulis, 2007).

Serotonin-Norepinephrine Reuptake InhibitorsSome antidepressants work in more than one way. Serotonin-norepinephrine reuptake inhibitors (SNRIs) are medicines used to treat depression that keep both serotonin and nor-epinephrine in the synapse longer TABLE 15-6. This gives them the benefits of SSRIs while also treating depression in an additional way by targeting norepinephrine. Unfortunately, SNRIs also have additional side effects, including nervousness, insomnia, and increase in blood pressure (Stahl, 2009).

serotonin to build up in the synaptic gap and increases the likelihood that serotonin will bind with the receptor sites on the postsynaptic neuron. Serotonin is normally removed from the synapse by reuptake sites on the presynaptic neuron. SSRIs block the serotonin reuptake sites, allowing serotonin to remain active in the synapse longer.

citalopram (Celexa)escitalopram (Lexapro)paroxetine (Paxil)sertraline (Zoloft)

TABLE 15-5 Commonly Prescribed Selective Serotonin Reuptake Inhibitors (SSRIs)

venlafaxine (Effexor)desvenlafaxine (Pristiq)duloxetine (Cymbalta)

TABLE 15-6 Commonly Prescribed Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

FIGURE 15-14 SSRIs are a class of antidepressants used in the treatment of depression and anxiety disorders. They block the reabsorption of serotonin to the presynaptic cell and therefore increase the avail-ability of serotonin in the synapse. Here serotonin is represented as green beads that have been blocked from reentering the presynaptic cell by the SSRI (red), at left.

Presynaptic Neuron

Postsynaptic Neuron

Synaptic vesicles

Serotonin(neurotranmitters)

Receptors

Synaptic gap

Reuptake blocker


Some SNRIs offer different kinds of action on serotonin and norepinephrine. Venlafaxine, for example, inhibits the reuptake only of serotonin in low doses, meaning it works just like an SSRI. At moderate doses, venlafaxine inhibits more serotonin and starts to block norepinephrine as well. At high doses, venlafaxine blocks reuptake of serotonin, norepinephrine, and dopamine (Stahl, 2008).

Taking an AntidepressantWhen taking an antidepressant, it is important to follow the prescriber’s directions very carefully. It is also important not to stop taking the medication, even if you start to feel better. Antidepressants are not taken like you might take an aspirin for a headache. Nor-mally, prescribers will suggest that a person remain on a medication for a few months to a few years (Preston et al., 2010). Many times, when people stop taking the medicine too quickly, they will have headaches and feel dizzy, tired, and irritable. This is because they are experiencing a discontinuation syndrome. It is not that they are hooked on the medicine—antidepressants are not associated with dependency. Taking an antidepressant to treat depression decreases the severity of the depression and reduces the likelihood of a relapse, meaning a recurrence of the condition. If a person has had several episodes of depression, the guidelines suggest that it is better to stay on the medication than go on and off the medication. If one antidepressant does not work, your prescriber may recommend trying a different one. Among patients whose depression is not helped by one antidepressant, about 25% improve when their prescriber changes their medication (Rush, 2007).

Antianxiety DrugsAn antianxiety medication is a type of drug used to reduce the symptoms of agitation and nervousness. Nervousness and tension are present in a number of different anxiety disorders, including flight anxiety. The most common antianxiety medications are ben-zodiazepines, SSRIs, and SNRIs.

Benzodiazepines TABLE 15-7 are the most commonly used antianxiety medications. Sometimes known as tranquilizers, benzodiazepines are fast-acting and effective (Stahl, 2009). While some caution against their use because of the risk that patients will develop tolerance, a reduction in a person’s sensitivity to a drug over time, others suggest they are not as risky as once believed (Ballenger, 2000).

Benzodiazepines work on the neurotransmitter GABA. Gamma-aminobutyric acid (GABA) is an all-purpose inhibitory neurotransmitter. By affecting GABA, benzodiazepines reduce central nervous system arousal, dampening the anxiety response.

In addition to benzodiazepines, SSRIs and SNRIs are also effective antianxiety medica-tions. Just as when they are used for depression, SSRIs and SNRIs take a few weeks to start working and may need to be taken in larger doses than when used as an antidepressant.

You are already familiar with the advantages and disadvantages of using SSRIs and SNRIs, but benzodiazepines present some different challenges. Long-term use of benzodiaz-epines is associated with both tolerance and dependence. In addition, many people report having memory problems and feeling tired and dizzy when they take benzodiazepines.

Mood-Stabilizing DrugsMood stabilizers TABLE 15-8 are a family of medications used to treat the symptoms of bipolar mood disorders. True mood-stabilizing drugs will treat both the manic/hypomanic phase as well as the depressive phase of a bipolar condition (Stahl, 2008a). The gold stan-dard medication to treat bipolar mood disorders is lithium (Stahl, 2008a). Unfortunately, lithium is associated with some serious potential side effects. Although it is more like an antimanic medication than a true mood stabilizer, Depakote (divalproex) is more widely prescribed than lithium (Thase & Denko, 2008).

alprazolam (Xanax)diazepam (Valium)

TABLE 15-7 Commonly Prescribed Benzodiazepines

Relapse A recurrence of a condition or disorder.

Antianxiety medication A type of drug used to reduce the symptoms of agitation and nervousness.

Tolerance A reduction in a person’s sensitivity to a drug over time.

Gamma-aminobutyric acid (GABA) The nervous system’s primary inhibitory neurotransmitter.

Dependence When a person’s drug use has led to distress or impairment and unsuccessful efforts to reduce drug use.

Mood stabilizers A family of medications used to treat bipolar mood disorders.

Lithium A medication used to treat bipolar mood disorders.

Citalopram (Celexa) is an antidepressant and antianxiety medication which acts as a selective serotonin reuptake inhibitor (SSRI), increasing the amount of the neurotransmitter in the synaptic gap.


Australian medical scientist Dr. John Cade first used lithium as a treatment for psy-chological conditions in the 1940s. He discovered the treatment almost by mistake after delivering the medicine to a group of mice. He thought that the lithium calmed them, although it actually made them sick. Luckily, the lithium treatment did help his patients, and lithium is an effective treatment (Gim et al., 2009). It does, however, have some limitations. Lithium has a narrow therapeutic window. If lithium levels are too low, the medication will not be helpful, but if they are too high, thyroid and kidney damage can result. Lithium’s mechanism of action is on the neurotransmitter glutamate (Grandjean & Aubry, 2009). Glutamate is an all-purpose excitatory neurotransmitter, the “gas” or “accel-erator” of the nervous system. By stabilizing glutamate, lithium treats the manic and depressive phases of bipolar disorder. Valproate is helpful for those who do not respond well to lithium (Davis, Bartolucci, & Petty, 2005).

While medicines like lithium combat the symptoms of both mania and depression, other medicines, such as the anticonvulsant lamotrigine (Lamictal), target only manic symptoms. They often need to be combined with an antidepressant for the depressive phase of the condition. Lamotragine helps with rapid cycling (Calabrese et al., 2000). Lamotragine does not have the same side-effect profile as lithium. It has a broader thera-peutic window but has its own unwanted side effects, including, in rare cases, a terrible rash (Stahl, 2009).

Antipsychotic DrugsAntipsychotic medications TABLE 15-9 are a type of drug used to reduce the symp-toms of psychosis as seen in schizophrenia. Symptoms of psychosis can include posi-tive symptoms such as hallucinations, sensory experiences with no sensory input, and delusions—beliefs that most people would think are incredible or impossible. Psychosis can also include deficits of behavior, or negative symptoms, such as anhedonia, or lack of pleasurable experiences, avolition, or lack of will, and alogia, or lack of elaborative speech. Antipsychotic medications diminish psychosis in about 70% of patients (Sadock & Sadock, 2010) in just a few weeks (Emsley, Rabinowitz, & Medori, 2006).

The dopamine hypothesis of psychosis suggests that symptoms of psychosis are associated with low amounts of dopamine. Some of the early medications used to treat psychosis targeted this neurotransmitter. By blocking dopamine, they reduced dopamine activity in brain areas in which it was thought to be overactive. Since they were used so regularly, medications such as haloperidol (Haldol) were known as typical antipsychotics. Typical antipsychotics were beneficial at targeting the positive symptoms of psychosis, like hallucinations and delusions. The impact of these drugs on the lives of people expe-riencing these symptoms is powerful. Many have seen dramatic improvement in just a few weeks of treatment.

Adverse effects of typical antipsychotics include debilitating symptoms such as tardive dyskinesia, a neurological condition involving involuntary, repetitive movements caused by typical antipsychotics’ effects on dopamine. Tardive dyskinesia is estimated to occur in one in five people who take the typical antipsychotics (Miyamoto, Lieberman,

Lithiumdivalproex (Depakote)

TABLE 15-8 Commonly Prescribed Mood Stabilizers

Typical Antipsychotics Atypical Antipsychotics

haloperidol (Haldol) risperidone (Risperdal)aripiprazole (Abilify)

TABLE 15-9 Commonly Prescribed Antipsychotic Medications

Antipsychotic medication A type of drug used to reduce the symptoms of thought disorders.

Hallucination Sensory experience with no sensory input.

Delusion A belief that most people would think is incredible or implausible.

Negative symptoms of psychosis Symptoms of psy-chosis that involve behavior deficits, or expected behav-iors that are absent.

Anhedonia A reduced capac-ity to experience pleasure.

Avolition Lack of will.

Alogia Lack of elaborative speech.

Tardive dyskinesia A neurological condition involving involuntary, repetitive movements.


Fleishhacker, Aoba, & Marder, 2006). While reducing dopamine in places in which its concentration may be too high, typical antipsychotics may also reduce dopamine levels in places in which it is in the normal range, resulting in adverse effects such as tardive dyskinesia. The name of this condition literally means “late to arrive” (like tardy) and “abnormal” (like dysfunction) “movements” (like kinetics), because tardive dyskinesia is associated with abnormal movements like lip smacking, blinking, puckering, and grimac-ing. Although it can be controlled with medication, the condition is considered permanent.

Another disadvantage of typical antipsychotics is that the treatment effects seem to focus only on the positive symptoms of psychosis. Although those are important symp-toms, the negative symptoms of psychosis, including flat affect, avolition, and alogia, also have a great impact on the lives of people who experience them.

More recently, newer medications have been discovered that reduce both the posi-tive and negative symptoms of psychosis. Since these new medications were not the ones normally given, they were called atypical antipsychotics. Atypical antipsychotics (or second-generation antipsychotics) target dopamine as well as other neurotransmitters. Atypical antipsychotic medications, also listed in Table 15-9, are drugs that reduce both the positive and negative symptoms of psychosis. Atypical antipsychotics have an addi-tional benefit of producing lower rates of tardive dyskinesia than typical antipsychotics (Stahl, 2009). Atypical antipsychotics do cause weight gain and higher rates of diabetes than the earlier medications (Stahl, 2009).

Medical ProceduresMedicines are not the only medical treatment for psychological conditions. Medical treat-ments also include electroconvulsive therapy and medical devices such as transcranial magnetic stimulation and deep brain stimulation.

Electroconvulsive TherapyElectroconvulsive therapy (ECT), sometimes referred to as shock therapy, is a biologi-cal treatment in which seizures are induced in anesthetized patients FIGURE 15-15. Back in the 1930, Ladislas von Meduna noticed that very few people who had epilepsy also had schizophrenia (Dukakis & Tye, 2007). Von Meduna hypothesized that epilepsy and schizophrenia were not able to exist in the same body. Perhaps, he surmised, seizures were curative of schizophrenia. If schizophrenia and epilepsy are incompatible, maybe seizures could treat psychological conditions. Although von Meduna’s hypothesis proved false, the connection he saw between seizures and the absence of schizophrenia led to an effective treatment for the condition.

When most people think about ECT, they think of a barbaric procedure. ECT procedures in the movies are very different than modern electroconvulsive therapy. Improvements in techniques make it a differ-ent kind of intervention than you might think. Around 100,000 people receive ECT annually in the United States. While most often used to treat depression, ECT has been effective for treating mania and catatonia as well (Glass, 2001).

The ECT procedure begins with a patient receiving a muscle relaxant and a general anesthetic so that the patient will be unconscious during the procedure. Then a short burst of electrical current is sent through electrodes placed on one or both sides of the patient’s temple. The electrical cur-rent creates a seizure that lasts between 30 and 60 seconds. Often 6 to 10 sessions are used to treat depression.

Unlike antidepressant medications that can often take months to work, ECT relieves symptoms after only a few days. In fact, about 80% of depressed patients who receive ECT improve (Glass, 2001). Unfortu-nately, ECT has a high relapse rate. About half of people treated with ECT will have a recurrence of their depression within just 6 months (Glass, 2001). Additional ECT

Electroconvulsive therapy (ECT) A biological treatment in which seizures are induced in anesthetized patients.

FIGURE 15-15 Patient undergoing ECT in which seizures are electrically induced in anesthetized patients for therapeutic effect.

Risperdal is a second-generation antipsychotic.


treatments or the addition of antidepressants can stave off these new depressive episodes. Side effects include memory loss about the treat-ment. Research suggests that ECT does not produce any brain damage ( Eschweiler et al., 2007 ).

Despite the benefits of ECT, it is still a rare procedure, prescribed by only 8% of all psychiatrists. Although the side effects are relatively minor, such as memory loss around the time of the procedure, some researchers think the low usage rates of the procedure are due to the misunderstand-ings and fears that people have about ECT.

How ECT works is still a mystery. Some theories suggest that ECT lowers activity in brain areas that might be involved in depression ( Nobler et al., 2001 ), while others suggest that ECT stimulates neurogenesis , or new nerve growth, that may be the source of the symptom relief.

Other Medical Procedures There are other medical procedures that can help with psychological con-ditions. Psychosurgery , or treatment of mental and behavioral conditions using an invasive biological procedure, has come a long way since early treatments. Previously, medical procedures were limited to drilling holes in the head to release spirits or less specific surgical procedures such as lobotomy , a surgery that involves destruction of nerves in the pre-frontal cortex in order to improve symptoms of psychological conditions FIGURE 15- 16 .

One example of newer medical procedures is transcranial magnetic stimulation(TMS) FIGURE 15- 17 . This procedure uses magnetic fields generated by electromagnetic coils to activate or deactivate nerve cells in specific areas of the brain. Depressed moods seem to improve when TMS is applied. TMS has a benefit over ECT in that TMS causes no memory loss or seizures. About 50% of those who have received TMS procedures show an improvement in their symptoms ( Schutter, 2009 ). Another procedure is deep brain stimulation (DBS) , in which a small electrode connected to a pulse generator stimulates the overexcited junction between the limbic system and the frontal lobe FIGURE 15- 18 . In addition, some patients with chronic depression have found relief through a chest implant that stimulates the vagus nerve, which sends signals to the brain’s mood related limbic system ( Conway et al., 2011 ).

FIGURE 15- 17 Using a high-power magnet, transcranial magnetic stimulation (TMS) excites neurons in the brain, triggering activity.

FIGURE 15- 18 Electrodes for deep brain stimulation treatment.

Explaining the Use of Medicines for Psychological Conditions CONCEPT LEARNING CHECK 15. 7

1. A friend of yours has just returned from a psychiatrist and is confused. Even though your friend went with a presenting problem of anxiety, the doctor prescribed him Prozac, an antidepressant. Explain why this is not an unusual choice.

FIGURE 15- 16 Frontal lobotomies used to be performed to intentionally damage the regions involved in emotion in an attempt to cure or improve individuals with severe aggression. This was performed by drilling holes into the skull. After the holes were drilled, needles were placed into the frontal lobe and rocked back and forth to sever neuronal connections. In this image you can see inactive (dark) regions in the frontal lobe near the top of the image.


15.8 Evaluating Therapies for Psychological DisordersResearchers use clinical trials to test treatments for psychological conditions and have found psychotherapy to be an effective treatment.

Describe how clinical trials test treatments for psychological conditions.

Discuss types of research that have provided evidence of the efficacy of treatments for psychological disorders.

Before we discuss the effectiveness of therapies for psychological conditions, it is important to understand the natural progression of a disorder. Many psychological conditions are self-limiting, meaning they go away all by themselves. This is true for some nonpsycho-logical conditions, too. The average length of the common cold, for example, is about 10 days. In contrast, the average of an episode of major depressive disorder is between 6 months and 2 years (Katon & Schulberg, 1992). After that point, many people experi-ence a spontaneous remission, or a reduction of symptoms of a condition even in the absence of treatment. People who are depressed, for example, do not stay depressed in exactly the same way for the rest of their lives. Although some people with psychological conditions do remain impaired for significant amounts of time, there is also a propensity for symptoms to change over time. This change is called regression toward the mean and refers to a tendency for those with severe symptoms to move to more moderate symptoms. What is more, many people with psychological conditions experience a placebo effect with treatment. “Placebo effect” refers to a client’s response to nontreatment disguised as treatment, such as receiving a sugar pill while being told it is a therapeutic drug. Clients will sometimes improve by being on a waiting list for psychotherapy or even receiving a sugar pill (Kirsch, Moore, Scoboria, & Nicholls, 2002).

Effectiveness of Therapies for Psychological DisordersHow can psychologists and other mental health care practitioners tell if therapy is work-ing? The scientific method is a powerful tool in evaluating the effectiveness of both psy-chotherapy and biomedical therapies. People who measure the effectiveness of therapies often use a clinical trial, which employs the scientific method to test a treatment for a disorder or condition. In a clinical trial meant to test a treatment for depression, for example, researchers ideally would like to study everyone who is depressed. But since that would be impossible, researchers instead use a convenience sample made up of people who volunteer to be part of their study. Then, the researchers randomly assign these participants into two groups—the “treatment” group gets the intervention (a type of psychotherapy or perhaps a drug that is being tested), and the “no treatment” group gets no treatment (they may be assigned to a waiting list for psychotherapy or receive a placebo instead of the drug being tested). Other than receiving or not receiving the intervention being tested, the two groups are treated in exactly the same way. Before the intervention takes place, researchers measure the severity of the participants’ conditions. For our depression example, they might use a standard depression survey such as the Beck Depression Inventory (Beck & Aaron, 1988). Then, at regular intervals, they retake the measurements. If the participants’ final depression scores were different, the research-ers would conclude that the change was due to the administration of the dependent variable, which would be receiving the particular therapy. This technique distributes any nontreatment artifacts, such as regression to the mean, spontaneous remission, or the placebo effect, into both groups randomly since all of the participants have an equal chance of getting the intervention.

Often researchers replicate studies like the one described and compare the inter-ventions to other drugs or other therapies. After a while, researchers know a lot about a particular intervention. At that point, researchers can statistically combine the individual studies to get a broad view of the intervention using a meta-analysis. A meta-analysis is a statistical technique that pools the results of several research studies so that practitioners can make the best decisions for their clients. Evidence-based practice involves selecting therapy treatments using information gained through research. For example, a meta-analysis (Davidson & Parker, 2001) of a sometimes-controversial therapeutic technique, eye movement desensitization reprocessing (EMDR), a therapy technique involving bilateral stimulation in order to process distressing memories, revealed that EMDR is an

Neurogenesis New nerve growth.

Psychosurgery Treatment of mental and behavioral conditions using an invasive biological procedure.

Lobotomy A surgery that involves destruction of nerves in the prefrontal cortex in order to improve symptoms of psychological conditions.

Transcranial magnetic stim-ulation (TMS) A procedure that uses electromagnetic coils to activate nerve cells in the brain.

Deep brain stimulation (DBS) A surgical treatment in which a medical device is used to send electrical impulses to parts of the ner-vous system.

Spontaneous remission Reduction of symptoms of a condition in the absence of treatment.

Regression toward the mean The inclination for extreme scores to move toward the average over time.

Clinical trial The use of the scientific method to test a treatment for a disorder or condition.

Dependent variable The measurement collected to determine if there was any effect of the independent variable in an experiment.

Meta-analysis A statisti-cal technique that pools the results of several research studies.

Evidence-based practice Selecting therapy treatments using information gained through research.

Eye movement desensitiza-tion reprocessing (EMDR) A therapy technique involv-ing bilateral stimulation in order to process distressing memories.

15.8 Evaluating Therapies for Psychological Disorders 601

Common Factors That Increase EffectivenessThere appear to be some crosscutting factors related to the effectiveness of psychotherapy treatments. Across all therapy techniques, the better the quality of the therapeutic relation-ship, the better the outcomes. Similar to what the humanistic psychologists Carl Rogers suggested, genuineness and warmth are important therapeutic characteristics, and they appear to have a treatment effect of their own (Lambert & Barley, 2001). In addition to therapist factors, client factors are important, too. For example, clients’ outcomes are better when they have greater access to support in their environments and when they are motivated (Lambert & Barley, 2001).

effective treatment for PTSD, but perhaps not in the way originally thought. Through meta-analysis and subsequent research, it was determined that it was the exposure and not the bilateral stimulation that appeared to be the most important part of the intervention.

Effectiveness of Different TherapiesSo what have we discovered through research techniques like clinical trials and meta-anal-yses? Psychotherapy is effective. Half of all people who enter therapy show improvement by the second month, and by 9 months, three out of four show significant improvement (McNeilly & Howard, 1991). In fact, according to a classic meta-analysis, those in the treatment group show a greater improvement than 80% of those untreated (Smith & Glass, 1977). Treatment effects are good for medication, too, and patients fare even bet-ter when the two are combined. What researchers have not found is one therapy that is best for everyone when comparing psychodynamic, humanistic, behavioral, cognitive, or drug treatments (Nathan, Stuart, & Dolan, 2000). Smith and Glass’s (1977) meta-analysis of 400 clinical trials showed that no one therapy was best overall. However, there were some winners for particular kinds of conditions: Behavioral and cognitive behavioral therapies were the best treatment for panic disorder and obsessive compulsive disorder, and cognitive behavioral therapy was best for depression TABLE 15-10.

Problem Strong Research Support* Modest Research Support**

Bipolar disorder • Cognitive therapy

Depression • Cognitive therapy• Behavioral therapy

• Short-term psychodynamic therapy

Generalized anxiety disorder • Behavioral therapy• Cognitive therapy

Insomnia • Cognitive behavioral therapy• Relaxation training

• Biofeedback

Obsessive-compulsive disorder • Behavioral therapy• Cognitive therapy

Panic disorder • Cognitive behavioral therapy • Relaxation• Psychoanalytic treatment

PTSD • Exposure therapy• Eye movement desensitization

reprocessing

Schizophrenia • Social skills training• Cognitive behavioral therapy

Social phobia • Cognitive therapy• Behavioral therapy

Specific phobias • Exposure therapies

TABLE 15-10 Empirically Supported Therapies for Psychological Conditions

*Research support for a given treatment is labeled “strong” if criteria are met for what Chambless et al. (1998) termed “well-established” treatments. To meet this standard, well-designed studies conducted by independent investigators must converge to support a treatment’s efficacy.**Research support is labeled “modest” if criteria are met for what Chambless et al. (1998) termed “probably efficacious treatments”. To meet this standard, one well-designed study or two or more adequately designed studies must support a treatment’s efficacy.

Source: Data from the American Psychological Association, Division 12, Society of Clinical Psychology.


Treatments for psychological conditions can be effective in relieving stress and help-ing those with psychological disorders. Professional organizations, client advocate groups, and government agencies all give advice about how to choose a therapist.

This information is subject to bias toward the particular group, so sorting through the information can be confusing to those unfamiliar with psychology. Finding the right therapist and therapy is important, and those seeking help should be encouraged to ask questions and to find the best person and treatment for them.

Using the Internet, search the websites of agencies such as the American Psychiatric Association, PsychCentral, and the American Psychological Association, construct a guide for a person seeking therapy. In your guide, be sure to fold in information about the cross-cutting themes of effective therapies that are mentioned in this chapter. Your guide should encourage those seeking therapy to ask direct questions about how long the therapists have

been seeing clients, their areas of expertise, the types of treatments they use, and what licenses they hold. In addition, it is important to talk about finances, fees, and if health insurance is accepted.

It will also be important to note in your guide that there are licensing boards to report a therapist if you feel the therapist is engaging in unethical behavior. A person can stop treatment with a psychotherapist at any time.

Culture, Cultural Values, and Psychotherapy Cultures can vary on the amount of stigma associated with seeking treatments for psychological conditions. The more stigma associated with seeking help, the fewer choices for help, and the less likely those who suffer will look for assistance. Although psycho-therapy is relatively accepted in the United States, this is not the case all over the world. China, for example, has relatively few therapists that are as extensively trained as those in the United States ( Gao et al., 2010 ).

Psychotherapy treatments also reflect the values of a particular culture. Cultures that place an emphasis on interreliance rather than self-reliance, or collectivist cultures , for example, often discourage public emotional displays and focusing on the self too much ( Lee, 2006 ). Other cultures place an emphasis on the family, and sharing problems out-side of the family is discouraged ( La Roche & Maxie, 2003 ). A focus away from the self can run counter to many insight-oriented therapies, such as self-exploration, emotional expression, and self-disclosure.

Understanding cultural nuances can be important in psychotherapy. Professional associations such as the American Psychological Association, the Association for Psy-chological Science, the American Psychiatric Association, and many state psychological licensing boards require training in cultural differences that could potentially influence the therapeutic relationship and emphasize awareness of the influences and challenges that are faced. Despite additional training, some clients prefer therapists who are cultur-ally similar to them ( Sanchez & Atkinson, 1983 ).

Summary of Multiple Influences on Therapies forPsychological Disorders

Ideally, psychological conditions are treated on multiple levels as seen in FIGURE 15- 19 . For example, many research studies have shown that depression responds better when treated with both medication and psychotherapy ( Zuckerbrot, 2007 ). Two are better than one alone. It results in a faster recovery and a lower chance of relapse than when the depression is treated with only one intervention.

For example, cognitive therapy with a systems approach might examine family dynamics that have contributed to the problem. Learned behaviors may intersect with

Collectivist culture A culture that places an emphasis on interreliance rather than self-reliance.

15.8 Evaluating Therapies for Psychological Disorders 603

the larger social environment. Some psychologists are examining large-scale interventions that target the social issues that may set the stage for psychological conditions or may pre-vent those suffering from seeking treatment. In fact, many college residence halls focus on prevention in this way. Targeting society may well be the best way to attack psychological conditions, since it will allow a psychological condition to be targeted on many levels.

The medicine I took for my flight quelled my anxiety for the first few hours. Ultimately, my nearly 6,000-mile flight from Chicago to Istanbul, Turkey, meant that a behavioral exposure technique for my anxiety would also be at work due to the length of the flight. I landed exhausted but relaxed, jetlagged, and with a huge reduction of my fear of flying. To this day, I am still not convinced that it was the medication that got rid of my flight anxiety. There were probably multiple influences on my treatment. Sure, the medicine helped biologically by reducing my central nervous system activity, but I also realized that I may have had an unconscious worry about not being in control (psychodynamic). I had to trust what I felt would be best for me to take care of myself in that situation (humanistic) and even question my irrational thoughts and fears (cognitive) while I lis-tened to relaxing music, although I was feeling frightened (behavioral). Ultimately, there were multiple influences on my treatment of my flight anxiety. I fly all the time now with only the slightest hint of anxiety, but I still prefer the window seat.

Summarizing the Factors of Effective Psychotherapy CONCEPT LEARNING CHECK 15. 8

1. Summarize some of the crosscutting factors thought to increase likelihood of effective psychotherapy.

FIGURE 15- 19 Interventions for psychological conditions can occur on multiple levels.

Culture

Individualtherapy

Culturee

vvidualalallrapy System

Medication


Visual Overview Common Medications Used to Treat Psychological Disorders

Those who prescribe medication to treat psychological conditions choose from a number of medicines. This overview summarizes the common classes of psychotropic medications, the conditions they treat, as well as examples of each class of medicine.

SNRI (Serotonin Norepinephrine Reuptake Inhibitors)

Uses include treatments for mood disorders like depression, anxiety disorders like generalized anxiety disorder

MAOI

(Monoamine Oxidase

Inhibitors)

Uses include treatm

ents for

major depressive d

isorder

Benzodiazepines Uses include treatments for anxiety disorders

Examples include: diazepam (Valium) alprazolam (Xanax)

Anticonvulsants

Uses include treatments

for the manic phase of

bipolar disorder.

Lithium

Uses include treat

ments

for both mania and

depression in b

ipolar

disorder

SSRI (Selective Serotonin Reuptake Inhibitors)

Uses include treatments for mood disorders like major depressive disorder, anxiety disorders like PTSDExamples include: citalopram (Celexa) escitalopram (Lexapro) paroxetine (Paxil) sertraline (Zoloft) vilazodone (Viibryd)

Antipsychotics Uses include treatments for psychotic disorders like schizophrenia. Some antipsy-chotics are used to boost the effectiveness of an SSRI in the treatment of depression.

Examples include: Typical antipsychotic: haloperidol (Haldol)

Atypical antipsychotics: risperdal (Risperidone) aripiprazole (Abilify)

Examples include:

lamotrigine (Lamictal)

Examples include: venlafaxine (Effexor) duloxetine (Cymbalta) desvenlafaxine (Pristiq)

Examples include:

phenelzine (Nardil)

tranylcypromine (Parnate)

emsam (Selegiline)

Chapter Review 605

15.1 Mental Health Practitioners and Settings• Despite effective treatment, many people

wait years to get help for psychological conditions.

• There are a number of mental health practitioners with various approaches to mental health concerns.

• Psychiatrists are medical doctors with a clinical specialty in treating psychological conditions.

• Clinical and counseling psychologists both study and treat individuals with psychological concerns.

• Although much improved, historically, mental hospitals have had a stormy history in providing adequate care for those in need of psychological treatment.

15.3 Humanistic Therapy• Humanistic therapy is based on the

idea that all humans have an actualizing tendency.

• Carl Rogers pioneered client-centered therapy based on humanistic personality theory.

• Client-centered therapists create the proper conditions so that therapeutic change will occur in their clients.

• Client-centered approaches are powered by genuineness, acceptance, and empathy.

15.4 Behavior Therapy• Behavior therapies for psychological

conditions are based on the assumption that psychological disorders are the result of maladaptive behavior patterns.

• Behavioral therapies attempt to change maladaptive associations, discourage maladaptive behaviors, or encourage more adaptive ones.

• Behavioral therapies use classical conditioning techniques to decouple

problematic associations using counterconditioning techniques to attempt to extinguish the behaviors.

• Classical conditioning techniques include exposure therapies, aversive conditioning, and systematic desensitization.

• Operant conditioning techniques attempt to increase the occurrence of behaviors and reduce the occurrence of others using positive reinforcement.

Visual Summary of Therapies for Psychological Disorders

606

15.2 Psychodynamic Therapy• Modern psychodynamic therapy emerged

out of the personality theories and treatments of Sigmund Freud.

• Psychodynamic treatments are based on settling unconscious conflicts that are created in childhood.

• Psychodynamic therapists use many tools, including free association, dream analysis,

carefully timed interpretations and analysis of transference, and resistance for treatments.

• There are several types of psychodynamic therapies, including classical psychoanalysis and short-term psychodynamic therapy.

15.5 Cognitive Therapies• Cognitive therapies suggest that the

causes of psychological conditions are the results of maladaptive thoughts.

• Cognitive therapists use various techniques to recognize patterns of maladaptive thinking and construct

intervention strategies to reshape ways of thinking.

• The two most common types of cognitive therapy are Beck’s cognitive therapy and Ellis’s rational emotive therapy.

Culture

Individualtherapy

Culturee

vvidualalallrapy System

Medication

Presynaptic Neuron

Postsynaptic Neuron

Synaptic vesicles

Serotonin(neurotranmitters)

Receptors

Synaptic gap

Reuptake blocker

15.6 Family Systems and Group Therapy• Family systems therapy focuses on how

individuals function in their relationships.

• The focus of interventions for systems approaches is on communication patterns.

15.7 Biomedical Therapies• Biomedical therapies focus on changing

physiological problems that lead to psychological conditions using drug treatments as well as surgical interventions.

• Most antidepressants are constructed by the monoamine hypothesis of depression, suggesting that depression is related to problems in a family of neurotransmitters that includes serotonin, norepinephrine, and dopamine.

• Monoamine oxidase inhibitors (MAOIs) work by preventing the enzyme monoamine oxidase from metabolizing the neurotransmitters serotonin, norepinephrine, and dopamine in the synaptic gap.

• Selective serotonin reuptake inhibitors (SSRIs) increase the efficiency of serotonin by blocking the reabsorption of the neurotransmitter serotonin into the presynaptic neurons.

• Serotonin-norepinephrine reuptake inhibitors (SNRIs) are medicines that keep both serotonin and norepinephrine in the synapse longer.

• Antianxiety medications reduce the symptoms of agitation and nervousness.

• Benzodiazepines work by affecting gamma-aminobutyric acid (GABA) in the nervous system.

• Mood stabilizers are a family of medications used to treat bipolar mood disorders.

• Lithium is a medication that will stabilize the manic and depressive phases of bipolar disorder.

• Anticonvulsants such as lamotrigine and valproate are helpful antimanic medications for those who do not respond well to lithium.

• Antipsychotic medications reduce the symptoms of thought disorders like schizophrenia.

• Older medications such as the typical antipsychotics improve the positive symptoms of psychosis (including hallucinations and delusions) but have limited impact on the negative symptoms of psychosis (i.e., affective flattening and avolition).

• Typical antipsychotics can have disruptive side effects including tardive dyskinesia.

• Newer atypical antipsychotics have a lower rate of tardive dyskinesia and offer relief for both positive and negative symptoms of psychosis but are associated with higher rates of weight gain and diabetes.

• In addition to medications, other medical treatments for psychological conditions include electroconvulsive therapy, transcranial magnetic stimulation, and deep brain stimulation.

Visual Summary of Therapies for Psychological Disorders, continued

15.8 Evaluating Therapies for Psychological Disorders• Clinical researchers utilize clinical trials

to test treatments for psychological conditions.

• Research has provided evidence of the efficacy of treatments for psychological disorders.

• Researchers did not find one kind of therapy that was better than others, except for specific treatments for specific disorders.

• Research has found some crosscutting factors for effective psychotherapy treatments, including therapist factors such as genuineness and warmth and client factors such as access to supportive environments and client motivation.

• Combining psychotherapy and drug therapy can be more effective than one alone.

607

15.1 Mental Health Practitioners and Settings

1. Your friend just returned from a visit with a mental health practitioner. He said the person had a DO degree after her name and gave your friend a prescription for a medication for anxiety. Your friend cannot remember the kind of practitioner. Based on this information, the practitioner was most likely a:A. psychiatrist.B. counseling psychologist.C. clinical psychologist.D. psychiatric nurse.

15.2 Psychodynamic Therapy

2. If a client comes in 20 minutes late to every session soon after the therapist has uncovered an important issue, this could be a sign of:A. insight.B. free association.C. resistance.D. transference.

3. Which type of therapy is most like the one that Freud would have practiced?A. Transference therapyB. Short-term psychodynamic therapyC. Psychodynamic therapyD. Psychoanalysis

15.3 Humanistic Therapy

4. Client-centered approaches are rooted in:A. creating an environment of genuineness, acceptance,

and empathy.B. examining intrapsychic conflicts.C. increasing the occurrence of adaptive behaviors.D. challenging maladaptive cognitions.

5. What emotions do humanists explore most often?A. The emotions that arise naturally in therapyB. The emotions generated from projective tests, such as

the Rorschach inkblot testC. Emotions that occur from early memoriesD. Emotions that the client recalls from dreams

15.4 Behavior Therapy

6. In the bell-and-pad treatment, the bell serves as a(n):A. unconditioned stimulus.B. unconditioned response.C. conditioned stimulus.D. conditioned response.

7. In systematic desensitization, each step of the hierarchy of fears is associated with:A. an aversive stimulus.B. relaxation.C. the feared outcome.D. a substitute symptom.

15.5 Cognitive Therapies

8. In cognitive therapy, clients are taught to identify negative thoughts and then:A. relax.B. question them.C. stop thinking the thought.D. think more positive thoughts.

9. Beck’s cognitive therapy (CT) differs from Ellis’s rational emotive therapy [RET] in that:A. RET has homework and CT does not.B. RET is more directive and CT is more guiding.C. RET suggests that psychological conditions are caused by maladaptive thoughts and CT suggests that psychological

conditions are caused by maladaptive behaviors.D. Ellis was trained as a psychoanalyst while Beck was trained as a behaviorist.

608

1. Section 15.1 describes three main types of mental health practitioners: psychiatrists, counseling psychologists, and clinical psychologists. Compare and contrast the assistance you would receive from each type of mental health practitioner. Are there some situations where one type of practitioner might be more appropriate than another?

2. Imagine that you are suffering from test anxiety and that you are researching a different therapy approaches that might help you overcome your anxiety. Review psychodynamic, humanistic, behavioral, cognitive, and family and group therapy techniques. Then, rank each theory in terms of how effective you think it would be in helping you with your test anxiety. Explain the order of your rankings.

3. Review all the approaches to therapy from Section 15.2–7 and evaluate how comfortable you would be accepting each form of therapy for yourself. Once you’ve gone through all the therapies, look at your ratings for biological versus nonbiological therapies. Do you see a preference for biological or nonbiological? What are the reasons for your preference?

4. Section 15.8 explains how to evaluate the effectiveness of different forms of therapy, but also highlights some other factors that may improve a person’s mental state such as a placebo effect. Differentiate those factors other than therapy that may influence a person’s psychological status.

15.6 Family Systems and Group Therapy

10. Systems approaches will sometimes use genograms in order to:A. uncover the source of blame in the family.B. examine patterns of intrapsychic conflicts in the family.C. explain and examine the common roles that people play in the family.D. interpret dreams.

15.7 Biomedical Therapies

11. SSRIs work by:A. blocking the reabsorption of serotonin.B. binding to receptor sites.C. encouraging the release of more serotonin.D. inhibiting the removal of serotonin by the

enzyme MAO.

12. If a client takes the antipsychotic Haldol, which of the following symptoms is it most likely to help?A. A flat affectB. Auditory hallucinationC. Lack of elaborative speechD. Lack of pleasurable experiences

13. Which of the following is considered an advantage of a benzodiazepine like Xanax?A. Benzodiazepines have a low risk for abuse.B. Benzodiazepines are an effective treatment for

depression.C. Benzodiazepines work quickly.D. Benzodiazepines have an action on the neurotransmitter

serotonin.

15.8 Evaluating Therapies for Psychological Disorders

14. If a client comes in with lots of anxiety it is likely that, on its own, the anxiety will decrease because of the phenomenon of:A. resistance.B. regression toward the mean.C. counterconditioning.D. transference.

15. Your friend Emily said that she is looking for a therapist to help with some personal struggles. Without knowing her specific condition, which type of psychotherapist would be best for her, according to the research?A. PsychodynamicB. HumanisticC. BehavioralD. CognitiveE. They are all equally effective.

Chapter Review 609

15.1 Comparing the Roles and Settings of Mental Health Care Practitioners

1. Deinstitutionalization created more freedom and choices for treatment, but it also created more homelessness and a population that did not receive the treatment it needed.

2. Psychiatrists typically use medicine to treat psychological disorders and counseling and clinical psychologists employ psychotherapy. Clinical and counseling psychologists are more similar than different in the way they research and treat psychological conditions.

15.2 Understanding Psychodynamic Therapies

1. Psychoanalytic therapies provide insight into problematic intrapsychic conflicts.

2. Traditional psychoanalytic therapy is long term and more formal, whereas short-term psychodynamic therapy is time limited and more casual in focus.

15.3 Describing the Elements of Humanistic Therapy

Humanistic therapies attempt to active the actualizing tendency or the instinctual desire to be the best possible version of oneself. By providing the correct environment, the therapist releases this the potential in the client.

Acceptance

Active listening

Actualizing tendency

Alogia

Anhedonia

Antianxiety medication

Antidepressant medication

Antipsychotic medication

Aversive conditioning

Avolition

Behavior therapy

Bell-and-pad treatment

Biomedical therapies

Classical conditioning

Client-centered therapy

Clinical psychologist

Clinical researcher model

Clinical trial

Cognitive therapy

Collectivist culture

Counseling psychologist

Counterconditioning

Deep brain stimulation (DBS)

Defense mechanism

Deinstitutionalization

Delusions

Dependence

Dependent variable

Dream analysis

Eclectic approach

Electroconvulsive therapy (ECT)

Empathy

En vivo

Etiology

Evidence-based practice

Exposure therapy

Eye movement desensitization

reprocessing (EMDR)

Family therapy

Free association

Gamma-aminobutyric acid (GABA)

Genogram

Genuineness

Group therapy

Hallucination

Humanism

Insight

Insight therapies

Interpretation

Latent content

Lithium

Lobotomy

Manifest content

Mental hospital

Meta-analysis

Mood stabilizers

Negative symptoms of psychosis

Neurogenesis

Outpatient

Phenomenology

Placebo

Placebo effect

Positive psychology

Practitioner-scholar model

Psychiatry

Psychoanalysis

Psychodynamic therapies

Psychopharmacologist

Psychopharmacology

Psychosurgery

Psychotropic medication

Rational emotive therapy

Regression toward the mean

Relapse

Resistance

Scientist-practitioner model

Selective serotonin reuptake

inhibitor (SSRI)

Shaping

Short-term psychodynamic therapy

Social skills training

Spontaneous remission

Support group

Symptom substitution

Systematic desensitization

Tardive dyskinesia

Tolerance

Transcranial magnetic

stimulation (TMS)

Transference

Unconditional positive regard

Virtual reality exposure therapy

1. Imagine that you have a friend who has come to you for advice about choosing a type of therapy for depression. Formulate a guide for your friend to help him or her understand the pros and cons of each type of therapy.

2. Identify a common problem among college students that might require psychological therapy. Then, act out

a therapy session to work through the problem using at least four different approaches to therapy. Develop a script for each therapy session. Use a video camera to record the sessions. To complete the project, write a summary of the results of each session and your conclusions about what worked and what might have been done differently.

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15.1 Mental Health Practitioners and Settings

1. A. Rationale: Psychiatrists are practitioners with professional medical doctorates (like MD or DO). Psychiatrists will sometimes treat psychological conditions using medication.

15.2 Psychodynamic Therapy2. C. Rationale: Resistance is a

client’s employment of a defense mechanism during therapy.

3. D. Rationale: Psychoanalysis is a type of therapy based on Freud’s theory of personality.

15.3 Humanistic Therapy4. A. Rationale: Client-centered

approaches are powered by the creation of an environment of genuineness, acceptance, and empathy.

5. A. Rationale: Instead of recalling and discussing emotions, humanists discuss the ones that occur during real time in therapy.

15.4 Behavior Therapy6. A. Rationale: The bell would

naturally wake you up, and this

is an unconditioned stimulus that generates an unconditioned response of waking.

7. B. Rationale: Systematic desensitization is a treatment for phobia in which a client practices relaxation during progressively more fear-inducing stimuli.

15.5 Cognitive Therapies8. B. Rationale: Rather than just

thinking positively, the therapist encourages the client to notice and test out maladaptive beliefs through questioning techniques and homework.

9. B. Rationale: RET and CT are similar, except RET takes a more active and directive approach as compared to CT.

15.6 Family Systems and Group Therapy

10. C. Rationale: Systems approaches also note that people will often play roles in certain systems. These patterns can sometimes be revealed in genograms, or family trees.

15.7 Biomedical Therapies11. A. Rationale: Selective serotonin

reuptake inhibitors are a class

of medications that increase the efficiency of serotonin by binding to the reuptake sites.

12. B. Rationale: Hallucinations are positive symptoms of psychosis.

13. C. Rationale: Benzodiazepine are fast-acting medicines for the treatment of anxiety. They have an action on the neurotransmitter GABA and have a high risk for abuse.

15.8 Evaluating Therapies for Psychological Disorders

14. B. Rationale: Regression toward the mean is the inclination for extreme scores to move toward the average over time.

15. E. Rationale: Without knowing the specific condition, the research suggests that all the interventions are about equally effective.

15.4 Designing a Behavioral Treatment Plan

The behavioral treatment plan should include relaxation training, a hierarchy of fears, and paired exposure with relaxation.

15.5 Comparing Cognitive Therapies

Both Beck and Ellis emphasize the importance of action and maladaptive thoughts. Ellis’s approach is more directive and active, while Beck’s approach is to encourage clients to test out their beliefs.

15.6 Describing an Eclectic Systems Approach

1. The components of the client-centered approaches are genuineness, acceptance, and empathy. The therapist would help the members of the group to practice those components in the group.

15.7 Explaining the Use of Medications for Psychological Conditions

Although called an antidepressant, Prozac is an SSRI that can also be used for chronic anxiety.

15.8 Summarizing the Factors of Effective Psychotherapy

The better the quality of the therapeutic relationship, the better the outcomes such as genuineness and warmth. Client factors are important, too, such as supportive environments and client motivation.

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