Mental Health TreatmentToday

Q: How many therapists does it take to change a light bulb?

Psychotherapy

Psychotherapy: refers to a broad range of techniques designed to address problems of psychological functioning and improve an individual’s personal and social adjustment.

– It involves an interaction between a trained therapist and someone suffering from psychological difficulties.

There are several different types of psychotherapy, based on different theories of human nature:

– Psychoanalysis/Psychodynamic Therapy– Behavioral Therapies– Cognitive Therapies– Humanistic Therapies– Group, Family, or Couples Therapy

Eclectic Approach

The most popular form of therapy – it’s basically a smorgasbord where the therapist combines techniques from different schools of psychology.

Psychoanalytic/Psychodynamic Therapy

Emphasizes the recovery of __________ conflicts, motives, and defenses through a variety of techniques.

Psychoanalysis/Psychodynamic Therapy

This is an example of an insight therapy – insight therapies involve verbal interactions intended to enhance clients’ self-knowledge and thus promote healthful changes in personality and behavior.

With psychoanalysis or psychodynamic therapy, treatment is designed to help the patient bring unconscious material to awareness, where it can be dealt with.

Similarities

Both psychoanalysis and psychodynamic therapies:– Use free association, which encourages the patient to talk

without focusing on the analyst’s reaction. Patients report whatever thoughts, memories, or images come to mind, with as little censorship as possible. In the course of free association, unconscious or repressed feelings, thoughts, and memories should surface. It is the analyst’s job to look for these clues about what is going on in the unconscious.

– May involve transference, where the patients unconsciously start relating to their therapist in ways that mimic critical relationships in their lives. When the analyst points it out, it can provide valuable information for the patient’s self-understanding.

Similarities, cont.

– Use dream analysis, which involves the therapist interpreting the symbolic meaning (latent content) of the client’s dreams. Freud called dreams the “royal road to the unconscious.“

– May involve resistance, which refers to the largely unconscious defensive maneuvers intended to hinder the progress of therapy.

During free association, the patient edits his thoughts, resisting his or her feelings to express emotions. Such resistance becomes important in the analysis of conflict-driven anxiety.

– Use interpretation, which refers to the therapist’s attempts to explain the inner significance of the client’s thoughts, feelings, memories, and behaviors in order to bring the unconscious thoughts or feelings to a conscious level.

Differences

Psychoanalysis:– Not commonly practiced– Meet with patient 4-5 times a week for 2 years or more;

therefore, it is costly and impractical for most– Patient lies on a couch, not looking at the analyst

Psychodynamic Therapy:– More common– Meet with patient much less often – once or twice a week

sessions for a few months– The therapist may not use the “couch” (often face-to-face)– They focus more on current issues instead of simply what

happened in the past. (Although, they do still place focus on learning about a patient’s childhood experiences, unconscious drives, and unresolved conflicts).

Behavioral Therapy

Classical Conditioning (Exposure Therapy, Aversive Conditioning) and Operant Conditioning (Behavior Modification and Token Economies)

Behavioral Therapies

Behavior therapy applies learning principles (classical conditioning and operant conditioning) to the elimination of unwanted behaviors.

– Instead of trying to trace a fear of dogs to some unresolved childhood conflict (like a psychoanalyst)

– A behaviorist would instead focus on the present by attempting to replace your fearful thoughts and related behaviors with constructive, relaxing thoughts and actions.

– The behaviors are the problems, so we must change the behaviors.

Psychoanalytic Therapist vs. Behavioral Therapist

Classical Conditioning Techniques

Remember, classical conditioning is a type of learning in which we associate two things that occur together (remember John B. Watson?)

So if we can learn fears, can we unlearn them? In some cases, yes – through

counterconditioning (a behavioral therapy that conditions new responses to stimuli that trigger unwanted behaviors). – There are two commonly used types of

counterconditioning: exposure therapy and aversive conditioning.

Exposure Therapy

Expose patients to things they fear and avoid.

Through repeated exposures, anxiety lessens because they habituate to the things feared. If they’re no longer allowed to avoid the stimulus, they will gradually become desensitized to it.

If the client learns to tolerate the feared object or situation through exposure to a high level of that stimulus, it is termed flooding.

Exposure therapy with an elevator phobia

Systematic Desensitization

Joseph Wolpe (1958) pioneered this specific type of exposure therapy.

Systematic desensitization associates a pleasant, relaxed state (called progressive relaxation) with gradually increasing, anxiety-triggering stimuli.

If you can repeatedly relax when faced with higher and higher levels of the anxiety-producing stimulus, you will gradually overcome your problem.

– The basic idea is that you cannot be anxious and relaxed at the same time.

– Research shows that this technique is very effective in treating phobias.

Example of Systematic Desensitization

Fear of flying:– Write down a hierarchy of anxiety-triggering flying

situations. The ideas about flying that cause you the most anxiety are at the top of the list, and they gradually decrease as you move down the list.

– Practice progressive relaxation – start with the bottom item on your list, and try to maintain a sense of relaxation while thinking about this scenario. You continue the process until you can think about it and still maintain your relaxed state.

– Next, you move on to the next item on your hierarchy, and continue until you reach the top of your list.

– After several therapy sessions, thoughts and photos are replaced by experience, beginning with somewhat easy tasks like watching planes land. Eventually, you move to more difficult tasks (like boarding the plane) until your fear is gone.

Systematic Desensitization

Instructor’s Notes

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Aversive Conditioning

Aversion therapy is the most controversial of the behavior therapies.

Purposefully associates an unpleasant state (such as a bitter-tasting nail polish) with an unwanted behavior (such as biting one’s nails).– This process is the opposite of systematic

desensitization. Here, you replace a positive response to a harmful experience with a negative (aversive) response.

Examples of Aversive Conditioning

Alcoholism:– Antabuse is a drug therapy for alcoholics. Here,

the addict can drink anything he wants, but every time, a tasteless, odorless drug is mixed in with it that causes severe nausea and vomiting.

– Over time, the addict will associate this negative response with the alcohol, and stop wanting it.

– In one study, 63% of people treated with this method were still abstaining from alcohol one year later. Unfortunately, only 33% of them were successfully abstaining from alcohol after 3 years.

– Why might that be?

Examples of Aversive Conditioning (cont.)

Read the ABC News article “’Shocking’ School Takes on Severe Autism: A Painful Treatment Inspires Controversy” (http://abcnews.go.com/Primetime/Story?id=2887677&page=1)– What do you think about aversive

conditioning being used in this sense?

Operant Conditioning Techniques

This technique uses the idea of rewarding desired behaviors, and withholding rewards for unwanted behaviors or punishing them.

Therapists shape behavior by reinforcing small steps in the right direction.

Treatments aim to encourage patients to voluntarily reduce their maladaptive behaviors and replace them with more constructive and healthy ones.

Two types of operant conditioning techniques are behavior modification and token economy.

Behavior Modification

Involves identifying one or more specific target behaviors that need to be increased or eliminated and providing reinforcers accordingly.

Eventually, as the behavior becomes habitual, the reinforcers are decreased in frequency.

Example of Behavior Modification

In one two year study, 19 uncommunicative, withdrawn 3-year-olds with autism underwent behavior modification techniques.

Parents worked 40 hours a week reinforcing appropriate or desired behavior while ignoring or punishing self-abusive and aggressive behaviors.– 9 of the 19 became successfully functioning first

graders with normal intelligence.

Token Economy

It is called a token economy because it rewards desired behaviors with some kind of token.

Patients (or inmates) earn the tokens by behaving appropriately, then exchange them for simple things like candy, or privileges like watching TV.

This has been successful with day-care centers, delinquent teens, schools, hospitals, and even private homes.

What are the downsides to operant conditioning techniques?

What happens after a person is no longer reinforced for proper behavior?

– People who leave an institution will not receive tokens for getting out of bed on time.

Doctors remedy this by trying to gradually shift patients away from external rewards to internal ones (satisfaction, pride, etc.)

– Is this ethical? – Is it right to deprive someone of a privilege, television,

or dessert in order to obtain a desired behavior? – Or is this process too controlling?

Cognitive Therapy

Rational-Emotive Therapy and Cognitive-Behavior Therapy

Cognitive Therapies

Cognition is _________, and cognitive therapies are designed to change the patient’s thoughts.

The underlying theory here is that it is the way a person thinks about the situation, not the actual situation, that is the main cause of poor adjustment and distress.– The two major types of cognitive therapies are

Rational-emotive therapy (RET) and Cognitive-behavior therapy (CBT).

Rational-emotive therapy (RET)

This was developed in the 1950s by Albert Ellis. He believed that irrational thoughts lead to

negative emotions and that controlling and changing such thoughts is the key to better mental health.1. Patient identifies unrealistic and self-defeating

thoughts.

2. Therapist uses suggestions, logic, and encouragement to help the client replace such thoughts with more realistic and beneficial ones.

Example of rational-emotive therapy

Before RET:– “I lost my job because I’m worthless. I’m awful at

everything I do and I’ll never be successful.”

After RET:– “I lost my job because they had to make budget

cuts as a result of the bad economy. I was a hard worker and I did my best. Employers will recognize my efforts and I will find a new job – probably even a better one than the one I lost.”

Aaron Beck’s Theory of Depression

In 1976, Aaron Beck proposed that depression and other mood disorders result primarily from negative self-talk and the distorted perceptions of self that result from it.

– Depressed patients believe that they can never be happy (thinking) and thus associate minor failings (e.g. failing a test [event]) in life as major causes for their depression.

Beck believes that cognitions such as “I can never be happy” need to change in order for depressed patients to recover.

This change is brought about by gently questioning patients.

– Used cognitive therapy get people to take off the “dark sunglasses” in which they view their surroundings

Cognitive-behavior therapy

CBT, another insight therapy, combines cognitive therapy (changing self-defeating thoughts) with behavior therapy (changing inappropriate behaviors).

With this therapy, people become aware of their irrationally negative thoughts, and are taught to practice a better everyday approach by changing those thoughts and letting the new thoughts guide their behavior.

– Patients are also given behavioral “homework assignments” that focus on changing overt behaviors.

Example of cognitive-behavior therapy

Before CBT:– “I’m no good around the house.”

Changing thoughts:– “I may not be able to do everything, but I can still help out

around the house in a worthwhile way.”

“Homework” assignment from therapist:– Tasks such as cleaning out the basement, getting advice on

hanging a picture, or cutting the grass.

After CBT:– Success at accomplishing even one of the homework tasks

provides concrete evidence to challenge a false belief, thus helping to reduce it.

Humanistic Therapy

Humanistic Therapies

To a humanistic therapist, the potential for self-fulfillment already exists in each one of us.

This therapy promotes self-fulfillment by increasing self-acceptance and self-awareness.– Carl Rogers developed the most famous form of

humanistic therapy, sometimes referred to as “client-centered therapy.”

Client-Centered Therapy

Client-centered therapy is an insight therapy that emphasizes providing a supportive emotional climate for clients, who play a major role in determining the pace and direction of their therapy.

Rogers maintained that most personal distress is due to incongruence between a person’s self-concept and reality.

The goal of therapy involves helping people restructure their self-concept to correspond better to reality.

Rogers held that there are 3 main elements to creating this atmosphere:

– Genuineness, or the therapist being completely honest and spontaneous with the client

– Unconditional positive regard, or a complete nonjudgmental acceptance of the client as a person

– Empathy, an understanding of the client’s point of view.

Characteristics of Humanistic Therapy

Treatment is an encounter between equals, fostering growth; not a “cure” given by an expert. This is why “patient” is often changed to “client” by humanistic therapists.

Focuses of people’s potential for self-fulfillment (self-actualization).

Focus is on the present and future instead of the past. Take responsibility for your actions, instead of blaming

childhood anxieties. Use of nondirective methods – therapists listen without

interpreting and do not direct clients to any particular insight.

The client should feel unconditional positive regard: a feeling of being accepted by the therapist, not depending on any specific behaviors.

Characteristics of Humanistic Therapy, cont.

Uses active listening:– Paraphrasing – uses the words of the

client to summarize the conversation.

– Clarifying – encourage clients to say more by asking questions like:

“Could you give me an example of what you’re saying?”

– Reflecting feelings – The therapist mirrors the feelings of the client with statements like

“That must really be frustrating.”

Group, Family, and Couples Therapy

Group, Family, and Couples Therapy

The one-to-one methods of psychodynamic, humanistic, and behavioral treatment we have discussed are often adapted for use with groups of clients or family units.

Group therapy

Many groups are organized around:– one type of problem (such as alcoholism)– one type of client (such as adolescents)

In most cases, 6-12 clients meet with their therapist at least once a week for about 2 hours.

All members of the group agree to hold confidential everything that occurs within group sessions.

Benefits to group therapy

Allows the therapists to observe the clients interacting with one another.

Groups encourage the members to talk about themselves and explore their feelings.

It can help more people and costs less to the client/patient. Clients feel less alone because they realize that other people

are struggling with difficulties at least as severe as their own. Group members can boost one another’s self-confidence and

self-acceptance as they come to trust and value one another.

Clients learn from one another by sharing ideas for improvement and giving honest feedback.

Allows clients to try out new skills in a supportive environment.

Family therapy

Involves treatment of two or more individuals from the same family.

This format gives the psychologist an excellent view of how the initially identified client interacts with others, thus providing a basis for discussion of topics important to each family member.

The goal of family therapy is not just to ease the identified client’s problems, but to create greater balance and harmony within the family by helping each member understand family interaction patterns and the problems they create.

Couples therapy

Discussion typically focuses on identifying and improving the miscommunication or lack of communication that is interfering with the couples’ happiness and intimacy.

Therapy helps the couple to express their emotions more honestly and to be more accepting of one another.

Sometimes it offers preventive treatment to couples who are at risk for relationship problems.

What kind of therapy do most psychologists use?

Table 15.1Myers: Psychology, Ninth EditionCopyright © 2010 by Worth Publishers

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