Franzoi Chapter 14

8/8/2019 Franzoi Chapter 14

1/51

Copyright Atomic Dog Publishing, 2007

Chapter 14Therapy


2/51


14-1aThere Are Both Psychological and BiomedicalTherapies

In treating psychological disorders, there are twobroad categories of therapy:

Psychotherapy is the treatment of psychologicaldisorders by employing psychological methods thatinclude a personal relationship between a trainedtherapist and a client.Biomedical therapies are the treatment of psychologicaldisorders by altering brain functioning with physical or chemical interventions.


3/51


14-1bThree Primary Mental Health ProfessionsProvide Therapy

Ps ychiatri s ts Medical doctors (M.D.) who have been trained intreating mental and emotional disturbances.They can prescribe medication.

So cial w o rker s Most obtain masters degrees in social work (M.S.W.),while a smaller percentage have their doctorate(D.S.W.).Clinical and psychiatric social workers providepsychotherapy and coordinate with social supportagencies.

Ps ych o log is ts Work with either a masters degree or a doctoraldegree (Ph.D.). Some doctoral degrees are inpsychology (Psy. D.) or educa tion (Ed.D).Psychologists who receive training in psychotherapyalso receive extensive training in conducting research.(This is less true for Psy. D.)


4/51


14-1bThree Primary Mental Health ProfessionsProvide Therapy (cont.)

Two specialty areas in psychology providepsychotherapy.

Clinical psychology is the field that works withpsychological disorderstheir assessment, explanation,and treatmentCounseling psychology is the field that works withessentially normal individuals who experienceproblems in living and so could benefit fromeducational, vocational, or personal counseling


5/51


14-1bThree Primary Mental Health Professions

Provide Therapy (cont.)Training in one profession does not restrict individualpractitioners from specializing in any theoreticalapproach to therapy.

Therapists who combine techniques from varioustheoretical perspectives in treating psychologicaldisorders are known as having an eclectic approach(Stricker, 1996).

Other health professionals may also become involvedwith patients who have psychological disorders. For example, nurses, occupational therapists, physicaltherapists, speech therapists, and other healthprofessionals may work in mental health settings.


6/51


7/51


14-2aPsychoanalysis Laid the Groundwork

for Psychodynamic TherapiesFreud asserted that some traumatic childhood event,often of a sexual or aggressive nature, leaves peoplewith troubling memories or feelings.

To manage the resulting anxiety, people repress thetroubling material.

Although this material is now unconscious, it continuesto have an effect on functioning and eventually causespsychological symptoms.The goal of therapy is to bring the troubling material intoconscious awareness.The release of pent-up emotion is called catharsis.


8/51


14-2bFree Association Is the Primary Psychodynamic

Technique All Freudian-based therapy techniques are directedtoward helping the client gain insight.

The primary technique in Freudian therapy is freeassociation.

Free association is a psychodynamic therapy techniquedeveloped by Freud, in which clients say whatever comes to mind, without making any effort to inhibit their speech.

The psychodynamic therapist also draws inferencesfrom Freudian slips , which are instances in which theclient means to say one thing but actually sayssomething else.


9/51



Technique (cont.)The psychodynamic therapist interprets theunderlying meaning in other forms of expression:dreams, daydreams, artwork, poetry, and so on.

Psychodynamic therapists interpret the clientsrelationship with the therapist and should be aware of transference and countertransference.

Transference involves feelings the client develops for

the therapist that are presumed to reflect the clientsfeelings for significant others early in life.Countertransference involves feelings the therapistdevelops for the client that are presumed to reflectfeelings the therapist had for others early in life.


10/51



Technique (cont.)Over the course of therapy, the client may begin tosabotage therapy by missing or coming late tosessions, talking only about trivial issues, or bringingup significant issues only at the very end of a sessionso that there is no time to address them.

This type of behavior is referred to as resistance.Resistance is anything the client does to interfere withthe therapeutic process.


11/51


14-2cPsychodynamic Therapy Is Lengthy and

ExpensivePsychodynamic therapy is lengthy, and a client couldpay between $40,000 to $120,000 after five years.

Interpretations can never be disproved.For example, if a therapist interprets a client's tardinessas a sign of resistance, the clients attempt to disagreemay be perceived as further proof of the initialinterpretation.


12/51


14-2cPsychodynamic Therapy Is Lengthy and

Expensive (cont.)Though still available, classic psychoanalysis is notwidely practiced today.

However, even those who reject Freuds theoreticalbasis for mental illness often use his technique of developing a one-to-one therapist-client relationshipaimed at increasing client insight.


13/51


14-3Behavior Therapies

Behavior therapies are psychotherapies that applylearning principles to the elimination of unwantedbehaviors.

Behaviorists do not believe in the unconscious, andthus, insight is not important in the treatment of psychological disorders. Instead, psychologicaldisorders and healthy behaviors are thought to bothdevelop through learning.


14/51


14-3aSome Behavioral Therapies Rely

upon Classical ConditioningIn classical conditioning, an unconditioned stimulus(UCS) automatically elicits an unconditioned response(UCR). The UCS is paired with a neutral stimulus thatinitially has no effect on the response. However, after repeated pairings of the two stimuli, the previouslyneutral stimulus, now called the conditioned stimulus(CS), elicits the response, now called the conditionedresponse (CR).

The most widely used form of psychotherapy that isbased on classical conditioning is counterconditioning.

Counterconditioning involves conditioning newresponses to stimuli that trigger unwanted behaviors.


15/51



upon Classical Conditioning (cont.)Systematic desensitization:

Commonly used to treat people suffering from phobiasby gradually exposing the phobic client to the feared

object without arousing anxiety and fear (Wolpe, 1958;Wolpe & Plaud, 1997)

Response prevention:Commonly used to treat compulsive behaviors

(Abramowitz, 2002); clients are exposed to situationsthat trigger the distressing thoughts and feelings, butthey are prevented from engaging in the compulsivebehaviors.


16/51


Table 14-2 A Sample Desensitization HierarchyThe scenes in this hierarchy are typical of those used in the systematic desensitization of afear of snakes. The numbers to the left of each statement represent one patientssubjective rating of how anxiety-provoking a situation is, on a scale from 0 (not at allanxious) to 100 (uncontrollable anxiety).

F ear Level S ceneI imagine seeing a snake.I see a line drawing of a snake.I see a photograph of a small, harmless garden snake.

I see a photograph of a large python.I hold a rubber snake in my hands.I watch a nature video on snakes.I am in the same room with a snake in a cage.I am standing next to the snake cage.I am looking into the top of the snake cage with the lid open.I am standing next to a person holding a snake.

I touch a snake held by someone else.I am holding a snake.

A review of 375 therapy outcome studies indicates that systematic desensitization is themost effective therapy for treating phobias (Smith & Glass, 1977). Other reviews haveconcluded- that desensitization is also effective in treating other problems that may occur as a result of anxiety, such as sexual dysfunction (Emmelkamp, 1986; North et al., 2002).

10202530405060708090

95100


17/51



upon Classical Conditioning (cont.) Aversive conditioning

Clients are classically conditioned to react with aversionto a harmful or undesirable stimulus (Hermann et al.,

2002).


18/51


Figure 14-1(a) Aversive Conditioning for Alcoholism

(a) Before therapy, alcohol is an unconditioned stimulus for alcoholics, naturallyevoking a pleasant unconditioned response.


19/51


Figure 14-1(b) Aversive Conditioning for Alcoholism

(b) During therapy, the Antabuse drug is mixed with alcohol given to the alcoholic,which causes severe nausea.


20/51


Figure 14-1(c) Aversive Conditioning for Alcoholism

(c) After repeated pairings, the alcohol becomes a conditioned stimulus, evokingthe conditioned nausea response.


21/51


14-3bOperant Conditioning Is Used in Token

EconomiesOperant conditioning involves learning throughreinforcement and punishment.

One therapeutic application of operant conditioning

principles is the token economy.The token economy is a technique often used to modifythe behavior of severely disturbed people in institutionalsettings (Bellus et al., 1999; Kopelowicz et al., 2002)that involves reinforcing desirable behaviors with tokens(Ayllon & Azrin, 1968) that can be exchanged for other forms of reinforcement, such as snacks or televisionprivileges

Critics charge that this type of behavior modificationmakes people too dependent on the external rewardsearned in the token economy.


22/51


14-3cObservational Learning Is Used in Modeling

and Social Skills TrainingObservational learning is learning by observing andimitating the behavior of others, who are calledmodels.

The therapeutic application of observational principlesis called modeling.

Modeling is a behavioral method of psychotherapy inwhich desirable behaviors are demonstrated as a wayof teaching them to clients.In participatory modeling, the therapist or someone elsemodels more effective ways of behaving, and graduallythe client is invited to participate in the behavior.


23/51


14-3cObservational Learning Is Used in Modeling

and Social Skills Training (cont.) Another therapeutic technique that involvesobservational learning is social skills training.

Social skills training is a behavioral method of

psychotherapy in which clients are taught how tointeract with others more comfortably and effectively(Hersen & Bellack, 1999).Social skills training programs employ various learningtechniques:

- Modeling of socially skilled trainers- Role-playing various problematic social encounters


24/51


14-4Cognitive Therapies

The cognitive perspective suggests that theimmediate cause of psychological problems isinaccurate or ineffective thinking.

Cognitive therapies seek to identify and then modify

dysfunctional patterns of thought.Unlike psychodynamic therapies, cognitive therapiestend to be short term, problem-focused, and highlydirective.


25/51


26/51


14-4bCognitive-Behavior Therapy Focuses

on Emotional ProblemsCognitive-behavior therapy (CBT) is the cognitivetherapy of Aaron Beck that identifies and thenchanges negative thinking and behavior by using bothcognitive and behavioral principles

CBT was originally developed to treat depression butwas later applied to anxiety and other emotionalproblems (Beck & Emery, 1985).

Clients are encouraged to keep a diary of their thoughts before and after sad episodes. Therapiststhen discuss these episodes with clients and helpthem develop new thinking patterns that are morepositive, accurate, and effective.


27/51


28/51


14-5aClient-Centered Therapy Focuses on Clients

Conscious Self-PerceptionsClient-centered therapy is a humanistic therapy inwhich the client and not the therapist directs thecourse of therapy.

Therapists are viewed as facilitators of personal growthby providing a supportive environment where clientscan discover their true selves.To counteract the effects of conditional positive regard,psychotherapy should be built around the principle of unconditional positive regard.

- Key ingredients in unconditional positive regard aregenuineness, warmth, and empathy.


29/51


14-5aClient-Centered Therapy Focuses on Clients

Conscious Self-Perceptions (cont.)In expressing unconditional positive regard, therapistsuse open-ended statements, reflection, andparaphrasing.

Open-ended statements encourage clients to speak,without limiting the topic of conversation.Reflection: The therapist acknowledges some emotionthat the client has expressed verbally or nonverbally.Paraphrasing: The therapist summarizes the expressedverbal content of the clients statements.

Therapists from many theoretical schools use some or all of these client-centered techniques to build rapportwith their clients.


30/51


14-5bGestalt Therapy Encourages Clients to Get

in Touch with Their FeelingsGestalt therapy is a humanistic psychotherapy thatstresses awareness of feelings in the here and now.

Gestalt therapy employs a very directive approach, sothat clients can gain insight.

- A clients frown following a comment by the therapistwould be met with the therapist directly confronting this byasking the client if he or she is aware of the facialexpression.

Perhaps the most popular technique used in Gestalt

therapy to help clients gain insight into their truefeelings is the empty-chair technique.- With the empty-chair technique, clients engage in

emotional expression by imagining that the person whomthey would like to speak to is sitting in an empty chair facing them.


31/51


14-5cExistential Therapy Helps Clients Deal

with the Fundamental Problems of ExistenceExistential therapy is a philosophical approach totreating clients who are experiencing distressprincipally related to a lack of meaning in their lives.

A form of existential therapy called logotherapy(Frankl, 1963, 1969) contends that a fundamentalhuman motive is to find meaning in life and thatemotional problems develop when such meaningcannot be found.

Meaning can be found for ones self through:Your life contributions (what you give to the world)Your life experiences (what you take from the world)Your attitudes in facing difficult situations


32/51


14-6aChild Therapies Use Techniques Designedfor Younger Minds

In offering therapy to a child, therapists must keep inmind that children differ from adults:

Childrens vocabulary is fairly simple andunderdeveloped.

Childrens thinking is much more concrete and orientedto present events.

Child therapy includes the use of techniques like playtherapy (Booth & Lindaman, 2000; Gil, 2003) toovercome some of difficulties associated withproviding psychotherapy to children .

Play therapy is a therapeutic technique in which thetherapist provides children with toys and drawingmaterials, on the assumption that whatever is troublingthem will be expressed in their play.


33/51


14-6bGroup Therapy Involves Clients DiscussingTheir Problems with One Another Under aTherapists Guidance

Group therapy is the simultaneous treatment of severalclients under the guidance of a therapist.

Some groups can consist of relatively well-functioning clientsin an outpatient setting.Many groups are organized around one kind of problem(such as alcoholism or depression) or one kind of client(such as adolescents or police officers).

All of the major theoretical schools of psychotherapy havesome sort of group format (Edelman et al., 2003; Valbak,2003; Yalom, 1995).Group therapy is more cost-effective than individual therapy.Group therapy helps clients realize that others also strugglewith many of the same problems.Group members can become an important support group.Therapists can observe how clients interact with one another.


34/51


35/51


14-6cFamily and Couples Therapies Try to Change

Dysfunctional Interaction PatternsFamily therapies are designed to constructively modify thedysfunctional relationships among family members.

Family therapists often base their work on systems theory ,

which is based on the assumption that the whole isgreater than the sum of its parts (Ackerman, 1966;Bowen, 1960, 1966).

According to family systems therapy, an individual familymembers problems cannot be understood and treated inisolation but must be examined and treated within thefamily system (Clarkin & Carpenter, 1995; Levant, 1984).

Family systems therapy is a form of family therapy in whichthe family is treated as a dynamic system, with each member being an important interacting element in that system.


36/51


14-6cFamily and Couples Therapies Try to Change

Dysfunctional Interaction Patterns (cont.)

A variant of family therapy is couples therapy.Couples therapy is therapy designed to help couples

improve the quality of their relationship.Over half the couples entering therapy state that their number one problem involves faulty communication(OLeary et al., 1992).


37/51


14-6dTherapy Is Sometimes Offered through the

Internet A growing number of therapists are interacting withtheir clients, and providing therapy, through email,chat rooms, and message boards.

Online therapy can provide help to people who aregeographically isolated, extremely socially anxious,disabled, or fearful that others will discover that they areseeing a mental health professional (J. Fink, 1999).


38/51


14-6dTherapy Is Sometimes Offered through the

Internet (cont.)Potential benefit of using online therapy

Clients may feel more at ease more quickly, and thusreveal the most troubling and important problemssooner and with greater honesty (Grohol, 1998).

Drawback for the therapistInformation, like physical appearance, tone of voice,and body language, is missing.


39/51


Figure 14-2Use of Drugs in Treating Psychological

Disorders


40/51


14-7a Antipsychotic Drugs Affect Dopamine

NeurotransmittersIn the 1950s, certain drugs used for other medicalpurposes were discovered to reduce the positive,uncontrollable psychotic symptoms of

schizophrenia, such as auditory hallucinations andparanoia (Lehman et al., 1998).

Chlorpromazine and other antipsychotic medicationsare thought to work by blocking dopamine receptor sites in the brain, thereby reducing dopamine activity(Bernstein, 1995; Remington et al., 2001).

Antipsychotic medications do not actually cureschizophrenia they merely help control its severesymptoms.


41/51


14-7a Antipsychotic Drugs Affect Dopamine

Neurotransmitters (cont.) Although they reduce positive schizophrenicsymptoms, antipsychotic drugs do not relievenegative symptoms that may be related to structural

defects in the brain.These drugs also have some very unpleasant sideeffects.Recent medical advances have led to the developmentof newer replacement drugs that do not appear to havesome of the dangerous side effects.However, even these new drugs are not risk free.


42/51


14-7b Antidepressant Drugs Affect Serotonin and

Norepinephrine NeurotransmittersMonoamine oxidase inhibitors (MAOI) drugs work byinhibiting the monoamine oxidase (MAO) enzymeinvolved in breaking down the neurotransmitters

norepinephrine and serotonin.By inhibiting MAO, the available supply of norepinephrine and serotonin is increased, which hasthe effect of elevating mood.

A second class of antidepressant medications iscomposed of the tricyclics (Bernstein, 1995).These drugs increase the available supply of serotoninand norepinephrine by decreasing their reuptake at theneurons receptor sites.


43/51


14-7b Antidepressant Drugs Affect Serotonin and

Norepinephrine Neurotransmitters (cont.)The most popular antidepressants are those thataffect only serotoninthe selective serotoninreuptake inhibitors (SSRIs).

SSRIs inhibit the reuptake of the neurotransmitter serotonin, which increases the available supply of serotonin in the body, making it easier for neuralimpulses to be transmitted along serotonin pathways inthe brain.

Lithium is used to treat bipolar disorder .With lithium, manic attacks occur as infrequently asonce every 9 years.It is unclear how lithium works.


44/51


14-7c Antianxiety Drugs Are the Most Widely Used

Legal Drugs A class of antianxiety drugsthe benzodiazepinesis the most frequently prescribed anxiety medicationin the United States (Roy-Byrne & Crowley, 2002).

These drugs seem to produce their effects byfacilitating the action of the neurotransmitter gamma-amino-butyric acid (GABA), which has an inhibitoryeffect on the central nervous system .Benzodiazepines are dangerous when combined withalcohol.These drugs can also lead to physical dependence.


45/51


14-7dElectroconvulsive Therapy Is Sometimes Used

to Treat DepressionElectroconvulsive therapy (ECT) is a physiologicaltreatment for severe depression in which a brief electric shock is administered to the brain of ananesthetized patient.

While ECT is effective in treating severe depression, noone is sure why (Coffey, 1993; Sackheim et al., 2000).Recent evidence suggests that ECT may be effective intreating severe depression by promoting new cell

growth in the brain.ECT is generally used only when severely depressedpatients either cannot tolerate or have not responded todrug therapy.


46/51


14-7ePsychosurgery Involves Removing Portions

of the BrainPsychosurgery is a rarely used surgical procedure totreat psychological disorders in which brain tissuethought to be the cause of the disorder is destroyed.

Prefrontal lobotomy: Two small holes are drilled in the

skull, and a sharp instrument is inserted and movedfrom side to side, severing the neural connectionsbetween the prefrontal lobes and the rest of the brain(Egas Moiz, 1948).

- This treatment profoundly altered patients personalities,with some patients becoming extremely apathetic andothers becoming excitable and impulsive.

Today, MRI-guided precision psychosurgery isperformed only in extreme cases when other types of treatment have been ineffective. It focuses on muchsmaller brain areas than those involved in lobotomies.


47/51


14-8Economic and Social Trends in Mental Health

TreatmentThe system of insured health care known as amanaged care system has had a significant impact onthe treatment of psychological disorders (Alegria et

al., 2001; Sharfstein, 2001).


48/51


14-8aManaged Health Care Involves a Trade-Off

in Treating Psychological DisordersCost-cutting measures introduced by healthmaintenance organizations or HMOs have had thefollowing effects:

Long-term therapies are rare.Greater number of referrals to less well-trainedtherapists (masters degree) (Pope & Vasquez, 2001)Older, less effective drugs prescribed due to reducedcosts over newer, more effective drugs (Docherty,1999)Cutbacks in combining drug therapy with psychologicaltreatment, thus reducing effectiveness (Duckworth &Borus, 1999)


49/51


14-8bEfforts to Document Treatment Effectiveness

Are IncreasingManaged care has encouraged efforts to documenttreatment effectiveness:

Psychotherapy generally has a positive effect (Lambert

& Bergin, 1992; Seligman, 1995).Different types of therapy are often about equallyeffective for many disorders.Brief therapy helps many clients, with about 50 percentimproving by the eighth session.The more treatment clients receive, the more theyimprove.


50/51


51/51

C i h A i D P bli hi 2007

14-8cMinorities Underutilize Therapeutic Services

(cont.)Sociocultural factors provide some insight into thissocial problem.

The belief system in a persons culture can influencethat persons willingness to seek psychotherapy.Minorities are more mistrustful of the medical andmental health professions than White Americans.Many ethnic minorities turn to more culturallycomfortable sources of help.

Dropout rates for therapy are higher among poorer clients.While ethnic minorities make-up about one-fourth of the population, only about 10 percent of mental healthproviders are ethnic minorities.

Documents

Franzoi Chapter 14