Therapies Chapter 14
Psychotherapy • Psychotherapy - use of psychological techniques to treat problems in personality and behavior (as opposed to biological therapies) • General categories • insight therapies • behavioral therapies • cognitive therapies • group therapies
Insight Therapies • A variety psychotherapies designed to give people a better awareness and understanding of their feelings, motivations, and actions • Types of insight therapies • psychoanalysis • client-centered therapy • gestalt therapy
Psychoanalysis • Based on Freud’s belief that anxiety and other problems are symptoms of inner conflicts • Many of these conflicts have their origins in childhood traumas • These conflicts are “unconscious” • The goal of therapy is to make them conscious and understood
Techniques used in Psychoanalysis • hypnosis: by Freud early in his career • free association: patient is encouraged to talk without inhibition about whatever thoughts or fantasies come to mind. • dream interpretation: therapist discovers the real meaning “latent content” from the patient’s description of his dreams “manifest content”
Transference • transference: an essential part of psychoanalysis. Patient reacts to the analyst with feelings held toward childhood and other authority figures. • positive transference: warn loving feelings expressed toward the analyst • usually happens early in the therapy process • negative transference: angry hostile feelings expressed toward the analyst • usually happens later as therapy becomes harder
Transference (cont.) • counter-transference: analyst unintentionally tranfers HIS feelings for others onto the patient • insight: The goal of psychoanalysis. Awareness of previously unconscious feelings and how they influence present behavior • current status: psychoanalysis is NOT among the more commonly used therapies today
Client-Centered Therapy • a “Nondirective” form of therapy developed by the “humanist” Carl Rogers • Rogers used the term “client” rather than “patient” to highlight the more active and equal role of the client • goal is to make the client “fully functioning” • One who is “fully functioning” is reaching his full potential, taking responsibility, and living life to its fullest
Client-Centered Therapy • unconditional positive regard: the patient is fully accepted by the therapist despite his/her faults (within reason) • The therapist must be nondirective and reflect or “mirror” back to the client what he/she has said • current status: This client-therapist relationship may be the “key” element in therapy. Rogers’ ideas do not receive the attention they should!
Gestalt Therapy • a confrontive “in your face” style of therepy developed by Frederick “Fritz” Perls • emphasizes the “wholeness” of the personality and living in the “here-and-now” • recall that the term “Gestalt” means “whole” • The GOAL is to make the person whole, responsible and self sufficient (in all ways, emotional, financial, etc.)
Gestalt Therapy • therapy takes place in the “Here and Now” • Fritz Perls encouraged face-to-faceconfrontationsto help people become more genuine or “real” in their day-to-day interactions • The therapist is active and directive. • current status: not a widely used method
Behavior Therapies • All behavior is learned. Therefore, bad behaviors can be unlearned and new more adaptive behaviors learned. • behavior therapies are based on the principles of: • classical conditioning • operant conditioning • modeling (social learning)
Use of Classical Conditioning • systematic desensitization: Technique for reducing fears and phobias by pairing a new response (relaxation) with stimuli that have been causing the fear and anxiety. • Joseph Wolpe: isthe developer of systematic desensitization • Wolpe’s focus is on promoting relaxation because (he feels) you cannot be both anxious and relaxed at the same time
Systematic desensitization involves 3 steps 1. the client learns relaxation techniques such as deep breathing and muscle relaxation 2. a “hierarchy” or listing of fearful situations is created 3. the client is gradually exposed to more fearful and difficult situations while using the relaxation techniques
Other Uses of Classical Conditioning • flooding: idea is to eliminate anxiety through intense and prolonged exposure to anxiety-producing stimuli. “Extinction” is the mechanism of change • example: someone with a fear of contamination, as in OCD, might have to handle garbage until their fears subside • flooding can also be done “imaginally” as opposed to “in vivo” (in reality)
Other Uses of Classical Conditioning • aversive conditioning: eliminating undesirable behaviors by associating them with pain and discomfort • examples: • drug-induced nausea paired with alcohol • shock paired with puffing on a cigarette • bad tasting nail coating for nail biting • shock paired with a pedophile’s sexual response
Use of Operant Conditioning • behavior contracting: client and therapist agree on goals and reinforcements the client will receive upon reaching those goals. • token economy: Patients earn tokens (reinforcers) for desired behaviors and exchange them for desired items or privileges. • token economy: the ONLY therapy demonstrated effective with hospitalized schizophrenics
Modeling • based on Albert Bandura’s Social Learning Theory • the patient learns desired behaviors by observing a “model” perform those behaviors and imitating the behaviors • uses include overcoming fears (e.g., snake phobia) or learning new skills (social skills training)
Cognitive Therapies Goal is to change “maladaptive belief systems” held by the patient • stress-inoculation therapy • Albert Ellis’s rational-emotive-therapy • Beck’s cognitive therapy
Stress-Inoculation Therapy • helps clients prepare for stressful situations • differs from systematic desensitization in that it is “pre-emptive” • Steps involved • discussing beliefs and their accuracy with therapist • getting familiar (practice) with the situation • actually entering and coping with the situation • examples: dental work, air travel, surgery
Cognitive Therapy and RET Both Ellis and Beck assume distress is caused by irrational and self-defeating beliefs and the therapist’s job is to challenge those dysfunctional beliefs. Examples ofIrrational/self-defeating beliefs: • “musts” and “shoulds” • all or none (black and white) thinking • over-generalization • personalization
Cognitive Therapy and RET • directive: cognitive therapists are directive and tell the client what is rational and what is not • expert therapists: the therapists are the experts(in contrast to Rogers’ approach) • homework: the client may be sent out on assignments to test his/her beliefs • logical argument: is used to convince the client of the irrationality of his beliefs
Group Therapies • Many are modeled after individual therapies (e.g., Gestalt, client centered) • particularly well suited to problems involving interaction with others (e.g., social phobia) • Types of group therapies • family therapy • marital/couples therapy • self-help/support groups
Advantages of Group Therapy • Allows therapist to see how client acts around others. • Offers a client social support system. • Client can develop new behaviors via observational learning and modeling. • Interaction with others may lead to insight into one’s own behavior. • Less expensive than individual therapy.
Self-help/Support Groups • Come in a wide variety • Usually there is NO professional leader • Can provide information and support at minimal or no charge • Alcoholics Anonymous is one example • In many cases, someone who has suffered a disorder may have more insight into problems than a professional
Family Therapy • The family “system” is the patient. • Often one person is the scapegoat for the family’s problems. • Family relationships (dynamics) are targeted. • Problems can cross generations (e.g., grandparents sabotaging parents’ efforts)
Marital/Couples Therapy Focus is on improving: 1 poor communication: People often don’t listen to each other. They may be fighting about one thing when they are really angry about something else. 2 correcting unrealistic expectations: especially true for young couples. They may have unrealistic ideas about what the other is capable of or “should” be doing.
Effectiveness of Psychotherapy Data from the Consumer Reports Survey Note: a change score of 180 (not 0) indicates “no change”
Does Psychotherapy Work? • About 2/3 of people say therapy helped them. • About 1/3 of people improve without therapy. • Starting with Hans Eysenck in 1952, many have questioned (and continue to question) the effectiveness of psychotherapy • Many studies supporting therapy (such as the Consumer Reports Survey) may be flawed. • This question continues to be difficult to answer
Does Psychotherapy Work? • In general, no one therapy appears to be more effective than another. Why? • The “main ingredient” may be just having someone to talk to (as in client centered therapy) • Experts agree that therapy may be more effective for specific minor problems (fear of flying) than for more general and severe problems (major depression or OCD)
Biological Treatments • A group of treatment that focus on changing the “biology” of the brain. • May be used alone or in conjunction with psychotherapy. • Types of biological treatments: • medications/drugs • electroconvulsive therapy (ECT) • psychosurgery
Basic Categories of Drugs • antipsychotics: used to treat very severe disorders of thought such as schizophrenia. • antidepressants: to combat depression (*as well as panic, OCD, and social phobia). • anxiolytics: to treat a wide variety of anxiety and stress related problems • pychostimulants: to treat ADHD and other disorders involving impulsivity and conduct
Antipsychotics • chemical class: neuroleptics, phenothiazines • examples: Thorazine, Mellaril, Prolixin • mechanism: blocking dopamine receptors • side effects: these drugs have many severe side effects that cause people to not want to take the drugs • tardive dyskinesia: a severe irreversible side effect involving disruption of motor activity (movement), occurs with long term use
3 Classes of Antidepressants • 1. Monoamine Oxidase Inhibitors (MAOs) • the first group to be discovered • examples: Parnate, Nardil • mechanism: blocks MAO, increases levels of norepinephrine and serotonin • side effects: dry mouth, dizziness, sexual dysfunction, digestive problems, etc. • dietary restrictions: must avoid certain foods to prevent high blood pressure and stroke
2. Tricyclic Antidepressants • the second major group to be discovered • examples:Elavil, Anafranil • mechanism:llike MAOs, increases levels of norepinephrine and serotonin • side effects:dry mouth, dizziness, sexual dysfunction, digestive problems, etc. • Side effects are similar to the MAOs except for the dietary restrictions
3. Serotonin Reuptake Inhibitors (SSRIs) • the most recent group to be discovered (1987) • examples: Prozac, Paxil, Zoloft • mechanism: prevents reuptake of serotonin leaving more in synapse • side effects: fewer than MAO or Trichyclics but still headache, anxiety, sexual dysfunction • popularity: because of the less severe side effects, more people are willing to take these.
Lithium Carbonate • Lithium is a naturally occurring salt that is used to treat bipolar disorder. • Lithium helps level out the extreme highs of mania and the extreme lows of depression. • Exact mechanism is not known but may involve NA (sodium) channels in CNS axons • Narrow “window” of effectiveness, too little - no effect, too much - danger • Blood levels must be checked often
Anxiolytics (anti-anxiety) Drugs • Two basic categories • barbiturates:powerful sedatives, first anxiolytic to be developed • example: Seconal • mechanism: CNS depressant • side effects: sleepiness, slowed reflexes, very dangerous when combined with alcohol • tolerance and dependence are potential problems
2. Benzodiazepines • safer: than barbiturates, highly prescribed • examples:Valium, Xanax, Tranxene, Ativan • mechanism:binds to GABA (gamma amino butyric acid) receptors in the CNS • side effects:few and minor, some drowsiness, slowed reflexes, etc. • tolerance and dependence:psychological and physical dependence are possible. However, many experts disagree on this issue
Psychostimulants • in children and some adults these improve attention, help the person “settle down,” and reduce impulsivity • example - Ritalin • mechanism - these are CNS stimulants • side effects - sedation, some long term physical effects • tolerance or dependence - usually not a problem
Other Biological Treatments • Electroconvulsive therapy (ECT) • Psychosurgery: brain surgery performed to change a person’s behavior and/or emotional state • prefontal lobotomy • modern psychosurgery
Electroconvulsive Therapy (ECT) • An electrical current is passed through the brain for a second or two • This produces convulsions and temporary coma. Today, muscle relaxants reduce severity of convulsions • Seen by most as a treatment of “last resort” for the most severe depressions • The mechanism by which ECT works remains unknown.
Psychosurgery • prefrontal lobotomy: “ice pick surgery” widely used during the first half of this century before modern medications a crude operation in which axons connecting the frontal lobes with lower brain areas were severed, rarely used today. • modern psychosurgery: in addition to traditional methods, multi-source beams of low energy radiation can modify brain tissue with pinpoint accuracy
Deinstitutionalization • treating people with severe psychological disorders in the community rather than in large public hospitals. • made possible largely by the development of “anti-psychotic” drugs in the 1950s
Problems with Deinstitutionalization • Community mental-health centers are poorly funded and understaffed. • Ex-patients are poorly prepared to live in the community. • Not enough housing available. • Social stigma of having a mental disorder, neighborhoods may resist these centers. • Large insurance companies would rather pay for inpatient care.
Types of Mental Illness Prevention • primary prevention • secondary prevention • tertiary prevention
Prevention • Primary Prevention Improving the social environment so that new cases of mental disorders do not develop. • Secondary Prevention identifying high risk groups and intervening before problems become serious. • Tertiary Prevention helping people adjust to community life after release from a mental hospital.
Gender Differences in Treatment • Women are more likely than men to be in psychotherapy, possibly because is more socially accepted for women. • Women receive more psychotropic medications than men. • Men are more likely to self medicate with alcohol and other drugs.
Cultural Differences in Treatment • One’s ethnic and cultural background may influence how he/she responds to a therapist. • A therapist who is more similar to the client (e.g., gender, cultural group) may be better able to understand and relate to the problems of a particular client.