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Chapter 16
Therapies for Personal Change
As presented by
Dr. Shannon Wright-Johnson
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1
Lecture Objectives
Examine the goals of therapy
Briefly examine the historical
treatment of the mentally ill
Introduce the main types of therapy
interventions used and a few of
techniques employed
Examine the effectiveness of
treatment modalities
2
Therapy
What is Therapy?
What do you think therapy entails?
What theoretical orientation do you
gravitate towards?
Despite differences in intervention
types – all therapies are designed to
change a person’s functioning in some
way
3
Goals of Major Therapies
Reaching a diagnosis
Proposing a probable etiology
Making a prognosis
Treatment
4
Goals of Major Therapies
Therapy Types can be further
catergorized as
Biomedical therapies
Alter brain functioning with chemical or
physical interventions (e.g., ECT)
Psychotherapy
Focus on changing faulty behaviors, thoughts,
perceptions, and emotions (cognitive)
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Problems
Happen to everyone at sometime in
their life
Who do people typically talk to?
6
Therapists and Therapeutic Settings
Counseling psychologist
Clinical social worker
Pastoral counselor
Clinical psychologist
Psychiatrist
Psychoanalyst (MD or Ph.D)
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Therapists and Therapeutic Settings
Patient
Used by biomedical approach
Client
Used by clinicians who think of
psychological disorders as problems in
living
8
Historical and Cultural Contexts
History of Western treatment
Bedlam (orig Bethlehem)
1400’s – London hospital
First pt w/psychological problem adm
mental patients chained, tortured
Mental illness
Late 18th century- concept emerged in Europe
First time seen as “sick people”
U.S. – housed but no tx
Cult of curability – environment
Madness cured via mental hygiene
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Historical and Cultural Contexts
History of Western treatment
Rehabilitation
1900s – asylum – from stress
Overcrowded – good intentions simply became a
human warehouse
Deinstitutionalization
1960s – reformers
Mainstream back into society
Increase in homelessness,
Increase in arrests
10
Historical and Cultural Contexts
Not covering in class but just remember
that our culture’s cure are not the only
solutions (avoid ethnocentrism)
Cultural symbols and rituals of curing
Shamanism
Ritual healing
Dissociation of consciousness
Mana
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Therapies to be discussed
Psychodynamic
Behavior Therapy
Cognitive Therapy
Existential-Humanistic
Group Therapies
Biomedical Therapies
12
Psychodynamic Therapies
Developed by Sigmund Freud
Explores unconscious motivations and
conflicts in neurotic, anxiety-ridden
individuals
Before exploring techniques, let’s
review some of Freud’s main tenets of
how he viewed behavior
13
Breuer and Freud:
The “Talking Cure”
• Freudian Theory
– Structure of the Mind
– The Mind’s Protective Mechanisms
– Stages of Psychosexual Development
20th Century traditions
Psychoanalytic TheoryMesmer, Charcot, Freud and Breuer
Discovered unconscious
Id, ego superego (structural theory)
Defense mechanisms
Psychosexual stages of development
15
Ego
id
ID
Libido
Pleasure Principle
Primary Process
Thinking
Ego
• ID
• EGO
id
– Reality Principle
– “Executive of Personality”
– Secondary Process Thinking
Ego
id
• SUPEREGO
– Rules / Standards of Conduct
– Right vs Wrong
•Ego’s Battles
•Keep Id in Check
•Anxiety results with inability to
resolve inner conflicts between the
unconscious, irrational impulses of
the id AND the superego
•Anxiety -inner conflicts between id
AND the superego
•Thus 1 Goal of tx – intrapsychic
harmony
•Strengthen ego
•Reduce demands of superego
•Increase awareness of the id
• Displacement - kick dog
•Reaction formation – do opposite
•Most important =Repression – very
important in handling conflicts
•messages from the unconscious that
something is wrong
• Repression – very important in
handling conflicts
•Goals
•– Bring repressed thoughts to
consciousness ;
•Gain insight about the relationship
between current symptoms and
repressed conflicts
Psychodynamic Therapies
Freudian psychoanalysis
Intensive and prolonged technique for exploring
unconscious motivations and conflicts
Insight therapy
Therapist guides patient toward discovering
insights (increased awareness) between
present symptoms and past origins
YAVIS
Takes long time
23
Psychodynamic Therapies
Main Techniques employed include:
Free association
Thoughts, wishes, physical sensations,
and mental images as they occur
volunteer
Catharsis
Expressing strongly felt but usually
repressed emotions
24
Psychodynamic Therapies
Resistance- understanding the role of
Barrier between unconscious and
conscious(e.g., sex life,anger)
Dream analysis – “unconscious”;
manifest (openly visible) and latent
(hidden content)
Transference
Countertransference
25
Psychodynamic Therapies
Neo-Freudian therapies
Borne out of reaction to Freud’s theory
Kept some main tenets but added a diff
twist
26
Neo-Freudian therapies
Harry Stack Sullivan
Added importance of social relationships
Need for acceptance, respect and love
“troubled interpersonal relationships” and
societal pressures
Melanie Klein
Death instinct - aggression
Building blocks of how people experience the
world emerge from their relations to loved
and hated objects
27
Psychoanalysis
Descendents:
Heinz Kohut
Emphasis on self ( and how others and
objects play a role in shaping our
interpretation of self)
Founder of Object Relations
Object relations theory
Building blocks of how people experience the
world emerge from their relations to loved
and hated objects
28
Premise of Behavior Therapy
All (most) behavior is learned
Focus on observable behaviors
Abnormal behavior is learned similar
to normal behaviors via conditioning
and learning
Thus therapy applies principles of
conditioning and reinforce to modify
unwanted behavior
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Premise of Behavior Therapy
Works best with specific behaviors
Could care less about underlying
cause
Symptom substitute?
Research indicates “no”
Let’s briefly review some of the main
tenets
30
Behavioral Model
1. Important to understanding the role
of counterconditioning
2. Pavlov- classical conditioning
(UCS,UCR,CS,)
Some Sexual disorders begin
Men and shoe example
1.
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Conditioning Theory
Pavlov
Dog, salivation, bell
CSCR
UCSUCR
CS UCSUCR/CR
Tone + Meat Powder -> Salivation
CS
UCS
UCR
Tone ----------------------> Salivation
CS
CR
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Counterconditioning
New response is conditioned to
replace a maladaptive response
Types of counterconditioning include:
Systematic desensitization
Implosion
Flooding
Aversion Therapy
33
Behavioral Model
1. Watson- systematic desensitization
2. B.F. Skinner- science of human
behavior should be based on
observable events
-operant conditioning
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Conditioning Theory
When behavior is reinforced – either
through pleasure, reward, or removal of
some unpleasant stimulus – it is likely to be
REPEATED.
Negative consequences of a behavior
through unpleasant results, pain, or loss of
rewarding stimuli tend to DECREASE THE
FREQUENCY of the behavior.
35
Conditioning Theory
Operant Conditioning
Response that is voluntarily emitted is
learned as a result of how it operates on
the environment
Thorndike –Law of Effect
Learned as a result of environmental
consequences that follow that behavior,
either positive or negative
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Conditioning Theory
Reinforcement
by definition, the “targeted”
behavior increases
Punishment
by definition, the “targeted”
behavior decreases
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OPERANT CONDITIONING:
ADD
REMOVE
Positive
Reinforcement
Negative
Reinforcement
Behavior increases
Behavior increases
Positive Punishment
Negative Punishment
Behavior decreases
Behavior decreases
38
Behavior Therapies
Thus, Behavior therapy (behavior
modification)
Systematic use of principles of learning
to increase or decrease the frequency
of behaviors
39
Behavior Therapies
Counterconditioning
Substitute a new response for a maladaptive
one
Systematic desensitization
Reciprocal inhibition
Incompatible behaviors cannot occur simultaneously
Client is taught to prevent arousal of anxiety
by confronting feared stimulus while relaxed
40
Behavior Therapies
Systematic desensitization
Gradual Steps Employed
Identify anxiety provoking stimuli via
hierarchy
Deep-muscle relaxation
Desensitization – pairing of weakest stimuli
(visually) with relaxation
Impotence
Stage fright
Test anxiety
41
Behavior Therapies
Implosion therapy
Opposite of SD
Exposes client to most anxiety-provoking stimuli
through visual imagery in safe setting
Karen
Flooding (in –vivo)
Clients are exposed to stimuli most frightening
to them physically rather than via imagery
More effective than SD in some cases (e.g.,
agoraphbia)
Key to ALL is “ EXPOSURE
42
Behavior Therapies
Aversion therapy
Attractive stimulus is paired with
noxious stimulus
(uses counterconditioning procedures)
Cigarette smoking (rubber band around
wrist), child molesters (shock tx); selfinjurious behaviors (mild shock)
43
Behavior Therapies
Contingency management
Changing behavior by modifying its
consequences
Positive Reinforcement Strategies
Token economies
(autistic child)
Extinction Strategies
Dysfunctional beh maintained by
unrecognized reinforcers
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Behavior Therapies
Social-learning therapy
Clients observe models’ desirable
behaviors being reinforced
phobias
Imitation of models
Participant modeling ( on film or in
person see success w/feared stimuli)
Social-skills training
Behavioral rehearsal
Assertiveness training
45
Behavioral Model
1.
Cognitive-behavioral or social learning
model
A
B
C’
S
of
EMOTIONS
A Perceptions (Activating Event – anything
you can see, hear, smell, taste, or touch.)
B Self-Talk
C Feelings
Actions
Consequences
46
Cognitive Therapies
Cognitive therapy
Attempts to change feelings and
behaviors by changing the way a client
thinks about or perceives significant life
experiences
47
Cognitive Therapies
Cognitive therapy
Abnormal behavior/emotional distress
start with what you think
Goal – change your thought process
48
Cognitive Therapies
Cognitive behavior modification
Tenets
Focus on the present
We all engage in self-talk
You are what you tell yourself
You are guided by what you believe
Faulty thinking can lead to unproductive or
dysfunctional behaviors
There is power in thought, how do you use
your power?
49
Cognitive Therapies
Cognitive behavior modification
Combines cognitive emphasis on thoughts
and attitudes, and behavioral emphasis
on changing performance
Unacceptable behavior modified via cognitive
restructuring
Change negative self-statements into constructive
coping statements
Key to process -First identify thought content
Fosters self-efficacy and + expectations about
your ability to cope and deal effectively
50
Cognitive Therapies
Changing false beliefs
Cognitive therapy for depression
Replace faulty patterns of thinking by
substituting more effective problem solving
techniques
Aaron Beck (time permitting, take BDI)
Identify warped thinking –learn more realistic
ways to formulate his experiences
Maintained b/c unaware of negative automatic
thoughts
51
Beck’s Cognitive Model of
Depression
1.Thinking (content) becomes
negative(re: self, world, future)
(past, present, future)
2.Systematic bias and distortion
in info processing results
cognitive distortions and errors in
reasoning
52
Cognitive Therapies
Changing false beliefs
Aaron Beck
Challenge basic assumptions about functioning
Evaluate evidence client has for and against
accuracy of automatic thoughts
Reattribute blame to situational factors rather
than to patient’s incompetence
Discuss alternative solutions to complex tasks
that could lead to failure experiences
53
Cognitive Therapies
Changing false beliefs
Rational-emotive therapy (RET)
Albert Ellis
1.Basis of Undesirable behavior/reactions is
“irrational beliefs”
2. Beliefs are powerful in controlling our
behavior
3. Goal – teach clients to recognize “shoulds,
oughts, and musts
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Cognitive Therapies
Changing false beliefs
Rational-emotive therapy (RET)
Albert Ellis
4. faulty beliefs are openly and strongly
disputed; very confrontational
5. Increase sense of worth
55
Humanistic Approaches
Jung and Adler-
broke from psychoanalysis and are
thought of as humanistic today
Maslow-
self-actualization; hierarchy of needs
Rogers-
person-centered therapy; unconditional
positive regard
56
Existential-Humanistic Therapies
Human-potential movement
Release the potential of the average
human being for greater levels of
performance and greater richness of
experience
57
Existential-Humanistic Therapies
Client-centered therapy
Emphasizes the healthy psychological
growth of the individual
Unconditional positive regard
Gestalt therapy
Focuses on the ways to unite mind and
body to make a person whole
58
Group Therapies
Marital and family therapy
Couples counseling
Family therapy
Community support groups
Self-help groups
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Biomedical Therapies
Psychosurgery
Prefrontal lobotomy
Electroconvulsive therapy (ECT)
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Mood Disorders
Drug
Treatment
61
Antidepressants
Do not work quickly
(2- 6 weeks to become
effective)
Effective in alleviating
depression, but they do not
cause euphoric states
62
Antidepressants
Three classes of
antidepressants
Tricyclics
Selective Serotonin Reuptake
Inhibiots (SSRIs)
Monoamine Oxidase inhibitors
(MAOIs)
63
TRICYCLICS
Include
Imipramine (Tofranil),
Clomipramine (Anafranil)
and Amitriptyline
(Elavil)
64
TRICYCLICS
Side effects
include:
Dry mouth
Constipation
Blurred vision
Urinary
retention
Tachycardia
Palpitations
Skin Rash
Memory
Impairments
Impaired sexual
functioning
65
SSRIs
Include
Fluoxetine (Prozac)
Setraline (Zoloft)
Paroxetine (Paxil)
66
SSRIs
Also used in the treatment
of OCD and eating
disorders
Increase serotonin
67
SSRIs
SIDE EFFECTS:
Gastrointestinal problems
Decreased libido
Headaches
At least initially, may worsen
sleep and anxiety problems
Can cause serious problems
when combined with a tricyclic
or MAOI
68
MOOD STABILIZERS
Lithium
treatment-of-choice for
bipolar disorder
Reduces or eliminates
symptoms of mania and
levels out mood swings
69
LITHIUM
SIDE EFFECTS
Gastric distress
Weight gain
Tremor (most affects the fingers)
Fatigue
Mild Cognitive impairment
70
LITHIUM
SIDE EFFECTS
Too high a dosage can cause lithium
toxicity (vomiting abdominal pain,
profuse diarrhea, severe tremor,
and ataxia)
Can lead to seizures, coma, and/or
death
71
BENZODIAZEPINES
Include
Valium
Xanax
Klnopin
Ativan
72
BENZODIAZEPINES
Used to treat anxiety
symptoms such as
generalized anxiety or
panic
Enhance the activity of the
neurotransmitter GABA
73
BENZODIAZEPINES
SIDE EFFECTS:
Drowsiness
Sedation
Weight gain
Apathy
Dry mough
Gastric distress
Ataxia
Motor disturbances
Anteriograde amnesia
chronic use-results in
tolerance and severe
withdrawal symptoms
mixing w/alcohol or
other CSN depressant
can be fatal
74
Drug therapy
Antipsychotic drugs
Chlorpromazine
Haloperidol
Clozapine
75
Does Therapy Work?
Evaluating therapeutic effectiveness
Spontaneous-remission effect
Placebo effect
Meta-analysis
76
Today
Scientific Method- Integrated
Approach
1.increased sophistication of science,
technology, and methodology
2. No one influence occurs in isolation
77