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Module 32: Psychological Therapies

What are the three basic approaches to treating psychological disorders?
The three basic approaches to treating psychological disorders are:
o Psychological therapies assume PDs are learned behaviors or beliefs that
can be unlearned.
o Biological therapies assume PDs are the result of biochemistry imbalances
and should be treated with medication.
o Social therapies see PDs as natural consequences to “sick” environment
and focus their attention on changing our social environments.
“Psychotherapy” is the emotionally charged, confiding interaction (usually
verbal) between a trained therapist and someone who suffers from psychological
difficulties.
There are some 250 different psychotherapies, but the four major approaches are:
psychoanalytic, humanistic, behavioral and cognitive.
*Eclectic” = using techniques from various forms of therapy depending on the
client’s problems. Probably half the therapists practicing today refer to themselves as
eclectic.
Meta-analysis = systematic statistical method for synthesizing the results of
numerous studies dealing with the same variables. MA is used in outcome research, i.e.,
evaluating what particular therapy seems most beneficial in dealing with particular
mental illnesses.
Psychotherapy integration = combining different therapeutic approaches into a
single, coherent model.
Insight therapies try to help clients develop insight and self-awareness about the
causes of their problems and road to behavioral changes. ITs include psychoanalysis,
psychodynamic therapy, interpersonal psychotherapy, humanistic client-centered therapy
and Gestalt psychotherapy. They can be effective with eating disorders, depression and
marital discord.
Behavioral therapies see abnormal behavior as a result of maladaptive learning
through faulty operant conditioning. The goal of behavior therapy is simply to extinguish
unwanted behavior and replace it with something adaptive. Causes, inner conflicts and
the like are irrelevant. They are effective for anxiety disorders, substance abuse
problems, sexual dysfunction, bedwetting and autism.
Cognitive therapies seem effective with depression, eating disorders, chronic pain,
marital and anxiety disorders.

What is Freudian “psychoanalysis”?
Review main points of Freud’s theory on the unconscious; and the structure of
personality (module 25, p. 480-3).
Freudian “psychoanalysis” revolves around unearthing past, repressed id-egosuperego conflicts. The belief is that once all that pent up energy devoted to these
conflicts is released (through catharsis), the client lives a healthier, less anxious life (i.e.,
is no longer caught in a repetition compulsion).
The basic techniques are “free association” and “interpretation”. A traditional PA
will have you relax on a couch, seat themselves out of your line of vision and ask you to
free associate, i.e., share whatever comes into your mind without editing. This sounds
easy, but in actually it soon becomes clear how often we consciously or unconsciously
block sharing our thoughts. PAs call this phenomena “resistance”. Resistance = to the
blocking from consciousness of anxiety-laden material.
The PA makes interpretations, i.e. suggestions about what underlying wishes,
feelings and conflicts might be operating, prompting the client to insight. Interpretations
include not just FA blockages, but also, analyzing the “latent content” of dreams and
analyzing “transference”.
Transference = the client’s transferring onto the analyst emotions linked with
other relationships, most frequently feelings about their parents.
*Catharsis = release of emotional tension after remembering or reliving an
emotionally charged experience from the past; it may result in the relief of anxiety.
Critics of PA note:
o It is time consuming and expensive: usually involving multiple meetings
per week over many years.
o It has heavy reliance on the notion of “repression” (which has largely been
discredited by modern-day psychologists)
o “Resistance” can easily be a self-confirming justification for the PA.
o Its all non-proven, after-the-fact explanations
Modern psychodynamic therapists still subscribe to the basic idea that to
understand a client’s current symptoms you must explore early childhood experiences to
help the client discover unconscious and unresolved conflicts.
However, they sit face to face with clients, meet once a week and therapy is
generally terminated more quickly; and although delving into childhood roots, they focus
on more current issues. They are also more active in working with the client.
Interpersonal therapists are also insight oriented, but they focus almost
exclusively on current symptoms and problems.

What is humanistic therapy?
Humanistic therapists see the key to self-fulfillment as helping people become
more self-aware and self-accepting.
As opposed to PAs and PD-oriented therapists, their focus is on the present, on
conscious-processing (not delving into the unconscious) and on growth rather than
neuroses.
Probably the most famous humanistic therapy is Roger’s client-centered or
person-centered therapy which revolves around non-directive, non-judgmental listening.
The therapist focuses simply on actively listening to the client, i.e., echoing/paraphrasing
client’s words, asking clarifying questions and acknowledging/reflecting emotional
feelings. This non-directive approach is based on the premise that the client’s own
tendency to self-actualization will lead them to the insights they need.
The essential belief is that if the therapist provides the three key relationship
ingredients of genuineness (i.e., sharing), UPR & empathy, the client’s natural striving
for self-actualization will emerge and direct the client’s own healing (reversing whatever
external psychosocial constraints have compromised this natural process).
Fritz Perls Gestalt therapy is based on notion that people create their own reality
through attributing meaning to experiences and grow only when they continue to
perceive, stay aware and act on their true feelings. It is much more directive and
challenging, daring the client to take action in the here and now instead of repeating past
conflicts. Dream interpretation and role-playing are common.

What are behavioral therapies?
Behavioral therapy goes directly after changing an unwanted behavior using
learning principles. No attempt is made to understand the underlying reasons for the
behavior. Classical and operant conditioning principles are used extensively.
Re: classical conditioning, the key principle is “counterconditioning”, i.e.,
creating conditions whereby new responses are learned to stimuli that trigger unwanted
behaviors. 2 examples are “systematic desensitization” and “aversive conditioning”
Systematic desensitization or reciprocal inhibition = a type of counterconditioning
that associates a pleasant, relaxed state (using progressive relaxation) with gradually
increasing hierarchy of anxiety-triggering stimuli. (Joseph) Wolpe and Jones created SD.
Often SD also includes an observational learning component where the therapist models
the desired behavior. The 3 steps are: teaching relaxation; establishing the anxiety
hierarchy; and the actual systematic desensitization trials of increasing anxiety. SD is the
treatment of choice for phobias. It can usually be accomplished in 10 sessions.
Flooding or exposure technique = repeated exposure to feared stimuli (without
traumatic expectations happening) until extinction takes place
Implosion therapy = is exaggerated flooding, i.e., repeated exposure to the
extreme end of the fear anxiety spectrum (Mustachio!)
Virtual reality exposure therapy = using virtual reality technology (which is more
vivid than the imagination for many) for SD counterconditioning It has been used to
overcome fear of flying, public speaking, heights and animals.
Modeling has also been used in association with SD.
Aversive conditioning works in the opposite direction. AC trains a client to
associate an unpleasant state with unwanted behavior, i.e., nail polish for nail biters,
shocks to child molesters viewing child pornography, water spray for self-injuring
autistic children, nausea-inducing drugs for alcoholics, etc.,
Antabuse has some success: a 63% success rate after a one year follow-up; a 33%
after a three year follow-up.
Basic operant conditioning principles—provide rewards after desired behaviors
(i.e., Weight Watchers) and withhold rewards or punishes unwanted behaviors—has been
used successfully to teach the mentally retarded w/ self-care, autistic children to interact,
SZ to act more rationally.
Token economies = OC procedure that attempts to modify behavior by giving
rewards for desired behavior in the forms of tokens (secondary reinforcers) that can be
exchanged for privileges or treats (primary reinforcers). TE have been successfully used
with SZs, delinquent teens and other groups.
Social skills training = uses OC & Bandura’s social learning theory, i.e.,
modeling, shaping and behavioral rehearsal (role playing in a structured situation, with
feedback and positive reinforcement) to establish socially appropriate behavior.
Biofeedback training = using monitoring of sympathetic NS, i.e., heart rate,
muscle tension and skin temperature to improve physiological control over anxiety
symptoms.
There are two basic critiques of behavioral therapy. One, new associations can
become extinguished once the client steps out of the supportively reinforcing
environment of the therapist. Also since causes aren’t addressed, symptom substitution
and a new problem may result.
Second & more fundamentally, is it ethical to “control” another person’s behavior
through conditioning principles?

What is cognitive therapy?
Recently, there has been a marked shift away from behavioral psychology to
cognitive oriented psychology (and therapy).
The basic assumption of cognitive therapy is that our thinking colors our feelings
(Activating Event/Action  Belief  Consequence). Mental illness is seen as caused by
faulty thinking; the job of the therapist is to help the patient cognitively restructure their
thinking so it’s more adaptive
In particular, many people suffering from depression tend to fall into self-blaming
and overgeneralizing thinking patterns. Explanatory styles are skewed: good events are
seen as luck; bad events as “all my fault”.
The crux of cognitive therapy is to help the client identifying maladaptive beliefs,
then construct and rehearse new, more positive ways of thinking. CT is the therapy of
choice for treating depression.
Cognitive-behavioral therapy combines changing self-defeating thinking and selfdefeating behavior. It has been successfully used with OCD patients.
Albert Ellis developed Rational Emotive (Behavioral) Therapy or RE(B)T. The
therapist actively confronts self-defeating thoughts about actions, beliefs and
consequences. His goal is to replace the “tyranny of shoulds” with what’s realistic and
necessary.
Aaron Beck’s cognitive triad therapy = analyzes how the person feels about
themselves, their world/circumstances and their future. The goal is to change pessimistic
to optimistic thinking (stable, internal, global  temporary, external, specific). Specific
techniques include: evaluating evidence, reattributing blame to situational factors and
discussing alternative solutions.

What is family and group therapy?
(Small) group therapy has several advantages over one-on-one:
o More people are helped in less time
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Sessions usually cost less
Normalization, i.e., people find out that others have similar problems
A sense of community developed
(Less verbal and more resistant clients may find it easier to open up)
(A richer well of personal experience and feedback to draw from)
(Broader role-playing opportunities)
Family therapy = therapy that treats the family as a system; and views an
individual’s unwanted behaviors as influenced by or directed by other members of the
family. FT aims at helping family identify dysfunctional roles and communication
patterns; and guide them toward more positive relations and communication.
Self help groups = individuals who share the same problem assist each other, i.e.,
AA. This is a peer support model.

How do I know if I need psychotherapy?
Getting help for a personal problem that you are not managing is a sign of
strength and smarts, not a sign of weakness.
Warning signs include: thoughts of suicide; drug abuse or other self-destructive
behavior; disruptive fears; lasting depression; sudden mood shifts; compulsive rituals.
Psychological counseling is provided by a host of mental health professionals:
o Psychiatrists are MDs who specialize in psychological disorders; they
have completed a hospital psychiatric residency. They can prescribe
medication and perform surgery. They usually tend to those with the most
serious PD. There usual approach is biological.
o Clinical psychologists usually have a PhD, which includes an internship
and passing a licensing exam. They have expertise in research,
assessment and therapy. Half work in institutions; half in private practice.
They are exposed to a variety of therapeutic approaches beyond simply the
biological and also tend to deal with more disturbed individuals.
o Counseling psychologists deal with less severe mental illness in college
setting or marital or family therapy practices.
o Psychoanalysts follow Freudian or neo-Freudian principles. They receive
extensive training and self-analysis with mentor psychoanalysts.
o Clinical or psychiatric social workers have MSW and provide
psychotherapy to people with everyday personal and family problems
o Marriage and family counselors, pastoral counselors and abuse counselors
all have particular levels of expertise
Check on a professional’s licensure, area of expertise and fees. Anyone can call
themselves a therapist. Non-licensed practitioners rarely receive insurance
reimbursement.

*How effective is therapy?
NIMH estimates that 15% of the population seek therapy every year for help with
psychological & addiction problems. About 2 in 5 seek mental health specialists.
Most clients who undergo therapy speak positively of it. One study reports: ¾ of
clients interviewed feeling satisfied; ½ very satisfied. And of course clinicians believe in
the effectiveness of what they’re doing: clients come in unhappy and leave happier.
However, several extraneous factors might explain this. For one, research shows
the power of belief otherwise known as the “placebo effect”. Basically the PE means that
if you believe something’s going to have a particular effect, the belief itself will make the
effect more likely.
There’s also “regression toward the mean” phenomena, which refers to the
tendency for any extremes of unusual scores to fall back/regress toward their average. So
someone who is feeling under hard times is likely to regress back to a normal state with
or without the help of psychotherapy.
Clients may also feel called to rate their psychotherapy highly as a selfjustification of time, money and energy they’ve spent. Or they may have developed
positive experiences towards their therapist, whether or not their problems/lives have
significantly changed.
Clinician perceptions are just as biased.
Controlled research studies has shown that people undergoing psychotherapy do
in fact improve by wider margins than people who don’t undergo therapy (despite Hans
Eysenck’s study showing that two thirds of those suffering nonpsychotic disorders
improve markedly—with or without therapy).
Mary Lee Smith analysis of 475 investigations showing that the average PT client
is better off than 80% of untreated). [At this point psychotherapy can be pronounced as
“somewhat effective”. It’s also worth noting that improvement is often temporary: only
¼ of those attending PT didn’t relapse; only 1/6 for those attending substance-abuse PT.]
PT is most effective when the client is mature and the problem is clear-cut.
[Cognitive, interpersonal and behavior PT seem to work best with depression;
cognitive-behavior PT for bulimia; and behavior-mod for enuresis.]
Also worth noting is the fact that there is little if any correlation between a
clinician’s experience, training, supervision and licensing with client outcomes. Group or
individual therapy also show no correlational advantage.

How effective are alternative therapies?
Alternative therapies are notably under-researched; and what little research is
available is not particularly enrolling.
Research re: practitioners of “therapeutic touch” found them no more ability to
feel the outstretched hand of young Emily than chance.
Early supporting research for Francine Shapiro’s EMDR technique that allegedly
markedly reduces stress from traumatic memories hasn’t been replicated. Other studies
seem to indicate that the hand-waving movement itself isn’t the key change agent.
Research on light exposure therapy does seem to indicate that “light boxes” that
mimic outdoor light do have a beneficial effect on those suffering from seasonal affective
disorder (SAD), more than can be accounted for simply as a placebo.

*What common ingredients do all psychotherapies have?
All therapies share certain common ingredients:
o First, they offer hope for demoralized people (which then kicks in the placebo
effect).
o Second, they offer a new perspective on oneself and the world.
o Finally, they offer an empathic, trusting, caring relationship (research shows that
the most effective therapists are those perceived as the most empathic and caring;
some research seems to suggest that paraprofessionals briefly trained in basic
empathic listening skills seem to be as effective as seasoned professionals).