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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 o o o o o o 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).