Download CHAPTER 17: TREATMENT OF PSYCHOLOGICAL DISORDERS

CHAPTER THIRTEEN
CHAPTER THIRTEEN: TREATMENT OF PSYCHOLOGICAL
DISORDERS
CHAPTER OUTLINE AND KEY TERMS AND CONCEPTS (O)
Prologue: Dr. Norman Endler: Darkness and Beyond
Looking Ahead
psychotherapy: Treatment in which a trained professional—a therapist—uses
psychological techniques to help someone overcome psychological difficulties and
disorders, resolve problems in living, or bring about personal growth
biomedical therapy: Therapy that relies on drugs and other medical procedures to
improve psychological functioning
eclectic approach to therapy: An approach to therapy that uses a variety of treatment
methods with a given person
Psychotherapy: Psychological Approaches to Treatment
INDEPENDENT PROJECT 13.1: Collecting Images of Psychotherapy
INDEPENDENT PROJECT 13.2: To Do or Not To Do—Psychotherapy, That Is
INDEPENDENT PROJECT 13.3: Psychotherapy: What’s Out There?
Psychodynamic Approaches to Therapy
psychodynamic therapy: First suggested by Freud, therapy based on the premise that the
primary sources of abnormal behaviour are unresolved past conflicts and the possibility
that unacceptable unconscious impulses will enter consciousness
defence mechanisms: Psychological strategies that protect people from unconscious
impulses
neurotic symptoms: According to Freud, abnormal behaviour brought about by anxiety
associated with unacceptable conflicts and impulses
Psychoanalysis: Freud’s Therapy
psychoanalysis: Psychodynamic therapy that involves frequent sessions and often lasts for
many years
free association: A Freudian therapeutic technique in which a patient is told to say aloud
whatever comes to mind, regardless of its apparent irrelevance or senselessness, in order to
give the therapist insight into the patient’s unconscious
dream interpretation: An examination of the patient’s dreams to find clues to the
unconscious conflicts and problems being experienced
manifest content of dreams: The surface description of dreams
latent content of dreams: The underlying meaning of dreams, which reveals the
unconscious meaning of the dream
resistance: An inability or unwillingness to discuss or reveal particular memories,
thoughts, or motivations
transference: A phenomenon in which patients may come to see their analyst as symbolic
of significant others in their past, perhaps a parent or a lover, and apply some of their
feelings for that person to the analyst
Contemporary Alternatives to Psychoanalysis
Behavioural Approaches to Therapy
behavioural treatment approaches: Treatment approaches that build upon the basic
processes of learning such as reinforcement and extinction
Aversive Conditioning
aversive conditioning: A technique used to help people break unwanted habits by creating
unpleasant reactions to stimuli that previously were enjoyed
Systematic Desensitization
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systematic desensitization: A behavioural technique in which gradual exposure to
anxiety-producing stimuli is paired with relaxation in order to extinguish the response of
anxiety
hierarchy of fears: A list, in order of increasing severity, of the things that are associated
with one’s fears
Operant Conditioning Techniques
token system: A procedure whereby a person is rewarded for desired behaviour with a
token such as a poker chip or some kind of play money
contingency conditioning: An approach to treatment in which a written agreement drawn
up between therapist and client (or teacher and student or parent and child) states a series
of behavioural goals the client hopes to attain; also specifies the consequences for the
client if the goals are reached and, frequently, states negative consequences if the goals are
not met
observational learning: Learning by watching others’ behaviour and the consequences of
that behaviour
How Does Behaviour Therapy Stack Up?
Cognitive Approaches to Therapy
cognitive treatment approaches: Approaches to treatment that teach people to think in
more adaptive ways by changing their dysfunctional cognitions about the world and
themselves
cognitive-behavioural approach: An approach used by cognitive therapists that attempts
to change the way people think through the use of basic principles of learning
rational-emotive behaviour therapy: A form of therapy that attempts to restructure a
person’s belief system into a more realistic, rational, and logical set of views
cognitive therapy: Psychotherapy based on Beck’s goal to change people’s illogical
thoughts about themselves and the world
LECTURE LEAD 13.1: The A-B-C’s of REBT
Applying Psychology in the 21st Century Beating the Video Lottery Terminals (VLTs): Problem
Gambling and Its Treatment
Humanistic Approaches to Therapy
humanistic therapy: Therapy in which the underlying assumption is that people have
control of their behaviour, can make choices about their lives, and are essentially
responsible for solving their own problems
Client-Centered Therapy
nondirective counseling: A therapeutic technique in which the therapist’s comments are
not interpretations or answers to questions that the client has raised, but rather they tend to
clarify or reflect back what the client has said
client-centered therapy: Therapy in which the goal is to reach one’s potential for selfactualization
unconditional positive regard: Acceptance and understanding expressed by the therapist,
regardless of the feelings and attitudes the client expresses
empathetic: Understanding of a client’s emotional experience
Gestalt Therapy
gestalt: The German term for “whole”
gestalt therapy: An approach to therapy that attempts to integrate a client’s thoughts,
feelings, and behaviour into a unified whole
Humanistic Approaches in Perspective
Group Therapy
group therapy: Therapy in which people discuss problems in a group
Family Therapy
family therapy: An approach that focuses on the family and its dynamics
Evaluating Psychotherapy: Does Therapy Work?
LECTURE LEAD 13.2: Therapy Fads
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Is Therapy Effective?
spontaneous remission: Recovery without treatment
CLASSROOM ACTIVITY 13.1: The Effectiveness of Psychotherapy
CLASSROOM ACTIVITY 13.2: Discussion: The Cost of a Psychotherapy Hour
CLASSROOM ACTIVITY 13.3: Exploring Therapy Sessions
CLASSROOM ACTIVITY 13.4: Some Ethical Issues Pertaining to Therapy
Which Kind of Therapy Works Best?
meta-analysis: Procedures in which data from a large number of studies are statistically
combined
eclectic approach to therapy: An approach to therapy that uses techniques taken from a
variety of treatment methods, rather than just one
Pathways Through Psychology Janet Stoppard
Exploring Diversity Clinical Practice and Training in a Multicultural Society
LECTURE LEAD 13.3: Experience and Treatment of Depression in Women
Biomedical Therapy: Biological Approaches to Treatment
Drug Therapy
drug therapy: Control of psychological problems through drugs
Antipsychotic Drugs
antipsychotic drugs: Drugs that temporarily reduce psychotic symptoms such as agitation,
over-activity, hallucinations, and delusions
chlorpromazine: An antipsychotic drug that is used in the treatment of schizophrenia
clozapine: An antipsychotic drug that represents the current generation of antipsychotic
drugs
Antidepressant Drugs
antidepressant drugs: Medication that improves a depressed patient’s mood and feeling
of well-being
tricyclic drugs: Antidepressant drugs that increase the availability of norepinephrine at the
synapses of neurons
MAO inhibitors: Antidepressant drugs that prevent the enzyme monoamine oxidase
(MAO) from breaking down neurotransmitters
selective serotonin reuptake inhibitors (SSRIs): Antidepressant drugs that target the
neurotransmitter serotonin, permitting it to linger at the synapse
Fluoxetine (Prozac): A widely used antidepressant drug
St. John’s Wort: An herb that has been likened to a “natural” antidepressant
LECTURE LEAD 13.4: Prozac: Miracle Drug or Media Madness?
Lithium
lithium: A drug comprised of mineral salts used to treat bipolar disorders
Depakote and Tegretol: Two drugs used to reduce manic episodes
Antianxiety Drugs
antianxiety drugs: Drugs that reduce the level of anxiety a person experiences, essentially
by reducing excitability and increasing feelings
of well-being
Electroconvulsive Therapy (ECT)
electroconvulsive therapy (ECT): A procedure in which an electric current of 70 to 150
volts is briefly administered to a patient’s head
CLASSROOM ACTIVITY 13.5: Should Electroconvulsive Therapy Be Banned?
Psychosurgery
psychosurgery: Brain surgery once used to alleviate symptoms of mental disorder
prefrontal lobotomy: Surgically destroying or removing certain parts of a patient’s frontal
lobes to improve the control of emotionality
INDEPENDENT PROJECT 13.4: Origins of Psychosurgery
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Biomedical Therapies in Perspective: Can Abnormal Behaviour Be Cured?
Community Psychology: Focus on Prevention
community psychology: A branch of psychology that focuses on the prevention and
minimization of psychological disorders in the community
deinstitutionalization: The transfer of former mental patients from institutions into the
community
LECTURE LEAD 13.5: Deinstitutionalization Revisited
LECTURE LEAD 13.6: Sex Offenders’ Rights?
CLASSROOM ACTIVITY 13.6: Devising Treatment Strategies for Sex Offenders
Becoming an Informed Consumer of Psychology Choosing the Right Therapist
LECTURE LEAD 13.7: Common Features of All Psychotherapists
Looking Back
Key Terms and Concepts
Psychology on the Web
OLC Preview
Epilogue
LEARNING OBJECTIVES (P)
Psychotherapy: Psychological Approaches to Treatment
1. Define psychotherapy and identify the main approaches/types. (p. 430)
2. Describe the psychodynamic approach to the treatment of abnormal behaviour, including the major techniques
and concepts employed by psychodynamic therapists. (pp. 430-433)
3. Describe the behavioural approaches to the treatment of abnormal behaviour, including aversive conditioning,
systematic desensitization, observational learning, and the use of operant conditioning principles. (pp. 433-436)
4. Discuss the cognitive therapy approaches of rational-emotive and cognitive therapy. (pp. 436-438)
5. Describe the application of humanistic theory in the approaches of Rogers’s client-centered therapy as well as
gestalt therapy. (pp. 439-441)
6. Describe group therapy, including family therapy. (pp. 441-442)
7. Discuss the methods used to evaluate psychotherapy and the arguments proposed to support and dispute the
effectiveness of psychotherapies, and explain the eclectic approach to psychotherapy. (pp. 442-444)
Biomedical Therapy: Biological Approaches to Treatment
8. Name and describe drugs used in the treatment of abnormal behaviour, and discuss the problems and
controversies surrounding their use. (pp. 447-450)
9. Describe electroconvulsive therapy and psychosurgery, and discuss the effectiveness of biomedical therapies.
(pp. 450-451)
10. Explain the concepts of community psychology and deinstitutionalization, and identify recommended
guidelines for selecting a psychotherapist. (pp. 451-453)
LECTURE LEADS
Lecture Lead 13.1: The A-B-C’s of REBT (W)
Albert Ellis’s (1994, 1998) rational-emotive behaviour therapy (REBT) is an example of the growing field of
cognitive-behavioural psychotherapy. REBT is also a relatively precise system of psychotherapy that is as simple as
A-B-C. “A” stands for any activating event or fact external to the person. “B” represents the person’s beliefs and
attitudes regarding “A.” “C” represents the person’s emotional responses or consequences.
There is a tendency for individuals to attribute emotional consequences to activating events. For example,
Jim becomes depressed after learning he has lost his college scholarship. If we asked Jim why he was depressed, his
obvious response would be that he feels down because of the lost scholarship. Ellis would counter that Jim is not
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depressed (“C”) because of the lost scholarship (“A”), but rather Jim is depressed because of his beliefs about the
lost scholarship, or “B.” In other words, Jim is depressed because he believes that losing his scholarship is a terrible
event. Even though most of us can readily empathize with Jim’s plight, there is nothing in “A” to cause him to be
depressed. Ellis is not suggesting that we should never experience negative emotions, but he is identifying irrational
or unfounded beliefs as the cause of persistent and troublesome negative emotions that typify an individual who is
seeking psychotherapy.
Ellis’s approach to therapy amounts to reeducating clients about the sources of their unhappiness. After
Ellis draws out the client’s belief system, he illustrates how these beliefs—and not the external events—are the
cause of the client’s difficulties. Many of the beliefs we hold are irrational, and Ellis uses logical reasoning to
challenge these irrational beliefs. Some common irrational beliefs include the following: everyone must like us, or
we must be completely competent (Ellis referred to this as “masturbatory thinking”); and it is a catastrophe when
things do not turn out the way we want them to because things should always turn out right (Ellis said we “should”
on ourselves). Once clients become aware of their irrational or maladaptive beliefs and realize how these beliefs
have caused negative emotional consequences, the clients are motivated to change their beliefs. Ellis will explain to
the client how to replace or simply disregard maladaptive beliefs and teach the client to think in a logical and
realistic manner.
At first glance, Ellis’s approach to clients may seem cold and calculated. For example, if a client is
mourning the loss of a loved one and comes to Ellis for counseling, it may seem unsympathetic for Ellis to suggest
that it is the client’s beliefs about death, not the actual event itself, that are causing the client’s emotional response.
On the other hand, clients often cannot change their circumstances or the events that have happened to them, but
they can change their beliefs and attitudes toward these events and, by doing so, experience relief from their
problems. Thus, REBT is a very positive approach to clients’ potential for behavioural change.
Ellis, A. (1994). Reason and emotion in psychotherapy. Birch Lane Press.
Ellis, A., & Powers, M. (1998). A guide for rational living. 3rd Ed. Los Angeles: Wilshire Books.
Lecture Lead 13.2: Therapy Fads (R)
While most students are aware that astrology, graphology, and the like are viewed as unscientific means of
investigating personality and perhaps gaining insight into one’s own psyche, many are not aware that there are quite
a few “therapists” out there who are all too willing to promote a “new and innovative” type of therapy that is
supposed to provide psychological help to those in need. Ask students if they have ever heard of “est,” the so-called
therapy that basically gathered people into one big room while a “therapist” shouted at them, belittled them, and
wouldn’t let them go to the bathroom. Or “primal scream” therapy, in which subjects were supposed to get out all of
their primal, basic anger at parents, peers, and life in general by screaming at the top of their lungs. Or ask your
students if they have ever been approached by someone who offered to “read” their “aura.” Of course, these days we
have psychological therapy using crystals, aromatherapy, and past-lives regression. Any one of these therapy fads
(and this is by no means an exhaustive list) would make a good lecture topic with a little further research.
Lecture Lead 13.3: Experience and Treatment of Depression in Women (W)
Women are twice as likely as men to become depressed, and depression is most prevalent in young women. Until
recently the factors contributing to depression in women and therapeutic strategies aimed specifically at women had
received little attention. At the 1997 annual convention of the CPA, a symposium was held entitled “New
Perspectives on Women and Depression.” The May 1999 issue of the journal, Canadian Psychology, was devoted to
women and depression.
Stoppard (1999) points out that quantitative research has provided little help to women in their attempts to
understand and explain depressive experiences. In advocating qualitative research strategies, she describes the need
to address the meaning of symptoms rather than to simply regard them as indicators of the existence of depression.
Women in our society bear the brunt of caring for others both in terms of stress and restricted financial means.
Walters, Avotri and Charles (1999) also attest to the social and material conditions of women’s lives that maintain
material deprivation and stress. Women frequently hide their symptoms to maintain harmony at home and avoid
social stigma (Gammell and Stoppard, 1999). Once a diagnosis of depression is given, most women cut back on
activities or lower their goals to reduce stress. Scattolon and Stoppard (1999) found that rural women typically
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discount their depressive symptoms, regarding them as just part of life. They ignore symptoms or distract
themselves in an effort to “get on with life.” Feminist therapists are critical of conventional “medicalization” of
women’s depression. The main principle of feminist therapies is empowerment, which frequently involves women’s
decision making about the type of therapy they wish to receive.
Gammell, D. J & Stoppard, J. M. (1999). Women’s experience of treatment of depression: Medicalization or
empowerment. Canadian Psychology, 40, 112–128.
Scattolon, Y. & Stoppard, J. M. (1999). “Getting on with life”: Women’s experiences and ways of coping with
depression. Canadian Psychology, 40, 205–219.
Stoppard, J. M. (1999). Why new perspectives are needed for understanding depression in women. Canadian
Psychology, 40, 79–89.
Walters, V., Avotri, J. Y. & Charles, N. (1999). “Your heart is never free”: Women in Wales and Ghana talking
about distress. Canadian Psychology, 40, 129–142.
Lecture Lead 13.4: Prozac: Miracle Drug or Media Madness? (W)
In the United States, the group that petitioned the Food and Drug Administration for a ban against Prozac was called
the Citizens Commission for Human Rights. This group is sponsored by the Church of Scientology, which is known
for its opposition to psychiatry and the use of psychiatric drugs. Eli Lilly is the producer of Prozac (its chemical
name is fluoxetine hydrochloride). The Citizens Commission took on Prozac just as it was becoming the top-selling
antidepressant in the world, with almost $1 billion in sales in 1991 (Kramer, 1997). The commission called Prozac
the “killer drug,” accusing it of causing suicides, homicides, and a number of other problems.
Prozac does not work on a third of those who try it, but for those for whom it has an effect, there are few side
effects. The FDA determined that the suicidal behaviours of patients could not be demonstrably linked to the drug
(Burton, 1991). In a news release supporting the FDA decision, the American Psychiatric Association made clear
what is obvious to most: suicide is a condition of the illness that Prozac is meant to treat, not a side effect of the drug
(English, 1991). In fact, in comparison to placebos, suicidality decreases in patients taking Prozac (FDA Talk Paper,
1991). Prozac is the treatment of choice because it has so few side effects and patients do not feel drugged and
drowsy as they may with other antidepressants (Burton, 1991). On the other hand, physicians’ indiscriminate
prescribing of Prozac for groups such as postpartum mothers who are breast-feeding their infants, and children with
nervous systems still in a state of development is contraindicated due to possible deleterious side effects, yet the
practice continues (Peryea & Murray, 1995).
Burton, T. (1991, April 19). Anti-depression drug of Eli Lilly loses sales after attack by sect. The Wall Street
Journal, pp. A1, A6.
English, J. (1991, August 1). News release. American Psychiatric Association, Washington, D.C.
Food and Drug Administration. (1991, October 18). Talk paper T91-64. Rockville, Maryland: U.S. Department of
Health and Human Services.
Kramer, P. (1997). Listening to Prozac. New York: Penguin Books.
Peryea, C., & Murray, P. (1995, manuscript in preparation). The effect of fluoexetine hydrochloride on the
developing nervous systems of nursing infants.
Lecture Lead 13.5: Deinstitutionalization Revisited (W)
With the introduction of new anti-psychotic drugs in the 1960s, it became possible to discharge patients from
psychiatric wards and to admit fewer patients. The drugs had the capacity to control symptoms, thereby permitting
patients to function in the community. Discharging these patients was a well-intentioned act; they were supposed to
be able to find adequate supports for living independently in the community. Many psychiatric wards were closed.
In practice, there were not enough community supports. And people had underestimated the impact of the problem
of nonadherence. In many cases, no one checked up on whether former patients were taking their prescribed drugs.
But one of the most unfortunate outcomes of deinstitutionalization was a significant number of mentally ill who
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became homeless. Canada’s largest homeless population, an estimated six to eight thousand people, lives in Toronto.
Homelessness is particularly difficult for the mentally ill. Compared to other members of the homeless population,
those who are mentally ill have a more difficult time finding employment and therefore remain homeless for longer.
They also have fewer close social ties, poorer health, and they tend to have problems with substance abuse.
Altogether life is so difficult that their very existence is threatened. Men using homeless shelters in Toronto have
higher mortality rates than men in the general population (Hwang, 2000).
Hwang, S. W. (2000). Mortality among men using homeless shelters in Toronto. Journal of the American Medical
Association, 283, 2152–2157.
Lecture Lead 13.6: Sex Offenders’ Rights? (W)
The state of Washington has been wrestling with the rights of individuals who have been labeled sexual predators.
Typically, the individual has committed a sex-related criminal offense and been sentenced. After serving the
sentence, the individual is released. Upon release, he or she is immediately taken into custody and placed in a mental
health setting within a prison, even though the individual has not committed another crime and is not insane
according to legal definitions. The American Civil Liberties Union maintains that the state has no right imprisoning
or otherwise detaining someone who has not committed a crime or who is not a danger to oneself or others, and
compares the detention to that of the detention of political dissidents in the USSR. Moreover, a fundamental
question in the discussion is “How is someone determined to be a sexual predator?” There is no DSM-IV (1994)
reference to sexual predator, yet being diagnosed as one is grounds for detention in a mental health facility. A
follow-up question is “How is it determined that the person is no longer a sexual predator?” Lastly, how do you
deliver psychological services to someone against his or her will, in that the detainees are typically uncooperative
because they are being held against their will? Obviously these issues are weighted against the backdrop of a society
intent on protecting itself from people who are chronic in their sexual offenses.
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. (1994). Washington, D.C.: The American
Psychiatric Association.
Lecture Lead 13.7: Common Features of All Psychotherapists (W)
Before embarking on a journey through the different types of psychotherapy, it is useful to emphasize that all
psychotherapists have much in common:
Training: In terms of educational background, almost all psychotherapists hold masters’ or doctoral degrees in
clinical or counseling psychology. Some psychotherapists hold medical degrees, like psychiatrists, while others
obtain only bachelor degrees, like drug and alcohol treatment providers. (Note: Licensed therapists are able to
practice more or less independently, whereas unlicensed therapists are supervised on a regular basis.) In most states,
the titles “psychologist” and “psychiatrist” may be used only by professionals who have the appropriate educational
background and have passed a state exam demonstrating the depth and breadth of their expertise. These state
licensing laws help to regulate who performs psychotherapy. The titles “counselor” and “therapist” often may be
legally used without any special training or license. As the text suggests, consumers should inquire about their
therapists’ credentials. In addition to their formal training, all psychotherapists have to be perceived by clients as
having personal credibility as well as a degree and license. Sometimes the therapist’s age, gender, or race interferes
with client confidence in the therapist.
Ethics: Psychotherapists attend to their clients with unswerving attention and act only in the client’s best interests.
Sexual contact between therapist and client is a prime example of the therapist not acting in the best interests of the
client. Therapist–client communication is confidential. Unless clients provide written consent or are dangerous to
themselves or others, all records and information regarding therapy sessions are held in confidence. For example, a
mother cannot call her son’s college counselor and expect to learn how things are going in therapy. When the client
shares with the therapist an intent to attempt suicide or harm a third party, the therapist has a legal obligation to
protect both the client and society. This may involve breaking confidentiality on a need-to-know basis. Thus, the
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mother cited above may be informed by the therapist of her son’s suicidal intentions if the mother could help prevent
the attempt.
The Relationship: All psychotherapists need to develop an atmosphere of rapport and trust with their clients for
effective psychotherapy to occur. All forms of psychotherapy require some degree of client self-disclosure, and the
extent to which the clients are at ease with their therapists often dictates the rate of progress in therapy. In addition
to self-disclosure, the client has to trust the therapist enough to follow the therapist’s direction and interventions.
While clients always have the right to discontinue therapy at any time or to refuse a particular type of intervention,
the degree to which they are willing to try to follow the treatment plan established by a competent therapist is often
dictated by the level of trust and rapport in the client–therapist relationship. Although rapport and trust are qualities
that most of us desire in our personal relationships with others, the therapist–client relationship should not be
misconstrued as a friendship. The relationship is strictly a professional one; it is time-limited and should not include
socializing outside therapy sessions, because the therapist needs to maintain objectivity.
Lichtenstein, E. (1980). Psychotherapy: Approaches and applications. Monterey, California: Brooks/Cole.
CLASSROOM ACTIVITIES
Classroom Activity 13.1: The Effectiveness of Psychotherapy (Student Study
Guide Essay Question 13.1) (R)
Describe the reasons why you think that psychotherapy works. Draw upon the principles of
psychology that have been discussed in previous chapters, such as learning principles, theories of
development, and theories of personality, to explain why you think it is effective.
The text has provided students with a cogent discussion of the issues involved in evaluating the effectiveness of
psychotherapy. Although most researchers now agree that psychotherapy is more effective than no treatment, there
is a lively debate regarding why it is effective. On one side of the debate, Frank (1981) argues that therapist and
client variables account for the success of psychotherapy. In contrast, Telch (1981) contends that it is the actual
psychotherapy techniques, not therapist and client variables, that account for the success of psychotherapy.
PRO
Therapist and client variables are most important and account for the success of psychotherapy.
1.
2.
3.
4.
All types of psychotherapy are, in general, equally effective.
One form of therapy has rarely been demonstrated to be more effective than any other type.
Most clients who show initial improvement maintain it.
If one therapy is initially more effective than others at treating a particular type of problem, this difference
decreases with time and may not be evident during follow-up.
CON
Psychotherapy techniques make psychotherapy effective.
1.
2.
3.
4.
Studies that have found no significant differences between types of therapies suffer from methodological flaws.
Some specific techniques, such as live modeling, have proven to be more effective than other techniques.
Most studies fail to find significant differences between patient and therapist variables.
Future research would be most productive if the best techniques were discovered for treating particular
problems. These findings could benefit all clients and all therapists.
Frank, J. D. (1981). Reply to Telch. Journal of Consulting and Clinical Psychology, 19, 476–477.
Telch, M. J. (1981). The present status of outcome studies: A reply to Frank. Journal of Consulting and Clinical
Psychology, 49, 472–475.
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Classroom Activity 13.2: Discussion: The Cost of a Psychotherapy Hour (R)
Overhead Masters or Handout Masters are provided with this activity.
In a survey (Behaviour Today Newsletter, August 27, 1984, p. 7), the most frequently cited psychotherapy fee for
private practitioners was $60 per 50-minute session, and that was over 17 years ago. Given that therapists typically
report seeing clients once a week for one or two years, psychotherapy is very costly. In the increasingly popular
short-term or brief psychotherapy, a client would pay about $300 per month for at least two months. Certainly, the
typical college student could not afford these private practice rates.
Community mental-health centers, which are funded in part by state and federal funds, offer clients a
sliding pay scale based on the client’s ability to pay. These clinics are often understaffed because of government
spending cuts and because experienced psychotherapists are often drawn to more lucrative private practices.
Therefore, these clinics often have waiting lists and may not offer the same quality of psychotherapy available from
private practitioners.
Health insurance policies sometimes provide mental-health benefits, but these benefits are typically limited
in scope. The average client is likely to pay a considerable portion of the costs of psychotherapy. Provide students a
copy of Handout Master 13.1. Have the students discuss in small groups the costs of psychotherapy and whether
they believe that the government or health insurance companies should provide better mental-health benefits. Would
they be willing to pay higher taxes or insurance premiums for such benefits?
The Editors. (1984, August 27). Survey of psychotherapy practices. Behaviour Today Newsletter, 7.
Classroom Activity 13.3: Exploring Therapy Sessions (R)
Transcripts of psychotherapy sessions, such as those that appear throughout the chapter, give students a feeling for
what transpires during a therapy session. If students role-play a transcript that clearly illustrates an approach to
psychotherapy covered in the text, the class can then be broken down into small groups to rewrite the transcript for
another type of therapy. Bach (1983) suggests that a client-centered transcript is the easiest one for students to roleplay. When working in small groups, students will be challenged to think about how a particular type of therapist
would conduct the session differently with the same client. Students may also have to rewrite some of the client’s
transcript to fit with the new therapy.
Corey (2001) has written an introductory psychotherapy text that deals with the same client from the
perspectives of different therapies. This exercise requires the students to invest considerable time and effort, but they
typically become engrossed in the task at hand. When the transcripts are rewritten, they should be distributed to the
entire class after the instructor has critiqued them. Finally, if time permits, each group should role-play its transcript
for the class.
Bach, W. R. (1983). The use of role-playing in a classroom demonstration of client-centered therapy. Teaching of
Psychology, 10, 173–174.
Corey, G. (2001). Theory and practice of counseling and psychotherapy. 6th Ed. Pacific Grove, California:
Brooks/Cole.
Classroom Activity 13.4: Some Ethical Issues Pertaining to Therapy (R)
Overhead Masters or Handout Masters are provided with this activity.
Ethical issues around psychological treatment of patients seem rather straightforward, but often the issues are not so
obvious. Have the class break up into small groups and develop discussions for or against the following ethical
considerations (distribute copies of Handout Master 13.2):
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1.
Is there ever a time when sex with an ex-client is seen as ethical?
The APA struggles with this question rather incessantly. The latest APA ethical guidelines state that therapists must
wait a minimum of two years before engaging sexually with a former client, take into account the client’s current
mental status, and must demonstrate that there was no exploitation of the client, that termination of the client was
not for the purpose of eventual sexual intimacies, that there would be little or no adverse impact on the client, and
that behaviour during the course of therapy on the part of the therapist was not in the service of inviting a posttermination sexual or romantic relationship with the client. The obverse side of this discussion is whether a therapist
can be effective with former sexual partners—No.
2.
Could you be someone’s therapist and his/her professor?
An in-depth discussion of the inviability of nearly any dual role is beneficial. It is recognized by the APA and
practicing psychologists that there is the ideal position of no dual role relationships, and then there is the reality that
all practicing professionals, whatever their profession, invariably find themselves confronted with a dual role. This
problem increases as the size of the community decreases, with rural practicing professionals more keenly aware of
the dilemma.
3.
Is it sensible to take credit cards for psychotherapy services rendered? Why or why not?
If it is clear that the client has no issues around money management and is obviously a responsible individual in
financial matters and merely prefers to pay with a credit card for financial history reasons, then a therapist might
allow the use of credit cards. Otherwise, credit card use is not indicated for numerous reasons, such as a therapist
establishes a fee predicated on what the client can presently afford, client debt can complicate therapy, the potential
dual role relationship of credit extender, and so on.
4.
Is it ever ethical to refuse treatment to someone?
Yes. If a therapist feels that he or she is unable to perform effectively, then the therapist is obligated to refer the
client elsewhere. Reasons for ineffectiveness include lack of training in the presenting problem, lack of training in
the cultural issues of the client, or if the therapist believes that the values held by the client are in conflict with his or
her own and this conflict would impede therapy, then a referral is warranted. For instance, a therapist who is African
American would likely find it difficult being effective with a client who is a member of the Aryan Nation, or a
therapist who is gay or lesbian may find it difficult being effective with a client who is a Neo-Nazi.
Classroom Activity 13.5: Should Electroconvulsive Therapy Be Banned? (Student
Study Guide Essay Question 13.2) (R)
Describe the advantages and disadvantages of electroconvulsive therapy. Do you think that it should be
banned from use? Explain your answer.
The following debate should help clarify the issue. Have students prepare their answers prior to class, and then have
them reconsider once the discussion is complete.
Electroconvulsive therapy (ECT) was developed on the faulty premise that it would cure schizophrenia.
The premise was based on the fact that schizophrenia rarely occurred in individuals with epilepsy. By passing an
electric current through the patient’s head, doctors are attempting to create experimentally a convulsion similar to an
epileptic seizure. The traditional approach to ECT developed in 1938 by Cerletti and Bini involved placing
electrodes on both sides of the patient’s forehead and passing a current of 70 to 130 volts between the electrodes for
less than one second. This procedure was used until recently, when a unilateral approach, which is equally effective
and has fewer side effects, was developed.
ECT procedures now involve giving the patient a muscle relaxant and a sedative before administering the
treatment. Thus the patient experiences no pain. The patient does experience confusion and a loss of memory for
recent events after treatment. ECT is usually given in a series of 10 to 12 treatments, at the rate of three per week. At
the end of a series of ECT treatments, the patient’s disorientation may last more than a month.
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ECT has been a controversial treatment for several reasons. First, ECT has been used for a variety of
disorders without any proof of its effectiveness. Although originally developed as a treatment for schizophrenia,
ECT has been most effective for treating major depression. Second, although there are as many as 500 published
theories on the subject of why ECT works, the reasons why ECT is often an effective treatment for depression are
presently unknown. Third, ECT was previously given to patients without relaxants and sedatives; thus, patients felt
the initial shock and often suffered broken bones during the convulsion. Fourth, ECT was given to patients too
frequently (in some cases, 100 treatments were given). Finally, even when given in limited amounts, ECT destroys
some neurons and may cause permanent brain damage if given too frequently.
PRO
Voters in Berkeley, California, passed a law to ban the use of ECT in their area. The law was later overturned in the
courts, but the Berkeley vote demonstrated that public attitudes toward ECT are often negative.
1.
2.
3.
4.
There are alternative forms of treatment for depression that are effective and do not have such side effects as
memory loss and the destruction of neurons.
We do not know how ECT works.
Patients and their families fear ECT.
Physicians do not always fully consider all of the costs and benefits of ECT treatments for every patient who
receives ECT.
CON
Although ECT has been abused in the past, it has, with its present safeguards, proved to be an effective treatment of
depression.
1.
2.
3.
4.
In some cases of depression, patients do not respond to drugs or psychotherapy; thus, ECT represents a positive
alternative treatment for these patients because of its proven effectiveness.
Most drug therapies take two to three weeks to relieve the symptoms of depression. For patients who are suicide
risks, ECT offers almost immediate relief from their symptoms. Thus, the side effects of ECT are marginal
compared to the dangers of suicide attempts.
The fact that we do not know exactly why ECT works should be overshadowed by its demonstrated
effectiveness.
Advances in the administration of ECT should ease patient fears about the treatment; with unilateral ECT, the
patient experiences no pain and there is less memory disruption.
Carson, R. C., Butcher, J. N., & Mineka, S. (2000). Abnormal psychology and modern life. 11th Ed. Boston: Allyn
& Bacon.
Davison, G. G., & Neele, J. M. (1986). Abnormal psychology: An experimental clinical approach. 4th Ed. New
York: Wiley.
Fink, M. (1999). Electroshock: Restoring the mind. New York: Oxford University Press.
Classroom Activity 13.6: Devising Treatment Strategies for Sex Offenders (R)
Overhead Masters or Handout Masters are provided with this activity.
Have the class break into small groups and devise a treatment strategy for sex offenders (provide them with a copy
of Handout Master 13.3). They should provide justification for their chosen course of treatment.
If they choose cognitive psychotherapy, then they should indicate it is because they believe that the
problem is due to irrational modes of thought. If they choose psychodynamic, then it is because they believe that the
problem is due to arrested psychological development. If they choose behavioural psychotherapy, then it is because
they believe that the offenders’ behaviour patterns have been reinforced. If they choose humanistic psychotherapy,
then it is because they believe the offenders suffer from conditions of worth. If they choose biological
psychotherapy, then it is because they believe that there is a hormonal or neurotransmitter imbalance. In addition,
have them indicate whether they would utilize individual or group therapy formats and indicate why.
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MULTIMEDIA
Online Learning Center Preview
Instructors should check the Online Learning Center for applicable PowerPoint slides and other resources relevant to
this chapter. Tables and figures available from the Image Gallery for this chapter:



TABLE 13-1: Getting Help from the Right Person
TABLE 13-3: Drug Treatments
FIGURE 13-1: The A-B-C Model of Rational-Emotive Behaviour Therapy
In-Psych Student CD-ROM
The In-Psych Student CD-ROM is organized according to the textbook chapter outlines and features exercises
chosen to illustrate especially difficult core introductory psychology concepts. Each exercise showcases one of three
types of media assets—an audio clip, a video clip, or a simulation—and includes a pre-test, follow-up assignments,
and Web resources. The CD-ROM also includes chapter quizzes, a student research guide, and an interactive
timeline that puts events, key figures, and research in psychology in historical perspective. As these
features effectively engage the student and help reinforce new knowledge retention, they function superbly as
homework or extra-credit assignments. The following [is/are] available on the CD-ROM for this chapter:
[Chapter 13 Treatment of Psychological Disorders]
Timeline
Virtual Reality Therapy (Audio)
Electroconvulsive Therapy (ECT) (Audio)
Chapter Quiz
Video Resources
FILMS FOR THE HUMANITIES AND SCIENCES
Phobia: When an Irrational Fear Takes Control (two-part series, 50 minutes each)
Understanding Depression (22 minutes)
Mistreating the Mentally Ill (56 minutes)
Advancements in Neurology and Neurosurgery (22 minutes)
Psychosurgery: Best Hope or False Hope? (52 minutes)
The Mind as Healer (22 minutes)
Healing Arts: The Arts and Medicine (29 minutes)
Depression and Manic-Depression (28 minutes)
Don’t Panic: The Promise of Intensive Exposure Therapy (17 minutes)
(Contact information for this material can be found in the Preface of this manual.)
PsychLink
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www.mcgrawhill.ca/college/feldman
INDEPENDENT PROJECTS
Independent Project 13.1: Collecting Images of Psychotherapy (E)
Psychotherapy is rarely presented in a positive light in cartoons and other forms of humor. A nonthreatening way for
students to explore society’s misconceptions and fears about psychotherapy is to collect cartoons that deal with
some aspect of psychotherapy. These can then be shared with the rest of the class. Between the guffaws, the
instructor can be listing the messages of each cartoon on the board. By reviewing the listings on the board, the class
can try to discover whether cartoon humor encourages or discourages people to seek psychotherapy.
Independent Project 13.2: To Do or Not To Do—Psychotherapy, That Is (E)
Overhead Masters or Handout Masters are provided with this activity.
Psychotherapy is a tool used by a clinician to alleviate dysfunction or improve everyday life. Occasionally, a student
learns some of the techniques of psychotherapy and begins utilizing those techniques at inappropriate times, as with
friends and colleagues. The following exercise is comparable to the behavioural intervention of “assigning the
problem.” (Use Handout Master 13.4.) Have students purposefully use some of the techniques described in this
chapter in a role-play with a friend or family member. That is, tell the friend that you would like to pretend as
though they were your friend and you were going to use some psychotherapeutic technique learned in class to help
them with some problem. The friend can make up the problem and begin to discuss the issues related to it. This
should provide an opportunity to understand the contextual nature of psychotherapy, as well as insights to the
inappropriateness of dual role relationships.
Independent Project 13.3: Psychotherapy: What’s Out There? (W)
Have students go through the yellow pages of the local telephone book to discover the number of therapists in their
area. Instruct them to write down what type of professionals advertise services (e.g., clinics, psychiatrists,
psychologists, therapists, hospitals) and whether the specific type of therapy is listed. Students may also want to
inquire, by mail or by phone, about the particular method that an individual therapist favors (eclectic,
psychoanalytic, REBT, etc.).
Independent Project 13.4: Origins of Psychosurgery (W)
Assign students the task of researching the beginnings of psychosurgery, from the method of trepanning used in
ancient times to the advent of the prefrontal lobotomy. Students will be fascinated by the experimentation that has
been done on the human brain in the name of therapy.
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HANDOUT MASTER 13.1 (USE WITH CLASSROOM ACTIVITY 13.2)
Mental Health Benefits
1. Should either the government or health-care companies provide better mental health benefits?
Arguments For:
Arguments Against:
2. Would you be willing to pay higher taxes or insurance premiums for such benefits?
Reasons I would be willing to pay more:
Reasons I would NOT be willing to pay more:
HANDOUT MASTER 13.2 (USE WITH CLASSROOM ACTIVITY 13.4)
Some Ethical Issues
Pertaining to Psychotherapy
Ethical issues around psychological treatment of patients seem rather straightforward, but often the
issues are not so obvious. For this activity, your group is to develop discussions for and against the
following ethical considerations:
1. Is there ever a time when sex with an ex-client is seen as ethical?
2. Could you be someone’s therapist and his/her professor?
3. Is it sensible to take credit cards for psychotherapy services rendered? Why or why not?
4. Is it ever ethical to refuse treatment to someone?
HANDOUT MASTER 13.3 (USE WITH CLASSROOM ACTIVITY 13.6)
Treatment Program for Sex Offenders
As a group, you are to devise a treatment program for someone who has been convicted of being a
sex offender. Answer the questions provided below.
1. What treatment approach did you select (cognitive, behavioural, psychodynamic, humanistic,
sociocultural, physiological)?
2. Why did your group select this approach?
3. Would you recommend group or individual therapy sessions? Why?
4. What major components of the treatment program would you be certain to include? That is, how
would you structure your therapy?
HANDOUT MASTER 13.4 (USE WITH INDEPENDENT PROJECT
13.2)
Untrained Psychotherapy
Psychotherapy is a tool used by a clinician to alleviate dysfunction or improve everyday life.
Occasionally, a person learns some of the techniques of psychotherapy and begins utilizing those
techniques at inappropriate times, as with friends and colleagues. The following exercise is
comparable to the behavioural intervention of “assigning the problem.” For this activity, you are to
purposefully use some of the techniques described in this chapter in role-plays with a friend or family
member. That is, tell the friend that you would like to pretend as though they were your client and
you were going to use some psychotherapeutic technique learned in class to help them with some
problem. The friend can make up the problem and begin to discuss the issues related to it. This should
provide an opportunity to understand the contextual nature of psychotherapy, as well as insights to the
inappropriateness of dual-role relationships.
1. Which technique did you try?
2. What was the response/outcome?
3. How did you feel about using this technique and the responses generated?