Download Treatments Biomedical and PsychoSocial

Psychopharmacology is the study of how
drugs affect the mind and behavior.
Psychoactive medication is a type of drug
that alleviates symptoms of mental disorders by
acting on the bodily processes that may cause
those symptoms.
Antipsychotic drugs are psychoactive medications used to treat disorders in which psychotic
symptoms, such as hallucinations, paranoia, and
delusions, predominate.
Antidepressant is a type of medication that
works to alleviate symptoms of depression by
altering how certain neurotransmitters—usually
serotonin and norepinephrine—are circulated
throughout the brain.
Biological
Treatments:
Biomedical
Therapies
For some, biomedical therapies
are a major part of an effective
treatment plan. Over the past
50 years or so, psychopharmacology, the study of how
drugs affect the mind and behavior, has led to the development of
a wide array of psychoactive
medications. These medications
alleviate symptoms of mental disorders by acting on the bodily
processes that may cause
those symptoms.
drugs indicates that too much dopamine is at
least partially responsible for schizophrenia
(Pickar et al., 1984; Taubes, 1994). A notable
limitation of typical antipsychotics, however, is
that they do not treat negative symptoms. In
addition, side effects of typical antipsychotics
can include sluggishness, tremors, and even
tardive dyskinesia, a serious and often irreversible motor disturbance in which the
tongue, face, and other muscles involuntarily
jerk or contract (Kaplan & Saddock, 1989). As
a result of these potentially severe side
effects, people with psychotic illnesses often
find it difficult to continue taking antipsychotics for extended periods of time.
For those afflicted with negative symptoms of schizophrenia, such as apathy or
prolonged lack of movement (see Chapter 17),
atypical antipsychotics can provide relief.
These newer medications can alleviate negative symptoms by altering the activity of other
neurotransmitters, such as serotonin, in addition to dopamine. They are also less likely to
produce the major side effects caused by typical antipsychotics because they target specific
ABC News political analyst George
Stephanopoulos, actress Brooke Shie
and comedian Rosie O'Donnell
them reclaim their lives after bout
with depression.
ANTIPSYCHOTIC DRUGS
Antipsychotic drugs are a class of psychoac-
tive medications used to treat disorders in which
psychotic symptoms, such as hallucinations,
paranoia, and delusions, predominate. There are
two types: typical and atypical.
Although many typical antipsychotics
have been around since the 1950s, they continue to be as effective as newer medications
at treating psychotic illnesses such as schizophrenia. Examples of typical antipsychotics
include chlorpromazine and haloperidol.
These drugs effectively reduce or eliminate
the positive symptoms of disorders like
schizophrenia, such as delusions and hallucinations (see Chapter 17), by decreasing
dopamine activity at certain synapses in the
brain (Lehman et al., 1998; Lenzenweger et
al., 1989). The relative effectiveness of these
dopamine receptors in the brain. Examples of
atypical antipsychotics include clozapine,
risperidone, and olanzapine. Although atypical
antipsychotics generally produce fewer side
effects than do typical antipsychotics, both
types of drugs can cause symptoms such as
dizziness, weight gain, constipation, sexual
impotence in men, and nausea.
ANTIDEPRESSANTS
Given the prevalence of major depressive disorder in the United States—each year, it affects
approximately 14.8 million American adults—
it's no wonder that antidepressant medications
have become well known to the general public
in recent years (Kessler et al., 2005).
Antidepressants work to alleviate symptoms
of depression by altering how certain neurotransmitters—usually serotonin and norepinephrine—are circulated throughout the brain.
Serotonin and norepinephrine are associated
with arousal and feelings of well-being, and
people suffering from depression often have
serotonin or norepinephrine deficiencies.
The earliest form of antidepressants,
most popular from the 1960s-1980s, are
called tricyclics. Examples include imipramine
(Tofranil) and amitriptyline (Elavil). Typically,
serotonin and norepinephrine are reabsorbed
by the synapses in the brain (see Chapter 3).
By blocking the reuptake of these neurotransmitters, tricyclics can elevate patients' moods.
However, tricyclics have a number of unpleasant side effects, including dry mouth, fatigue,
and blurred vision, and are more likely to
cause death in the case of an overdose than
are other types of antidepressants (Anderson,
2000; Mulrow, 1999).
Selective serotonin reuptake inhibitors,
or SSRIs, are a newer alternative to tricyclics.
These antidepressants, which began appearing in the mid-1980s, only block the reuptake
of serotonin in the brain and have relatively
few side effects. Fluoxetine
(Prozac), paroxetine (Paxil),
and sertraline (Zoloft) are all
SSRIs. Tricyclics and SSRIs tend
to have similar effectiveness in
Ids,
treating depression, but because
SSRIs have fewer unpleasant side
effects, they are more popular.
Testimonial evidence indicates
that these drugs can be powerfully
effective; ABC News political
analyst George Stephanopoulos,
actress Brooke Shields, and
comedian Rosie O'Donnell have
all publicly credited SSRIs with helping them
reclaim their lives after bouts with depression.
"The gray has gone away. I am living in bright
Technicolor," O'Donnell wrote of her experience with the medication.
Monoamine oxidase (MAO) inhibitors are
another type of antidepressant. MAO is an
enzyme that metabolizes monoamines such as
norepinephrine, so by inhibiting this enzyme,
these drugs allow for increased amounts of
norepinephrine in the brain.
Because they can have severe side
effects, including lethal food and drug combinations, MAO inhibitors are usually used as a
last resort, for people who don't respond to
other drug therapies.
The newest types of antidepressants,
atypical antidepressants, affect peurotransmitters
(including serotonin, norepinephrine, and
dopamine) in specific combinations. Bupropion
can include drowsiness and a decline in
(VVellbutrin) and duloketine hydrochloride
motor coordination. Although benzodi-
(Cymbalta) are examples of these drugs.
azepines are less addictive than barbiturates,
Interestingly, Wellbutrin, which works as an
they have several unpleasant withdrawal
antidepressant by inhibiting the reuptake of
symptoms. Furthermore, many practitioners
norepinephrine and dopamine, has also been
believe that anti-anxiety drugs relieve the
shown to be moderately effective in helping peo-
symptoms of the disorder without addressing
ple quit smoking.
the underlying causes; these practitioners
Millions of people have benefited from anti-
consist of both medication and therapy.
Prozac (Goode, 2000). The title of journalist
Other anxiety disorders, including OCD and
Elizabeth Wurtzel's 1994 memoir—Prozac
PTSD, are more likely to be treated with
Nation—serves as a facetious commentary on
antidepressants, specifically SSRIs.
the pervasiveness of antidepressants in the
keting campaigns. You're probably familiar with
the cartoonish butterfly-chasing egg featured in
Zoloft commercials or the emotionally wrought
voiceovers that reverberate throughout
Cymbalta ads. Some people even blithely refer
to antidepressant medications as "happy pills."
Yet the fact remains that antidepressants are
serious, psychoactive medications. They are
most effective and safe when they are usec in
conjunction with psychotherapy, and they
should.be taken only under close
Electroconvulsive therapy (ECT) is a type
of therapy in which electric shocks are sent to
patients' brains to treat certain psychological disorders in patients who don't respond to other
treatment methods.
used on a long-term basis (Solomon et al.,
1995). Exactly how and why the drug works
remains a mystery to medical professionals.
United States. Indeed, our use of these drugs
has become quite common over the last two
and panic disorder.
often recommend treatment plans that
depressants—more than 38 million alone from
decades, in part because of highly visible mar-
Benzodiazepines are anti-anxiety medications
used mainly to treat generalized anxiety disorder
Widespread advertising
for antidepressant
medications has helped
make them acceptable
to the mainstream.
What do you think of
such ads? Are they
V
V
helpful or harmful?
V
areg19760
supervision of a physician who is
The important thing is, however, that it does
work for so many afflicted with the disorder;
journalist and television host Jane Pauley, diagnosed as bipolar in 2001, says of lithium: "It just
is stabilizing. It allows me to be who I am."
ELECTROCONVULSIVE
THERAPY
If you have ever read Ken Kesey's One Flew
Over the Cuckoo's Nest, or seen the film adaptation, you likely have a very negative impression
of electroconvulsive therapy (ECT). Early uses
of ECT—which involves sending electric shocks
to patients' brains—were largely ineffective and,
hyperaware of the circumstances of
even worse, barbaric. However, with modern
treatment. Recent findings of a cor-
technology and careful medical supervision,
relation between antidepressant
ECT is now used to successfully treat people
use and increased suicide rates
suffering from severe depression
among children and young
who do not respond to
adolescents only strengthen
either psychotherapy
the case for careful
or antidepressant
physician supervision
medications.
(Olfson et al., 2006).
ECT today is administered much differently than
it used to be. Practitioners
ANTI-ANXIETY
MEDICATION
use muscle relaxants and
other drugs to block nerve
For those suffering
and muscle activity so the
from anxiety disor-
patient feels little pain and
ders, anti-anxiety
is not in danger of physical
medications can
harm. Studies have shown that
provide relief. These
up to 80 percent of patients expe-
drugs reduce the symptoms, such as
rience significant improvement in
tension and nervousness, associated with
their depressive symptoms after six
many anxiety disorders by slowing down the
central nervous system's activity. The first
to 12 ECT sessions over the course
of two to four weeks (Bergshlom
monly known as tranquilizers, and were
MOOD-STABILIZING DRUGS
highly addictive. Benzodiazepines, a safer
When people experience the rapid mood
effect; however, a new method called unilateral
class of drugs, largely replaced barbiturates
changes that are the hallmark of bipolar disor-
administration has helped to reduce its occur-
anti-anxiety drugs were barbiturates, com-
et al., 1989; Coffey, 1993). Memory
loss is typically the most troubling side
during the 1960s. These medications,
der, doctors often prescribe mood-stabilizing
rence. During unilateral administration, physicians
including Valium and Xanax, are mostly
drugs—namely, lithium—in response. Lithium is
administer shocks only to the right hemisphere
effective for treating generalized anxiety
a simple salt element that has been shown to
of patients' brains, lessening the treatment's
disorder and panic disorder. Side effects
benefit about seven in ten bipolar patients when
impact on conscious, verbal memories.
-6-111-0
Psychosurgery is a treatment method in which
parts of the brain are surgically altered to treat
mental disorders.
Psychotherapy is the interaction between a
therapist and someone suffering from a psychological problem, the goal of which is to provide
support or relief from the problem.
Eclectic psychotherapy is a type of psychotherapy involving the use of multifaceted
treatments that vary depending on each person's unique problem and take into account biological, psychological, and social influences.
Psychodynamic therapy is a type of therapy
based on Freudian psychodynamics, the theory of
which states that unconscious conflicts underlie
mental disorders, and these conflicts make their
way to the surface through a person's speech
and behavior.
Psychoanalysis is a type of psychotherapy
that relates closely to Freudian concepts like the
influence of the unconscious. It requires patients
to talk to a psychiatrist about their lives while the
psychiatrist listens, analyzes, and interprets
each word.
Free association is a psychoanalytic technique
in which the therapist encourages the client to relax
his or her mind and, starting from a recent experience, a memory, or a dream, report every image or
idea that enters awareness, refraining from logic or
self-editing.
For example, OCD that's untreatable by
other means can sometimes be treated with
psychosurgery. Doctors implant electrodes
in areas of the brain shown to be overactive
in OCD patients—the cingulum and basal
ganglia—and then stimulate these electrodes
with radio-frequency currents. Destroying
these small segments of brain tissue can
reduce OCD symptoms (Sachdev & Sachdev,
1997). In addition, a newer treatment called
deep brain stimulation can be used for rare
cases of otherwise untreatable OCD.
Surgeons implant a thin wire electrode in the
patient's brain; when activated, this electrode
can stimulate (not destroy) neurons lying near
it. Scientists believe this treatment effectively
combats OCD by disrupting the ongoing neural loop that may underlie obsessions and
compulsions.
Psychodynamic
and Humanistic
Psychotherapy
Psychotherapy refers to an interaction
between a therapist and someone suffering
from a psychological problem, the goal of
which is to provide support or relief from
the problem. Although some people view
psychotherapy as an alternative to biomedical treatments, it is often used along with
psychotropic drugs. This blended
approach—the use of multifaceted treatments that vary depending on each person's
unique problem and take into account
biological, psychological, and social influences—is called eclectic psychotherapy,
and it has becoming increasingly popular
among therapists over the past two decades
(Beitman et al., 1989; Castonguay &
Goldfried, 1994).
'
As with lithium, the mechanism that
rakes ECT an effective treatment remains
iknown. While ECT continues to be controtrsial, it is increasingly gaining a reputation
; a promising, effective treatment option for
rose who have been unable to find relief
)m their depression elsewhere. (Consensus
onference, 1985; Parker et al., 1992;
lass, 2001).
'SYCHOSURGERY
ke ECT, psychosurgery, for many, conjures
otesque images of cruel, practically slapash medical procedures from the past.
)rtunately, modern medicine has ended the
le of ill-advised lobotomies (a procedure
at disconnects the frontal lobe from the rest
the brain and results in a near vegetative
ate) and transformed psychosurgery—in
rich parts of the brain are surgically altered
treat mental disorders—into a humane
)atment option. These refined versions of
iychosurgery are highly localized and tarrted to specific areas of the brain. Because
iychosurgery is irreversible and carries all of
a risks of surgery, however, it is used only in
e or extreme cases.
-
Not all psychotherapies
are the same. In fact, each
approach to psychotherapy
represents a different
perspectiv, and how
best address "problc
the
Not all psychotherapies are the same.
In fact, each approach to psychotherapy
represents a different perspective on how
the mind works and how to best address
"problems of the mind."
PSYCHODYNAMIC
THERAPIES
Psychodynamic therapies are based on
Freudian psychodynamics (see Chapter 16).
According to psychodynamic theory, unconscious conflicts underlie mental disorders, and
these conflicts make their way to the surface
through our speech and behavior. This perspective leads psychodynamic therapists to
tend to view the symptoms of a disorder as
side effects of a deep, underlying problem that
needs to be resolved. Psychodynamic therapists apply Freud's ideas not only to their view
of psychological disorders but also to their
treatments. They tend to trace their clients'
problems to childhood or past experiences
and focus strongly on understanding symptoms in the context of the client's important
personal relationships.
Psychoanalysis
Although its popularity has waned considerably over the years due to its tendency to be
expensive and time intensive (requiring several
sessions a week for several years), some
psychodynamic therapists still employ
psychoanalysis when treating patients
(Goode, 2003). Psychoanalysis is a type of
psychotherapy that relates closely to
Freudian concepts like the influence of the
unconscious. It involves a number of specific
techniques and concepts, all with the aim of
helping clients "work through" their issues
and resolve their psychological problems.
"I went to the zoo yesterday. . . elephants
. . .gray . . . charcoal . . . campfire . . . oak
tree." This seemingly random string of
thoughts is an example of what might be produced during an exercise in free association.
Free association is a psychoanalytic technique
in which the therapist encourages the client to
relax his or her. mind and, starting from a
recent experience, a memory, or a dream,
report every image or idea that enters awareness, refraining from logic or self-editing. The
therapist then tries to discern if these seemingly random associations point to particular
underlying conflicts or anxiety in the client's
unconscious mind.
Freud believed that dreams are the
purest forms of free association, and dream
analysis is another notable psychoanalytic
technique. When analyzing clients' dreams,
Manifest content is what a person explicitly
remembers about a dream—its storyline, characters, and details.
Latent content describes the unconscious
meaning of a dream.
Resistance refers to a client's attempt to avoid
doing therapeutic work.
Transference is an instance in which a client's
unconscious feelings about a significant person
in his or her life are instead directed toward
the therapist.
Catharsis is healing emotional release.
Interpersonal psychotherapy is a type of
psychotherapy that focuses on helping clients
improve their relationships, particularly their current
relationships, as a means to resolving their psychological problems.
problems. His philosophy contributed to the rise
of interpersonal psychotherapy, which focuses on helping clients improve their relationships,
particularly their current relationships, as a
means to resolving their psychological problems. Like traditional psychoanalysis, interpersonal psychotherapy is based on the concept
that patients need to uncover the roots of their
problems, but it tends to be briefer, less intense,
and more practical and immediate than psychoanalysis. This type of therapy seems to be
particularly helpful for people suffering from
depression (Weissman, 1999).
Psychodynamic therapists may use
A psychoanalytic techniques including free
association and dream analysis. Do you think
these methods can produce great insights and
relieve psychological problems?
LA\
HUMANISTIC THERAPIES
If you believe that all people have the potential to grow, improve, and become their best
selves, you might look at life from a humanistic perspective. The humanistic approach to
psychology emphasizes humans' promise
and our capacities for health, happiness, and
generosity toward others (see Chapter 16). It
makes sense, then, that humanistic therapies
address psychological problems through a
lens of positivity and optimism. Psychological
problems are not necessarily problems at all,
a humanistic therapist might say, but opportunities for us to pause, reflect on our lives,
therapists wade through the manifest
content—the way the dream is experienced
and remembered by the dreamer—in order to
uncover the latent content, or the unconscious meaning of the dream.
Throughout sessions in psychoanalysis,
therapists remain on the lookout for instances
of resistance and transference in their clients.
perspective, a client who begins to resent her
therapist might in fact be transferring her
unconscious, unresolved resentment of her
mother. By identifying these instances and analyzing their roots, therapists attempt to provide
insights that will lead clients toward catharsis,
or a healing emotional release.
Resistance refers to a client's attempts to avoid
doing therapeutic work. For example, a client
Neo-Freudian Therapies
even greatness, and they're particularly
Several psychologists subscribe to Freud's fundamental ideas but have tweaked or amended
viduals' inner potential for positive growth.
his techniques to develop what are known as
neo-Freudian therapies. Harry Sullivan, for
Humanistic therapies center on the notion
that when it comes to happiness, the power
example, believed that interpersonal relationships have a significant impact on psychological
lies with the people; that is, the choices we
make regarding our own behavior can
might "forget" to go to sessions or refuse to talk
about certain topics. During transference, a
client's unconscious feelings about a significant
person in his or her life are instead directed
toward the therapist. From a psychoanalytic
and make changes that enhance our potential. Humanistic therapies tend to focus not
on treating illness but on achieving wellness,
concerned with recognizing and igniting indi-
Person-centered therapy is a type of
humanistic therapy in which the therapeutic
process focuses squarely on the client's abilities
and insights rather than the therapist's thoughts
and skills.
Client centered therapy see person -centered
-
therapy.
Gestalt therapy is a type of humanistic therapy
in which the therapist attempts to make the client
feel whole by helping the client feel aware of and
responsible for his or her thoughts, behaviors, experiences, and feelings.
Group therapy is a type of therapy that is led by
a therapist and involves a group of clients experiencing psychological disorders.
Family therapy is a type of therapy in which the
therapist views the family as a single unit and
attempts to resolve conflicts and stresses that arise
among the family members.
once or twice. The idea of being "heard," or
fully understood and listened to, comes from a
key component of Rogers's person-centered
therapy called active listening. When a therapist actively listens to a client, he or she tries to
understand what the client is saying from the
client's point of view, without judgment. Active
listening involves echoing, restating, and seeking clarification of clients' statements. At the
same time, therapists are careful to allow the
client to maintain control of the discussion and
direct its topics. An active listening session
might sound something like this:
Client: Sometimes I feel like such a failure.
Like I can't do anything right.
Therapist: So you feel like you're failing in
some ways, that you can't do things right? Is
that correct?
Client: Yeah, it's like every time I try to do
something, I just mess it up.
Therapist: That sounds painful and frustrating. Is there an example you'd like to discuss?
According to Rogers, "hearing" clients in
this fashion can be a powerful, uplifting force in
the lives and minds of clients seeking help.
effectively promote our survival and well-being.
Humanistic therapists aim to help their clients
develop the self-awareness and self-confidence
necessary to achieve happiness.
They don't "fix" clients so much
as show clients how to "fix"
themselves. You might think of
Humanistic psychologist Carl Rogers
them as the unrelentingly upbeat
cheerleaders of the psyche.
believed that in order to feel motivat
Person-Centered
Therapy
to move forward in life.
ee goo ourse ves an
ccepted and approved of by othe
regardless of our flaws.
Humanistic psychologist Carl
Rogers believed that in order to
feel motivated to move forward
in life, we have to feel good
about ourselves and feel
accepted and approved of by
others, regardless of our flaws.
This principle underlies a popular humanistic
therapy developed by Rogers (1961, 1980)
called person-centered, or client-centered,
therapy. In this model, the therapeutic process
focuses squarely on the client's abilities and
insights rather than the therapist's thoughts
and skills. Person-centered therapists assume
the roles of motivators, collaborators, and facilitators of their clients' mental health. They
believe their clients are worthy and capable,
even when the clients in question don't agree.
The therapists' expressions of genuine acceptance are intended to help clients begin to feel
more positive and self-confident, paving the
way for clients to advance on their quest for
personal fulfillment (Hill & Nakayama, 2000).
You might have heard a character on TV
complain, "You're not really hearing me!" or
you might have said something similar yourself
Gestalt Therapy
Gestalt means "whole," so it makes sense
that in gestalt therapy, another humanistic
method, therapists aim to "fill in the holes . . .
to make the person whole" (Perls, 1969).
Developed by psychologist Fritz Perils, gestalt
therapy helps clients become aware of, and
take responsibility for, their thoughts, behaviors, experiences, and feelings. Gestalt therapists move their clients toward this goal by
encouraging them to speak in the active
voice ("I called mi.y parents" rather than "my
parents were called") and to confront their
fears, conflicts, or other troubles head-on.
Group and Family Therapies
For some people, the prospect of sitting
down one-on-one with a therapist is too
Additionally, group
therapy gives clients the
opportunity to observe
others, practice their
interpersonal skills, and
change their thinking and
behaviors based on other
people :s influence and
in u People often find
lat hearing about others'
xperiences dealing with
similar problems can be
enormously comforting
and helpful.
intimidating to bear, no matter how
open, accepting, and empathic the
therapist may be. Group therapy
can be an effective alternative for
these people since it tends to be
less threatening than a one-on-one
session. Additionally, group therapy
gives clients the opportunity to
observe others, practice their interpersonal skills, and change their
thinking and behaviors based on
other people's influence and input.
People often find that hearing
about others' experiences dealing
with similar problems can be enormously
comforting and helpful. Community support
groups and self-help groups, such as
Alcoholics Anonymous, are examples of
highly effective group therapies (Galanter et
al., 2005; Kurtz, 2004; McKellar et al., 2003;
Ouimette et al., 2001).
When families experience significant
conflict or stress, they might look to a family
therapist for help. Family therapy treats the
family as a system or unit and can be an
effective tool in helping families cope with
and resolve conflict. The therapist focuses on
how conflict or stress manifests itself in the
relationships among the family members
rather than on each individual's unique set of
problems. Individual therapy often accompanies family therapy as part of.the overall
treatment plan.
Cognitive and
Behavioral
Psychotherapy
"I think, therefore I am": Even if you aren't an
expert in philosophy, you're probably familiar
with this statement from Rene Descartes, 17th
century scholar and thinker. Although Descartes
wasn't a psychologist, his belief about the interaction between thought, action, and existence is
a convenient starting place for a discussion of
cognitive and behavioral therapy as treatments
for psychological disorders.
Cognitive and behavioral therapies are
based on the idea that psychological problems
are caused by faulty or irrational thinking, which
in turn produces faulty or irrational behaviors.
Essentially, you are what you think you are. As a
result, cognitive and behavior therapies, which
are often combined in the form of cognitive—
behavior therapy (CBT), try to get people to
change the way they think (cognition) and the
SCENARIO 1
way they act (behavior). This approach is significantly different from both the psychodynamic
and humanistic approaches: The client's goal
isn't to gain insights into the unconscious mind
or to realize personal potential. Rather, CBT
asks clients to identify the thought and behavior
patterns that create their problems, and then
make immediate, quantitative changes to break
these patterns. Interestingly, the use of CBT to
treat phobias has been shown to have similar
brain effects to SSRI treatments: Both reduce
amygdala and hippocampus reactivity or activation (Furmark et al., 2002). This finding indicates
that there is a biophysiological aspect to CBT,
and that changing the way you think and act
can literally change your brain circuitry.
Cognitive-behavior therapy (CBT) is a type
of therapy centered on the idea that psychological
problems are caused by faulty or irrational thinking,
which in turn produces faulty or irrational behaviors;
therefore, this type of therapy focuses on getting
the client to change the way he or she thinks
and behaves.
Cognitive therapy is a type of therapy based on
the theory that people's psychological problems can
be traced to their can illogical or disturbed beliefs and
thoughts; therefore, this type of therapy attempts to
replace those cognitive patterns with healthier ones.
Cognitive restructuring is a therapeutic technique in which therapists teach clients to question the
automatic beliefs, assumptions, and predictions that
often lead to negative emotional states and to replace
negative thinking with realistic and positive thinking.
COGNITIVE THERAPY
Cognitive therapy, which can be either part of
CBT or a stand-alone treatment option, first
gained notice in the 1960s and is based on the
theory that people's psychological problems can
be traced to their own illogical or disturbed
beliefs and thoughts. For example, people are
depressed because
they have
depressive,
self-defeating, negative thoughts; people are
anxious because they have apprehensive, fearful,
panic-laced beliefs. Because these maladaptive
thoughts and beliefs can make reality seem
worse than it is, cognitive therapies attempt to
replace them with healthier cognitive patterns.
Cognitive restructuring is an important
part of most cognitive therapies. With this
technique, therapists teach clients to question
the automatic beliefs, assumptions, and predictions that often lead to negative emotional
states and to replace negative thinking with
realistic and positive thinking.
Psychologist Aaron Beck and
colleagues (1979) developed a
widely used method based on
this concept.
For instance, a client suffering from
depression might be consumed by self-defeating thoughts like, "I failed that math exam,
which means I'm going to fail the class, and I'll
probably never get my degree or a decent job.
I'm such a loser." A cognitive therapist applying
Beck's technique would encourage the client
to understand the illogical reasoning behind
this "awfulizing" of an isolated situation: Failing
one math exam doesn't
make anyone a loser.
"What does failing a
math test have to do with
your status as a human
being? You made some mistakes in solving
some math problems. Does that mean that
everyone who struggles with math is a loser?"
the therapist might say. The therapist would
continue to work with the client to replace
these thoughts with productive, effective ones
grounded in reality: "I failed an exam, but it
counts for only 10 percent of the final grade. If I
DEPRESSIONN
SCENARIO 2
One exam won t
make or break my
future. My prospects
are still good.
NO DEPRESSION
,mo\No
PosmvE 1 " -
Cognitive therapists work with clients to replace
negative thought patterns with more adaptive
ones that can help them avoid depression.
A
A
A
work hard and ask the professor for extra help,
I can still pass the class. Even if I don't, I can
Stress inoculation training is a therapeutic
technique in which clients are taught how to evaluate
and cope with various stressors and are then
exposed to ticreasingly stressful situations in a
controlled environment to strengthen these coping
mechanisms.
Behavioral therapy is a type of therapy that
attempts to change behaviors associated with
psychological distress.
Counterconditioning is a process that involves
replacing unwanted responses to particular situations
with new responses.
Exposure treatment is a type of opunterconditoning in which people who have a fear or phobia are
repeatedly exposed to what they fear over several
sessions until they become so accustomed to it that
they no longer fear it.
'61.1.11.1NE
retake it in summer school. I'll still graduate on
time. Failing one test is not going to destroy
my future job prospects."
Once the client understands how harmful
certain thought patterns can be, the therapist
and client work together to create clear-cut,
attainable goals as part of the treatment plan.
These goals might include completing homework assignments like keeping a diary or filling
out a form that describes troubling situations,
thoughts, and emotions. The client and therapist discuss and analyze the results of the
assignments in future sessions.
Sometimes, cognitive therapists encourage their clients to practice mindfulness
meditation, a technique based on Buddhist
teachings that emphasizes being fully present
in each moment. When clients are acutely
aware of their thoughts, feelings, and sensations, they can better detect symptoms before
those symptoms become problems.
According to psychologist Donald
Meichenbaum (1977, 1985), this awareness
can help people effectively self-edit their own
harmful thoughts in negative situations.
Meichenbaum called this stress inoculation
training. For example, a client struggling with
social anxiety may, at a party, begin to have
doubts and fears: "Everyone is looking at me
and judging me. They're wondering why I'm
even here." Mindfulness meditation and stress
inoculation training might allow the client to
recognize these anxious thoughts and change
them before they spiral out of control: "I feel
anxious, but there's no reason to. I feel like
people are judging me, but I realize that's
probably not really true. People are more
concerned with themselves than they are with
me. I'm going to let go of my anxiety and
enjoy the party."
Mindfulness meditation, most often associated
with Buddhist practices, has also found a place
in cognitive therapy. Clients may work on gaining
self-awareness through attending structured meditation sessions and paying close attention to their
everyday thoughts and actions.
A
A
A
Ultimately, cognitive therapists hope to
move from a teaching to a consulting role in
their clients' lives. Therapists hope that with the
techniques learned during the therapeutic
process, clients can achieve self-directed control of their problems and rely on the therapist
for guidance rather than treatment.
For Indiana Jones, receiving
exposure treatment
can spell trig soul
erious qu a lity t
with snakes.
BEHAVIORAL THERAPY
The other half of CBT, as well as a treatment
method in its own right, behavioral therapy
attempts to change behaviors associated with
psychological distress. This type of therapy has
two foundational assumptions:
• The behaviors associated with psychological
problems are not signs of a disorder or indications of an underlying issue; they are the
problems themselves.
•
Because these behaviors are learned,
through conditioning or modeling, they can
be "unlearned" through similar methods.
As a result of these assumptions, many of the
treatment plans that behavioral therapists prescribe involve training the mind and body to
react differently to various stimuli.
Counterconditioning is a process that
involves replacing unwanted responses to particular situations with new responses. For example, if a child is afraid of the dark, a behavioral
therapist might ask her to listen to her favorite
song while sitting in the dark. The song makes
the child feel happy and relaxed, and she begins
to associate darkness with happiness and relaxation rather than with fear. Ideally, the child will
eventually become completely habituated, or
familiarized, to darkness. (For more information
about conditioning and habituation, see
Chapters 13 and 8.)
Exposure Treatments
Exposure treatment, a specific type of counterconditioning, takes the mantra "Face your fear"
to a clinical level: Over several sessions, people
who have a fear or phobia are repeatedly
exposed to what they fear until they become so
accustomed to it that they no longer fear it
( Volpe, 1958; Wolpe & Plaud, 1997). For Indiana
Jones, receiving exposure treatment might mean
spending some serious quality time with snakes.
Systematic desensitization is a variation
of exposure treatment in which people, within a
therapeutic environment, learn to pair states of
deep relaxation with thoughts of anxietyprovoking situations. For example, a therapist
might begin a systematic desensitization treatment for a client who's terrified of enclosed
spaces by helping the client achieve a deeply
relaxed, almost drowsy state. Then, the therapist
might ask the person to engage in imaginative
exposure by imagining a series of increasingly
anxiety-inducing settings, from a large enclosed
room, to a smaller enclosed room, to a car, to an
elevator. The therapist would work with the client
to replace any anxiety evoked by each image
with relaxation, effectively "desensitizing" the
client to the stimulus. Eventually, clients practice
the desensitization by participating in real-life
situations—such as riding in an elevator—that
they previously feared and avoided.
For clients who have difficulty conjuring vivid
imagery in their heads, virtual reality exposure
provides a helpful alternative. Using computer
simulations, clients can learn to be increasingly
desensitized to anxiety-inducing situations, from
speaking in public to taking an airplane ride.
Systematic desensitization, whether through
imaginative exposure or virtual reality exposure,
has been shown to be an effective tool in the
treatment of phobias (Hazel, 2005; McNeil &
Zvolensky, 2000; Wang & Chen, 2000).
You might think of implosion therapy as
the "tough love" approach to exposure treatment. While systematic desensitization eases
clients gently into facing their phobias, implosion therapy does virtually the opposite: It
habituates clients by exposing them to very
intense stimuli. For example, a person afraid
of spiders might be asked to imagine having
hundreds of spiders crawling all over his
body; all of a sudden, that lone arachnid in
the bathroom sink doesn't seem so scary.
A technique called flooding takes implosion
therapy a step further, exposing the client
(with his or her permission) to the fear-inducing
stimulus in a direct, intense way. Someone
with an intense fear of dark underground
spaces, for instance, might experience
flooding in the form of spending several hours
in a subway station.
What if you could overcome your deepest
anxieties simply by moving your eyes? It sounds
too good to be true, but it's the premise of a
relatively new form of exposure therapy for
phobias and PTSD called eye movement
desensitization and reprocessing (EMDR).
EMDR therapists instruct clients to focus on a
disturbing image or traumatic memory as they
move their eyes back and forth. Studies conducted by psychologist Francine Shapiro (1989,
2002) have shown EMDR to be effective.
However, additional studies have shown that
clients tend to improve both with and without
eye movements (Cahill et al., 1999; Davidson &
Parker, 2001; Lohr et al., 1998). Skeptics suspect that the discussion of anxiety-provoking
thoughts in a nurturing therapeutic environment,
rather than the rapid eye movements, are
responsible for the success of EMDR.
Aversive Conditioning
Therapists often use behavioral therapies to treat
clients who have phobias, but what if phobias
aren't at the root of your problem? People who
struggle with alcoholism, for example, aren't
confronting a phobic behavior; they're facing an
addiction. In cases like these, therapists sometimes implement a treatment called aversive
conditioning. The goal of aversive conditioning
is to replace a positive response to a harmful
stimulus, such as alcohol, with a negative
response. For example, a therapist might pair a
drink or a cigarette with a nausea-inducing
chemical. When the client drinks or smokes, he
• • It
Systematic desensitization is a variation of
exposure treatment in which people, within a therapeutic environment, learn to pair states of deep relaxation with thoughts of anxiety-provoking situations,
with the goal of replacing the anxiety felt during these
situations with relaxation.
Implosion therapy is a type of exposure treatment in with dents are exposed to very intense
stimuli by being asked to imagine an extreme version
of their fears or phobias.
Flooding is a type of exposure treatment in which
chants are exposed to fear-inducing stimuli in an
intense way by directly exposing them to the stimuli.
Eye movement desensitization and
reprocessing (EMDR) is a form of exposure
therapy in which therapists instruct dents to focus on
a disturbing image or traumatic memory as they move
their eyes back and forth, \Oh the goal of helping
them deal with the psychological issues brought on
by the disturbing or traumatic event.
Aversive conditioning is a type of therapy in
which a harmful stimulus is paired with a negative
response, with the goal of replacing the usual positive response (such as the pleasure a client may
feel when drinking alcohol or smoking) with the
negative one.
Contingency management is an operant conditioning strategy that involves altering the relationship
between a person's actions and those actions' consequences to replace unwanted behaviors with
desirable ones.
or she becomes violently ill and begins to associate drinking or smoking with feelings of sickness.
Although aversive conditioning has been shown
to treat alcoholism effectively in the short run, its
long-term usefulness seems fairly limited (Wiens
& Menustik, 1983).
Operant Conditioning
Operant conditioning, or behavior shaping, forms
the basis of another category of behavior therapies. These therapies are centered on the idea
that rewards (or a lack thereof) strongly influence
our behavior. One strategy, contingency
management, involves altering the relationship
between a person's actions and those actions'
consequences to replace unwanted behaviors
with desirable ones. This type of technique can,
«< Therapists can use
virtual reality exposure
to treat people for their
phobias and anxieties
through a process of
desensitization.
--111-0— .
Token economy is a term for an operant conditioning procedure in which individuals earn tokens
when they exhibit desirable behavior; later, people
who've earned tokens can redeem them for privileges
Or treats.
Behavioral contract is an explicit agreement
that thoroughly explains the consequences of several
behaviors as well as expectations of the dent and
the therapist.
Social learning therapy is a type of therapy
designed to modify clients' problematic behavior patterns through observation and behavior reinforcement.
among other outcomes, successfully change the
behavior of withdrawn autistic children. For
example, parents saw great improvements in the
children's behavior and intellectual achievements
after they reinforced their children's
good behavior with attention and
rewards and punished or ignored
negative behaviors, such as hitting
or screaming (Lovaas, 1987). In
institutional settings, contingency
management is sometimes enacted
in token economies, an operant
conditioning procedure in which
individuals earn tokens when they
exhibit desirable behavior. Later,
E aluating
Ps chotherapies
Does talkin with a therapist really work? Does
it relieve psyc' ogical problems and help people achieve hap oier, healthier lives? And which
•
therapy is best— ychodynamic, humanistic,
cognitive, or behavioral? Are certain therapies
more useful for certai types of disorders, or
for certain types of peo. e? And what about
medications—where do t y fit in?
There's plenty of contro rsy and debate in
the world of psychology, and t field of treatment is no exception. Psycholog is don't all
agree as to whether any type of psychotherapy is
effective, and each type of psychoth apy has its
champions and skeptics. If you're wo ering
Other studies have confirmed these findings: In a meta-analysis of 475 investigations
into the efficacy of psychotherapy, Mary Lee
Smith and colleagues (1 980) concluded that
people who receive psychotherapy improve
more than about 80 percent of people we • do
not receive this treatment. Recent stud s have
yielded similar results, showing that i eneral,
most people who receive psychothe apy report
improvement, and that some ther. ay appears
to be better than no therapy at (Nathan &
Gorman, 2002; Shadish et al., '000; Kopta et
al., 1999). Additionally, a 199 study of 7,000
Consumer Reports subscr s found that the
longer people participate• in therapy, the more
they improved (Seligma , 1995).
It's important to • ep a few points in mind
in the context of the findings. In general, these
experiments are can ied out in research institu-
•
•
tions ith highly experienced, highly
train • d clinicians who are aware that
If yo u're wondering which type of therapy is
"bes t " however there's only one, safe answer:
Each client, each therapist, and each disorder
is different. As a result, the usefulness of any
therapy depends on the client, the therapist
and the nature of their relationship
people who've earned tokens can
redeem them for privileges or treats.
In behavioral therapy based on operant
conditioning, it's important for both the client
and the therapist to reach a clear understanding
about positive and negative behaviors and their
consequences, so a therapist might draw up a
behavioral contract, an explicit agreement that
thoroughly explains the consequences of several behaviors as well as expectations of the client
and the therapist.
Social Learning Therapy
Social learning therapy draws on the idea
that we learn to act the way that we do
through observing and modeling others'
behavior. Based on psychologist Albert
Bandura's research (see Chapter 7), social
learning therapy is designed to modify clients'
problematic behavior patterns through observation and behavior reinforcement. In a famous
study, Bandura and his colleagues helped people overcome their phobia of snakes by watching films in which others interacted comfortably
with snakes (Bandura, Blanchard, & Ritter,
which type of therapy is "best," however, there's
only one safe answer: Each client, each therapist
and each disorder is different. As a result, the
usefulness of any therapy depends on the clight,
the therapist, and the nature of their relationyhip.
THE EFFICACY OF
PSYCHOTHERAPY
Americans are turning to psychotherapy in
increasing numbers, but is this growing confidence in the value of therapy justified? Research
indicates that it is. In one classic study, psychologist R. B. Sloane and colleagues (1975) took a
group of participants witYgeneralized anxiety
and assigned them tofine of three groups: a
control group that received no psychotherapy, a
group that received psychodynamic psychotherapy, and a group that received behavioral
psychotherapy. After the participants were
double-blindly assessed both before and after
treatment (or no treatment in the control group),
Sloane found that although all groups improved,
th
are also being assessed. This,
many instances, leads to optimal
erapy conditions, which may or
may not be available to the average
person who seeks psychotherapy. In
addition, the clients recruited to participate in these experiments may be
a slightly biased group; their willingness to seek help may indicate an
already existing belief that it can,
and will, work.
It s been repeatedly shown that psychotherapy is effective for treating the conditions
for which people most commonly seek help-generalized anxiety and major depression.
Interestingly, however, research on the effectiveness of differenf4herapeutic techniques has not
discovered a single therapeutic strategy that is
uniquely effective in\treating all people with any
disorder. However, some therapies do tend to
treat certain disorders more effectively than others. For example, cognitive, interpersonal, and
behavior therapy have been shown to be most
effective in treating depression, while cognitive
and exposure therapy have proven useful in anxiety treatment. Behavioral therapy tends to be
effective for impulse-control disorders. For those
struggling with bulimia, CBT is perhaps the best
option (Chambless et al., 1997; Norcross, 2002).
FACTORS OF EFFECTIVE
PSYCHOTHERAPY
What makes psychotherapy an effective treatment? Its success can be attributed to a num ber
of identifiable factors (Frank, 1982; Goldfried
1969). Clients learn to perform desirable
behaviors by visualizing those behaviors and
the two treatment groups improved significantly
their consequences, and they receive positive
alth ugh the behavioral group improved slightly
Padawer, 1982; Strupp, 1986; Wampold, 2001).
reinforcement when they actually perform the
behaviors themselves.
re than the psychodynamic group, the
difference was insignificant.
Support. For people struggling with depression
:(0
more'than the control group did. Furthermore,
and self-doubt, psychotherapy can provide a