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Transcript
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