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CHAPTER 16
Treatment of Psychological Disorders
OUTLINE
I.
BASIC FEATURES OF TREATMENT
All methods of treatment share certain basic features, including a client or patient seeking relief
from problems; a person who is socially accepted as one who can help the client because of
training or experience; a special social relationship between client and therapist, which helps ease
the client’s problems; a theoretical explanation of those problems; and a set of procedures for
dealing with them.
Clients can be categorized as inpatients or outpatients. Psychiatrists are medical doctors who
specialize in the treatment of mental disorders and can prescribe medications. Psychologists who
do psychotherapy usually have a doctoral degree in clinical or counseling psychology, but only in
New Mexico and Louisiana can they prescribe drugs. The main goal of psychotherapists is to help
people change their thinking, feeling, and behavior so that they will be happier and more
productive.
II.
PSYCHODYNAMIC PSYCHOTHERAPY
Freud’s method of treatment, psychoanalysis, attempts to help the patient understand unconscious
conflicts and wishes and work through their implications for everyday life.
A.
Classical Psychoanalysis
Free association consists of asking a client to verbalize all thoughts, feelings, and memories
that come to mind. The content and pattern of associations contain clues to unconscious
material. In the interpretation of dreams, a patient reports the manifest content (the surface
story) of a dream and works to understand its latent content (the unconscious meaning), as
represented by the dream’s symbols. The psychoanalyst looks for evidence that the feelings,
reactions, and conflicts the client experiences toward others have been transferred onto the
therapist. Transference may help the client reenact and gain insight into old conflicts.
B.
Contemporary Variations on Psychoanalysis
Psychoanalysis requires much time, money, verbal skill, and abstract thinking ability; these
requirements limit its use. Variations on psychoanalytic treatments, such as ego analysis,
deemphasize the past and focus on helping the client use the ego to solve problems.
Object relations therapy is a contemporary psychodynamic approach to psychotherapy.
Therapists using this approach believe that personality and the arising conflicts that cause
problems stem from the need for supportive human relationships, such as the mother-child
bond. The therapist takes an active role in therapy and tries to establish a supportive and
nurturing relationship with the client so that she or he can experience what may have been
missed as an infant.
Other variations on psychoanalysis include psychoanalytically oriented psychotherapy and
time-limited dynamic psychotherapy.
III. HUMANISTIC PSYCHOTHERAPY
Humanistic psychologists believe that behavior is shaped by an innate drive toward growth that is
guided by an individual’s interpretation of the world. Humanistic treatment is based on the
following assumptions: Treatment is a human encounter between equals, not a cure; clients will
improve on their own, given the right conditions; an accepting and supportive relationship will
support clients’ growth; and clients must remain responsible for choosing how to feel and think.
A.
Client-Centered Therapy
Carl Rogers’s client-centered therapy, or person-centered therapy, is based on creating a
relationship characterized by unconditional positive regard or acceptance, empathy, and
congruence.
1.
B.
Unconditional Positive Regard. The therapist must show that he or she genuinely cares
about and accepts the client as a person and trusts the client’s ability to change.
2. Empathy. The therapist must appreciate how the world looks from the client’s point of
view. Empathy is communicated through a technique called reflection.
3. Congruence. The way the therapist feels is consistent with the way he or she acts
toward the client. The therapist’s unconditional positive regard and empathy are real,
not manufactured.
Gestalt Therapy
The goal of Frederick and Laura Perls’s Gestalt therapy is to help clients become more selfaware and self-accepting so that they can begin growing again in their own unique,
consciously guided directions. Gestalt therapists encourage clients to become aware of real
feelings that they have denied and to discard foreign feelings, ideas, and values. Therapists
are directive in helping clients focus on present, not past, feelings. Role play and imaginary
dialogues are two facets of this therapy.
IV. BEHAVIOR THERAPY
Therapists who use behavior therapies assume that problems are learned patterns of thinking and
behaving that can be changed without looking for the meanings behind them. Basic features of
behavioral treatment include the development of a good client-therapist relationship, a list of
behaviors and thoughts to be changed, a therapist who acts as a teacher by setting and
implementing specific treatment plans, and ongoing evaluation of the effects of therapy.
Treatments that utilize classical conditioning principles are referred to as behavior therapy; those
utilizing operant conditioning are called behavior modification. Therapies that focus on changing
thinking patterns as well as overt behavior are called cognitive-behavior therapy.
A.
Techniques for Modifying Behavior
1. Systematic Desensitization. During systematic desensitization, a client practices
progressive relaxation while imagining fear-provoking situations from an anxiety
hierarchy. The process of remaining calm while thinking about something feared
weakens the learned association between anxiety and the feared object or situation.
2. Exposure Techniques. A procedure called flooding extinguishes a classically
conditioned fear response by keeping a patient in a feared but harmless situation. As a
result, the client who is deprived of the normally rewarding escape pattern has no
reason for continued anxiety. Because flooding and similar methods continuously
expose the client to feared stimuli, they are called exposure techniques.
3. Modeling. Through participant modeling, a client can learn about or get comfortable
displaying desirable behaviors. The therapist demonstrates desirable behaviors, and the
client gradually practices them. The clients can learn to be more appropriately selfexpressive and more comfortable in social situations through assertiveness and social
skills training.
4. Positive Reinforcement. A therapist systematically uses positive reinforcement to alter
problematic behaviors. The receipt of rewards or tokens is dependent upon a client’s
display of desirable behaviors. In institutions, behavior therapists sometimes establish
a token economy.
5.
B.
Extinction, Punishment, and Aversion Conditioning. Extinction modifies behavior by
removing reinforcers that normally follow a particular response. Punishment eliminates
a dangerous or disruptive behavior by presenting an unpleasant stimulus after the
behavior, which reduces its occurrence. Aversion conditioning uses classical
conditioning to reduce undesirable behavior by associating it with some psychological
or physical discomfort.
Cognitive-Behavior Therapy
Cognitive-behavior therapy can help people change negative thoughts, which can induce
depression, anger, or anxiety.
1.
V.
Rational-Emotive Behavior Therapy. Rational-emotive behavior therapy (REBT) tries
to eliminate learned problem-causing thoughts. Cognitive restructuring and stress
inoculation training can teach a client new and calming thoughts to help her or him
cope with stressful or anxiety-provoking situations.
2. Beck’s Cognitive Therapy. Cognitive therapy rests on the assumption that a client has
cognitive distortions about the self and the world. Treatment involves demonstrating
the inaccuracy of these thoughts by testing them. Some cognitive therapists use
mindfulness-based cognitive therapy, which uses practices such as meditation to help
monitor problematic thoughts.
GROUP, FAMILY, AND COUPLES THERAPY
A. Group Therapy
Group therapy is the simultaneous treatment of several clients by one therapist. There is no
predominant theoretical approach to group therapy. Groups are organized around either one
type of problem or one type of client. Group therapy has several advantages: The therapist
can observe clients’ personal interactions; clients realize that they aren’t the only people
with a particular problem; clients support one another, which increases self-esteem; and
clients learn from one another. Some of these advantages are put to use in self-help
organizations.
B.
Family and Couples Therapy
Family therapy is based in part on the idea that a patient’s problems stem from early family
relationships and problems, and that problems are multifaceted and must be dealt with in the
family system in which they are maintained. In family therapy, the entire family is the
“client,” and the therapist attempts to create harmony within the family by facilitating each
member’s understanding of the family’s interactions and how they relate to problems.
Couples therapy focuses on communication between partners. Therapists and clients often
set “rules for talking” to improve communication skills.
VI. EVALUATING PSYCHOTHERAPY
A. Thinking Critically: Are All Forms of Therapy Equally Effective?
There is a push to gather empirical data about the effectiveness of various therapies.
What am I being asked to believe or accept?
That different forms of therapy are equally effective, independent of theoretical approach or
methods.
What evidence is available to support the assertion?
Meta-analyses combine the results of a large number of therapy studies and have shown
psychodynamic, humanistic, and behavioral therapies to be equally effective.
Are there alternative ways of interpreting the evidence?
Meta-analyses may be unable to detect the effect of different therapies for different
problems. Also, experimental methods and conclusions may not take into account the
personal qualities of psychotherapists practicing in the “real world” and how these may
interact with clients.
What additional evidence would help to evaluate the alternatives?
Research that focuses on which combinations of therapists, clients, and treatments produce
the most successful results still needs to be conducted.
What conclusions are most reasonable?
Caution should be used when drawing conclusions about the relative superiority of different
approaches to therapy.
B.
Focus on Research Methods: Which Therapies Work Best for Which Problems?
A task force examined the outcomes of thousands of experiments evaluating psychotherapy
methods used to treat different disorders. They found that certain therapies were identified as
effective for particular problems. These are called empirically-supported therapies (ESTs).
This study, however, focused on the therapeutic method only, rather than on the
characteristics and interaction of the therapists and clients, which could affect the therapy
outcome. Future research should include this facet in both laboratory and naturalistic studies.
C.
Choosing a Therapist
Although studies are still addressing which treatment, by whom, is most effective for
individuals with specific problems under specific circumstances, trends show that behavioral
and cognitive-behavioral methods show advantages, especially for anxiety disorders. The
client-therapist relationship, an “approach-free” factor, is extremely important in the success
of any therapy. When choosing a type of therapy, a person should give careful consideration
to what approach he or she finds appealing, the therapist’s “track record,” and the potential
for forming a productive client-therapist relationship.
D.
Cultural Factors in Psychotherapy
Cultural differences may lead a client and therapist to have different expectations and goals
about the outcome of therapy and the approach and methods used. Currently, psychologists
are working to align cultural influence and choice of a specific treatment. Also, mental
health training programs are trying to recruit more students from varying cultures, and
clinicians are being trained to recognize and understand cultural differences in verbal and
nonverbal communication.
E.
Rules and Rights in the Therapeutic Relationship
The ethical standards of the American Psychological Association forbid a sexual relationship
between therapist and client. A therapist must also hold whatever the client says in complete
confidentiality. Exceptions to this rule include situations in which the client’s current or
historical condition is used as part of a civil or criminal defense, the client is so severely
disturbed or suicidal that hospitalization is required, the therapist must defend against a
malpractice suit, the client reveals information about sexual or physical abuse of a child or
incapacitated adult, or the therapist believes that the client may commit a violent act against
another person.
Clients are also protected against being placed or kept in an institution unnecessarily. A
person threatened with commitment must have written notice, a chance to prepare a defense
with an attorney, a court hearing (with a jury if the client wishes), and the right to take the
Fifth Amendment. Furthermore, the prosecution must prove that the client is mentally ill and
poses a danger to himself or herself and others. Once in an institution, a client may refuse
certain treatments, and states are required to review every case periodically to determine if
the client should be released.
VII. BIOLOGICAL TREATMENTS
Biological treatments for psychological disorders have been in existence since the time of
Hippocrates. Methods used in the sixteenth through eighteenth centuries included laxative purges,
bleeding of “excess” blood, induced vomiting, cold baths, hunger, and other physical discomforts,
all of which were designed to shock the patient back to normality. Biological treatments have
advanced considerably since that time.
A.
Psychosurgery
Psychosurgical techniques, including prefrontal lobotomies, were once used to treat
problems involving strong emotional responses, such as schizophrenia, depression, anxiety,
aggressiveness, and obsessive-compulsive disorders. Today, psychosurgery is done only as a
last resort and involves the destruction of only a tiny amount of brain tissue.
B.
Electroconvulsive Therapy
Electroconvulsive therapy (ECT) was used in the 1940s and 1950s to treat schizophrenia,
depression, and sometimes mania. Today, ECT is used primarily to treat severe depression
in patients who don’t respond to psychoactive drugs and are at risk for suicide. ECT
procedures have changed; today, shock is applied to one hemisphere and patients are given a
deep muscle relaxant prior to treatment. Why ECT works is unclear. ECT is one of the most
controversial biological treatments.
C.
Psychoactive Drugs
Psychoactive drugs have largely replaced ECT and psychosurgery.
1.
D.
E.
Neuroleptics. Neuroleptic, or antipsychotic, drugs are effective in reducing delusions,
hallucinations, paranoid suspiciousness, and other severe forms of disturbed thought
and behavior. Phenothiazines and haloperidol are common neuroleptics that produce
improvement in 60–70 percent of patients. However, these drugs produce side effects
such as tardive dyskinesia and, in some cases, death. Clozapine, a new antipsychotic
drug, is equally effective and does not cause movement disorders.
2. Antidepressants. By increasing the amount of serotonin or norepinephrine available at
synapses, antidepressants such as monoamine oxidase inhibitors, tricyclic
antidepressants, and fluoxetine can produce a gradual lifting of depression, allowing
the person to return to normal life.
3. Lithium and Anticonvulsants. Lithium, although associated with severe side effects, is
helpful in reducing and even preventing both the depression and the mania associated
with the bipolar disorders. Anticonvulsants are becoming more popular in treating
mania.
4. Anxiolytics. Anxiolytics (originally called tranquilizers) are the most widely used of all
legal drugs. They relieve anxiety and tension. Some of them, however, are potentially
addictive and, when mixed with alcohol, can have fatal consequences.
5. Human Diversity and Drug Treatment. Drugs can have varying effects on different
ethnic groups and genders.
Evaluating Psychoactive Drug Treatments
Although drugs can at times be very useful in the treatment of mental disorders, enthusiasm
about drugs is not universal. At least three limitations apply: Drugs may cover up the
problem without permanently curing it; drugs carry the potential for abuse, resulting in
physical or psychological dependence; and many drugs have undesirable side effects.
Drugs and Psychotherapy
It is unclear which is more effective in treating psychological disorders: drugs or
psychotherapy. It has been suggested that, where indicated, treatment begin with some form
of psychotherapy and that drug treatments be added only if psychotherapy is ineffective.
F.
Linkages: Biological Aspects of Psychology and the Treatment of Psychological Disorders
Therapeutic drugs alter neurotransmitter activity by enhancing or inhibiting the binding of
neurotransmitters to receptors; acting as receptor antagonists by blocking neurotransmitters’
receptor sites and, as a result, inhibiting action potential activity; or increasing the amount of
neurotransmitter available at the synapse by stimulating neurotransmitter production or
blocking reuptake.
VIII. COMMUNITY PSYCHOLOGY: FROM TREATMENT TO PREVENTION
Community psychology is a movement that attempts to increase early detection of problems and
minimize or prevent mental disorders by making social and environmental changes.