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chap 15

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Psychology 2035A/B
Doug Hazlewood

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229 CHAPTER 15 PSYCHOTHERAPY LEARNING OBJECTIVES The Elements of the Treatment Process (APA Goal 4) • Identify the three major categories of therapy. • Discuss why people do or do not seek psychotherapy. • Describe the various types of mental health professionals involved in the provision of therapy. Insight Therapies (APA Goals 1, 3, 4) • Understand the logic of psychoanalysis, and describe the techniques used to probe the unconscious. • Discuss interpretation, resistance, and transference in psychoanalysis. • Describe therapeutic climate and process in client-centered therapy. • Describe how group therapy is generally conducted. • Summarize evidence on the efficacy of insight therapies. • Clarify the role of common factors in insight therapy. • Review both sides of the recovered memories controversy. Behavior Therapies (APA Goals 1, 4) • Summarize the general approach and principles of behavior therapies. • Identify the three steps in systematic desensitization and the logic underlying the treatment. • Describe the use of aversion therapy and social skills training. • Discuss the logic, goals, and techniques of cognitive therapy. • Summarize evidence on the efficacy of behavior therapies. Biomedical Therapies (APA Goals 1, 4) • Describe the principal drug therapies used in the treatment of psychological disorders, and summarize evidence regarding their efficacy. • Discuss some of the problems associated with drug therapies and drug research. • Describe ECT and discuss its efficacy and risks. Current Trends and Issues in Treatment (APA Goals 4, 8) • Discuss how managed care has affected the provision of therapy. • Discuss the merits of blending approaches to therapy and the rise of eclecticism. • Explain why therapy is underutilized by ethnic minorities. Application: Looking for a Therapist (APA Goal 9) • Discuss where to seek therapy. • Evaluate the potential importance of a therapist’s gender and professional background. • Summarize the evidence on whether therapists’ theoretical approaches influence their effectiveness. • Discuss what one should expect from therapy. 230 CHAPTER 15 CHAPTER OUTLINE I. The Elements of the Treatment Process A. Treatments: How many types are there? 1. Types and approaches are numerous, varied, there may be over 400 types 2. Three major categories a. Insight therapies, or "talk therapy," in tradition of Freud’s psychoanalysis b. Behavior therapies, based on principles of learning and conditioning c. Biomedical therapies, which focus on biological interventions B. Clients: Who seeks therapy? 1. Great diversity among clients 2. Nature and severity of trouble varies from individual to individual a. Most common problems are anxiety, depression b. People often delay for years before seeking treatment 3. Client in treatment does not necessarily have an identifiable psychological disorder 4. People vary in willingness to seek treatment a. Women more likely to seek treatment than men b. Treatment more likely for those who have medical insurance, college education 5. Many people who need therapy don't receive it C. Therapists: who provides professional treatment? 1. Psychologists a. Clinical psychologists and counseling psychologists specialize in the diagnosis and treatment of psychological disorders and everyday behavioral problems 1) Much overlap in training, skills, clients 2) Both must earn doctoral degree b. Use either insight or behavioral approaches 2. Psychiatrists are physicians who specialize in the treatment of psychological disorders a. Devote more time to relatively severe disorders (e.g., schizophrenia) b. Have M.D. degree with psychotherapy training in residency c. Tend to emphasize drug therapies 3. Other mental health professionals a. Psychiatric social workers, psychiatric nurses often work as part of treatment team with psychologist or psychiatrist b. Counselors also provide therapeutic services II. Insight Therapies involve verbal interactions intended to enhance clients' self-knowledge and thus promote healthful changes in personality and behavior A. Psychoanalysis 1. Psychoanalysis is an insight therapy that emphasizes the recovery of unconscious conflicts, motives, and defenses through techniques such as free association, dream analysis, and transference 2. Developed by Sigmund Freud: neurotic problems are caused by unconscious conflicts 3. Dominance has eroded in recent decades, but diverse array of psychoanalytic approaches continue to remain influential 231 4. Probing the unconscious a. Free association: clients spontaneously express their thoughts and feelings exactly as they occur, with as little censorship as possible b. Dream analysis: the therapist interprets the symbolic meaning of the client's dreams 5. Interpretation involves the therapist's attempt to explain the inner significance of the client's thoughts, feelings, memories, and behaviors a. Contrary to popular belief, analysts don’t try to interpret everything b. Therapists generally move forward very slowly 6. Resistance involves largely unconscious defensive maneuvers intended to hinder the progress of therapy a. Occurs because clients are reluctant to confront their problems b. May take a variety of forms 7. Transference occurs when clients start relating to their therapist in ways that mimic critical relationships in their lives a. In a sense, clients transfer conflicting feeling about important people onto therapist b. Psychoanalysts often encourage transference as a way to bring repressed feelings, conflicts to the surface 8. Understanding psychoanalysis a. Undergoing psychoanalysis can be slow, painful process of self-examination b. Classical psychoanalysis, as done by Freud, is not widely practiced anymore c. Variations are collectively known as psychodynamic approaches B. Client-centered therapy is an insight therapy that emphasizes providing a supportive emotional climate for clients, who play a major role in determining the pace and direction of their therapy 1. Stimulated by work of Carl Rogers, who took a humanistic perspective 2. Therapeutic climate a. Climate is more important than process b. Therapist must provide three conditions 1) Genuineness: honest and spontaneous 2) Unconditional positive regard: complete nonjudgmental acceptance 3) Empathy: understand the client’s point of view 3. Therapeutic process a. Client and therapist work together as equals b. Therapist's key role is clarification of client's true feelings C. Therapies inspired by positive psychology 1. Positive psychology uses theory and research to better understand the positive, adaptive, creative, and fulfilling aspects of human existence 2. Positive psychotherapy attempts to get clients to recognize their strengths, appreciate their blessings, savor positive experiences, forgive those who have wronged them, and to find meaning in their lives D. Group therapy is the simultaneous treatment of several or more clients in a group 1. Most major insight therapies have been adapted for use in groups 2. Group therapy can be conducted in a variety of ways 3. Participants' roles a. A group typically consists of 4-12 people, with 6-8 regarded as ideal 232 CHAPTER 15 b. Therapist usually screens participants, excluding potentially disruptive people c. Clients and therapist are on much more equal footing with groups than with individual therapy d. Clients function as therapists for each other 4. Advantages of the group experience a. Participants often realize that their misery is not unique b. Provides opportunities for clients to work on social skills in safe environment c. Certain kinds of problems especially well suited to group treatment (e.g., drug groups, single parents, former psychiatric patients) E. Evaluating insight therapies 1. Evaluating the effectiveness of any treatment is a complex challenge a. Clients’ ratings are likely to be slanted favorably in order to justify effort, expense, and time b. Allegiance effect involves researchers comparing different theories to obtain results that favor the therapeutic approach they champion 2. Generally, research indicates that insight therapy is superior to no treatment or to placebo treatment 3. There is vigorous debate about the mechanisms of action underlying the positive effects of therapy 4. Common denominators connecting diverse therapies a. Development of therapeutic alliance b. Emotional support and empathy from therapist c. Cultivation of hope and positive expectations d. Provision of rationale for problems and course of solution e. Opportunity to express feelings, confront problems, gain insight, learn new patterns of behavior F. Therapy and the recovered memories controversy 1. Spurred by recent spate of reports involving recovery of repressed memories of sexual abuse, other childhood trauma 2. Critical aspect is that there is no way to corroborate allegations of abuse 3. Some psychologists accept repressed memories at face value 4. Others suggest that persuasive therapists may have influenced clients a. Suggestible, confused, and struggling clients have been convinced by persuasive therapists that their emotional problems must be the result of abuse b. Therapists inadvertently create the memories of abuse that they assume exist when they are 1) Overly prone to see signs of abuse where none has occurred 2) Unsophisticated about the extent to which memories can be distorted 3) Naive about how much their expectations and beliefs can influence their patients c. Case studies and controlled laboratory research demonstrate the possibility of created false memories 5. General conclusion that therapists can unknowingly create false memories in their patients and that a significant portion of recovered memories of abuse are the product of suggestion, but some cases of recovered memories are authentic III. Behavior Therapies involve the application of the principles of learning to direct efforts to change clients' maladaptive behaviors 233 A. Introduction 1. Behaviorism has been influential since 1920s 2. Application of behaviorism to therapy began in 1950s B. General principles 1. Assumed that behavior is a product of learning 2. Assumed that what has been learned can be unlearned 3. Behavior therapies are close cousins of self-modification procedures (described in Chapter 4 Application) C. Systematic desensitization is a behavior therapy used to reduce clients' anxiety responses through counterconditioning 1. Devised by Joseph Wolpe 2. Involves three steps a. Therapist helps client build an anxiety hierarchy b. Therapist trains client in deep muscle relaxation c. Client tries to work through hierarchy, learning to remain relaxed while imagining each stimulus 3. Desensitization to imagined stimuli generally followed by exposure to real anxiety- arousing stimuli 4. Goal is to countercondition new response (relaxation) to original stimulus (object of anxiety) 5. Has been effective in eliminating specific anxieties D. Aversion therapy is a behavior therapy in which an aversive stimulus is paired with a stimulus that elicits an undesirable response 1. Most controversial of behavior therapies a. Psychologists usually suggest it only as treatment of last resort b. Client has to endure unpleasant stimuli (e.g., shock, drug-induced nausea) 2. Behaviors treated successfully include drug abuse, sexual deviance, gambling, etc. E. Social skills training is a behavior therapy designed to improve interpersonal skills; emphasizes shaping, modeling, and behavioral rehearsal 1. Many psychological problems grow out of interpersonal difficulties 2. Has yielded promising results in treatment of social anxiety, autism, attention deficit disorder, and schizophrenia 3. Can be conducted with individual clients or in groups 4. Depends on principles of operant conditioning, observational learning a. Modeling, such as encouraging clients to watch socially skilled friends, colleagues b. In behavioral rehearsal, client practices social techniques in role-playing exercises c. Shaping is used by having clients gradually handle more complicated and delicate social situations F. Cognitive-behavioral treatments employ varied combinations of verbal interventions and behavior modification techniques to help clients change maladaptive patterns of thinking 234 CHAPTER 15 1. Treatments include Ellis' rational emotive behavior therapy, Beck’s cognitive therapy from the insight therapy tradition, as well as others from the behavioral tradition 2. Ellis' rational-emotive behavior therapy is detailed in Chapter 4 3. Cognitive therapy employs specific strategies to correct habitual thinking errors that underlie various types of disorders, 4. Cognitive therapists assert that depression-prone individuals a. Blame their setbacks on personal inadequacies without considering circumstantial explanations b. Focus selectively on negative events while ignoring positive events c. Make unduly pessimistic projections about the future d. Draw negative conclusions about their worth as a person 5. Goal of cognitive therapy is to change clients’ negative thoughts and maladaptive beliefs a. Clients learn to detect their automatic negative thoughts b. Clients then learn to subject these automatic thoughts to reality testing 6. Cognitive therapy uses a variety of behavioral techniques, such as modeling, systematic monitoring of one’s behavior, and behavioral rehearsal, as well as "homework" G. Evaluating behavior therapies 1. Ample evidence regarding effectiveness a. Behavior therapists have historically placed more emphasis than insight therapists on importance of measuring outcomes b. May be slightly better than insight therapy for certain kinds of disorders 2. Not well suited for treatment of certain kinds of problems (e.g., vague feelings of discontent) 3. Seem to be particularly effective in treatment of anxiety problems, phobias, sexual dysfunction, drug-related problems, eating disorders, hyperactivity, autism, and mental retardation IV. Biomedical Therapies are physiological interventions intended to reduce symptoms associated with psychological disorders A. Introduction 1. Assume that psychological disorders are caused, at least in part, by biological malfunctions 2. Assumption seems to have merit, particularly when applied to more severe disorders B. Treatment with drugs 1. Psychopharmacotherapy involves the treatment of mental disorders with medication 2. Therapeutic drugs fall into three major categories a. Antianxiety drugs relieve tension, apprehension, and nervousness 1) Most popular are Valium, Xanax from benzodiazepine family 2) Routinely prescribed for people with anxiety disorders 3) Exert effects almost immediately; fairly effective but short-lived 4) Some potential for abuse, dependency, overdose problems, withdrawal symptoms 5) A newer drug, Buspar, is used for generalized anxiety disorder; is not of the benzodiazepine family 235 b. Antipsychotic drugs are used to gradually reduce psychotic symptoms, including hyperactivity, mental confusion, hallucinations, and delusions 1) Used primarily in treatment of schizophrenia 2) Most popular are Thorazine, Mellaril, Haldol 3) Reduce psychotic symptoms in varied degrees of responsiveness 4) Some problems associated with use a) Side effects include drowsiness, constipation, cotton mouth b) Tardive dyskinesia (a neurological disorder marked by chronic tremors and involuntary spastic movements) sometimes caused by antipsychotics 5) Psychiatrists currently experimenting with new class of antipsychotics, called atypical antipsychotic drugs a) Seem to produce fewer side effects than traditional antipsychotics b) Appear to help a significant proportion of patients who do not respond to conventional antipsychotic medications c. Antidepressant drugs gradually elevate mood and help bring people out of a depression 1) Early types were tricyclics (e.g., Elavil) and MAO inhibitors (e.g., Nardil) 2) Exert effects gradually, over a period of weeks 3) Psychiatrists today are more likely to prescribe newer class of antidepressants, called selective serotonin reuptake inhibitors (e.g., Prozac, Paxil, Zoloft) a) SSRIs are proven valuable in the treatment of anxiety disorders b) A major concern in recent years has been that SSRIs may increase suicide risk; data is not conclusive 4) The newest class of antidepressants consists of medications that inhibit reuptake at both serotonin and norepinephrine synapses (SNRIs) 3. Mood stabilizers are drugs used to control mood swings in patients with bipolar mood disorders a. Drugs can prevent future episodes of mania, depression b. For years, lithium was the only effective drug in this category but has dangerous side effects c. Recently alternatives to lithium have been developed (e.g., valproate) 4. Evaluating drug therapies a. Can produce clear gains for many kinds of patients b. Critics have raised number of issues 1) Often produce superficial curative effects 2) Many drugs are overprescribed, patients overmedicated 3) Side effects of some drugs are worse than illnesses 4) Research funded by drug companies may result in conflict of interest, biased research C. Electroconvulsive therapy (ECT) is a biomedical treatment in which electric shock is used to produce a cortical seizure accompanied by convulsions 1. Clinical use peaked in 1940s and 1950s, before effective drug therapies were widely available a. Use declined in 1970s and 1980s b. Not a rare form of treatment, about 100,000 in U.S. still receive ECT each year 2. Controversy about ECT a. Critics argue that ECT is overused because it boosts doctor's income b. Advocates argue that ECT is underused because of misconceptions 236 CHAPTER 15 3. Effectiveness of ECT a. Evidence open to varied interpretations b. Enough favorable evidence seems to exist to justify conservative use of ECT in treating severe mood disorders in patients who have not responded to medication c. Relapse rates are high 4. Risks associated with ECT a. Memory loss, impaired attention, other cognitive deficits b. Debate over whether impairments are temporary or permanent V. Current Trends and Issues in Treatment A. Grappling with the constraints of managed care 1. In managed care systems, people enroll in prepaid plans run by health maintenance organizations (HMOs), which agree to provide ongoing healthcare 2. Managed care usually involves a trade-off: lower prices but limited care options 3. Critics charge that HMOs limit access to medically necessary services, especially impacting mental health care a. Underdiagnosing conditions b. Failing to make mental health referrals c. Arbitrary limits on treatment length d. Barriers to access B. Blending approaches to treatment 1. No rule that a client must be treated with just one approach 2. Often a clinician will use several techniques 3. Studies show combining techniques has merit 4. Eclecticism in the practice of therapy involves drawing ideas from two or more systems of therapy, instead of committing to just one system C. Increasing multicultural sensitivity in treatment 1. Underutilization of mental health services by minority group members can be a result of barriers, including a. Cultural barriers b. Language barriers c. Institutional barriers 2. What can be done to improve mental health services for American minority groups? a. Need to recruit and train more ethnic minority therapists b. Cultural sensitivity training program for therapists c. Investigation of how traditional approaches to therapy can be modified and tailored to be more congruent with attitudes, values, norms, and traditions VI. Application: Looking for a Therapist A. Where do you find therapeutic services? 1. Can be found in variety of settings a. Contrary to popular belief, most therapists are not in private practice b. Many therapists work in institutional settings
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