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Chapter 15

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Wilfrid Laurier University
Mamdouh Shoukri

Lesson 15 1) The elements of the treatment process a. Treatments: how many types are there: three major categories i. Josef Breuer (1880) inspired Freud. ii. Insight therapies: ―talk therapy‖ in the tradition of Freud’s psychoanalysis. In insight therapies, clients engage in complex verbal interactions with their therapists. The goal in these discussions is to pursue increased insight regarding the nature of the client’s difficulties and to sort through possible solutions. Insight therapy can be conducted with an individual or with a group. Broadly speaking, family therapy and marital therapy fall in this category. iii. Behavior therapies: based on the principles of learning. Instead of emphasizing personal insights, behavior therapists make direct efforts to alter problematic responses (phobias, for instance) and maladaptive habits (drug use, for instance). Behavior therapists work on changing clients’ overt behaviors. They use different procedures for different kinds of problems. Most of their procedures involve classical conditioning, operant conditioning, or observational learning. iv. Biomedical therapies: Biomedical approaches to therapy involve interventions into a person’s biological functioning. The most widely used procedures are drug therapy and electroconvulsive (shock) therapy. As the term biomedical suggests, these treatments have traditionally been provided only by physicians with a medical degree (usually psychiatrists). This situation is changing, however, as psychologists have been campaigning for prescription privileges. To date, psychologists have obtained prescription authority in two states (New Mexico and Louisiana), and they have made legislative progress toward this goal in many other states. Although some psychologists have argued against pursuing the right to prescribe medication, the movement is gathering momentum and seems likely to prevail. b. Clients: who seeks therapy? i. In the therapeutic triad (therapists, treatments, clients), the greatest diversity is seen among the clients. ii. According to the 1999 Surgeon General’s report on mental health (U.S. Department of Health and Human Services, 1999) about 15% of the U.S. population use mental health services in a given year. These people bring to therapy the full range of human problems. iii. The two most common presenting problems are excessive anxiety and depression iv. One recent large-scale study found that the median delay in seeking treatment was 6 years for bipolar disorder and for drug dependence, 8 years for depression, 9 years for generalized anxiety disorder, and 10 years for panic disorder! v. Treatment seeking for various disorders: 1. Bipolar disorders: nearly 38% 2. Major depression: 37% 3. Panic disorder 34% 4. Generalized anxiety disorder: 33% 5. Drug dependence: 26% 6. Alcohol dependence: 21% 7. Posttraumatic stress disorder: 8% 8. Phobic disorder: 2% vi. A client in treatment does not necessarily have an identifiable psychological disorder. Some people seek professional help for everyday problems or vague feelings of discontent. Only about half of the people who use mental health services in a given year meet the criteria for a full-fledged mental disorder vii. One study found that even among people who perceive a need for professional assistance, only 59% actually seek professional help viii. Women are more likely than men to receive therapy. Treatment is also more likely when people have medical insurance and when they have more education. ix. Unfortunately, it appears that many people who need therapy don’t receive it 1. Lack of health insurance 2. Cost concern x. Therapy utilization rates: 1. Age: most: 35-44 least: 65 and over 2. Race: white 3. Sex: female 4. Education: 17 years and over 5. Marital status: divorced/separated c. Therapists: who provides professional treatment? i. Therapy refers to professional treatment by someone with special training. However, a common source of confusion about psychotherapy is the variety of ―helping professions‖ available to offer assistance ii. Psychologists: two types 1. Clinical psychologists and counseling psychologists specialize in the diagnosis and treatment of psychological disorders and everyday behavioral problems. 2. Clinical psychologists’ training emphasizes the treatment of full-fledged disorders. 3. Counseling psychologists’ training is slanted toward the treatment of everyday adjustment problems. 4. In practice, however, quite a bit of overlap occurs between clinical and counseling psychologists in training, skills, and the clientele that they serve. 5. Both types of psychologists must earn a doctoral degree (Ph.D., Psy.D., or Ed.D.). A doctorate in psychology requires about five to seven years of training beyond a bachelor’s degree. 6. Psychologists receive most of their training in universities or independent professional schools. They then serve a one-year internship in a clinical setting, such as a hospital, usually followed by one or two years of postdoctoral fellowship training. 7. In providing therapy, psychologists use either insight or behavioral approaches. 8. In comparison to psychiatrists, they are more likely to use behavioral techniques and less likely to use psychoanalytic methods. Clinical and counseling psychologists do psychological testing as well as psychotherapy, and many also conduct research. iii. Psychiatrists 1. Psychiatrists are physicians who specialize in the diagnosis and treatment of psychological disorders. Many psychiatrists also treat everyday behavioral problems. 2. Psychiatrists devote more time to relatively severe disorders (schizophrenia, mood disorders) and less time to everyday marital, family, job, and school problems. 3. Psychiatrists have an M.D. degree. Their graduate training requires four years of coursework in medical school and a four- year apprenticeship in a residency at a hospital. Their psychotherapy training occurs during their residency, since the required coursework in medical school is essentially the same for everyone, whether they are going into surgery, pediatrics, or psychiatry. 4. In their provision of therapy, psychiatrists increasingly emphasize drug therapies. 5. In comparison to psychologists, psychiatrists are more likely to use psychoanalysis and less likely to use group therapies or behavior therapies. That said, contemporary psychiatrists primarily depend on medication as their principal mode of treatment. iv. Other mental health professionals 1. Clinical social workers and psychiatric nurses often work as part of a treatment team with a psychologist or psychiatrist. 2. Psychiatric nurses, who may have a bachelor’s or master’s degree in their field, play a large role in hospital inpatient treatment. 3. Clinical social workers generally have a master’s degree and typically work with patients and their families to ease the patient’s integration back into the community. 4. Counselors are usually found working in schools, colleges, and assorted human service agencies. Counselors typically have a master’s degree. They often specialize in particular types of problems. 2) Insight therapies a. Psychoanalysis i. Insight therapies involve verbal interactions intended to enhance clients’ self-knowledge and thus promote healthful changes in personality and behavior. ii. Psychoanalysis is an insight therapy that emphasizes the recovery of unconscious conflicts, motives, and defenses through techniques such as free association and transference. iii. Freud mostly treated anxiety-dominated disturbances, such as phobic, panic, obsessive-compulsive, and conversion disorders, which were then called neuroses. iv. Freud believed that neurotic problems are caused by unconscious conflicts left over from early childhood. v. He thought that these inner conflicts involve battles among the id, ego, and superego, usually over sexual and aggressive impulses. He theorized that people depend on defense mechanisms to avoid confronting these conflicts, which remain hidden in the depths of the unconscious vi. However, he noted that defensive maneuvers often lead to self- defeating behavior. Furthermore, he asserted that defenses tend to be only partially successful in alleviating anxiety, guilt, and other distressing emotions. vii. Probing the unconscious 1. The analyst functions as a ―psychological detective.‖ 2. In this effort to explore the unconscious, the therapist relies on two techniques: free association and dream analysis. a. In free association clients spontaneously express their thoughts and feelings exactly as they occur, with as little censorship as possible. In free associating, clients expound on anything that comes to mind, regardless of how trivial, silly, or embarrassing it might be. Gradually, most clients begin to let everything pour out without conscious censorship. The analyst studies these free associations for clues about what is going on in the client’s unconscious. b. In dream analysis the therapist interprets the symbolic meaning of the client’s dreams. Freud saw dreams as the ―royal road to the unconscious,‖ the most direct means of access to patients’ innermost conflicts, wishes, and impulses. Clients are encouraged and trained to remember their dreams, which they describe in therapy. The therapist then analyzes the symbolism in these dreams to interpret their meaning. viii. Interpretation 1. Interpretation refers to the therapist’s attempts to explain the inner significance of the client’s thoughts, feelings, memories, and behaviors. 2. Contrary to popular belief, analysts do not interpret everything, and they generally don’t try to dazzle clients with startling revelations. Instead, analysts move forward inch by inch, offering interpretations that should be just out of the client’s own reach. ix. Resistance 1. Resistance refers to largely unconscious defensive maneuvers intended to hinder the progress of therapy. 2. Resistance can take many forms. Clients may show up late for their sessions, may merely pretend to en- gage in free association, or may express hostility to- ward their therapist. x. Transference 1. Transference occurs when clients unconsciously start relating to their therapist in ways that mimic critical relationships in their lives. 2. In a sense, the client transfers conflicting feelings about important people onto the therapist. 3. These reenactments can help bring repressed feelings and conflicts to the surface, allowing the client to work through them. The therapist’s handling of transference is complicated and difficult, because transference may arouse confusing, highly charged emotions in the client. 4. According to Freud, once clients recognize the unconscious sources of conflicts, they can resolve these conflicts and discard their neurotic defenses. xi. Modern psychodynamic therapies 1. Though still available, classical psychoanalysis as done by Freud is not widely practiced anymore 2. These descendants of psychoanalysis, which continue to emphasize exploration of the unconscious, are collectively known as psychodynamic approaches to therapy. 3. Some of these adaptations, such as those made by Carl Jung (1917) and Alfred Adler (1927), were sweeping revisions based on fundamental differences in theory. Other variations, such as those devised by Melanie Klein (1948) and Heinz Kohut (1971), made substantial changes in theory while retaining certain central ideas. b. Client-centered therapy i. These now-popular phrases emerged out of the human potential movement, which was stimulated in part by the work of Carl Rogers (1951, 1986). Using a humanistic perspective, Rogers devised client- centered therapy (also known as person-centered therapy) in the 1940s and 1950s. ii. 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. iii. Rogers maintains that most personal distress is due to inconsistency, or ―incongruence,‖ between a person’s self-concept and reality iv. Excessive incongruence is thought to be rooted in clients’ overdependence on others for approval and acceptance. v. Client-centered therapists help clients to realize that they do not have to worry constantly about pleasing others and winning acceptance. They encourage clients to respect their own feelings and values. They help people restructure their self-concept to correspond better to reality. Ultimately, they try to foster self-acceptance and personal growth. vi. Therapeutic climate 1. The lack of threat should reduce clients’ defensive tendencies and thus help them open up. To create this atmosphere of emotional support, client-centered therapists must provide three conditions: a. Genuineness. The therapist must be genuine with the client, communicating honestly and spontaneously. The therapist should not be phony or defensive. b. Unconditional positive regard. The therapist must also show complete, nonjudgmental acceptance of the client as a person. The therapist should provide warmth and caring for the client, with no strings attached. This does not mean that the therapist must approve of everything that the client says or does. A therapist can disapprove of a particular behavior while continuing to value the client as a human being. c. Empathy. Finally, the therapist must provide accurate empathy for the client. This means that the therapist must understand the client’s world from the client’s point of view. Furthermore, the therapist must be articulate enough to communicate this understanding to the client. vii. Therapeutic process 1. In client-centered therapy, the client and therapist work together as equals. The therapist provides relatively little guidance and keeps interpretation and advice to a minimum. 2. The therapist provides feedback to help clients sort out their feelings. The therapist’s key task is clarification. 3. Client-centered therapists try to function like a human mirror, reflecting statements back to their clients, but with enhanced clarity. They help clients become more aware of their true feelings by highlighting themes that may be obscure in the clients’ rambling discourse. 4. By working with clients to clarify their feelings, client-centered therapists hope to gradually build toward more far-reaching insights. In particular, they try to help clients better understand their interpersonal relationships and become more comfortable with their genuine selves. Obviously, these are ambitious goals. Client-centered therapy resembles psychoanalysis in that both seek to achieve a major reconstruction of a client’s personality. c. Group therapy i. Group therapy came of age during World War II and its aftermath in the 1950s ii. Group therapy is the simultaneous psychological treatment of several clients in a group. iii. In fact, the ideas underlying Rogers’s client-centered therapy spawned the much-publicized encounter group movement. iv. Although group therapy can be conducted in a variety of ways, we can provide a general overview of the process as it usually unfolds with outpatient populations v. Participants’ roles 1. A therapy group typically consists of 4–12 people, with 6–8 participants regarded as an ideal number. The therapist usually screens the participants, excluding persons who seem likely to be disruptive. Some theorists maintain that judicious selection of participants is crucial to effective group treatment. There is some debate about whether it is best for the group to be homogeneous—made up of people who are similar in age, sex, and psychological problem. Practical necessities usually dictate that groups are at least somewhat diversified. 2. In group therapy, participants essentially function as therapists for one another. Group members describe their problems, trade viewpoints, share experiences, and discuss coping strategies. Most important, they provide acceptance and emotional support for each other. In this supportive atmosphere, group members work at peeling away the social masks that cover their insecurities. Once their problems are exposed, members work at correcting them. As members come to value one another’s opinions, they work hard to display healthy changes to win the group’s approval. 3. In group treatment, the therapist’s responsibilities include selecting participants, setting goals for the group, initiating and maintaining the therapeutic process, and protecting clients from harm. The therapist often plays a relatively subtle role in group therapy, staying in the background and focusing mainly on promoting group cohesiveness (although this strategy will vary depending on the nature of the group). The therapist models supportive behaviors for the participants and tries to promote a healthy climate. He or she always retains a special status, but the therapist and clients are usually on much more equal footing in group therapy than in individual therapy. The leader in group therapy expresses emotions, shares feelings, and copes with challenges from group members. vi. Advantages of the group experience 1. Group therapies obviously save time and money, which can be critical in understaffed mental hospitals and other institutional settings 2. For many types of patients and problems, group therapy can be just as effective as individual treatment 3. In group therapy participants often come to realize that their misery is not unique. They are reassured to learn that many other people have similar or even worse problems. 4. Group therapy provides an opportunity for participants to work on their social skills in a safe environment. d. How effective are insight therapies? i. A spontaneous remission is a recovery from a disorder that occurs without formal treatment. Thus, if a client experiences a recovery after treatment, one cannot automatically assume that the recovery was due to the treatment ii. Various schools of thought pursue entirely different goals. And clients’ ratings of their progress are likely to be slanted toward a favorable evaluation because they want to justify their effort, their heartache, their expense, and their time. Even evaluations by professional therapists can be highly subjective iii. People enter therapy with diverse problems of varied severity, creating huge confounds in efforts to assess the effectiveness of therapeutic interventions. iv. Insight therapy is superior to no treatment or to placebo treatment and that the effects of therapy are reasonably durable. (psychological test) v. Studies generally find the greatest improvement early in treatment (the first 13–18 weekly sessions), with further gains gradually diminishing in size over time vi. Overall, about 50% of patients show a clinically meaningful recovery within about 20 sessions, and another 20% of patients achieve this goal after about 45 sessions e. How do insight therapies work? i. An alternative view espoused by many theorists is that the diverse approaches to therapy share certain common factors and that these common factors account for much of the improvement experienced by clients ii. Common denominators that lie at the core of diverse approaches to therapy: 1. The development of a therapeutic alliance with a professional helper 2. The provision of emotional support and empathic understanding by the therapist 3. The cultivation of hope and positive expectations in the client 4. The provision of a rationale for the client’s problems and a plausible method for reducing them 5. The opportunity to express feelings, confront problems, gain new insights, and learn new patterns of behavior iii. Some theorists argue that common factors ac- count for virtually all of the progress that clients make in therapy 3) Behavior therapies a. Behavior therapy is different from insight therapy in that behavior therapists make no attempt to help clients achieve grand insights about themselves. Behavior therapists believe that such insights aren’t necessary to produce constructive change. b. The crux of the difference between insight therapy and behavior therapy is this: i. Insight therapists treat pathological symptoms as signs of an underlying problem ii. Whereas behavior therapists think that the symptoms are the problem. Thus, behavior therapies involve the application of learning principles to direct efforts to change clients’ maladaptive behaviors. c. Behaviorism has been an influential school of thought in psychology since the 1920s. Nevertheless, behaviorists devoted little attention to clinical issues until the 1950s, when behavior therapy emerged out of three independent lines of research fostered by B. F. Skinner and his colleagues (Skinner, Solomon, & Lindsley, 1953) in the United States; by Hans Eysenck (1959) and his colleagues in Britain; and by Joseph Wolpe (1958) and his colleagues in South Africa. Since then, there has been an explosion of interest in behavioral approaches to psychotherapy. d. Behavior therapies are based on certain assumptions. i. First, it is assumed that behavior is a product of learning. No matter how self-defeating or pathological a client’s behavior might be, the behaviorist believes that it is the result of past learning and conditioning. ii. Second, it is assumed that what has been learned can be unlearned. The same learning principles that explain how the maladaptive behavior was acquired can be used to get rid of it. Thus, behavior therapists attempt to change clients’ behavior by applying the principles of classical conditioning, operant conditioning, and observational learning. e. Systematic desensitization i. Devised by Joseph Wolpe (1958), systematic desensitization revolutionized psychotherapy by giving therapists their first useful alternative to traditional ―talk therapy‖. ii. Systematic desensitization is a behavior therapy used to reduce phobic clients’ anxiety responses through counterconditioning. iii. The treatment assumes that most anxiety responses are acquired through classical conditioning. iv. The goal of systematic desensitization is to weaken the association between the conditioned stimulus (the bridge) and the conditioned response of anxiety. v. Systematic desensitization involves three steps: 1. First, the therapist helps the client build an anxiety hierarchy. The hierarchy is a list of anxiety-arousing stimuli related to the specific source of anxiety, such as flying, academic tests, or snakes. The client ranks the stimuli from the least anxiety arousing to the most anxiety arousing. This ordered list of stimuli is the anxiety hierarchy. 2. The second step involves training the client in deep muscle relaxation. This second phase may begin during early sessions while the therapist and client are still constructing the anxiety hierarchy. Various therapists use different relaxation training procedures. Whatever procedures are used, the client must learn to engage in deep, thorough relaxation on command from the therapist. 3. In the third step, the client tries to work through the hierarchy, learning to remain relaxed while imagining each stimulus. Starting with the least anxiety-arousing stimulus, the client imagines the situation as vividly as possible while relaxing. If the client experiences strong anxiety, he or she drops the imaginary scene and concentrates on relaxation. The client keeps repeating this process until he or she can imagine a scene with little or no anxiety. Once a particular scene is conquered, the client moves on to the next stimulus situation in the anxiety hierarchy. Gradually, over a number of therapy sessions, the client progresses through the hierarchy, unlearning troublesome anxiety responses. vi. As clients conquer imagined phobic stimuli, they may be encouraged to confront the real stimuli. vii. Although desensitization to imagined stimuli can be effective by itself, contemporary behavior therapists usually follow it up with direct exposures to the real anxiety-arousing stimuli. viii. Indeed, behavioral interventions emphasizing direct exposures to anxiety-arousing situations have become behavior therapists’ treatment of choice for phobic and other anxiety disorders. Usually, these real- life confrontations prove harmless, and individuals’ anxiety responses decline. ix. Anxiety and relaxation are incompatible responses. The trick is to recondition people so that the conditioned stimulus elicits relaxation instead of anxiety. This is counterconditioning—an attempt to reverse the process of classical conditioning by associating the crucial stimulus with a new conditioned response. f. Aversion therapy i. Aversion therapy is far and away the most controversial of the behavior therapies. It’s not something that you would sign up for unless you were pretty desperate. Psychologists usually suggest it only as a treatment of last resort, after other interventions have failed. ii. Aversion therapy is a behavior therapy in which an aversive stimulus is paired with a stimulus that elicits an undesirable response iii. Aversion therapy takes advantage of the automatic nature of responses produced through classical conditioning. iv. Troublesome behaviors treated successfully with aversion therapy have included drug and alcohol abuse, sexual deviance, gambling, shoplifting, stuttering, cigarette smoking, and overeating g. Social skills training i. Therapists are increasingly using social skills training in efforts to improve clients’ social abilities. This approach to therapy has yielded promising results in the treatment of social anxiety, autism, attention deficit disorder and schizophrenia. ii. Social skills training is a behavior therapy designed to improve interpersonal skills that emphasizes modeling, behavioral rehearsal, and shaping. This type of behavior therapy can be conducted with individual clients or in groups. iii. Social skills training depend on the principles of operant conditioning and observational learning. iv. With modeling, the client is encouraged to watch socially skilled friends and colleagues in order to acquire appropriate responses (eye contact, active listening, and so on) through observation. v. In behavioral rehearsal, the client tries to practice social techniques in structured role-playing exercises. The therapist provides corrective feedback and uses approval to reinforce progress. vi. Usually, they are given specific homework assignments. vii. Shaping is used in that clients are gradually asked to handle more complicated and delicate social situations h. Cognitive-behavioral treatments i. Cognitive- behavioral treatments use varied combinations of verbal interventions and behavior modification techniques to help clients change maladaptive patterns of thinking. ii. Albert Ellis’s (1973) rational emotive behavior therapy and Aaron Beck’s (1976) cognitive therapy, emerged out of an insight therapy tradition, whereas other treatments, such as the systems developed by Donald Meichenbaum (1977) and Michael Mahoney (1974), emerged from the behavioral tradition. iii. Cognitive therapy uses specific strategies to correct habitual thinking errors that underlie various types of disorders. It was originally devised as a treatment for depression. iv. According to cognitive therapists, depression is caused by ―errors‖ in thinking. They assert that depression prone people tend to 1. Blame their setbacks on personal inadequacies without considering circumstantial explanations 2. Focus selectively on negative events while ignoring positive events 3. Make unduly pessimistic projections about the future 4. Draw negative conclusions about their worth as a person based on insignificant events v. The goal of cognitive therapy is to change clients’ negative thoughts and maladaptive beliefs. To begin, clients are taught to detect their automatic negative thoughts. These are self-defeating statements that people are prone to make when analyzing problems. Clients are then trained to subject these automatic thoughts to reality testing. The therapist helps them to see how unrealistically negative the thoughts are. vi. Cognitive therapy uses a variety of behavioral techniques, such as modeling, systematic monitoring of one’s behavior, and behavioral rehearsal. vii. Cognitive therapists often give their clients ―homework assignments‖ that focus on changing clients’ overt behaviors. Clients may be instructed to engage in overt responses on their own, outside of the clinician’s office. i. How effective are behavior therapies? i. Behavior therapists have historically placed more emphasis on the importance of measuring therapeutic outcomes than insight therapists have. ii. Of course, behavior therapies are not well suited to the treatment of some types of problems (vague feelings of discontent, for instance). Furthermore, it’s misleading to make global statements about the effectiveness of behavior therapies, because they include many types of procedures designed for very different purposes. iii. Behavior therapies can make important contributions to the treatment of phobias, obsessive- compulsive disorders, sexual dysfunction, schizophrenia, drug-related problems, eating disorders, psycho- somatic disorders, hyperactivity, autism, and mental retardation 4) Biomedical therapies a. Chlorpromazine became the first effective antipsychotic drug, and a re
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