1) The elements of the treatment process
a. Treatments: how many types are there: three major
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
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
ix. Unfortunately, it appears that many people who need therapy don’t
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
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
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
7. In providing therapy, psychologists use either insight or
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
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
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
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
2) Insight therapies
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
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
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
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.
1. Interpretation refers to the therapist’s attempts to explain the
inner significance of the client’s thoughts, feelings, memories,
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
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.
1. Transference occurs when clients unconsciously start relating
to their therapist in ways that mimic critical relationships in
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
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
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
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
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
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
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
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
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
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
ii. Common denominators that lie at the core of diverse approaches to
1. The development of a therapeutic alliance with a professional
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
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
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
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
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
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
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
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
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
vi. Cognitive therapy uses a variety of behavioral techniques, such as
modeling, systematic monitoring of one’s behavior, and behavioral
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
i. How effective are behavior therapies?
i. Behavior therapists have historically placed more emphasis on the
importance of measuring therapeutic outcomes than insight therapists
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