Psychology, 5/e   Wortman, Loftus & Weaver
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CONCEPT I: Psychotherapies

Psychotherapy is a systematic series of interactions between a person who is trained in alleviating psychological problems and another who is suffering from them. Therapists differ in their theoretical orientation as well as their training. Although several distinct traditions for treatment exist, most therapists borrow ideas from several approaches in formulating a treatment program for a patient.

Psychoanalysis is a Freudian psychotherapy that probes a person’s current thoughts and feelings for clues to unconscious conflicts. The psychoanalyst tries to bring the patient’s unconscious thoughts into consciousness, where they can be confronted and understood. Psychoanalysts may use Freud’s technique of free association (talking about whatever enters one’s mind) to help uncover the source of patients’ problems. Dream analysis, in which the hidden meaning of dreams is brought to light, may also be used to help the analyst understand the nature of unconscious conflict. According to psychoanalytic theory, every dream has manifest content (what the person dreams) and latent content (the underlying meaning of the dream). Because confronting one’s repressed feelings is unpleasant, patients sometimes engage in resistance, an attempt to block treatment. If transference occurs, the patient directs emotions about some other person onto the analyst.

Later psychoanalytic thinkers, such as Carl Jung and Alfred Adler, focused on attempting to strengthen patients’ egos so their patients could better control their environments. Still others emphasized the importance of a person’s style of relating to others. In addition, object relations theorists focused on the ego and social relationships. Due to the length (typically several years) and cost of psychoanalysis, more recent theorists have also sought to develop shorter forms of psychoanalytic therapy.

Although psychoanalytic treatment has been found to be somewhat effective among those with anxiety disorders, its utility is limited by several factors. First, some have charged that psychoanalysis is geared toward young, attractive, verbal, intelligent, and successful (“YAVIS”) clients. This group tends to be in relatively little need of help. Moreover, reliable scientific studies of the long-term effectiveness of psychoanalysis have not been performed. However, some studies have provided evidence for the efficacy of brief forms of psychodynamic therapy for a wide variety of specific problems.

Humanistic therapies are based on the belief that psychological problems can be treated by giving people insight into needs and motives they may not be aware of. Perhaps the most famous of these therapies is Carl Rogers’s client-centered therapy. According to Rogers, others often impose conditions of worth on clients, which communicate that affection will only be given if the client acts as the others wish. Rogers offered his clients unconditional positive regard, acceptance and support without regard to the client’s behavior. Thus, the therapist seeks to arrange a situation in which the clients feel free to express and clarify their own feelings. Once primary empathy is established by the therapist’s mirroring, or reflecting, the client’s view of his or her self, the therapist seeks to develop advanced empathy, a deep understanding of the client’s problems and a suggestion about what might be causing the client’s problem.

Fritz Perls, the founder of gestalt therapy, emphasized the present and attempted to make a client whole by ridding him or her of defenses, increasing awareness, and releasing pent-up feelings. Gestalt therapy advocates that clients get in touch with their pent-up feelings through techniques such as using words to show that the client is taking charge (e.g., “That’s what I think and I take responsibility for it”).

Humanistic therapy’s popularity was at its peak in the 1960s. However, more recent studies have shown that it may be successful in some cases with some clients. The warmth and empathy expressed by the therapist have been related to successful therapeutic outcome.

Behavior therapies use experimentally derived principles of learning in an attempt to change maladaptive thoughts, feelings, and behaviors. Thus, they assume that the same learning principles governing normal behavior also govern abnormal behavior.

Two broad types of learning have been used in developing behavior therapies: classical conditioning (in which one stimulus is paired with another stimulus) and operant conditioning (in which behaviors are associated with certain outcomes).

Classical conditioning is the principle that underlies systematic desensitization, a technique pairing relaxation with mild but increasingly fearful events to relieve the patient of an irrational fear (phobia). Systematic desensitization also has been used effectively to treat recurrent nightmares; chronic alcoholism; complex interpersonal problems; and, along with medication, obsessive-compulsive disorders and panic disorders. Like systematic desensitization, flooding is an exposure-based treatment; however, it involves a more intense and rapid exposure to fearful stimuli. Aversive conditioning, also modeled after classical conditioning, pairs an aversive (unpleasant) stimulus with the unwanted behavior until the mere thought of the unwanted behavior becomes associated with an avoidance response. Aversive conditioning has been successfully used to treat alcoholism, but because it does not teach a new, desirable behavior, it is often paired with other, more positive forms of treatment.

In therapies based on operant conditioning, reward or punishment is used to increase or decrease the occurrence of a particular behavior. Timeout involves following unwanted behavior with the removal of all rewards for a period of time. Such contingency management programs are often effective in institutional settings. Token economies involve giving patients tokens (which can later be exchanged for privileges) when they exhibit the desired behavior. Such systems are effective in the classroom as well as for juvenile offenders, the mentally retarded, and people institutionalized with psychological disorders. Although token economies are not present in normal society, programs can be built so that people who move from institutionalized settings to the real world maintain their positive behavior. Stimulus control involves achieving the desired association between stimulus and response by eliminating all other options. This treatment has been used successfully for insomnia by establishing a bed’s association with sleep alone.

Learning through observation, called modeling, is also useful in therapy. Participant modeling, in which the therapist performs an act the patient fears and then guides the patient through the same act, seems to be a helpful technique in treating phobias.

Several therapies are based on cognitive restructuring. Cognitive-behavior therapies stress the teaching of new, healthier ways of thinking, that is, the restructuring of negative thoughts. For example, in Albert Ellis’s rational-emotive therapy (RET), clients are helped to replace irrational, problem-provoking outlooks with more realistic ones. In self-instructional training, Donald Meichenbaum’s version of cognitive therapy, clients are instructed to think rational and positive thoughts when they encounter an anxiety-producing situation. In Aaron Beck’s cognitive therapy, the therapist questions the patient in a way that helps the patient discover the irrational basis of negative self-evaluations. Thus, according to Beck, the negative interpretation of events which leads to depression can be modified so that the person feels better.

Family-systems therapies stress the importance of altering family roles and patterns of communication that maintain maladaptive behavior. Patients are encouraged and taught to communicate more effectively and help each other. The strategic approach to family therapy in particular focuses on getting family members to perform various tasks aimed at improving faulty communications in the family. For example, one way a therapist might use paradoxical intention with more resistant patients is to “order” the patient to perform his or her disruptive activity, thereby bringing the activity under the control of the therapist. The patient must either disrupt the session as directed or allow the session to proceed; both are positive outcomes. Structural family therapy involves role playing to teach the families of patients new ways to communicate. Family-systems therapies are often based in other philosophical traditions and may stress a behavioral approach, cognitive restructuring, or psychoanalytic techniques.

Group therapy describes any therapy that is applied to an interacting group of people. Usually those in the group share a common problem. Thus, patients learn from each other as well as from their therapist. They can also rely on each other for emotional support. Group therapy is especially useful in the promotion of better interpersonal relationships. This type of therapy generally costs less than more traditional therapies. Group therapies tend to borrow from all of the previously described traditions. Behavior and cognitive-behavior group therapies apply the principles of learning to help people develop more adaptive behaviors. A self-help group, in which people who share a common problem come together to talk without a therapist, is an increasingly popular form of support. Alcoholics Anonymous (AA) is such a group. Self-help groups can be very effective, probably because they bring together people who can share feelings similar to those of others in the group. Through modeling, they show people effective ways to cope, they provide for the exchange of practical information including what feelings are “normal” in a situation, and they provide a sense of “belonging” for the group members.

In the mid 1980s, some 30 to 40% of therapists reported using a combination of different therapies in their work. Therapists who believe that an openness to different approaches allow them to tailor treatment programs to the needs of particular clients are called eclectic therapists. An eclectic therapist might use, for example, a psychoanalytically-oriented approach to help reveal causes of inappropriate behavior and behavioral therapy to correct the problem behavior. This eclectic approach to treatment can be combined with biological therapies as well.

CONCEPT II: Biological Treatments

Some psychological disorders are associated with changes in the brain. Thus, biological treatments which alter the structural or biochemical mechanisms in the brain are sometimes useful in treatment.

In psychosurgery, portions of brain tissue are permanently destroyed. While the effectiveness of early surgeries was debatable, psychosurgery now involves operations that destroy very small amounts of tissue in specific locations. Such surgeries seem to be reasonably effective last-resort measures to bring relief from severe depression, intractable obsessive-compulsive disorder, and the manic episodes of severe and chronic manic-depression. Approximately 100 patients in the United States receive such surgery each year, and it is used only under the most stringent safeguards to protect the rights of the patient.

Electroconvulsive therapy (ECT), or “shock treatment,” is used to relieve severe depression that fails to respond to drugs. Each year, 30,000 to 50,000 Americans receive ECT. Over a period of several weeks, the patient is given a series of 70- to 130-volt electrical shocks, which produce convulsions. Although the patient experiences little or no discomfort, ECT frequently causes temporary memory loss. Since treatment gives immediate relief, it is especially useful for suicidal patients, although recent research shows that a combination of antidepressant drugs and lithium can produce similar results.

Psychoactive drugs, most of which have been introduced in the past few decades, are now the most common form of biological treatment. Drug therapy has been successfully used with all kinds of patients and many kinds of disorders. Drugs are generally grouped into categories, as follows.

Antianxiety drugs, or minor tranquilizers, are used to reduce excitability and cause drowsiness. There are three kinds of antianxiety drugs: barbiturates, propanediols, and benzodiazepines. Barbiturates are used as sleeping aids, but an overdose can be deadly. The propanediols such as Miltown and Equanil are now more commonly prescribed for stress and reduction of muscle tension. The benzodiazepines (Valium, Librium, Xanax, and Klonopin) reduce anxiety without affecting concentration and work by enhancing the neurotransmitter GABA which dampens excitement in the central nervous system. Xanax and Klonopin are effective in the treatment of panic disorder. Obsessive-compulsive disorder, although an anxiety disorder, is currently treated with the antidepressants Anafranil and Prozac which boost serotonin activity.

Antidepressant drugs fall into two categories. First, the MAO inhibitors, such as Iproniazid, act by stopping the action of the enzyme which normally breaks down the neurotransmitters norepinephrine and serotonin. Tricyclics, such as Elavil and Tofranil, work by blocking the reuptake of norepinephrine and serotonin, thereby increasing the activity of these chemicals at receptor sites. The drugs in both of these groups, however, cause side-effects. The second category of antidepressant drugs has more recently been introduced and generally have fewer side effects. This group includes Prozac, Asendin, and Dyserel. Even though Prozac has side-effects of its own, it has become the most-prescribed antidepressant drug in America. Lithium is a drug used to treat bipolar mood disorders. As with the antidepressants, Lithium also has negative side-effects.

The antipsychotic drugs, such as Thorazine and Stelazine, are used to reduce extreme symptoms of agitation in psychotic patients, such as schizophrenics. Antipsychotic drugs help alleviate active psychotic symptoms, but do not help and may even intensify passive symptoms. Antipsychotics are taken even during periods of diminished symptoms; therefore, patients take them for long periods, sometimes up to several years. Several side-effects can occur, including pseudoparkinsonism, characterized by trembling, and tardive dyskinesia, an irreversible condition that is characterized by grotesque facial movements and is incurred by 10 to 20% of patients. A relatively new drug, Clozaril, has fewer side-effects, but is toxic in overdose. It works by selectively reducing dopamine activity in the limbic system.

CONCEPT III: The Effectiveness of Psychological Treatments

Meta-analytic studies generally show that a person who undergoes psychotherapy is better off than 80% of those who remain untreated. Other research showed that drug therapy was more effective than cognitive and psychodynamic therapy for severe, but not for mild, depression. Most therapists believe the best treatment for depression is the combined use of appropriate drugs and psychotherapy.

CONCEPT IV: Treating Suicidal People

Suicide is the second most common cause of death among those aged 15 to 19. Social-psychological factors are related to suicide. Emile Durkheim found that suicide has been more likely among more isolated people--those with fewer social ties. Furthermore, suicide increased during times of rapid economic change. Freud suggested that suicide can result from a sense of interpersonal loss or disappointment, a view which is also supported. About half of all people who kill themselves suffer depression, but a sense of hopelessness is a better predictor of suicide than depression. Many suicide victims also have an impaired ability to solve problems. Risk factors associated with suicide include social isolation, recent interpersonal loss, sudden economic downturn, ill health, psychiatric condition, sense of hopelessness, impaired problem-solving, previous suicide attempt, communication of a wish to die, a family history of suicide, and being a man. Therapies usually aim at trying to reduce as many of these risk factors as possible.

Even with better therapies, the incidence of suicide has remained constant over the past 40 years. This may be because we aren’t getting help to those who need it or because we need a better way of identifying at-risk people. Recent work suggests that people who commit suicide have lower levels of serotonin in their brains, irrespective of other psychological disorders. Thus, the tendency for suicide should perhaps be treated as a disorder separate from other disorders, and drug therapies aimed at correcting this serotonin deficiency should be tried in conjunction with appropriate psychotherapy. Although Thomas Szasz argues that people have the right to kill themselves if they wish, most therapists believe they are obligated to help prevent a patient from committing suicide.

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