CONCEPT I: Psychotherapies

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 focuses on the interplay between conscious and unconscious forces first outlined by Freud. The psychoanalyst tries to bring the patient's repressed memories into consciousness, where they can be confronted and understood. Sometimes dream analysis is used to help the therapist understand the nature of unconscious conflict. Every dream has a manifest content (what the person dreams) and a 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. In transference, the patient may direct emotions about some other person onto the therapist. Psychoanalysts also use Freud's technique of free association (talking about whatever enters one's mind) to help uncover the source of patients' problems. Psychoanalysis is a long (several years) and costly procedure; and because it relies on the patient's verbal abilities, it works best for those who are well educated. Thus, as a general treatment strategy, its usefulness is limited. It does seem to be most effective for patients with anxiety disorders and least effective with those who suffer from severe psychopathology such as schizophrenia.

Later psychoanalytic thinkers developed the innovations and variations of Freud's early associates, such as Adler and Jung, by focusing their therapy on attempts to strengthen the patient's ego so the patient can better control the environment. This therapy differs from psychoanalysis in that it involves a face-to-face confrontation between therapist and patient, it places greater emphasis on present events, the therapists take a more active role in guiding discussion, and it is shorter and less intensive. This briefer form of "dynamic" therapy has been shown to be effective with a wide range of problems, including posttraumatic stress disorder, grief, and personality disorders.

Humanistic therapies all focus on freeing the client to move toward self-fulfillment and personal growth. Perhaps the most famous of these theories is Carl Roger'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 offers the clients unconditional positive regard, a liking of the client without regard to the client's behavior. Thus, the therapist seeks to arrange a situation in which the client feels free to express and get in touch with his or her own feelings. Once primary empathy is established by the therapist's mirroring, or reflecting, the client's view of self, the therapist seeks to develop advanced empathy, a deep understanding of the client's problems.

Fritz Perls, the founder of Gestalt therapy, believes that a client must get rid of defenses and release pent-up feelings in order to become a whole person. Gestalt therapy focuses on making the person more "whole," or well-integrated. It 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 ("That's what I think and I take responsibility for it.")

Behavior therapists believe that the same basic principles of learning govern all behaviors, normal and deviant. They also believe that the environment plays a crucial role in determining which behaviors will be exhibited. They analyze the behavior they see and generally do not concentrate on unconscious sources of pathology. They tend to focus on current factors and particular problems.

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. 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. In timeout, for example, unwanted behavior is followed by the removal of the misbehavior from the setting to a place where there are no rewards. Such contingency management programs are often effective in institutional settings. Token economies involve giving patients tokens (which can be exchanged later 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.

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 extinguishing phobias. Some studies suggest it is more effective than symbolic modeling (showing the patient pictures) or systematic desensitization.

Several therapies are based on a cognitive approach. Cognitive-behavior therapy is aimed at changing the patient's way of thinking. For example, in Ellis's rational-emotive therapy (RET), subjects are helped to construct a more accurate and positive view of themselves. In self-instructional training, Meichenbaum's version of cognitive therapy, clients are instructed to think rational and positive thoughts when they encounter an anxiety-producing situation. In 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 lead to depression can be modified so that the person feels better. Recent research also suggests that cognitive restructuring paired with relaxation can help to eliminate panic attacks.

In family-systems therapy, the therapist focuses on changing maladaptive patterns of interaction within the family. Sometimes patients are encouraged and taught to communicate more effectively and help each other. In more resistant cases, the patients are "ordered" to perform their disruptive activity, thereby bringing the activity under the control of a therapist. In this paradoxical intervention technique, the patient either must disrupt the session as directed or allow the session to proceed; both are positive outcomes. Family-systems therapies are especially useful in treating disturbed adolescents and marriage problems. Family-systems therapies are often based in other philosophical traditions and may stress cognitive restructuring, behavioral techniques, or psychoanalytic techniques. Research shows that the psychoanalytically oriented family therapy may be particularly successful when measured over the long run.

Group therapies are applied to an interacting collection of people, often who have a similar kind of problem. Thus, patients learn from each other as well as from the therapist and also can rely on each other for emotional support. Group therapy is especially useful in the promotion of better interpersonal relationships. They also cost less than more traditional therapies. Group therapies borrow from all of the previously described traditions, and there are many forms of group therapy, including family-systems therapy described above.

Behavior and cognitive-behavior group therapies apply the principles of learning to help people develop more adaptive behaviors. Self-help groups, in which people who share a common problem come together to talk without a therapist, are becoming more common. 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 with others, they show people through modeling effective ways to cope, they provide for the exchange of practical information including what feelings are "normal" in the situation, and they provide a sense of "belonging" for the group members.

Probably over 30 or 40 percent of therapists today use a combination of different therapies in their work. Oftentimes a psychoanalytically oriented approach can help reveal causes of inappropriate behavior and behavioral therapy can be used to correct it. 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 one hundred 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, and the procedure is quite simple. 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, the 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.

The 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 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 neurotransmitters GABA which dampens excitement in the central nervous system. Valium is the most prescribed psychoactive drug in America. 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. 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, and a new class of antidepressants, including Prozac, Asendin, and Dyserel, has been introduced. 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 don't help and may even intensify passive symptoms. Antipsychotics are taken even during periods of diminished symptoms; therefore, patients take them for long periods of sometimes up to several years. Several side effects can occur, including pseudoparkinsonism, characterized by trembling, and tardine dyskinesia, an irreversible condition that is characterized by grotesque facial movements and that is incurred by 10 to 20 percent 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: Evaluating the Effectiveness of Treatments

Meta-analytic studies generally show that a person who undergoes psychotherapy is better off than 80 percent of those who receive no therapy. 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.

Suicide is on the rise among young Americans: one study showed that a third of a group of college students had considered killing themselves. Early research by Durkheim suggested that suicide is more likely among people who are socially isolated and in times of rapid economic change, a view which appears to be valid. 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 than depression of who will commit suicide. Many suicide victims also have an impaired ability to solve problems. Following is a list of risk factors associated with suicide: 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 male. 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.