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3
Therapies
Recognizing Cries for Help on Social Media
magine checking your Facebook newsfeed to nd that a friend has posted that she is “giving up on life.” Is it just
another instance of everyday Facebook angst, or might something serious be developing?
Experts are looking at social media posts for signs of real need for psychological help (Norcross & others, 2013).
One study examining the Facebook status updates of 200 college students found that 25 percent showed depressive
symptoms (Moreno & others, 2011). Recognizing that some individuals might be expressing genuine deep distress,
Facebook provides users an option to report posts that may indicate suicidal thoughts. After verifying a troubling
post, Facebook sends a link to the National Suicide Prevention Lifeline and an online counselor. Yet even with such
resources in place, friends and parents might not know how to separate real need from the drama of everyday life.
One mother saw the following post on her 18-year-old daughter’s Facebook wall: “I just did something stupid,
mom. Help me.” The mother asked relatives nearby to check on her daughter, who had in fact taken an overdose, and
the young woman was brought to the ER (Hoffman, 2012). A dorm resident advisor at the University of Wisconsin
makes it a policy to “friend” the students on her oor. For any Facebook updates of concern, she checks in with the
students in person, explaining, “If they say something alarming on Facebook, they know it’s public and they want
someone to respond” (Hoffman, 2012).
Social media serve as an immediate outlet for our thoughts and feelings. They also provide a way to reach out to
friends in need. At the end of a lousy day, it might be common to vent on Facebook. When the bad days start piling
up, however, it might be time to seek help, not just from friends and family but also from a trained mental health
professional (Norcross & others, 2013).
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Biological Therapies // 483
The science of psychology has led to the development of various treatment approaches
to help relieve psychological suffering. These different forms of therapy are the subject
of this chapter. We review biological, psychological, and sociocultural approaches to
theuse of therapy to improve the lives of individuals with psychological disorders. We
close by examining the effectiveness of therapy and its broad array of benefi ts and by
exploring the factors that contribute to its success.
Biological therapies (biomedical therapies) are treatments that reduce or eliminate the
symptoms of psychological disorders by altering aspects of body functioning. Drug
therapy is the most common form of biomedical therapy. Electroconvulsive therapy and
psychosurgery are much less widely used biomedical therapies.
As medical doctors, psychiatrists can administer drugs as part of therapy. Family doc-
tors can also prescribe drugs for psychological disorders. In contrast, psychologists, who
are not trained as medical doctors, cannot administer drugs therapeutically in most states.
Drug Therapy
A l t h o u g h p e o p l e h a v e l o n g u s e d m e d i c i n e a n d h e r b s t o a l l e v i a t e s y m p t o m s o f
emotional distress, it was not until the twentieth century that drug treatments
revolutionized mental healthcare. Psychotherapeutic drugs are used mainly in
three diagnostic categories: anxiety disorders, mood disorders, and schizophre-
nia. In this section you will read about the effectiveness of drugs for these various
disorders—antianxiety drugs, antidepressant drugs, and antipsychotic drugs.
A N T I A N X I E T Y D R U G S Antianxiety drugs are commonly known as tranquiliz-
ers. These drugs reduce anxiety by making individuals calmer and less excitable.
B e n z o d i a z e p i n e s a r e t h e a n t i a n x i e t y d r u g s t h a t g e n e r a l l y o f f e r t h e g r e a t e s t r e l i e f f o r
anxiety symptoms, though these drugs are potentially addictive. They work by binding
to the receptor sites of neurotransmitters that become overactive during anxiety (Diaper
& others, 2012). The most frequently prescribed benzodiazepines include Xanax, Valium,
and Librium (Bernardy & others, 2012). A nonbenzodiazepine—buspirone, or BuSpar—
is commonly used to treat generalized anxiety disorder (Reinhold & others, 2011).
Benzodiazepines are relatively fast-acting, taking effect within hours. In contrast, bus-
pirone must be taken daily for two to three weeks before the patient feels bene ts. Side
effects of benzodiazepines include drowsiness, loss of coordination, fatigue, and mental
slowing (Fields, 2013). These effects can be hazardous when a person is driving or
operating machinery, especially when the individual rst starts taking the medication.
Benzodiazepines also have been linked to abnormalities in babies born to mothers who
took them during pregnancy (Hudak & others, 2012). Further, the combination of ben-
zodiazepines with alcohol and with other medications—including anesthetics, antihista-
mines, sedatives, muscle relaxants, and some prescription pain medicines—can lead to
problems such as depression (Dell’osso & Lader, 2012).
Why are antianxiety drugs so widely used? Many individuals experience stress,
anxiety, or both. Family physicians and psychiatrists prescribe these drugs to improve
people’s ability to cope with their problems. Antianxiety medications are best used only
biological therapies
(biomedical therapies)
Treatments that reduce or
eliminate the symptoms of
psychological disorders by
altering aspects of body
functioning.
antianxiety drugs
Commonly known as
tranquilizers, drugs that
reduce anxiety by making
individuals calmer and less
excitable.
1
Biological Therapies
Hav e y ou t ak en a
pr escr i pt i on dr ug f or a
psychol ogi cal pr obl em? As you
read, see if that medication is
descr i bed. Does t he descr i pt i on
fit with your experiences?
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484 // CHAPTER 13 // Therapies
temporarily for symptomatic relief. Too often, they are
overused and can become addictive (Lader, 2012;
Marazziti, Carlini, & Dell’osso, 2012).
A N T I D E P R E S S A N T D R U G S Antidepressant
drugs regulate mood. The three main classes of anti-
depressant drugs are tricyclics, such as Elavil; mono-
amine oxidase (MAO) inhibitors, such as Nardil; and
selective serotonin reuptake inhibitors, such as Prozac.
These antidepressants are all thought to help depressed
mood through their effects on neurotransmitters in the
brain. In different ways, they all allow the depressed
person’s brain to increase or maintain its level of
important neurotransmitters, especially serotonin and
norepinephrine.
Tricyclics, s o - c a l l e d b e c a u s e o f t h e i r t h r e e - r i n g e d
molecular structure, are believed to work by increasing
the level of certain neurotransmitters, especially nor-
epinephrine and serotonin (Taurines & others, 2011).
You might recall the role of low serotonin levels in
negative mood (Chapter 10) and aggression (Chapter 11).
Tricyclics reduce the symptoms of depression in
approximately 60 to 70 percent of cases. Tricyclics
usually take two to four weeks to improve mood.
Adverse side effects may include restlessness, faintness, trembling, sleepiness, and mem-
ory dif culties. A recent meta-analysis of 30 years of studies concluded that the older
antidepressant drugs, such as the tricyclics, reduced depression more effectively than the
newer antidepressant drugs (Undurraga & Baldessarini, 2012).
Related to the tricyclics are tetracyclic antidepressants , named for their four-ringed
structure. Tetracyclics are also called noradrenergic and speci c serotonergic antidepres-
sants, or NaSSAs. These drugs have effects on both norepinephrine and serotonin,
enhancing brain levels of these neurotransmitters. One recent analysis found that the
tetracylic Remeron (mertazapine) was more effective in reducing depression than any
other antidepressant drug (Cipriani & others, 2010).
MAO inhibitors are thought to work by blocking the enzyme monoamine oxidase,
which breaks down the neurotransmitters serotonin and norepinephrine in the brain
(Meyer, 2012). Scientists believe that the blocking action of MAO inhibitors allows
these neurotransmitters to stick around and help regulate mood. MAO inhibitors are
not as widely used as tricyclics because potentially they are more harmful. However,
some individuals who do not improve with tricyclics do respond to MAO inhibitors.
MAO inhibitors may be especially risky because of their potential interactions with
certain foods and drugs (Nishida & others, 2009). Cheese and other fermented
foods—including alcoholic beverages, such as red wine—can interact with
the inhibitors to raise blood pressure and, over time, cause a stroke.
In recent years psychiatrists have increasingly prescribed a type of antide-
pressant drug called selective serotonin reuptake inhibitors (SSRIs). SSRIs target
serotonin and work mainly by interfering with the reabsorption of serotonin in the
brain (Fooladi, Bell, & Davis, 2012). Figure 13.1 shows this process.
T h r e e w i d e l y p r e s c r i b e d S S R I s a r e P r o z a c ( uoxetine), Paxil (paroxetine),
and Zoloft (sertraline). The increased prescription of these drugs re ects their
effectiveness in reducing the symptoms of depression with fewer side effects
than other antidepressants (Fields, 2013). Nonetheless, they can have side
effects, including insomnia, anxiety, headache, and impaired sexual func-
tioning (Keeton, Kolos, & Walkup, 2009) and produce severe withdrawal
symptoms if the individual abruptly stops taking them (Kurose & others,
2012).
antidepressant
drugs
Drugs that
regulate mood.
Transmitting neuron
Receiving neuron
Prozac
Synaptic gap
Vesicle containing
serotonin
Normal serotonin
reuptake
Serotonin receptor
Release
FIGURE 13.1 How the Antidepressant Prozac Works
Secreted by a transmitting neuron, serotonin moves across the synaptic
gap and binds to receptors in a receiving neuron. Excess serotonin in
the synaptic gap is normally reabsorbed by the transmitting neuron.
The antidepressant Prozac blocks this reuptake of serotonin by the
transmitting neuron, however, leaving excess serotonin in the synaptic
gap. The excess serotonin is transmitted to the receiving neuron and
circulated through the brain. The result is a reduction of the serotonin
de cit found in depressed individuals.
As t heir name s uggest s ,
these drugs selectively inhibit
the reuptake of serotonin.
Ef f ex or i s al s o commonl y
pr escr i bed for depression.
It inhibits the reuptake of
ser ot onin and nor epinephr ine
and i s t hus cal l ed a
ser ot oni n
nor epi nephr i ne r eupt ak e
inhibit or,
or SNRI .
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Biological Therapies // 485
A r e c e n t l a r g e - s c a l e U . S . s t u d y r e v e a l e d t h a t t h e n u m b e r o f i n d i v i d u a l s t a k i n g a n t i d e -
pressants rose nearly 400 percent among all ages between 1988 and 2008, with 11 percent
of individuals 12 years and older taking an antidepressant in 2008 (Pratt, Brody, & Gu,
2011). In this study, more than 60 percent of individuals in the United States reported
that they have been taking antidepressants for two years or longer, and 14 percent for
10 years or longer.
Beyond their usefulness in treating mood disorders, antidepressant drugs are often
effective for a number of anxiety disorders, as well as some eating and sleep disorders
(Bernardy & others, 2012; Wu & others, 2012). Increasingly, antidepressants are pre-
scribed for other common problems, such as chronic pain. Such prescriptions are called
“off label” because they involve using a drug for reasons other than those recommended.
In fact, in 2005, less than half of the individuals in the United States who had taken
prescribed antidepressants were doing so for depression (Olfson & Marcus, 2009).
Lithium is widely used to treat bipolar disorder. Lithium is the lightest of the solid
elements in the periodic table of elements. If you have ever used a lithium battery (or
are a fan of Nirvana or Evanescence), you know that lithium has uses beyond treating
psychological disorders. The amount of lithium that circulates in the bloodstream must
be carefully monitored because the effective dosage is precariously close to toxic levels.
Kidney and thyroid gland complications as well as weight gain can arise as a conse-
quence of lithium therapy (Bauer & others, 2007). Lithium is thought to stabilize
moods by in uencing norepinephrine and serotonin, but the exact mechanism of
its effect is unknown (Ago & others, 2012). The effectiveness of lithium depends
on the person’s staying on the medication. Some consumers may be troubled by
the association between lithium and weight gain, and others may go off the drug
when they are feeling well.
The use of antidepressant drugs to treat depression in children is controversial. To
read more about this issue, see Challenge Your Thinking.
A N T I P S Y C H O T I C D R U G S Antipsychotic drugs are powerful drugs that diminish
agitated behavior, reduce tension, decrease hallucinations, improve social behavior, and pro-
duce better sleep patterns in individuals who have a severe psychological disorder, especially
schizophrenia (Guo & others, 2012). Before antipsychotic drugs were developed in the
1950s, few, if any, interventions brought relief from the torment of psychotic symptoms.
Neuroleptics a r e t h e m o s t e x t e n s i v e l y u s e d c l a s s o f a n t i p s y c h o t i c d r u g s ( G a r v e r , 2 0 0 6 ) .
When taken in suf cient doses, neuroleptics reduce schizophrenic symptoms (Nasrallah
& others, 2009). The most widely accepted explanation for the effectiveness of neurolep-
tics is their ability to block dopamine’s action in the brain
(Zhai, Miller, & Sammis, 2012).
N e u r o l e p t i c s d o n o t c u r e s c h i z o p h r e n i a ; t h e y t r e a t i t s
symptoms, not its causes. If an individual with schizophre-
nia stops taking the drug, the symptoms return. Neuroleptic
drugs have substantially reduced the length of hospital
stays for individuals with schizophrenia. However,
when these individuals are able to return to the com-
munity (because the drug therapy reduces their
symptoms), many have dif culty coping with the
demands of society. In the absence of symptoms,
many struggle to justify to themselves that they
should continue to take the very medications that
have reduced their symptoms, particularly because
neuroleptic drugs can have severe side effects, including
stroke. Drugs that treat disturbed thought by reducing dopa-
mine can also induce a lack of pleasure (Kapur, 2003).
Another potential side effect of neuroleptic drugs is tar-
dive dyskinesia, a n e u r o l o g i c a l d i s o r d e r c h a r a c t e r i z e d b y
involuntary random movements of the facial muscles,
lithium
The lightest of the solid ele-
ments in the periodic table
of elements, widely used to
treat bipolar disorder.
antipsychotic drugs
Powerful drugs that diminish
agitated behavior, reduce
tension, decrease hallucina-
tions, improve social behav-
ior, and produce better sleep
patterns in individuals with a
severe psychological disor-
der, especially schizophrenia.
The di agnosi s of bi pol ar
di s or der may be made
because
the person is responsive
to lithium.
Recal l f r om Chapt er 12
that people with schizophrenia
have d i f f i c ul t y r egul at i ng t he
neur ot r ansmi t t er d opami ne,
whi c h i s associ at ed wi t h
the experience of reward.
LAB RAT REHAB
Used by permission of CartoonStock, www.CartoonStock.com.
EXPERIENCE IT!
Depression Theories
and Treatments
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486 // CHAPTER 13 // Therapies
Challenge
YOUR THINKING
I
n 2000, Caitlin McIntosh, a
12-year-old straight-A student,
artist, and musician, hanged
herself with her shoelaces. Caitlin
had been struggling with depres-
sion and had begun taking anti-
depressants shortly before her
suicide. Tragic cases such as
Caitlin’s have stirred deep con-
cerns among parents and mental
health professionals. Could the
very drugs prescribed to alleviate
depression be causing children to
become suicidal?
In response to the public un-
ease, the FDA in 2004 reviewed
clinical trials of antidepressant
use with children (Hammad,
2004). No child in the studies
attempted or committed suicide,
and there were no differences
between the antidepressant and placebo groups on ratings of
suicidal thoughts and behaviors. However, children who received
antidepressants were two times more likely than those in the
placebo groups to spontaneously mention thoughts of suicide,
asnoted by parents or doctors (the rate of such events was 4
percent in the antidepressant group versus 2 percent for the
placebo group). Based on this difference, the FDA required prescrip-
tion antidepressants to carry the severest “black box” warning,
describing the potential of antidepressants to be associated with
suicidal thoughts and behaviors in children and adolescents
(FDA, 2004). The warning, which was widely publicized, had a
chilling effect: Between March 2004 and June 2005, the number
of prescriptions fell 20 percent compared to the same time
frame the year before (Rosack, 2007).
Since the advent of the black box warning, a number of studies
have shown no link between antidepressants and suicidal
thoughts or behavior among youth (Gibbons & others, 2012a,
2012b; Sharmila, 2012). Some observers have noted that
in the months after the warning took effect, suicide rates
among youth increased after having steadily declined for a
decade (Bridge & others, 2008; Gibbons & others, 2007).
An analysis of data from annual national surveys of youth
found that among those who were depressed, reports of
delinquent behaviors and illicit drug use increased while
grade point average declined in the years after the warning,
compared to their levels in the years before (Busch, Gol-
berstein, & Meara, 2011). Such ndings could suggest that
the black box warning had unexpected consequences on
youth struggling with depression.
Perhaps most troubling, there is no strong evidence that
depressed adolescents were more likely to receive psycho-
therapy after the warning took effect (Busch & others,
2010). Such ndings are especially disappointing because
drug therapy may not be the rst-choice treatment for
depressed children. Many children and adolescents with
depression respond well to psychotherapy alone (Morris,
2012).
This controversy high-
lights issues we have explored
throughout this book. How do
we weigh dramatic case study
evidence against less vivid sci-
enti c data that do not bear out
those cases? Are special con-
siderations required when pro-
fessionals suggest drug therapy
in children? How can we best
balance the potential bene ts
and risks of drug treatment?
Throughout this debate, the
tragedy of suicide looms, and
professionals have been moved
to change their thinking and
practices with regard to treating
depression in youth.
Do Antidepressants Increase Suicide Risk in Youth?
What Do You Think?
Have antidepressants
helped anyone you know?
Ifso, were you aware of
negative side effects?
Positive side effects? What
was the nature of these
effects?
What other events might
explain the changes in
academic and other
outcomes from depressed
youth after the black box
warning took effect?
tongue, and mouth, as well as extensive twitching of the neck, arms, and legs. Up to 20
percent of individuals with schizophrenia who take neuroleptics develop this disorder. As
you may recall from Chapter 12, movement disorders are a positive symptom of
schizophrenia, and tardive dyskinesia can also occur in individuals suffering from
psychiatric disorders who have not taken neuroleptic drugs (Chouinard, 2006).
N e w e r a n t i p s y c h o t i c d r u g s c a l l e d atypical antipsychotic medications , i n t r o -
duced in the 1990s, appear to in uence dopamine as well as serotonin (Germann,
Kurylo, & Han, 2012). The two most widely used medications in this group,
Clozaril (clozapine) and Risperdal (risperidone), show promise for reducing
Of f - l abel us es of Ri s per d al
include t reat ing aggressive and
sel f - inj ur ious behavi or in chi ldr en,
peopl e wi t h aut i sm, and el der l y
peopl e wi t h dement i a.
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Biological Therapies // 487
schizophrenia’s symptoms without the side effects of neuroleptics (Covell & others, 2012;
Nielsen & others, 2012).
S t r a t e g i e s t o i n c r e a s e t h e e f f e c t i v e n e s s o f a n t i p s y c h o t i c d r u g s i n v o l v e a d m i n i s t e r i n g
small dosages over time rather than a large initial dose, and combining drug therapy with
psychotherapy. Along with drug treatment, individuals with schizophrenia may need train-
ing in vocational, family, and social skills (Tungpunkom, Maayan, & Soares-Weiser, 2012).
F i g u r e 1 3 . 2 l i s t s t h e d r u g s u s e d t o t r e a t v a r i o u s p s y c h o l o g i c a l d i s o r d e r s , t h e i r e f f e c t i v e -
ness, and their side effects. Note that for some anxiety disorders, such as agoraphobia,
MAO inhibitors (antidepressant drugs) might be used instead of antianxiety drugs.
Electroconvulsive Therapy
The goal of electroconvulsive therapy (ECT) , commonly called shock the r apy, is to set
off a seizure in the brain, much like what happens spontaneously in some forms of epi-
lepsy. The notion of causing a seizure to help cure a psychological disorder has been
around since ancient times. Hippocrates, the ancient Greek father of medicine, rst
noticed that malaria-induced convulsions would sometimes cure individuals who were
thought to be insane (Endler, 1988). Following Hippocrates, many other medical doctors
electroconvulsive
therapy (ECT)
Also called shock therapy, a
treatment, sometimes used
for depression, that sets off
a seizure in the brain.
Antianxiety drugs;
antidepressant drugs
Everyday Anxiety
Psychological Disorder
Drug Effectiveness Side Effects
Everyday Anxiety and Anxiety Disorders
Mood Disorders
Antianxiety drugs
Generalized Anxiety
Disorder
Antianxiety drugs
Panic Disorder
Tricyclic drugs and
MAO inhibitors
Agoraphobia
Antianxiety drugs
Substantial improvement
short term
Not very effective
About half show
improvement
Majority show
improvement
Not very effective
Majority show moderate
improvement
Large majority show
substantial improvement
Majority show partial
improvement
Antianxiety drugs: less powerful the longer people take them;
may be addictive
Antidepressant drugs: see below under depressive disorders
Less powerful the longer people take them; may be addictive
Less powerful the longer people take them; may be addictive
Tricyclics: restlessness, fainting, and trembling
MAO inhibitors: toxicity
Less powerful the longer people take them; may be addictive
Tricyclics: cardiac problems, mania, confusion, memory loss,
fatigue
MAO inhibitors: toxicity
SSRI drugs: nausea, nervousness, insomnia, and, in a few cases,
suicidal thoughts
Neuroleptics: irregular heartbeat, low blood pressure,
uncontrolleddgeting, tardive dyskinesia, and immobility of face
Atypical antipsychotic medications: less extensive side effects
than with neuroleptics, but can have a toxic effect on white
blood cells
Toxicity
Spe cic Phobias
Tricyclic drugs, MAO
inhibitors, and SSRI
drugs
Depressive Disorders
Lithium
Bipolar Disorder
Schizophrenic Disorders
Neuroleptics; atypical
antipsychotic
medications
Schizop hre nia
FIGURE 13.2 Drug Therapy for Psychological Disorders This gure summarizes the types of drugs used to treat various psychological disorders.
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488 // CHAPTER 13 // Therapies
noted that head traumas, seizures, and convulsions brought
on by fever would sometimes lead to the apparent cure of
psychological problems.
In the early twentieth century, doctors induced seizures
by insulin overdose and other means and used this procedure
primarily to treat schizophrenia. In 1937, Ugo Cerletti, an
Italian neurologist specializing in epilepsy, developed the
procedure by which seizures could be induced using electri-
cal shock. With colleagues, he developed a fast, ef cient
means of causing seizures in humans, and ECT gained wide
use in psychiatric hospitals (Endler, 1988). Unfortunately, in
earlier years, ECT was used indiscriminately, sometimes
even to punish patients, as in the book and lm One Flew
Over the Cuckoo’s Nest .
Today, doctors use ECT primarily to treat severe depression.
As many as 100,000 individuals a year undergo ECT, primar-
ily as treatment for major depressive disorder (Mayo Founda-
tion, 2006). Fortunately, the contemporary use of ECT bears little resemblance to its earlier
uses. A small electric current lasting for one second or less passes through two electrodes
placed on the individual’s head. The current stimulates a seizure that lasts for approximately
a minute. ECT is given mainly to individuals who have not responded to drug therapy or
psychotherapy, and its administration involves little discomfort (Gallegos & others, 2012).
The patient receives anesthesia and muscle relaxants before the current is applied; this
medication allows the individual to sleep through the procedure, minimizes convulsions, and
reduces the risk of physical injury. Increasingly, ECT is applied only to the brains right
side. The individual awakens shortly afterward with no conscious memory of the treatment.
A recent study used fMRI to compare brain scans before and after ECT and found that the
procedure reduced or weakened connections in the prefrontal cortex (Perrin & others, 2012).
One analysis of studies of the use of ECT found that ECT was as effective as cogni-
tive therapy or drug therapy, with about four of ve individuals showing marked improve-
ment in all three therapies (Seligman, 1995). What sets ECT apart from other treatments
is the rapid relief it can produce in a person’s mood (Merkl, Heuser, & Bajbouj, 2009;
Popeo, 2009). ECT may be especially effective as a treatment for acute depression in
individuals who are at great risk of suicide (Kellner & others, 2006).
E C T i s c o n t r o v e r s i a l . I t s p o t e n t i a l s i d e e f f e c t s r e m a i n a s o u r c e o f d e b a t e a n d c o n t r a d i c -
tory ndings (Crowley & others, 2008). These possible effects include memory loss and
other cognitive impairments and are generally more severe than drug side effects (Caverzasi
& others, 2008). Some individuals treated with ECT report prolonged and profound
m e m o r y l o s s ( C h o i & o t h e r s , 2 0 1 1 ) . S i d e e f f e c t s a r e t y p i c a l l y l e s s e n e d i f o n l y o n e s i d e
of the brain is stimulated. Despite the potential problems of ECT, some psychiatrists argue
that for certain individuals this invasive treatment can have life-enhancing—and even life-
saving—bene ts (Huuhka & others, 2012; Martinez-Amoros & others, 2012).
More recently, practitioners are treating some forms of depression, as well as other
disorders, by applying electrical stimulation in very precise locations in the brain (Luigjes
& others, 2012). In deep brain stimulation, doctors surgically implant electrodes in the
brain that emit signals to alter the brain’s electrical circuitry. Deep brain stimulation is
being used to treat individuals with treatment-resistant depression and obsessive-compulsive
disorder (Chabardès & others, 2012). For instance, deep brain stimulation of the nucleus
accumbens (part of the brain’s reward pathways) has been effective in treating severe
depression (Bewernick & others, 2012).
Psychosurgery
Psychosurgery is a biological intervention that involves the removal or destruction of
brain tissue. Its effects are irreversible.
psychosurgery
A biological therapy, with
irreversible effects, that
involves removal or de-
struction of brain tissue
toimprove the individual’s
adjustment.
Electroconvulsive therapy (ECT), commonly called shock
therapy, causes a seizure in the brain. ECT is given to as
many as 100,000 people a year, mainly to treat major
depressive disorder.
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Biological Therapies // 489
In the 1930s, Portuguese physician Antonio Egas Moniz developed a new surgical
procedure on the brain. In this operation, a surgical instrument was inserted into
the brain and rotated, severing bers that connect the frontal lobe, which is
important in higher thought processes, and the thalamus, which plays a key
role in emotion. Moniz theorized that by breaking the connections between
these structures, the surgeon could alleviate the symptoms of severe mental
disorders. In 1949, Moniz received the Nobel Prize for developing this proce-
dure. However, although some patients may have bene ted from this surgery,
many were left in a vegetable-like state because of the massive assaults on their brain.
Moniz himself felt that the procedure should be used with extreme caution and only
as a last resort.
A f t e r h e a r i n g a b o u t M o n i z s w o r k , A m e r i c a n p h y s i c i a n a n d n e u r o l o g i s t W a l t e r F r e e m a n
became the champion of prefrontal lobotomies (a term Freeman coined to describe
Moniz’s procedure). With his colleague James Watts, he performed the rst lobotomy in
the United States in 1936 (El-Hai, 2005). Freeman developed his own technique, which
he performed using a device similar to an ice pick, in surgeries that lasted mere minutes.
Throughout the 1950s and 1960s, Freeman, a charismatic showman, traveled the country
in a van he called the “lobotomobile, demonstrating the surgery (El-Hai, 2005). Pre-
frontal lobotomies were conducted on tens of thousands of patients from the 1930s
through the 1960s. These numbers speak not only to Freeman’s persuasive charm but
also to the desperation many physicians felt in treating institutionalized patients with
severe psychological disorders (Lerner, 2005).
Subsequent research challenged the effectiveness of lobotomies in enhancing the lives
of individuals who had undergone the procedure, pointing instead to the considerable
damage that resulted (Landis & Erlick, 1950; Mettler, 1952). Many individuals who
received lobotomies suffered permanent and profound brain damage (Whitaker, 2002).
Ethical concerns were raised because in many instances, giving consent for the lobotomy
was a requirement for release from a mental hospital. Like ECT, lobotomies were
used as a form of punishment and control.
By the 1950s drug therapies had emerged as alternatives to lobotomy (Juckel
& others, 2009). By the late 1970s new regulations classi ed the procedure
as experimental and established safeguards for patients. In current practice,
psychosurgery is more precise (Heller & others, 2006; Kopell, Machado, &
Rezai, 2006) and involves making just a small lesion in the amygdala or another
part of the limbic system (Fountas & Smith, 2007).
Today, psychosurgery is performed rarely, only as a last resort, and with the utmost
caution (Ruck, 2003). Psychiatrists and psychologists recognize that science should tam-
per with the brain only in extreme cases (Pressman, 1998).
In 1939 a former
pat i e nt shot Moni z, l eavi ng hi m
a par apl egi c; Moni z subs eq uent l y
retired.
It makes more sense to
target the amygdalae rather than
the frontal lobes, considering the
functions associated with
these brain structures.
1. _______ are used to treat schizophrenia,
whereas _______ are used to treat
anxiety.
A. Benzodiazepines; neuroleptics
B. Neuroleptics; benzodiazepines
C. MAO inhibitors; tricyclics
D. Tricyclics; MAO inhibitors
2. Atypical antipsychotic medications
workby
A. increasing the release of presynaptic
neurotransmitters.
B. acting as an antagonist to dopamine.
C. stopping the reuptake of serotonin.
D. inhibiting enzymes that break down
norepinephrine.
3. A true statement about electroconvul-
sive therapy is that
A. it is less effective than medication.
B. it takes several weeks to see results.
C. its side effects are more severe than
those for medication.
D. it is painful.
APPLY IT! 4. Serena experienced times
when her mood was very negative for pro-
longed periods. She was deeply troubled by
her feelings and lacked a sense of pleasure
in life. At other times, she felt on top of
the world. Antidepressant medications
brought her no relief. Finally, her
psychiatrist prescribed a different drug,
which is helping Serena. Not only have her
dark moods leveled out, but she is experi-
encing more stable positive moods. Which
of the following is likely true of Serena’s
experience?
A. Serena has a depressive disorder, and
the drug is an MAO inhibitor.
B. Serena has an anxiety disorder, and the
drug is a benzodiazipene.
C. Serena has bipolar disorder, and the
drug is lithium.
D. Serena has an eating disorder, and the
drug is an SSRI.
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490 // CHAPTER 13 // Therapies
Although their ability to prescribe drugs is limited, psychologists and other mental health
professionals may provide psychotherapy , a nonmedical process that helps individuals
with psychological disorders recognize and overcome their problems. Psychotherapy may
be given alone or in conjunction with biological therapy administered by psychiatrists
and other medical doctors (Davidson, 2009). In many instances, a combination of psy-
chotherapy and medication is a desirable course of treatment (Nolen-Hoeksema, 2011).
Unfortunately, even as prescriptions for medications have increased dramatically over the
years, the number of people receiving psychotherapy has dropped. According to a recent
study, among individuals receiving antidepressant medication, the number in therapy fell
from 32 percent in 1996 to less than 20 percent in 2005 (Olfson & Marcus, 2009).
P s y c h o t h e r a p i s t s e m p l o y a n u m b e r o f s t r a t e g i e s t o a l l e v i a t e s y m p t o m s o f p s y c h o -
logical disorders: talking, interpreting, listening, rewarding, and modeling, for example
(Prochaska & Norcross, 2010). Although most psychotherapy is conducted face-to-face,
many contemporary therapists communicate with clients through e-mail or text messag-
ing (Berger, Hohl, & Caspar, 2009; Wangberg, Gammon, & Spitznogle, 2007).
Psychotherapy is practiced by a variety of mental health professionals (Figure 13.3).
Society retains control over psychotherapy practitioners through state laws that address
psychotherapy
A nonmedical process that
helps individuals with
psychological disorders
recognize and overcome
their problems.
2
Psychotherapy
Professional Type
Educat ion Beyond
Bachelor’s Degree Nature of TrainingDegree
Clinical Psychologist PhD or PsyD 57 years
Requires both clinical and research training. Includes a 1-year internship in a
psychiatric hospital or mental health facility. Some universities have developed
PsyD programs, which have a stronger clinical than research emphasis. The
PsyD training program takes as long as the clinical psychology PhD program
and also requires the equivalent of a 1-year internship.
Psychiatrist
MD 7–9 years Four years of medical school, plus an internship and residency in psychiatry,
is required. A psychiatry residency involves supervision in therapies, including
psychotherapy and biomedical therapy.
Counseling
Psychologist
MA, PhD,
PsyD, or EdD
37 years
Similar to clinical psychologist but with emphasis on counseling and therapy.
Some counseling psychologists specialize in vocational counseling. Some
counselors complete master’s degree training, others PhD or EdD training, in
graduate schools of psychology or education.
School
Psychologist
MA, PhD,
PsyD, or EdD
37 years Training in graduate programs of education or psychology. Emphasis on
psychological assessment and counseling practices involving students
school-related problems. Training is at the master’s or doctoral level.
Social Worker MS W/DSW
or PhD
2–5 years Graduate work in a school of social work that includes specialized clinical
training in mental health facilities.
Psychiatric Nurse RN, MA, or
PhD
0–5 years
Graduate work in a school of nursing with special emphasis on care of
mentally disturbed individuals in hospital settings and mental health facilities.
Occupational
Therapist
BS, MA, or
PhD
0–5 years Emphasis on occupational training with focus on physically or psychologically
handicapped individuals. Stresses getting individuals back into the
mainstream of work.
Pastoral Counselor None to PhD
or DD (Doctor
of Divinity)
0–5 years Requires ministerial background and training in psychology. An internship
in a mental health facility as a chaplain is recommended.
Counselor MA or MEd 2 years Graduate work in a department of psychology or department of education
with specialized training in counseling techniques.
FIGURE 13.3 Main Types of Mental Health Professionals A wide range of professionals with varying levels of training have taken on the challenge
of helping people with psychological disorders.
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Psychotherapy // 491
licensing and certi cation. These laws differ from state to state, but invariably they
specify the training the mental health professional must have, and they provide for assess-
ment of an applicant’s skill through formal examination. Regardless of their particular
occupation, psychotherapists use a range of techniques to help alleviate suffering. This
section focuses on four main approaches to psychotherapy: psychodynamic, humanistic,
behavioral, and cognitive.
Psychodynamic Therapies
The psychodynamic therapies stress the importance of the unconscious mind, extensive
interpretation by the therapist, and the role of early childhood experiences in the devel-
opment of an individual’s problems. The goal of psychodynamic therapies is to help
individuals gain insight into the unconscious con icts that are the source of their prob-
lems. Many psychodynamic approaches grew out of Freud’s psychoanalytic theory of
personality. Today some therapists with a psychodynamic perspective practice Freudian
techniques, but others do not (Brusset, 2012; Wolson, 2012).
P S Y C H O A N A L Y S I S Psychoanalysis is Freud’s therapeutic technique for analyzing
an individuals unconscious thoughts. Freud believed that a person’s current problems could
be traced to childhood experiences, many of which involved unconscious sexual con icts.
Only through extensive questioning, probing, and analyzing was Freud able to put together
the pieces of the client’s personality and help the individual become aware of how these
early experiences were affecting present behavior. The psychoanalyst’s goal is to bring uncon-
scious con icts into conscious awareness, thus giving the client insight into his or her core
problems and freeing the individual from unconscious in uences. To reach the shadowy
world of the unconscious, psychoanalytic therapists use the therapeutic techniques of free
association, interpretation, dream analysis, analysis of transference, and analysis of resistance.
Free association involves encouraging individuals to say aloud whatever comes to
mind, no matter how trivial or embarrassing. When Freud detected a person resisting the
spontaneous ow of thoughts, he probed further. He believed that the crux of the person’s
problem probably lurked below this point of resistance. Encouraging people to talk freely,
Freud reasoned, would allow their deepest thoughts and feelings to emerge. Catharsis is
the release of emotional tension a person experiences when reliving an emotionally
charged and con icting experience.
psychodynamic therapies
Treatments that stress the
importance of the uncon-
scious mind, extensive
interpretation by the
therapist, and the role of
early childhood experiences
in the development of an
individual’s problems.
psychoanalysis
Freud’s therapeutic tech-
nique for analyzing an
individual’s unconscious
thoughts.
free association
A psychoanalytic technique
that involves encouraging
individuals to say aloud
whatever comes to mind,
nomatter how trivial or
embarrassing.
To encourage his patients to
relax, Freud had them
recline on this couch while
he sat in the chair on the
left, out of their view.
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492 // CHAPTER 13 // Therapies
Interpretation plays an important role in psychoanalysis. Interpretation means that
the analyst does not take the patient’s statements and behavior at face value; rather, to
understand the source of the person’s con icts, the therapist searches for symbolic, hid-
den meanings in the individual’s words and deeds. From time to time, the therapist
suggests possible meanings of the person’s statements and behavior.
Dream analysis i s a p s y c h o a n a l y t i c t e c h n i q u e f o r i n t e r p r e t i n g a p e r s o n s d r e a m s .
Psychoanalysts believe that dreams contain information about unconscious thoughts,
wishes, and con icts (Freud, 1899/1911). From this perspective, dreams provide our
unconscious with an outlet to express our unconscious wishes, a mental theater in which
our deepest and most secret desires can be played out (Meghnagi, 2011). According to
Freud, every dream, even our worst nightmare, contains a hidden, disguised wish. Night-
mares might express a wish for punishment, or the sheer horror we feel during the
nightmare might itself be the disguise.
Freud distinguished between the dream’s manifest content and latent content. Manifest
content refers to the conscious, remembered aspects of a dream. If you wake up remem-
bering a dream about being back in sixth grade with your teacher scolding you for not
turning in your homework, that is the dream’s manifest content. Latent content refers to
the unconscious, hidden aspects that are symbolized by the manifest content. To under-
stand your dream, a psychoanalyst might ask you to free-associate to each of the
elements of the manifest content. What comes to your mind when you think of
being in sixth grade or of your teacher? According to Freud, the latent mean-
ing of a dream is locked inside the dreamer’s unconscious mind. The psycho-
analysts goal is to unlock that secret meaning by having the individual
free-associate about the manifest dream elements. The analyst interprets the
dream by examining the manifest content for disguised unconscious wishes and needs,
especially those that are sexual and aggressive. Dream symbols can mean different things
to different dreamers. Freud (1899/1911) recognized that the true meaning of any dream
symbol depends on the individual.
Freud believed that transference was an inevitable—and essential—aspect of the
a n a l y s t p a t i e n t r e l a t i o n s h i p . Transference i s t h e p s y c h o a n a l y t i c t e r m f o r t h e c l i e n t s
relating to the analyst in ways that reproduce or relive important relationships in the
client’s life. A client might interact with an analyst as if the analyst were a parent or
lover, for example. Transference can be used therapeutically as a model of how individuals
relate to important people in their lives (Faimberg, 2012).
Resistance is the psychoanalytic term for the client’s unconscious defense strategies that
prevent the analyst from understanding the person’s problems. Resistance occurs because it
is painful for the client to bring con icts into conscious awareness. By resisting
analysis, the individual does not have to face the threatening truths that underlie
his or her problems (Scharff, 2012). Showing up late or missing sessions,
arguing with the psychoanalyst, and faking free associations are examples of
resistance. A major goal of the analyst is to break through this resistance.
C O N T E M P O R A R Y P S Y C H O D Y N A M I C T H E R A P I E S Psychodynamic
therapy has changed extensively since its beginnings almost a century ago. Nonetheless,
many contemporary psychodynamic therapists still probe unconscious thoughts about
early childhood experiences to get clues to their clients’ current problems, and they try
to help individuals gain insight into their emotionally laden, repressed con icts (Leuzinger-
Bohleber & Teising, 2012; Werbart, Forsstrom, & Jeanneau, 2012). However, contempo-
rary psychoanalysts accord more power to the conscious mind and to a person’s current
relationships, and they generally place less emphasis on sex (Wallerstein, 2012). In addi-
tion, clients today rarely lie on a couch as they did in Freud’s time (see the photo on
the previous page) or see their therapist several times a week, as was the norm in early
psychodynamic therapy. Instead, they sit in a comfortable chair facing the therapist, and
weekly appointments are typical.
Some contemporary psychodynamic therapists (Caston, 2011; Stern, 2012) focus on
the self in social contexts, as Heinz Kohut (1977) recommended. In Kohut’s view, early
interpretation
A psychoanalyst’s search for
symbolic, hidden meanings
in what the client says and
does during therapy.
dream analysis
A psychoanalytic technique
for interpreting a person’s
dreams.
transference
A client’s relating to the
psychoanalyst in ways that
reproduce or relive impor-
tant relationships in the
client’s life.
resistance
Unconscious
defense strate-
gies on the part
of a client that
prevent the psy-
choanalyst from
understanding
the client’s
problems.
The dr eamer k nows
what t he d r eam mean s, bu t t hi s
me a n i n g i s l o c k e d i n h i s o r h e r
unconsci ous mi nd.
Fr eud woul d say t hat
the appearance of resistance means
that the analyst is getting very
cl ose t o t he t r u t h.
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Psychotherapy // 493
social relationships with attachment gures such as parents are critical. As we develop,
we internalize those relationships, and they serve as the basis for our sense of self. Kohut
(1977) believed that the therapist’s job is to replace unhealthy childhood relationships
with the healthy relationship the therapist provides. From Kohut’s perspective, the ther-
apist needs to interact with the client in empathic and understanding ways. Empathy and
understanding are also cornerstones for humanistic therapies, as we next consider.
Humanistic Therapies
T h e u n d e r l y i n g p h i l o s o p h y o f h u m a n i s t i c t h e r a p i e s i s c a p t u r e d b y t h e m e t -
aphor of how an acorn, if provided with appropriate conditions, will grow
in positive ways, pushing naturally toward its actualization as an oak
( S c h n e i d e r , 2 0 0 2 ) . Humanistic therapies encourage individuals to
understand themselves and to grow personally. Humanistic thera-
pies are unique in their emphasis on the person’s self-healing
capacities. In contrast to psychodynamic therapies, humanistic
therapies emphasize conscious rather than unconscious thoughts, the
present rather than the past, and growth and self-ful llment rather than illness.
Client-centered therapy (also called Rogerian therapy or nondirective therapy ) is
a form of humanistic therapy developed by Carl Rogers (1961, 1980), in which the
therapist provides a warm, supportive atmosphere to improve the client’s self-concept
and to encourage the client to gain insight into problems. Compared with psychodynamic
therapies, which emphasize analysis and interpretation by the therapist, client-centered
therapy places far more emphasis on the client’s self-re ection (Hill, 2000). In client-
centered therapy, the goal is not to unlock the deep secrets of the unconscious but rather
to help the client identify and understand his or her own genuine feelings (Hazler, 2007).
One way to achieve this goal is through active listening and re ective speech , a tech-
nique in which the therapist mirrors the client’s own feelings back to the client. For
example, as a woman is describing her grief over the traumatic loss of her husband in
a drunk-driving accident, the therapist, noting her voice and facial expression, might
suggest, “You sound angry” to help her identify her feelings.
In Rogers’s therapy, the therapist must enter into an authentic relationship with the
client, not as a physician diagnosing a disease but as one human being connecting to
another. Indeed, in talking about those he was trying to help, Rogers referred to the
“client’and eventually to the “person’rather than to the “patient.
Rogers believed that each of us is born with the potential to be fully functioning but
that we live in a world in which we are valued only if we live up to conditions of worth.
That is, others value us only if we meet certain standards, and we come to apply those
standards to ourselves. Each of us needs to feel the positive regard of others, but this
positive regard is often conditional—it comes with strings attached. Rogers asserted that
each of us requires three essential elements to grow to our full potential: unconditional
positive regard, empathy, and genuineness. Let’s review these three conditions, which are
strongly re ected in Rogerian therapy.
To free a person from conditions of worth, the therapist engages in unconditional
positive regard, which involves creating a warm, caring environment and never
disapproving of the client as a person. Rogers argued that unconditional posi-
tive regard provides a context for personal growth and self-acceptance, just
as soil, water, and sunshine provide a context for the acorn to become an
oak . The Rogerian therapist’s role is nondirective —that is, he or she does
not lead the client to any particular revelation. The therapist is there to listen
empathically to the client’s problems and to encourage positive self-regard,
independent self-appraisal, and decision making.
In addition to unconditional positive regard, Rogers emphasized the
importance of empathy and genuineness. Through empathy the therapist
strives to put himself or herself in the client’s shoes—to feel the client’s
humanistic
therapies
Treatments,
unique in their
emphasis on
people’s self-
healing capaci-
ties, that
encourage clients
to understand
themselves and
to grow
personally.
client-centered therapy
Also called Rogerian therapy
or nondirective therapy, a
form of humanistic therapy,
developed by Rogers, in
which the therapist provides
a warm, supportive atmo-
sphere to improve the
client’s self-concept and to
encourage the client to gain
insight into problems.
refl ective speech
A technique in
which the thera-
pist mirrors the
client’s own feel-
ings back to the
client.
To experience Rogerian therapy
rsthand, watch a video of Carl
Rogers describing his approach
andparticipating in a session
with a client at www.viddler.com/
v/2b20cab0.
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494 // CHAPTER 13 // Therapies
Put your s el f i n t he
shoes of t he t her apist who
mu s t ma i n t a i n p o s i t i v e r e g a r d f o r
a cl i ent whi l e al s o bei ng genui ne.
Imagine that your client talks
about phys i cal l y har mi ng a chi l d.
Coul d y ou s ucces s f ul l y of f er
your cl i ent uncondi t i onal
posi t i ve r egar d?
1 A month before an examination
2 Two weeks before an examination
3 A week before an examination
4 Five days before an examination
5 Four days before an examination
6 Three days before an examination
7 Two days before an examination
8 One day before an examination
9 The night before an examination
10 On the way to the university on the
day of an examination
11 Before the unopened doors of the
examination room
12 Awaiting distribution of examination
papers
13 The examination paper lies facedown
before her
14 In the process of answering an
examination paper
FIGURE 13.4 A Desensitization
Hierarchy Involving Test Anxiety In this
hierarchy, the individual begins with her least feared
circumstance (a month before the exam) and moves
through each of the circumstances until reaching
her most feared circumstance (answering the exam
questions on test day). At each step, the person replaces
fear with deep relaxation and successful visualization.
emotions. Genuineness requires the therapist to let the client openly know the thera-
pist’s own feelings. Genuineness is meant to coexist with unconditional positive
regard. The therapist must provide the client with positive regard no matter what,
but at the same time that regard must be a genuine expression of the therapists
true feelings.
The therapist may distinguish between the person’s behavior and the person
himself or herself. Although the client is always acknowledged as a valuable
human being, his or her behavior can be evaluated negatively: “You are a good
person but your actions are not.Rogers’s positive view of humanity extended
to his view of therapists. He believed that by being genuine with the client, the
therapist could help the client improve.
Behavior Therapies
Psychodynamic and humanistic methods are sometimes called insight
therapies because they encourage self-awareness as the path to psy-
chological health. Behavior therapies take a different approach.
Insight and self-awareness are not the keys to helping individuals
develop more adaptive behavior patterns, behavior therapists say.
Rather, behavior therapists offer action-oriented strategies to help
people change their behavior (Trull & Prinstein, 2013). Speci cally,
behavior therapies , based on behavioral and social cognitive theo-
ries, use principles of learning to reduce or eliminate maladaptive
behavior. Behavior therapists say that individuals can become aware
of why they are depressed and yet still be depressed. They strive to
eliminate the depressed symptoms or behaviors rather than trying to
get individuals to gain insight into, or awareness of, why they are
depressed (Miltenberger, 2012).
Although initially based almost exclusively on the learning prin-
ciples of classical and operant conditioning, behavior therapies have
become more diverse (Bankoff & others, 2012; Harned & others,
2012). As social cognitive theory grew in popularity, behavior thera-
pists increasingly included observational learning, cognitive factors,
and self-instruction in their treatments (Freedy & others, 2012). In
self-instruction, therapists try to get people to change what they say
to themselves.
C L A S S I C A L C O N D I T I O N I N G T E C H N I Q U E S Various
techniques of classical conditioning have been used in treating pho-
bias. Among them is systematic desensitization , a behavior therapy
that treats anxiety by teaching the client to associate deep relaxation
with increasingly intense anxiety-producing situations.
F i g u r e 1 3 . 4 s h o w s a d e s e n s i t i z a t i o n h i e r a r c h y . Desensitization
involves exposing someone to a feared situation in a real or an imag-
ined way (Donahue, Odlaug, & Grant, 2011). Desensitization is
based on the classical conditioning process of extinction. During
extinction, the conditioned stimulus is presented without the uncon-
ditioned stimulus, leading to a decreased conditioned response.
In Chapter 5 we saw that aversive conditioning entails repeated
pairings of an undesirable behavior with aversive stimuli to
decrease the behaviors positive associations. Through aversive
conditioning people can learn to avoid such behaviors as smoking,
overeating, and drinking alcohol. Electric shocks, nausea-inducing
substances, and verbal insults are some of the noxious stimuli used
behavior
therapies
Treatments,
based on the
behavioral and
social cognitive
theories, that use
principles of
learning to re-
duce or eliminate
maladaptive
behavior.
systematic
desensitization
A behavior ther-
apy that treats
anxiety by teach-
ing the client to
associate deep
relaxation with
increasingly
intense anxiety-
producing
situations.
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Psychotherapy // 495
in aversive conditioning (Sommer & others,
2006). Figure 13.5 illustrates how classical
conditioning is the backbone of aversive con-
ditioning.
O P E R A N T C O N D I T I O N I N G T E C H -
NIQUES The idea behind using operant
conditioning as a therapeutic approach is that
just as maladaptive behavior patterns are
learned, they can be unlearned. Therapy
involves conducting a careful analysis of the
person’s environment to determine which fac-
tors need modi cation. Especially important is
changing the consequences of the persons
behavior to ensure that healthy, adaptive
replacement behaviors are followed by positive
reinforcement.
Applied behavior analysis, described in
Chapter 5, involves establishing positive rein-
forcement connections between behaviors and
rewards so that individuals engage in appropri-
ate behavior and extinguish inappropriate
behavior. Consider, for example, a man with
obsessive-compulsive disorder (OCD) who
engages in a compulsive ritual such as check-
ing that he has locked the door of his house
10 times every time he leaves his home. If he
does not complete his ritual, he is overcome
with anxiety that something dreadful will hap-
pen. Note that whenever he completes the ritual, nothing dreadful does happen and his
anxiety is relieved. His compulsion is a behavior that is reinforced by the relief of
anxiety and the fact that nothing dreadful happens. Such a ritual, then, could be viewed
as avoidance learning. An operant conditioning–based therapy would involve stopping
the behavior to extinguish this avoidance. Speci cally, allowing the man to experience
the lack of catastrophic consequences in the absence of repeatedly checking the lock, as
well as training him to relax, might help to eliminate the compulsive rituals. Indeed,
behavior therapy is effective in treating OCD (Bonchek, 2009).
It may strike you as unusual that behavioral approaches do not emphasize
gaining insight and self-awareness. However, for the very reason that they
do not stress these goals, such treatments may be particularly useful in indi-
viduals whose cognitive abilities are limited, such as adults with developmen-
tal disabilities or children. Applied behavior analysis can be used, for instance,
to treat individuals with autism who engage in self-injurious behaviors such as
head banging (LeBlanc & Gillis, 2012).
Cognitive Therapies
Cognitive therapies e m p h a s i z e t h a t cognitions, or thoughts, are the main source of
psychological problems, and they attempt to change the individual’s feelings and behav-
iors by changing cognitions. Cognitive restructuring, a general concept for changing a
pattern of thought that is presumed to be causing maladaptive behavior or emotion, is
central to cognitive therapies.
Cognitive therapies differ from psychoanalytic therapies by focusing more on overt
symptoms than on deep-seated unconscious thoughts, by providing more structure to the
individual’s thoughts, and by being less concerned about the origin of the problem.
cognitive therapies
Treatments emphasizing
that cognitions (thoughts)
are the main source of psy-
chological problems and
that attempt to change the
individual’s feelings and
behaviors by changing
cognitions.
Because
it does not rely on
the cognitive ability of the client,
therapy directed at changing
be havi or s can be r emar kabl y u se f ul .
PSYCHOLOGICAL INQUIRY
FIGURE 13.5 Classical Conditioning: The Backbone of
Aversive Conditioning This gure shows how classical conditioning
can produce a conditional aversion to alcohol. Recall the abbreviations US
(unconditioned stimulus), UR (unconditioned response), CS (conditioned
stimulus), and CR (conditioned response). > What is the conditioned
stimulus? > What is the likely effect of alcohol prior to aversion therapy?
Is this effect learned or not? > What role, if any, does a person’s
motivation play in aversive conditioning?
US UR
Neutral stimulus US+ UR
Alcohol + Nausea
Nausea-inducing drug
Nausea-inducing
drug
Nausea
CS CR
Alcohol Nausea
Before Aversive Conditioning
During Aversive Conditioning
After Aversive Conditioning
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496 // CHAPTER 13 // Therapies
Compared with humanistic therapies, cognitive therapies provide more
of a framework and more analysis, and they are based on speci c
cognitive techniques.
Cognitive therapists guide individuals in identifying their irrational
and self-defeating thoughts. Then they get clients to challenge these
thoughts and to consider more positive ways of thinking. Cognitive
therapies all involve the basic assumption that human beings have con-
trol over their feelings and that how individuals feel about something
depends on how they think about it. In this section we examine three
main types of cognitive therapy: Albert Ellis’s rational-emotive behav-
ior therapy, Aaron Beck’s cognitive therapy, and cognitive-behavior
therapy.
R A T I O N A L - E M O T I V E B E H A V I O R T H E R A P Y Rational-
emotive behavior therapy (REBT) w a s d e v e l o p e d b y A l b e r t E l l i s
(1913–2007), who argued that individuals develop a psychological dis-
order because of their irrational and self-defeating beliefs. Ellis held
that our emotional reactions to life events are a product of our irratio-
nal beliefs and expectations along with the central false belief that we
cannot control our feelings (1962, 1996, 2000, 2002, 2005). A highly
confrontational therapist, Ellis aggressively attacked these irrational
beliefs in his practice.
Ellis (2000, 2002) believed that many individuals construct three
basic demands for themselves, which he called musterbating: (1)I
absolutely must perform well and win the approval of other people;
(2) other people must treat me kindly and fairly; and (3) my life
conditions must not be frustrating but rather should be enjoyable. Once people convert
their important desires into demands, they often create dysfunctional, exaggerated
beliefs such as “Because I’m not performing well, as I absolutely must, I’m an inad-
equate person.
The goal of REBT is to get the individual to eliminate self-defeating beliefs
by rationally examining them (Sava & others, 2009). A client is shown how
to dispute his or her dysfunctional beliefs—especially those “musts”and
how to convert them into realistic and logical thoughts. Homework assignments
provide opportunities to engage in the new self-talk and to experience the
positive results of not viewing life in such a catastrophic way. For Ellis, a suc-
cessful outcome meant getting the client to live in reality, where life is sometimes
tough and bad things happen.
B E C K S C O G N I T I V E T H E R A P Y Aaron Beck (b. 1921) developed a somewhat
different form of cognitive therapy to treat psychological problems, especially depression
(1976, 1993). A basic assumption Beck makes is that a psychological problem such as
depression results when people think illogically about themselves, their world, and the
future (2005, 2006). Like Ellis, Beck believes that therapy’s goal should be to help
people to recognize and discard self-defeating cognitions.
In the initial phases of Beck’s therapy, individuals learn to make connections between
their patterns of thinking and their emotional responses. From Beck’s perspective,
emotions are a product of cognitions. By changing cognitions, people can change
how they feel. Unfortunately, thoughts that lead to emotions can happen so
rapidly that a person is not even aware of them. Thus, the rst goal of therapy
is to bring these automatic thoughts into awareness so that they can be changed.
The therapist helps clients to identify their own automatic thoughts and to keep
records of their thought content and emotional reactions.
W i t h t h e t h e r a p i s t s a s s i s t a n c e , c l i e n t s l e a r n t o r e c o g n i z e l o g i c a l e r r o r s i n t h e i r
thinking and to challenge the accuracy of these automatic thoughts. Logical errors in
rational-emotive
behavior therapy
(REBT)
A therapy based
on Ellis’s assertion
that individuals
develop a
psychological
disorder because
of irrational and
self-defeating
beliefs and whose
goal is to get cli-
ents to eliminate
these beliefs by
rationally examin-
ing them.
Aaron Beck (b. 1921)
Aaron Beck’s method stresses that the goal of
therapy should be to help people to recognize
and eliminate illogical and self-defeating
thinking.
El l i s b el i ev ed t h at o ur
thoughts determine all of our
emot i onal r es pons es and t hat we
have t he capaci t y t o n ever be
mi s e r a b l e . Wh a t d o y o u t h i n k ?
Wh e n w a s t h e l a s t t i me
somet hing upset you? What ki nds
of t hought s di d you have about
that event or situation?
EXPERIENCE IT!
Virtual Therapy for
Agoraphobia
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Psychotherapy // 497
thinking can lead individuals to the following erroneous beliefs (Carson, Butcher, &
Mineka, 1996):
Perceiving the world as harmful while ignoring evidence to the contrary—for exam-
ple, when a young woman still feels worthless after a friend has just told her
how much other people genuinely like her.
Overgeneralizing on the basis of limited examples, such as a man’s seeing
himself as worthless because one individual stopped dating him.
Magnifying the importance of undesirable events, such as seeing being
rejected by a love interest as the end of the world.
Engaging in absolutist thinking like exaggerating the importance of some-
one’s mildly critical comment and perceiving it as proof of total inadequacy.
Figure 13.6 describes some of the most widely used cognitive therapy
techniques.
Seeking Therapy?
There Might Be an App for That
A
lthough many contemporary therapists communicate with
clients through e-mail or text messaging (Berger, Hohl,
& Caspar, 2009; Wangberg, Gammon, & Spitznogle, 2007),
these are just a taste of how technology is transforming psy-
chological interventions. For example, researchers are develop-
ing and studying smartphone applications for therapy (Carey,
2012). Such apps would provide immediate feedback aimed at
modifying thoughts and behaviors. Therapy apps could mean
access to therapy for millions of people—advice and strategies
for managing emotions and changing thoughts at the tap of
the screen. An iPad app for art therapy is already available.
Although possibly less portable, cybertherapy or e-therapy involves getting therapeutic help
online (Klein & others, 2010; Murphy, Mitchell, & Hallett, 2011; Postel, de Haan, & de Jong,
2010). E-therapy websites are controversial among mental health professionals, however
(Emmelkamp, 2011). For one thing, many of these sites do not include the most basic informa-
tion about the therapists’ qualifi cations (Norcross & others, 2013). In addition, because cyber-
therapy occurs at a distance, these sites typically exclude individuals who are having thoughts
of suicide. Further, con dentiality, a crucial aspect of the therapeutic relationship, cannot
always be guaranteed on a website. On the plus side, though, individuals who are unwilling or
unable to seek out face-to-face therapy may be more disposed to get help online (Norcross &
others, 2013; Van Voorhees & others, 2009).
E-therapy and therapeutic apps may represent the wave of the future, but for many profession-
als, human contact is a vital ingredient in psychological healing. Psychiatrist Andrew Garber cau-
tions, “We are built as human beings to gure out our place in the world, to construct a narrative
in the context of a relationship that gives meaning to our lives” (Carey, 2012). Technology, in
other words, may never replace the power of human conversation.
PSYCHOLOGY IN OUR WORLD
The Beck Institute maintains a
website chronicling the latest
developments in cognitive therapy
and including a variety of videos of
Beck himself. Check out the site at
www.beckinstitute.org/.
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498 // CHAPTER 13 // Therapies
Ellis’s and Becks cognitive therapies share some differences as well as similarities.
Ellis’s rational-emotive behavior therapy is directive, persuasive, and confrontational;
in contrast, Beck’s cognitive therapy involves more of an open-ended dialogue between
therapist and client. The aim of this dialogue in Becks approach is to get individuals
to re ect on personal issues and discover their own misconceptions. Beck also encour-
ages clients to gather information about themselves and to try out unbiased experi-
ments that reveal the inaccuracies of their beliefs. So whereas Ellis’s approach was
to bring a sledgehammer down on irrational beliefs, Beck’s therapy involves a subtler
process of coaxing a client to recognize that these beliefs promote thoughts that in u-
ence feelings. One study revealed that Elliss rational-emotive behavior therapy and
Cognitive Therapy
Technique Description Example
Explore personal meaning attached to
the client’s words and ask the client to
consider alternatives.
When a client says he will be “ devastated by his spouse leaving, ask
just how he would be devastated and ways he could avoid being
devastated.
Challenge Idiosyncratic
Meanings
Systematically examine the evidence for
the client’s beliefs or assertions.
When a client says she can’t live without her spouse, explore how she
lived without the spouse before she was married.
Question the Evidence
Help the client distribute responsibility for
events appropriately.
When a client says that his son’s failure in school must be his fault,
explore other possibilities, such as the quality of the school.
Reattribution
Help the client generate alternative
actions to maladaptive ones.
If a client considers leaving school, explore whether tutoring or going
part-time to school are good alternatives.
Examine Options and
Alternatives
Help the client evaluate whether he is
overestimating the nature of a situation.
If a client states that failure in a course means he or she must give up the
dream of medical school, question whether this is a necessary conclusion.
Decatastrophize
Explore fantasies of a feared situation: if
unrealistic, the client may recognize this;
if realistic, work on effective coping
strategies.
Help a client who fantasizes falling apart when asking the boss for a
raise to role-play the situation and develop effective skills for making the
request.
Fantasize
Consequences
Examine advantages and disadvantages
of an issue, to instill a broader
perspective.
If a client says he “ was just born depressed and will always be that way,”
explore the advantages and disadvantages of holding that perspective
versus other perspectives.
Examine Advantages
and Disadvantages
Turn Adversity to
Advantage
Explore ways that difficult situations can
be transformed into opportunities.
If a client has just been laid off, explore whether this is an opportunity
for her to return to school.
Help the client see connections between
different thoughts or ideas.
Draw the connections between a client’s anger at his wife for going on a
business trip and his fear of being alone.
Guided Association
Ask the client to rate her emotions or
thoughts on scales to help gain
perspective.
If a client says she was overwhelmed by an emotion, ask her to rate it on
a scale from 0 (not at all present) to 100 (I fell down in a faint).
Scaling
Provide the client with ways of stopping a
cascade of negative thoughts.
Teach an anxious client to picture a stop sign or hear a bell when anxious
thoughts begin to snowball.
Thought Stopping
Help the client find benign or positive
distractions to take attention away
from negative thoughts or emotions
temporarily.
Have a client count to 200 by 13s when he feels himself becoming
anxious.
Distraction
Provide labels for specific types of
distorted thinking to help the client gain
more distance and perspective.
Have a client keep a record of the number of times a day she engages in
all-or-nothing thinking—seeing things as all bad or all good.
Labeling of Distortions
FIGURE 13.6 Cognitive Therapy Techniques Cognitive therapists develop strategies to help change the way people think.
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Psychotherapy // 499
Becks cognitive therapy were more effective in treating depression than drug therapy
(Sava & others, 2009).
C O G N I T I V E - B E H A V I O R T H E R A P Y Cognitive-behavior therapy is a combi-
nation of cognitive therapy, with its emphasis on reducing self-defeating thoughts, and
behavior therapy, with its emphasis on changing behavior (Reaven & others, 2012; Sa r,
Wallach, & Bar-Zvi, 2012). An important aspect of cognitive-behavior therapy is self-
ef cacy, Albert Bandura’s concept that one can master a situation and produce positive
outcomes (1997, 2001, 2008, 2010a, 2010b). Bandura believes that self-ef cacy is the
key to successful therapy. At each step of the therapy, clients need to bolster their con-
dence by telling themselves messages such as “I’m going to master my problem, “I
can do it,and “I’m improving.” As they gain con dence and engage in adaptive behav-
ior, the successes become intrinsically motivating. Before long, individuals persist (with
considerable effort) in their attempts to solve personal problems because of the positive
outcomes that were set in motion by self-ef cacy.
Self-instructional methods are cognitive-behavior techniques aimed at teaching indi-
viduals to modify their own behavior (Sharf, 2012). Using self-instructional techniques,
cognitive-behavior therapists prompt clients to change what they say to themselves. The
therapist gives the client examples of constructive statements, known as rei n forcing self-
statements, that the client can repeat in order to take positive steps to cope with stress
or meet a goal. The therapist also encourages the client to practice the statements through
role playing and strengthens these newly acquired skills through reinforcement.
USE OF COGNITIVE THERAPY TO TREAT PSYCHOLOGICAL DISORDERS
Cognitive therapy has successfully treated some anxiety disorders, mood disorders,
schizophrenia, and personality disorders (Britton & others, 2012; Forman & others, 2012;
O’Donnell & others, 2012). In many instances, cognitive therapy used with drug therapy
is an effective treatment for psychological disorders (Soomro, 2012).
Panic disorder is among the anxiety disorders to which cognitive therapy has been
applied (Nations & others, 2011). The central concept in the cognitive model of panic
is that individuals catastrophically misinterpret relatively harmless physical or psycho-
logical events. In cognitive therapy, the therapist encourages individuals to test the cata-
strophic misinterpretations by inducing an actual panic attack. The individuals then can
test the notion that they will die or go crazy, which they nd out is not the case. Cogni-
tive therapy also shows considerable promise in the treatment of post-traumatic stress
disorder, especially when therapists encourage clients to relive traumatic experiences so
that they can come to grips with the threatening cognitions precipitated by those experi-
ences (Forbes & others, 2012). In addition, cognitive therapy has been successful in
treating generalized anxiety disorder, certain phobias, and obsessive-compulsive disorder
(Donegan & Dugas, 2012).
One of the earliest applications of cognitive therapy was in the treatment of depres-
sion. A number of studies have shown that cognitive therapy can be just as success-
ful as, or in some cases superior to, drug therapy in the treatment of depressive
disorders (Sado & others, 2009; Sava & others, 2009). Some studies also have dem-
onstrated that individuals treated with cognitive therapy are less likely to relapse into
depression than those treated with drug therapy (Jarrett & others, 2001).
Practitioners have made considerable strides in recent years in applying cognitive
therapy to the treatment of schizophrenia. Although not a substitute for drug therapy in
the treatment of this disorder, cognitive therapy has been effective in reducing some
schizophrenia symptoms, such as belief in delusions and impulsive acting out (Christopher
Frueh & others, 2009). Cognitive therapy also has proved effective in treating personality
disorders (McMain & Pos, 2007), where the focus has been on changing individuals’
core beliefs and reducing their automatic negative thoughts.
So far, we have studied the biological therapies and psychotherapies. The four
psychotherapies—psychodynamic, humanistic, behavior, and cognitive—are compared in
Figure 13.7.
cognitive-behavior therapy
A therapy that combines
cognitive therapy and
behavior therapy with the
goal of developing the
client’s self- effi cacy.
Pl us cogni t i v e t her apy
lacks t he side effect s of
dr ug t her api es.
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500 // CHAPTER 13 // Therapies
Psychoanalysis, including free association, dream
analysis, resistance, and transference: therapist
interprets heavily, operant conditioning.
Discover underlying unconscious
conflicts and work with client to
develop insight.
Client’s problems are symptoms
of deep-seated, unresolved
unconscious conflicts.
Psychodynamic
Therapies
Person-centered therapy, including unconditional
positive regard, genuineness, accurate empathy, and
active listening; self-appreciation emphasized.
Develop awareness of inherent
potential for growth.
Client is not functioning at an
optimal level of development.
Humanistic
Therapies
Learn adaptive behavior patterns
through changes in the environ-
ment or cognitive processes.
Observation of behavior and its controlling
conditions; specific advice given about what should
be done; therapies based on classical conditioning,
operant conditioning.
Client has learned maladaptive
behavior patterns.
Behavior
Therapies
Change feelings and behaviors
by changing cognitions.
Conversation with client designed to get him or her
to change irrational and self-defeating beliefs.
Client has developed
inappropriate thoughts.
Cognitive
Therapies
Cause of Problem Therapy Emphasis
Nature of Therapy and Techniques
FIGURE 13.7 Therapy Comparisons Different therapies address the same problems in very different ways. Many therapists use the tools that seem
right for any given client and his or her problems.
Therapy Integrations
As many as 50 percent of therapists identify themselves as not adhering to one particu-
lar method. Rather, they refer to themselves as “integrative” or “eclectic. Integrative
therapy is a combination of techniques from different therapies based on the therapist’s
judgment of which particular methods will provide the greatest bene t for the client
(Clarkin, 2012; Prochaska & Norcross, 2010). Integrative therapy is characterized by
openness to various ways of applying diverse therapies. For example, a therapist might
use a behavioral approach to treat an individual with panic disorder and a cognitive
approach to treat a client with major depressive disorder.
B e c a u s e c l i e n t s p r e s e n t a w i d e r a n g e o f p r o b l e m s , i t m a k e s s e n s e f o r t h e r a p i s t s t o u s e
the best tools in each case rather than to adopt a “one size ts all” program. Sometimes
a given psychological disorder is so dif cult to treat that it requires the therapist to bring
all of his or her tools to bear (Kozaric-Kovacic, 2008). For example, borderline personal-
ity disorder (see Chapter 12) involves emotional instability, impulsivity, and self-harming
behaviors. This disorder responds to a therapy called dialectical behavior therapy, o r DBT
(Bedics & others, 2012). Like psychodynamic approaches, DBT assumes that early child-
hood experiences are important to the development of borderline personality disorder.
However, DBT employs a variety of techniques, including homework assignments, cogni-
tive interventions, intensive individual therapy, and
group sessions involving others with the disorder.
Group sessions focus on mindfulness training as well
as emotional and interpersonal skills training.
Another integrative method is to combine psycho-
therapy with drug therapy (Schneier & others, 2012).
Combined cognitive therapy and drug therapy has
been effective in treating anxiety and depressive
disorders (Dunner, 2001), eating disorders
(Wilson, Grilo, & Vitousek, 2007), and schizo-
phrenia (Rector & Beck, 2001). This integra-
tive therapy might be conducted by a mental
health team that includes a psychiatrist and a
clinical psychologist.
At their best, integrative therapies are effective,
systematic uses of a variety of therapeutic approaches
(Prochaska & Norcross, 2010). However, one worry
integrative therapy
Use of a combination of
techniques from different
therapies based on the ther-
apist’s judgment of which
particular methods will pro-
vide the greatest benefi t for
the client.
“Life’s little wonders are too big for me.”
Used by permission of CartoonStock, www.CartoonStock.com.
In most U.S. states,
psychol ogi st s cannot pr escr i be
dr ugs.
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Sociocultural Approaches and Issues in Treatment // 501
about integrative therapies is that their increased use will result in an unsystem-
atic, haphazard use of therapeutic techniques that some therapists say would be
no better than a narrow, dogmatic approach (Lazarus, Beutler, & Norcross, 1992).
Therapy integrations are conceptually compatible with the biopsychosocial model
of abnormal behavior described in Chapter 12. That is, many therapists believe that
abnormal behavior involves biological, psychological, and social factors. Many single-
therapy approaches concentrate on one aspect of the person more than others; for exam-
ple, drug therapies focus on biological factors, and cognitive therapies probe
psychological factors. Therapy integrations take a broader look at individuals’ problems,
and such breadth is also implied in sociocultural approaches to therapy, our next topic.
Wh a t m i g h t t h e p o p u l a r i t y
of i nt egr at i ve t her apy mea n
for the training of future
psychot her api st s?
1. A behavioral therapy technique that is
often used for treating phobic disorder is
A. aversive conditioning.
B. self-instruction.
C. systematic desensitization.
D. counterconditioning.
2. The psychotherapy approach that focuses
on the ways in which early childhood
relationships have taught people how to
behave in current relationships is
A. client-centered therapy.
B. psychodynamic therapy.
C. cognitive therapy.
D. rational-emotive behavior therapy.
3. The therapy that has unconditional
positive regard at its core is
A. psychodynamic therapy.
B. cognitive therapy.
C. dialectical behavior therapy.
D. client-centered therapy.
APPLY IT! 4. Cara has taken a few psy-
chology classes. When she decides to see a
therapist for help with her relationship with
her mother, she is certain that the therapist
will make her lie on a couch and talk about
her childhood. When her appointments
begin, Cara is surprised that the therapist
asks her to just talk about her feelings and
offers little feedback. At other times, the
therapist talks to Cara about her thoughts
and beliefs and gives her homework. On
other appointments, the therapist asks Cara
about her dreams and childhood. The kind
of therapy Cara is getting is
A. cognitive-behavioral.
B. humanistic.
C. psychodynamic.
D. integrative.
In the treatment of psychological disorders, biological therapies change the body, behav-
ior therapies modify behavior, and cognitive therapies alter thinking. This section focuses
on sociocultural approaches to the treatment of psychological disorders. These methods
view the individual as part of a system of relationships that are in uenced by social and
cultural factors. We rst review common sociocultural approaches and then survey vari-
ous cultural perspectives on therapy.
Group Therapy
Individuals who share a psychological problem may bene t from observing others cope
with a similar problem. In turn, helping others can improve individuals’ feelings of
competence and ef cacy. The sociocultural approach known as group therapy brings
together individuals who share a psychological disorder in sessions that are typically led
by a mental health professional.
Advocates of group therapy point out that individual therapy puts the client outside
the normal context of the relationships—family, marital, or peer-group relation-
ships, for example—where many psychological problems develop. Yet such rela-
tionships may hold the key to successful therapy, these advocates say. By taking
the context of important groups into account, group therapy may be more suc-
cessful than individual therapy.
Group therapy takes many diverse forms—including psychodynamic, humanistic,
behavior, and cognitive therapy—plus approaches that do not re ect the major
group therapy
A sociocultural
approach to the
treatment of psy-
chological disor-
ders that brings
together individ-
uals who share a
particular psy-
chological disor-
der in sessions
that are typically
led by a mental
health profes-
sional.
3
Sociocultural Approaches and
Issues in Treatment
A group of people
in t herapy t oget her is st ill a
gr oup, s o pr oces s es des cr i bed
in Chapt er 11, such as
informat ional and normat ive
soci al i nf l uence, appl y.
EXPERIENCE IT!
Using Soccer as Therapy
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502 // CHAPTER 13 // Therapies
psychotherapeutic perspectives (Corey, 2012; Simon & Sliwka, 2012; Tasca & others, 2011).
Six features make group therapy an attractive treatment format (Yalom & Leszcz, 2006):
Information: I n d i v i d u a l s r e c e i v e i n f o r m a t i o n a b o u t t h e i r p r o b l e m s f r o m e i t h e r t h e
group leader or other group members.
Universality: Many individuals develop the sense that no one else has frightening and
unacceptable impulses. In the group, individuals observe that others feel anguish and
suffering as well.
Altruism: G r o u p m e m b e r s s u p p o r t o n e a n o t h e r w i t h a d v i c e a n d s y m p a t h y a n d l e a r n
that they have something to offer others.
Experience of a positive family group: A therapy group often resembles a family (in
family therapy, the group is a family), with the leaders representing parents and the
other members siblings. In this new family, old wounds may be healed and new, more
positive family ties may be made.
Development of social skills: Feedback from peers may correct aws in the individ-
ual’s interpersonal skills. Self-centered individuals may see that they are self-centered
if ve other group members inform them about this quality; in one-on-one therapy,
the individual might not believe the therapist.
Interpersonal learning: The group can serve as a training ground for practicing new
behaviors and relationships. A hostile person may learn that he or she can get along
better with others by behaving less aggressively, for example.
Family and Couples Therapy
R e l a t i o n s h i p s w i t h f a m i l y m e m b e r s a n d s i g n i cant others are certainly an important part
of human life. Sometimes these vital relationships can bene t from a helpful outsider.
Family therapy i s g r o u p t h e r a p y a m o n g f a m i l y m e m b e r s ( W a g e n a a r & B a a r s , 2 0 1 2 ) .
Couples therapy i s g r o u p t h e r a p y i n v o l v i n g m a r r i e d o r u n m a r r i e d c o u p l e s w h o s e m a j o r
problem lies within their relationship. These approaches stress that although one person
may have psychological symptoms, these symptoms are a function of the family or cou-
ple relationship (O’Leary, Heyman, & Jongsma, 2012).
In family therapy, four of the most widely used techniques are
1. Validation: The therapist expresses an understanding and acceptance of each family
member’s feelings and beliefs and thus validates the person. The therapist nds
something positive to say to each family member.
2. Reframing: The therapist helps families reframe problems as family problems, not
an individual’s problems. A delinquent adolescent boy’s problems are reframed in
terms of how each family member contributed to the situation. The parents’ lack of
attention to the boy or marital con ict may be involved, for example.
3. Structural change: T h e f a m i l y t h e r a p i s t t r i e s t o r e s t r u c t u r e t h e c o a l i t i o n s i n a f a m i l y .
In a mother–son coalition, the therapist might suggest that the father take a stronger
disciplinarian role to relieve the mother of some burden. Restructuring might be as
simple as suggesting that the parents explore satisfying ways of being together,
such as going out once a week for a quiet dinner.
4. Detriangulation: In some families, one member is the scapegoat for two other
members who are in con ict but pretend not to be. For example, parents of a girl
with anorexia nervosa might insist that their marriage is ne but nd themselves in
subtle con ict over how to handle the child. The therapist tries to disentangle, or
detriangulate, this situation by shifting attention away from the child to the con ict
between the parents.
C o u p l e s t h e r a p y p r o c e e d s s i m i l a r l y t o f a m i l y t h e r a p y . C o n ict in marriages and in
relationships between unmarried individuals frequently involves poor communication. In
some instances, communication has broken down entirely. The therapist tries to improve
family therapy
Group therapy
with family
members.
couples therapy
Group therapy involving
married or unmarried cou-
ples whose major problem
lies within their relationship.
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the communication between the partners (Meneses & Greenberg,
2011) and help them understand and solve their problems. Cou-
ples therapy addresses diverse problems such as alcohol abuse,
jealousy, sexual issues, in delity, gender roles, two-career fami-
lies, divorce, remarriage, and the special concerns of stepfamilies
(Sandberg & Knestel, 2011).
Self-Help Support Groups
Self-help support groups a r e v o l u n t a r y o r g a n i z a t i o n s o f i n d i v i d u -
als who get together on a regular basis to discuss topics of com-
mon interest. The groups are not conducted by a professional
therapist but by a paraprofessional or a member of the common
interest group. A paraprofessional is an individual who has been
taught by a professional to provide some mental health services
but who does not have formal mental health training. The para-
professional may have personally had a disorder; for example, a
chemical dependency counselor may also be a person recovering
from addiction. The group leader and members provide support
to help individuals with their problems.
Self-help support groups play a key and valuable role in our
nation’s mental health (Norcross & others, 2013). A survey in 2002
revealed that for mental health support alone, nearly 7,500 such
groups existed in the United States, with more than 1 million members (Goldstrom & oth-
ers, 2006). In addition to reaching so many people in need of help, these groups are
important because they use community resources and are relatively inexpensive. They also
serve people who are otherwise less likely to receive help, such as those with a limited
education or on a low income.
S e l f - h e l p s u p p o r t g r o u p s p r o v i d e m e m b e r s w i t h a s y m p a t h e t i c a u d i e n c e f o r s o c i a l
sharing and emotional release. The social support, role modeling, and sharing of concrete
strategies for solving problems that unfold in self-help groups add to their effectiveness.
A woman who has been raped might not believe a male therapist who tells her that, with
time, she will put the pieces of her shattered life back together. The same message from
another rape survivor—someone who has had to work through the same feelings of rage,
fear, and violation—might be more believable.
There are myriad self-help groups, including groups for cocaine abusers, dieters, victims
of child abuse, and people with various medical conditions (heart disease, cancer, diabetes,
and so on). Alcoholics Anonymous (AA) is one of the best-known self-help groups. Mental
health professionals often recommend AA for clients struggling with alcoholism (Kaskutas
& others, 2009). Some studies show a positive effect for AA, but others do not (Kaskutas,
2009). A recent study found that AA reduced drinking by improving self-ef cacy related to
not drinking in social contexts, fostering positive changes in social networks, increasing
spirituality/religiousness, and reducing negative affect (Kelly & others, 2012).
For individuals who tend to cope by seeking information and af liation with
similar peers, self-help support groups can reduce stress and promote adjustment.
However, as with any group therapy, there is a possibility that negative emotions
will spread through the group, especially if the members face circumstances that
deteriorate over time, as terminal cancer patients do. Group leaders who are sensi-
tive to the spread of negative emotions can minimize such effects.
In addition to face-to-face groups, a multitude of online support groups has also
emerged (Norcross & others, 2013). Online support groups have promise (Ellis & oth-
ers, 2011), but they can have downsides. In the absence of guidance from a trained
professional, members may lack the expertise and knowledge to provide optimal
advice. The emergence of pro-anorexia (or “pro-ana”) websites, which promote
a n o r e x i a , e x e m p l i es the potentially negative side of the online “support” phenomenon
(Bardone-Cone & Cass, 2006).
“That’s precisely what we are talking about, Bob. You
cannot simply play dead anytime Vera raises a
difficult issue.”
Used by permission of CartoonStock, www.CartoonStock.com.
Sociocultural Approaches and Issues in Treatment // 503
Pr o b l e ms s u c h a s
soci al cont agi on and gr oupt hink
(see Chapt er 11) can arise in
suppor t gr oups.
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504 // CHAPTER 13 // Therapies
Community Mental Health
T h e c o m m u n i t y m e n t a l h e a l t h m o v e m e n t w a s b o r n i n t h e 1 9 6 0 s ,
when society recognized that locking away individuals with psy-
chological disorders and disabilities was inhumane and inappro-
priate. The deplorable conditions inside some psychiatric facilities
spurred the movement as well. The central idea behind the com-
munity mental health movement was that individuals with disor-
ders ought to remain within society and with their families and
should receive treatment in community mental health centers. This
movement also re ected economic concerns, as it was thought that
institutionalizing people was more expensive than treating them
in the community at large. Thus, with the passage of the Com-
munity Mental Health Act of 1963, large numbers of individuals
with psychological disorders were transferred from mental institu-
tions to community-based facilities, a process called dei n stitutionalization. A l t h o u g h a t
least partially motivated by a desire to help individuals with psychological disorders more
effectively, deinstitutionalization has been implicated in rising rates of homelessness. The
success of community mental health services depends on the resources and commitment
of the communities in which they occur.
C o m m u n i t y m e n t a l h e a l t h i n v o l v e s t r a i n i n g t e a c h e r s , m i n i s t e r s , f a m i l y p h y s i c i a n s ,
nurses, and others who directly interact with community members to offer lay counseling
and workshops on topics such as coping with stress, reducing drug use, and assertiveness
training (A. Lim & others, 2012). Advocates and providers of community mental health
believe that the best way to treat a psychological disorder is through prevention (Feinstein,
Richter, & Foster, 2012; Thota & others, 2012).
An explicit goal of community mental health is to help people who are disen-
franchised from society, such as those living in poverty, to lead happier, more
productive lives (Cook & Kilmer, 2012; Simning & others, 2012). A key objec-
tive in this effort is empowerment—assisting individuals to develop skills for
controlling their own lives. All community mental health programs may rely on
nancial support from local, state, and federal governments.
Cultural Perspectives
T h e p s y c h o t h e r a p i e s d i s c u s s e d e a r l i e r i n t h i s c h a p t e r p s y c h o d y n a m i c , h u m a n i s t i c , b e h a v -
ior, and cognitive—center on the individual. This focus is generally compatible with the
needs of people in Western cultures such as the United States, where the emphasis is on
the individual rather than the group (family, community, or ethnic group). However, these
psychotherapies may not be as effective with people who live in collectivistic cultures that
place more importance on the group (Sue & others, 2013). S o m e p s y c h o l o g i s t s a r g u e t h a t
family therapy is likely to be more effective with people in cultures that place a high
value on the family, such as Latino and Asian cultures (Guo, 2005). Research shows that
adapting or tailoring the therapist relationship to cultural background and to religious/
spiritual orientation improves therapy effectiveness (Norcross, 2011).
If you think about psychotherapy as a conversation among people, you can appreciate
the profound and intricate ways culture can in uence the psychotherapeutic process.
Throughout our exploration of psychology, we have noted the ways in which culture is
expressed in language, in our modes of talking to one another, and in the things we talk
about. Placing the conversation that is psychotherapy within a cultural framework is
enormously complex. Cultures may differ, for instance, in terms of how they view the
appropriateness of talking with an elder about personal problems or of talking about
one’s feelings at all (Asnaani & Hofmann, 2012; Naeem & others, 2009). Cultural issues
in therapy include factors such as socioeconomic status, ethnicity, gender, country of
Community mental health includes services such as
medical care, one-on-one counseling, self-help
support groups, workshops, and supported residences
like halfway houses.
How mu c h woul d y ou be
wi l l i ng t o pay i n taxes to support
communi t y me n t a l h e a l t h
pr ogr ams?
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Sociocultural Approaches and Issues in Treatment // 505
origin, current culture, and religious beliefs and traditions (Farren, Snee, & McElroy,
2012; Joutsenniemi & others, 2012).
Cross-cultural competence refers both to how skilled a therapist feels about
being able to manage cultural issues that might arise in therapy and to how the
client perceives the therapist’s ability (Asnaani & Hofmann, 2012). Dominant
features of cross-cultural competence are demonstrating respect for cultural
beliefs and practices and balancing the goals of a particular therapeutic approach
with the goals and values of a culture. To read more about the issues, see the
Intersection.
cross-cultural
competence
A therapist’s
assessment of his
or her abilities to
manage cultural
issues in therapy
and the client’s
perception of
those abilities.
Clinical and Cultural Psychology: How Can
Cognitive-Behavior Therapy Work Across
Different Belief Systems?
INTERSECTION
Pakistan found that students perceived
being assertive, talking about ones
feelings with an elder, and gaining con-
trol over one’s feelings and life choices
as inconsistent with their religious val-
ues (Naeem & others, 2009). In con-
trast, research in Thailand showed that
Buddhists found the goals of CBT to
bequite in keeping with their spiritual
values. Buddhism views misery as
originating in conscious thought, and in
this sense, the CBT focus on changing
thoughts is well suited to the Buddhist
mindset (Reinke-Scorzelli & Scorzelli,
2001).
How might a therapist use CBT with a client whose cultural and
religious beliefs clash with the values of CBT? Anu Asnaani and
Stefan Hofmann (2012) presented a case study of a woman of
Jamaican heritage who was struggling with a psychological disorder.
Deeply religious, the woman found that her desire for therapy
placed her at odds with her family and friends. In their eyes, her
need for therapy signi ed a weakness of faith. Why did she need
therapy? She should put her faith in God and prayer, they insisted.
To resolve this con ict, the woman’s therapist suggested that she
try regarding her therapy as an expression of her spiritual drive
toward healing. Through this approach the woman was able to
embrace therapy as a means to a
spiritual goal. When CBT became part
of the healing process embedded in
her strong religious faith, she was
able to accept that healing could
come not only through prayer and the
support of a faith community but also
through therapy.
A
ll therapies seek to help
people become psychologi-
cally healthier and able to
lead more ful lling lives.
What is a psychologically healthy per-
son like? What makes a human life
ful lling? For many people, the an-
swers are provided by culture and
especially by religious beliefs. How
these cultural and religious values
match up with the values inherent in
therapeutic approaches is important,
especially as Western psychotherapy
perspectives spread around the world.
Cognitive-behavior therapy (CBT)
involves nudging individuals to question the validity of their beliefs
and the reasonableness of their thoughts. From the CBT perspec-
tive, changing the ways people think about their life experiences
gives them a sense of control over their emotions and reactions.
Consider, though, that some of our beliefs are embedded in our
cultural worldview, including our cultural and religious beliefs. Cli-
ents in therapy might view others’ efforts to change such beliefs
as judgmental or biased (Asnaani & Hofmann, 2012). As CBT has
gained popularity, research has begun to investigate whether and
how the values of CBT “ t” in a broad range of cultures.
Cultures and religions differ in terms of how well they match up
with the values of CBT. For instance, in one study of college stu-
dents in India, many felt that the goals of CBT con icted with their
personal, cultural, and religious beliefs (Scorzelli & Reinke- Scorzelli,
1994). Among these students, the notion that individuals might,
through therapy, gain greater control over their life was viewed as
clashing with cultural and religious values emphasizing that super-
natural forces de ne one’s destiny and that a person should live in
accord with familial and societal expectations. Similarly, a study in
\\
What makes a person
psychologically healthy?
\\
How does your cultural
experience influence
your answer?
Wh e n t h e r a p i s t s e n g a g e
wi t h cl i ent s i n a c ul t ur al l y
sensi t i ve way, a key goal is t o
not i mmedi at el y assume t oo much
ab o ut how cul t u r e i nf l uences
the person. Each person must be
treated as an individual.
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506 // CHAPTER 13 // Therapies
E T H N I C I T Y Many ethnic minority individuals prefer discussing problems with par-
ents, friends, and relatives rather than mental health professionals (Sue & others,
2013). Might therapy progress best, then, when the therapist and the client are
from the same ethnic background? Researchers have found that when there is an
ethnic match between the therapist and the client and when ethnic-speci c ser-
vices are provided, clients are less likely to drop out of therapy early and in
many cases have better treatment outcomes (Jackson & Greene, 2000). Ethnic-
speci c services include culturally appropriate greetings and arrangements (for
example, serving tea rather than coffee to Chinese American clients), providing ex-
ible hours for treatment, and employing a bicultural/bilingual staff (Nystul, 1999).
Nonetheless, therapy can be effective when the therapist and client are from different
ethnic backgrounds if the therapist has excellent clinical skills and is culturally sensitive
(Akhtar, 2006). Culturally skilled psychotherapists have good knowledge of their clients’
cultural groups, understand sociopolitical in uences on clients, and have competence in
working with culturally diverse groups (Austad, 2009).
G E N D E R O n e b y p r o d u c t o f c h a n g i n g g e n d e r r o l e s f o r w o m e n a n d m e n i s r e e v a l u a t i o n
of the goal of psychotherapy (Gilbert & Kearney, 2006; Nolen-Hoeksema, 2011). Tradi-
tionally, the goal has been autonomy or self-determination for the client. However, auton-
omy and self-determination are often more central to men than to women, whose lives
generally are characterized more by relatedness and connection with others. Thus, some
psychologists argue that therapy goals should involve increased attention to relatedness
and connection with others, especially for women, or should emphasize both autonomy/
self-determination and relatedness/connection to others (Notman & Nadelson, 2002).
Feminist therapists believe that traditional psychotherapy continues to carry considerable
gender bias and has not adequately addressed the speci c concerns of women. Thus, several
alternative, nontraditional therapies have arisen that aim to help clients break free from
traditional gender roles and stereotypes. In terms of improving clientslives, the goals of
feminist therapists are no different from those of other therapists. However, feminist thera-
pists believe that women must become alert to the possibility of bias and discrimination in
their own lives in order to achieve their mental health goals (Herlihy & McCollum, 2007).
Wo u l d y o u b e c o m f o r t a b l e
receiving treatment from a
therapist who differs from you
in et hnic background? I n gender?
In religious faith?
1. A family therapist who attempts to
change the alliances among members
ofa family is using the technique of
A. reframing.
B. structural change.
C. detriangulation.
D. validation.
2. A paraprofessional is
A. someone who helps a therapist to
conduct therapy.
B. an unlicensed therapist.
C. the leader of a therapy group.
D. someone who has training in helping
but lacks formal training as a
therapist.
3. Deinstitutionalization is
A. the release of a convict from the
prison system.
B. the transfer of mental health clients
from institutions to community
agencies.
C. the process of having someone ad-
mitted to a treatment center against
his or her will.
D. discharging someone with a psycho-
logical disorder from treatment.
APPLY IT! 4. Frank, an Asian American,
is struggling with depression. When he tells
a friend that he plans to get therapy, Frank
mentions that he hopes the therapist is
Asian American. His friend responds that
Frank is biased and that he should be open
to a therapist from any background. Based
on research findings, what is Frank’s wisest
course of action if he genuinely wants his
therapy to succeed?
A. Frank should insist on an Asian Ameri-
can therapist because he can benefit
from counseling only if his therapist
shares his ethnicity.
B. Frank is being close-minded and should
take whatever therapist he gets.
C. Frank should be open to a therapist who
understands the cultural issues that
might affect Frank’s life.
D. Frank should seek out a therapist who
does not share his ethnicity because
that way he will be forced to think
outside the box.
Do individuals who go through therapy get better? Are some approaches more effective
than others? How would we know if a therapy worked? During the past several decades,
a large volume of research has addressed these questions (Kazdin, 2007).
4
The Effectiveness of Psychotherapy
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The Effectiveness of Psychotherapy // 507
Research on the
Effectiveness
of Psychotherapy
A large body of research points to the conclu-
sion that psychotherapy works (Beck, 2005;
Butler & others, 2006; Lambert, 2001; Luborsky
& others, 2002). Researchers have carried out
hundreds of studies examining the effects of
psychotherapy. The strategy used to analyze
these diverse studies is meta-analysis, in which
the researcher statistically combines the results
of many different studies.
Figure 13.8 provides a summary of numerous
studies and reviews of research in which clients
were randomly assigned to a no-treatment con-
trol group, a placebo control group, or a psy-
chotherapy treatment (Lambert, 2001). As can
be seen, some individuals who did not get
treatment improved. These cases tell us that
some psychological symptoms are likely to
improve on their own, although it is also pos-
sible that these individuals sought help from
friends, family, or clergy. Individuals in a pla-
cebo control group fared better than untreated
individuals, probably because of having con-
tact with a therapist, expectations of being
helped, or the reassurance and support that they got during the study. However, by far
the best outcomes occurred for individuals who received psychotherapy.
Individuals contemplating seeing a psychotherapist want to know not only whether
psychotherapy works but also which form is most effective. The situation is similar
to that of the Dodo bird in Alice’s Adventures in Wonderland. Dodo was asked to
judge the winner of a race. He decided, “Everybody has won and all must have
prizes. Many studies of psychotherapy have supported the Dodo bird hypothesis all
“win and all must have “prizes. That is, although research con rms that therapy
works, no single therapy has been shown to be signi cantly better than the others
(Hubble & Miller, 2004; Lambert, 2001; Luborsky & others, 2002; Wampold, 2001;
Wampold & others, 2011).
Still, research has begun to indicate that certain therapies may work better than others
for speci c psychological disorders (Gould, Coulson, & Howard, 2012). For example, a
recent meta-analysis on anxiety disorders found that for children with an anxiety disor-
der, psychotherapy was more effective when individual therapy was used and when
treatment targeted a speci c anxiety disorder, while parental involvement in therapy did
not confer any bene ts for therapy outcomes (S. Reynolds & others, 2012). The idea that
speci c therapeutic techniques work best for particular disorders has led to the develop-
ment of evidence-based practice . This relatively new therapeutic approach integrates
the best available research with clinical expertise in the context of client characteristics,
culture, and preferences (APA Presidential Task Force on Evidence-Based Practice,
2006). From this perspective, decisions about treatment are optimally based on research
demonstrating effectiveness (Norcross, 2011).
How long does it take therapy to work? In one study, clients rated their symptoms,
interpersonal relations, and quality of life weekly before each treatment session (Anderson
& Lambert, 2001). Figure 13.9 shows that one-third of the individuals had improved
outcomes by the 10th session, 50 percent by the 20th session, and 70 percent by the 45th
evidence-based practice
Integration of the best avail-
able research with clinical
expertise in the context
ofclient characteristics,
culture, and preferences.
0
10
20
30
40
50
60
70
80
Psychotherapy Placebo No treatment
Percent improved
PSYCHOLOGICAL INQUIRY
FIGURE 13.8 The Effects of Psychotherapy In a review of
studies, more than 70 percent of individuals who saw a therapist improved,
whereas less than 40 percent who received a placebo and less than 20 percent
who received no treatment improved (Lambert, 2001). > Why do youthink
participants in the “no treatment” group improved? > Do these results
allow us to make a causal claim about the effectiveness of therapy? Why
or why not?
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508 // CHAPTER 13 // Therapies
Percent of individuals with
improved outcomes
60
70
80
30
50
20
40
10
0
5 10 15 2520 3530 40 45
Therapy session
FIGURE 13.9 Number of Therapy Sessions and
Improvement In one study, a large number of people undergoing therapy
rated their well-being (based on symptoms, interpersonal relations, and quality of
life) before each treatment session (Anderson & Lambert, 2001). The percent-
age of people who showed improved outcomes after each additional session of
treatment indicated that about a third of the individuals recovered by the 10th
session, 50 percent by the 20th session, and 70 percent by the 45th session.
session. In sum, therapy bene ts individuals
with psychological problems at least through
the rst six months of treatment and possibly
longer.
Health and Wellness
Benefits of
Psychotherapy
T h e r a p y g e n e r a l l y t a r g e t s t h e r e l i e f o f p s y c h o -
logical symptoms. A therapy is considered
effective if it frees a person from the negative
effects of psychological disorders. Does
therapy have larger implications related to a
person’s psychological wellness and even
physical health?
For example, receiving a cancer diagnosis
is stressful for diagnosed individuals. Might
psychotherapeutic help aimed at reducing this
stress improve patientsability to cope with the disease? New research indicates
that therapy does have such a positive effect. One study revealed that
group-based cognitive therapy that focused on sharpening prostate
cancer patientsstress management skills was effective in improv-
ing their quality of life (Penedo & others, 2006). Another study
found that individual cognitive-behavior therapy reduced symp-
tom severity in cancer patients undergoing chemotherapy
(Sikorskii & others, 2006).
P s y c h o t h e r a p y m i g h t a l s o h a v e b e n e ts for physical
health. Depression is associated with coronary heart dis-
ease, for example (Linke & others, 2009). Psychotherapy
that reduces depression is likely, then, to reduce the risk of
heart disease (K. W. Davidson & others, 2006). A research
review also revealed evidence of positive effects of psycho-
therapy on health behavior and physical illness, including
habits and ailments such as smoking, chronic pain, chronic
fatigue syndrome, and asthma (Eells, 2000).
Psychotherapy might even be a way to prevent psychological and
physical problems. In one study (Smit & others, 2006), individuals waiting
to see their primary healthcare provider were assigned to receive either physical
health treatment as usual or that same treatment plus brief psychotherapy (a simple ver-
sion of minimal contact cognitive-behavior therapy). The brief psychotherapy included
a self-help manual, instructions in mood management, and six short telephone conversa-
tions with a prevention worker. The overall rate of depression was signi cantly lower in
the psychotherapy group, and this difference was cost effective. That is, the use of brief
psychotherapy as a part of regular physical checkups was psychologically and econom-
ically advantageous.
Finally, although typically targeted at relieving distressing symptoms, might
psychotherapy enhance psychological well-being? This question is important
because the absence of psychological symptoms (the goal of most psycho-
therapy) is not the same thing as the presence of psychological wellness. Just
as an individual who is without serious physical illness is not necessarily at
the height of physical health, a person who is relatively free of psychological
s y m p t o m s s t i l l might not show the qualities we associate with psychological
The quest i on i s whet her an
individual whose sympt oms have
been t r eat ed can go on t o enj oy a
pr oduct i ve wor k l i f e, a r ewar di ng
relationship with a romantic
par t ner , and cl ose f r i endshi ps.
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The Effectiveness of Psychotherapy // 509
thriving. Studies have found that a lack of psychological wellness
may predispose individuals to relapse or make them vulnerable
to problems (Ryff & Singer, 1998; Ryff, Singer, & Love, 2004;
Thunedborg, Black, & Bech, 1995). Research has revealed that
individuals who show not only a decrease in symptoms but also
an increase in well-being are less prone to relapse (Fava, 2006;
Ruini & Fava, 2004).
Recently, therapists have developed a new type of treatment
speci cally aimed at enhancing well-being. Well-being therapy
(WBT) is a short-term, problem-focused, directive therapy that
encourages clients to accentuate the positive (Fava, 2006; Ruini
& Fava, 2009). The rst step in WBT is recognizing the positive
in one’s life when it happens. The initial WBT homework assign-
ment asks clients to monitor their own happiness levels and to keep track of moments
of well-being. Clients are encouraged to note even small pleasures—a beautiful spring
day, a relaxing chat with a friend, the great taste of morning coffee. Clients then identify
thoughts and feelings that are related to the premature ending of these moments. WBT
is about learning to notice and savor positive experiences and coming up with ways to
promote and celebrate life’s good moments. WBT is effective in enhancing well-being,
and it may also allow individuals to enjoy sustained recovery from mental disorders
(Fava, Ruini, & Belaise, 2007; Ruini & Fava, 2009; Ruini & others, 2006).
Common Themes in Effective
Psychotherapy
In this nal section, we look at common threads in successful psychotherapy. Two key
ingredients in successful therapy are the therapeutic alliance and client factors.
T H E T H E R A P E U T I C A L L I A N C E The therapeutic alliance is the relationship
between the therapist and client. This alliance is an important element of successful
psychotherapy (Horvath & others, 2011; Prochaska & Norcross, 2010). A relationship in
which the client has con dence and trust in the therapist is essential to effective psycho-
therapy (Knapp, 2007; McLeod, 2007). The quality of the therapeutic alliance is a sig-
ni cant factor in whether therapy is effective, regardless of the speci c type of therapy
used (Norcross, 2011).
C L I E N T F A C T O R S In all of the meta-analyses of therapeutic outcome studies,
one major factor in predicting therapeutic outcome is the client himself or herself.
Indeed, the quality of the client’s participation is the chief determinant of therapy
outcome (McKay, Imel, & Wampold, 2006; Wampold, 2001). Even though the indi-
vidual may seek therapy from a place of vulnerability, it is that persons strengths,
abilities, skills, and motivation that account for therapeutic success (Hubble & Miller,
2004; Wampold & Brown, 2005). In a review of the extensive evidence on therapeu-
tic ef cacy, researchers noted, “The data make abundantly clear that therapy does not
make clients work, but rather clients make therapy work” (Hubble & Miller, 2004,
p. 347). Therapy becomes a catalyst for bringing the person’s own strengths to the
forefront of his or her life.
L i f e i s c o m p l i c a t e d a n d lled with potential pitfalls. We all need help at times, and
therapy is one way to improve oneself physically and psychologically—to grow and
become the best person we can be. Therapy is as complex as any other human rela-
tionship and potentially as rewarding—producing positive changes in one person’s life
through a meaningful association with another person (Joseph & Linley, 2004).
well-being
therapy (WBT)
A short-term,
problem-focused,
directive therapy
that encourages
clients to accen-
tuate the
positive.
therapeutic alliance
The relationship between
the therapist and client—
an important element of
successful psychotherapy.
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510 // CHAPTER 13 // Therapies
1. Among the following therapies, the
most effective is
A. psychodynamic therapy.
B. cognitive therapy.
C. humanistic therapy.
D. They are all equally effective.
2. Across different types of therapy,
_____________ is most related to
successful outcomes.
A. theoretical orientation
B. the therapeutic relationship
C. validation
D. cognitive restructuring
3. In evidence-based practice, the decision
about which therapy to use in a given
case depends most on
A. the credentials of the therapist.
B. the client’s preferences.
C. research demonstrating the effective-
ness of various treatments.
D. the input of the client’s closest
associates.
APPLY IT! 4. Drake has been in
cognitive-behavior therapy for two months
for treatment of his depression. Although
he is no longer down in the dumps, he finds
that his life is not as joyful as he would
like. He just does not feel very enthusiastic
about things. What is the best advice to
give Drake?
A. “Life is difficult; just consider yourself
lucky that you are no longer depressed.”
B. “Find a therapy that works on improving
your well-being, not just treating your
symptoms.”
C. “You’re probably still depressed. You
should stick with the cognitive-behavior
therapy.”
D. “You should see a psychodynamic thera-
pist, who’ll treat the unconscious con-
flicts that are blocking your joy.”
symptoms or behaviors rather than to help individuals gain insight into
their problems.
T h e t w o m a i n b e h a v i o r t h e r a p y t e c h n i q u e s b a s e d o n c l a s s i c a l c o n d i -
tioning are systematic desensitization and aversive conditioning. In
systematic desensitization, anxiety is treated by getting the individual
to associate deep relaxation with increasingly intense anxiety-produ