CHAPTER 17
Therapies
Theme: Psychotherapies are based on a common core of therapeutic principles. Medical therapies treat the physical causes of psychological disorders. In many cases, these approaches are complementary.
Preview
Cold Terror on a Warm Afternoon
The warm Arizona sun was shining brightly. Outside my office window an assortment of small birds sang sweetly. I could hear them between Susan’s frightened sobs.
As a psychologist, I meet many students with personal problems.
Still, I was surprised to see Susan at my office door.Her excellent work in class and her healthy, casual appearance left me unprepared for her first words. “I feel like I’m losing my mind,” she said. “Can I talk to you?” In the next hour, Susan described her own personal hell.Her calm appearance hid a world of overwhelming fear, anxiety, and depression. At work, she was deathly afraid of talking to coworkers and customers. Her social phobia led to frequent absenteeism and embarrassing behavior. At each job she held, it was only a matter of time until she got fired.
At school Susan felt “different” and was sure that other students could tell she was “weird.” Several disastrous romances had left her terrified of men. Lately she had been so depressed that she had thought of suicide. Often, she became terrified for no apparent reason. Each time, her heart would pound wildly and she felt she was about to completely lose control.
Susan’s visit to my office was an important turning point.
Emotional conflicts had made her existence a nightmare. At a time when she was becoming her own worst enemy, Susan realized she needed help from another person. In Susan’s case, that person was a talented psychologist to whom I referred her.With psychotherapy, the psychologist was able to help Susan come to grips with her emotions and restore her balance.
This chapter discusses methods used to alleviate problems like Susan’s. First, we will describe therapies that emphasize the value of gaining insight into personal problems. Then, we will focus on behavior therapies and cognitive therapies, which directly change troublesome actions and thoughts. Later, we will conclude with medical therapies, which employ psychiatric drugs and other physical treatments.
¡ Psychotherapy facilitates positive changes in personality, behavior, and adjustment.
¡ Before the development of modern therapies, superstition dominated attempts to treat psychological problems.
¡ Five major categories of psychotherapy are psychodynamic, insight, behavioral, cognitive, and group therapies.
¡ Psychotherapy is generally effective, although no single form of therapy is superior to others.
¡ All medical treatments for psychological disorders have pros and cons.Overall, however, their effectiveness is improving.
¡ Some personal problems can be successfully treated with self-management techniques.
¡ Everyone should know how to obtain high-quality mental health care in his or her community.
¡ Culturally aware therapists have the knowledge and skills needed to intervene successfully in the lives of clients from diverse cultural backgrounds.
Gateways to Therapy
How do psychotherapies differ? How did psychotherapy originate?
Is Freudian psychoanalysis still used?
What are the major humanistic therapies?
What is behavior therapy?
How is behavior therapy used to treat phobias, fears, and anxieties?
What role does reinforcement play in behavior therapy?
Can therapy change thoughts and emotions?
Can psychotherapy be done with groups of people?
What do various therapies have in common?
How do psychiatrists treat psychological disorders?
How are behavioral principles applied to everyday problems?
How could a person find professional help?
Do cultural differences affect counseling and psychotherapy?
Key Questions
Psychotherapy—Getting Better by the Hour
Humpty-Dumpty sat on a wall.
Humpty-Dumpty had a great fall.
All the King’s horses and all the King’s men, Couldn’t put Humpty together again.
Psychotherapy refers to any psychological technique that can bring about positive changes in personality, behavior, or adjustment.
In most cases, psychotherapy involves verbal interaction between trained mental health professionals and their clients.
Some therapists also use learning principles to directly alter troublesome behaviors.
Psychotherapists have many approaches to choose from: psychoanalysis, desensitization, Gestalt therapy, client-centered therapy, reality therapy, and behavior therapy—to name but a few. With so many therapies in use, some confusion may exist about how they differ. To begin, it is helpful to recognize that therapies vary greatly in emphasis. For this reason, the best approach for a particular person or problem may also vary.
Dimensions of Therapy
The terms listed here describe basic aspects of various therapies.
Notice that more than one term may apply to a particular therapy. For example, it is possible to have a directive, actionoriented group therapy or a nondirective, individual, insightoriented therapy.
¡ Individual therapy: A therapy involving only one client and one therapist.
¡ Group therapy: A therapy session in which several clients participate at the same time.
¡ Insight therapy: Any psychotherapy whose goal is to lead clients to a deeper understanding of their thoughts, emotions, and behavior.
¡ Action therapy: Any therapy designed to bring about direct changes in troublesome thoughts, habits, feelings, or behavior, without seeking insight into their origins or meanings.
Psychotherapy Any psychological technique used to facilitate positive changes in a person’s personality, behavior, or adjustment.
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¡ Directive therapy: Any approach in which the therapist provides strong guidance.
¡ Nondirective therapy: A style of therapy in which clients assume responsibility for solving their own problems; the therapist assists but does not guide or give advice.
¡ Time-limited therapy: Any therapy begun with the expectation that it will last only a limited number of sessions.
¡ Supportive therapy: An approach in which the therapist’s goal is to offer support rather than to promote personal change. A person trying to get through an emotional crisis or one who wants to solve day-to-day problems may benefit from supportive therapy.
Myths
Psychotherapy has been depicted as a complete personal transformation —a sort of “major overhaul” of the psyche. But therapy is not equally effective for all problems. Chances of improvement are fairly good for phobias, low self-esteem, some sexual problems, and marital conflicts.More complex problems can be difficult to solve. For many people, the major benefit of therapy is that it provides comfort, support, and a way to make constructive changes (Hellerstein et al., 1998).
In short, it is often unrealistic to expect psychotherapy to undo a person’s entire past history. Yet even when problems are severe, therapy may help a person gain a new perspective or learn behaviors to better cope with life. Psychotherapy can be hard work for both clients and therapists. But when it succeeds, there are few activities more worthwhile.
It is also worth noting that psychotherapy is not always used to solve problems or end a crisis. Therapy can promote personal growth for people who are already doing well (Buck, 1990).
¡Table 17.1 lists some of the elements of positive mental health that therapists seek to restore or promote (Bergin, 1991).
Origins of Therapy—Bored Skulls and Hysteria on the Couch
Early treatments for mental problems give ample reason for appreciating modern therapies. Archaeological findings dating to the Stone Age suggest that most primitive approaches were marked by fear and superstitious belief in demons, witchcraft, and magic. One of the more dramatic “cures” practiced by primitive “therapists” was a process called trepanning (treh- PAN-ing; also sometimes spelled trephining). In modern usage,
trepanning is any surgical procedure in which a hole is bored in the skull. In the hands of primitive therapists it meant chipping,
TABLE
17.1 Elements of Positive Mental Health
¡ Personal autonomy and independence
¡ A sense of identity
¡ Feelings of personal worth
¡ Skilled interpersonal communication
¡ Sensitivity, nurturance, and trust
¡ Genuineness and honesty with self and others
¡ Self-control and personal responsibility
¡ Committed and loving personal relationships
¡ Capacity to forgive others and oneself
¡ Personal values and a purpose in life
¡ Self-awareness and motivation for personal growth
¡ Adaptive coping strategies for managing stresses and crises
¡ Fulfillment and satisfaction in work
¡ Good habits of physical health
(left) Supernatural explanations attributed abnormal behavior to the work of the devil or “possession” by demons. A modern analysis of “demonic possession” suggests that some victims were suffering from dissociative disorders (van der Hart, Lierens,& Goodwin, 1996). (right) Many other cases of “possession” in medieval Europe and “bewitchment” in colonial New England may be explained by the psychedelic effects of ergot fungus. Rye infested with the fungus (dark areas) is shown here. (© Demon from “The Temptation of St. Anthony,” by Martin Schonganer.Treasury of Fantastic and Mythological Creatures by Richard Huber.Dover, 1981.)
CIMMYT
Adapted from Bergin, 1991.
THERAPIES 631
boring, or bashing holes into a patient’s head. Presumably, this was done to relieve pressure or release evil spirits (œFig. 17.1).
Actually, trepanning may have simply been an excuse to kill people who were unusual, given that many “patients” didn’t survive the “treatment.” During the Middle Ages, treatments for mental illness in Europe focused on demonology, the study of demons and persons plagued by spirits.Medieval “therapists” commonly blamed abnormal behavior on supernatural forces, such as possession by the devil, or on curses from witches and wizards. As a cure, they used exorcism to “cast out evil spirits.” For the fortunate, exorcism was a religious ritual. More often, physical torture was used to make the body an inhospitable place for the devil to reside.
One reason for the rise of demonology may lie in ergotism
(AIR-got-ism), a psychotic-like condition caused by ergot poisoning.
In the Middle Ages, rye (grain) fields were often infested with ergot fungus. Ergot, we now know, is a natural source of LSD and other mind-altering chemicals. Eating tainted bread could cause symptoms that were easily mistaken for possession, bewitchment, or madness. Pinching sensations, muscle twitches, facial spasms, delirium, and hallucinations are all signs of ergot poisoning (Kety, 1979; Matossian, 1982). Thus, many people “treated” by demonologists may have been doubly victimized.
It wasn’t until 1793 that the emotionally disturbed were regarded as “mentally ill” and given compassionate treatment.
That was the year a French doctor named Philippe Pinel
changed the Bicêtre Asylum in Paris from a squalid “madhouse” into a mental hospital by personally unchaining inmates. Although it has been more than 200 years since Pinel began humane treatment, the process of improving psychiatric care continues today.
When was psychotherapy developed? The first true psychotherapy was created around the turn of the twentieth century by Sigmund Freud. As a physician in Vienna, Freud was in-
Trepanning In modern usage, any surgical procedure in which a hole is bored in the skull; historically, the chipping or boring of holes in the skull to “treat”mental disturbance.
Demonology In medieval Europe, the study of demons and the treatment of persons “possessed” by demons.
Exorcism In medieval Europe, the practice of driving off an “evil spirit,” especially from the body of a person who is “possessed.”
Ergotism A pattern of psychotic-like symptoms that accompanies poisoning by ergot fungus.
Philippe Pinel The French physician who initiated humane treatment of mental patients in 1793.
© Danielle Pellegrini/Photo Researchers
œFigure 17.1 Primitive “treatment” for mental disorders sometimes took the form of boring a hole in the skull.This example shows signs of healing, which means the patient survived the treatment.Many didn’t.
© Bettmann/CORBIS © Bettmann/CORBIS
(left) Many early asylums were no more than prisons with inmates held in chains. (right) One late nineteenth-century “treatment”was based on swinging the patient in a harness—presumably to calm the patient’s nerves.
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trigued by cases of hysteria. People suffering from hysteria have physical symptoms (such as paralysis or numbness) for which no physical causes can be found. (Such problems are now called somatoform disorders.) Slowly, Freud became convinced that hysteria was related to deeply hidden unconscious conflicts.
Based on this insight, Freud developed a therapy called psychoanalysis.
Because it is the “granddaddy” of more modern therapies, let’s examine psychoanalysis in some detail.
Psychoanalysis—Expedition into the Unconscious
Isn’t psychoanalysis the therapy where the patient lies on a couch? Freud’s patients usually reclined on a couch during therapy, while Freud sat out of sight taking notes and offering interpretations. This procedure was supposed to encourage a free flow of thoughts and images from the unconscious. However, it is the least important element of psychoanalysis, and many modern analysts have abandoned it.
How did Freud treat emotional problems?
Freud’s theory stressed that “neurosis” and “hysteria” are caused by repressed memories, motives, and conflicts—particularly those stemming from instinctual drives for sex and aggression. Although they are hidden, these factors force people to develop rigid ego-defense mechanisms and to engage in compulsive and self-defeating behavior. Thus, the main goal of psychoanalysis is to resolve internal conflicts that lead to emotional suffering (Wolitzky, 1995).
Freud relied on four basic techniques to uncover the unconscious roots of neurosis (Freud, 1949). These are free association, dream analysis, analysis of resistance, and analysis of transference.
Free Association
The process of free association involves saying whatever comes to mind. Patients must speak without caring if ideas are painful, embarrassing, or illogical. Thoughts are simply allowed to move freely from one association to the next. The purpose of free association is to lower defenses so that unconscious material can emerge (Wolitzky, 1995).
Dream Analysis
Freud believed that dreams provide a “royal road to the unconscious” because they freely express forbidden desires and unconscious feelings. Such feelings are found in the latent content
(hidden, symbolic meaning) of dreams. A dream’s manifest content (obvious, visible meaning) tends to disguise information from the unconscious.
Freud was very interested in unconscious messages revealed by dream symbols (images that have personal or emotional meanings). Let’s say a young man reports a dream in which he pulls a pistol from his waistband and aims at a target while his wife watches. The pistol repeatedly fails to discharge, and the man’s wife laughs at him.
Freud might have seen this as an expression of repressed feelings of sexual impotence,with the gun serving as a disguised image of the penis.
Analysis of Resistance
When they are free associating or describing dreams, patients may resist discussing or thinking about certain topics. Such resistances
(blockages in the flow of ideas) are said to reveal particularly important unconscious conflicts. As analysts notice resistances, they bring them to the patient’s awareness so that the patient can deal with them realistically (Wolitzky, 1995). Thus, rather than being roadblocks in therapy, resistances can be challenges and guides (May, 1996).
Analysis of Transference
Transference is the tendency for patients to “transfer” feelings to a therapist that are like feelings they have for important persons in their lives. At times, the patient may act as if the analyst is a rejecting father, an unloving or overprotective mother, or a former lover.As the patient relives repressed emotions, the therapist can help the patient recognize and understand them.
Troubled persons often provoke anger, rejection, boredom, criticism, and other negative reactions from others. Effective therapists learn to avoid reacting as others do and playing the patient’s habitual “games.” This, too, contributes to therapeutic change (Strupp, 1989).
Psychoanalysis Today
What is the status of psychoanalysis today? Traditional psychoanalysis called for three to five therapy sessions a week, often for many years. Today, most patients are seen only once or twice per week, but treatment may still go on for years (Friedman et al., 1998). Because of the huge amounts of time and money this
© Archive/Photo Researchers
Pioneering psychotherapist Sigmund Freud in his office.
Some theorists dispute the psychodynamic claim that dreams have symbolic meaning.
See Chapter 7, pages 262–263.
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THERAPIES 633
requires, psychoanalysts have become relatively rare. Nevertheless, psychoanalysis made a major contribution to modern therapies by highlighting the importance of unconscious conflicts (Rangell, 2002).
Many therapists have switched to doing brief psychodynamic therapy, which uses direct questioning to reveal unconscious conflicts (Book & Luborsky, 1998). Modern therapists also actively provoke emotional reactions that will lower defenses and provide insights (Davanloo, 1995). Interestingly, brief therapy seems to accelerate recovery. Patients seem to realize that they need to get to the heart of their problems quickly (Reynolds et al., 1996).
The development of newer, more streamlined dynamic therapies is in part due to questions about the effectiveness of traditional psychoanalysis. One critic,Hans J. Eysenck (1994), suggested that psychoanalysis simply takes so long that patients experience a spontaneous remission of symptoms (improvement due to the mere passage of time). How could we tell if a particular therapy, rather than the passage of time, is responsible for a person’s improvement? Typically, some patients are randomly assigned for treatment while others are placed on a waiting list. If members of this waiting-list control group, who receive no treatment, improve at the same rate as those in therapy, the therapy may be of little value.
How seriously should the idea of spontaneous remission be taken? It is true that problems ranging from hyperactivity to anxiety improve with the passage of time. However, researchers have confirmed psychoanalysis does, in fact, produce improvement in a majority of patients (Doidge, 1997).
The real value of Eysenck’s critique is that it encouraged psychologists to try new ideas and techniques. Researchers began to ask: “When psychoanalysis works, why does it work? What procedures are vital, and which are unnecessary?”Modern therapists have given surprisingly varied answers to these questions.
Upcoming sections will acquaint you with some of the therapies currently in use.
Humanistic Therapies— Restoring Human Potential
When most people picture clinical psychologists at work, they probably imagine them doing insight therapy. As stated earlier, insight therapists help clients gain a deeper understanding of
Hysteria Wild emotional excitability sometimes associated with the development of apparent physical disabilities (numbness, blindness, and the like) without known physical cause.
Psychoanalysis A Freudian therapy that emphasizes the use of free association, dream interpretation, resistances, and transference to uncover unconscious conflicts.
Free association In psychoanalysis, the technique of having a client say anything that comes to mind, regardless of how embarrassing or unimportant it may seem.
Latent dream content The hidden or symbolic meaning of a dream, as revealed by dream interpretation and analysis.
Manifest dream content The surface,“visible,” content of a dream; dream images as they are remembered by the dreamer.
Dream symbols Images in dreams whose personal or emotional meanings differ from their literal meanings.
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