Myers Chapter 16

1. Therapy“The trouble with most therapy is that it helps you to feel better. But you don’t get better. You have to back it up with action, action, action.” -Albert Ellis Myers Chapter 16

2. Availability and Adequacy of Treatment • 2004 APA poll • Half of Americans had someone in their household seek mental health treatment

3. Availability and Adequacy of Treatment • Delay of access • Average delay nearly 10 years • Earlier onset, longer delay, more persistent disorder • Bipolar disorder = 6 years • Generalized anxiety disorder = 9 years • ADHD = 13 years • Specific phobia = 20 years

4. Availability and Adequacy of Treatment • Prevention of Access (APA, 2004) • Cost • 81% cost • 87% lack of insurance coverage • Stigma • 30% concerned about others finding out • 20% said stigma important reason not to seek • 47% stigma has decreased in recent years • Media • Society in general

5. Approaches to Therapy • Psychotherapy: a trained therapist uses psychological techniques to assist someone seeking to overcome difficulties or achieve personal growth • Learning-related disorders (e.g. phobias)

6. Approaches to Therapy • Biomedical therapy: a prescribed medication or medical procedure that acts directly on the patient’s nervous system • Biologically influenced disorders (e.g. schizophrenia)

7. Approaches to Therapy • Eclectic approach: an approach to psychotherapy that, depending on the client’s problems, uses techniques from various forms of therapy • Psychotherapy integration: combine into coherent system

8. Psychological Therapies • Major Theories • Psychoanalytic • Humanistic • Behavioral • Cognitive • All used one-on-one or in groups

9. Psychoanalysis • Sigmund Freud • Release previously repressed feelings to allow patient’s self-insight • Take responsibility for own growth

10. Psychoanalysis • Free-associations • Resistances • Dreams • Transferences • Therapist’s interpretation

11. Psychoanalyis • Critiques • Cannot be proven or disproven • Costly • >$100/hour • $30,000/year

12. Psychoanalysis • Good candidates • Motivation • Capacity to form interpersonal relationships • Capacity for introspection and insight • Ego strength • Sarason & Sarason (2005)

13. Psychodynamic Therapy • Derived from psychoanalysis • Explore themes from childhood and other relationships • Face-to-face • Less frequent • Shorter duration

14. Interpersonal Psychotherapy • Brief variation of psychodynamic therapy • Effective in treating depression • Goal is symptom relief, not personality change • Improve relationship skills • Resolve conflicts • Express emotions effectively

15. Humanistic Therapies • Emphasize people’s inherent potential for self-fulfillment • Help people grow in self-awareness and self-acceptance • Reduce inner conflicts & provide new insights

16. Humanistic Therapies • Contrast with psychoanalysts • Present & future vs. past • Conscious vs. unconscious • Take immediate responsibility vs. external explanations • “Clients” vs. “Patients” • Growth, not cure of illness

17. Humanistic Therapies • Client-centered therapy: non-directive therapy in which the therapist uses techniques to promote the client’s growth (Carl Rogers) • Active listening • Genuine • Accepting • Empathic

18. Humanistic Therapies • Active listening: echo, restate, and seek clarification • Unconditional positive regard: a caring, accepting, nonjudgmental attitude • Paraphrase – summarize speaker’s words • Invite clarification – ask for an example • Reflect feelings – “that sounds frustrating”

19. Therapeutic Approaches • Insight Therapies • Psychoanalytic: problems subside as people gain insight into unresolved & unconscious tensions • Humanistic: problems diminish as people get in touch with their feelings • Behavior Therapy • Applies principles of learning to eliminate unwanted behaviors

20. Behavior Therapies • Seek to replace learned behaviors with constructive behaviors • Classical conditioning • Exposure Therapies • Aversive conditioning • Operant conditioning • Token economies

21. Behavior Therapies • Classical conditioning • Bed-wetting alarm • Counter-conditioning: pair the trigger stimulus with a new response that is incompatible with the previous response

22. Behavior Therapies • Counter-conditioning • Exposure therapies: expose people to what they normally avoid • Systematic desensitization: relax while exposed to gradually increased levels of anxiety-provoking stimuli • Repeated pairings • Work up through stress-hierarchy

23. Behavior Therapies • Aversive Conditioning: counter-conditioning that associates an unpleasant state with an unwanted behavior • Substitute an aversive response for a positive response to a harmful stimulus

24. Behavior Therapies

25. Behavior Therapies • Operant conditioning • Voluntary behaviors are strongly influenced by their consequences • Behavior modification: reinforce desired behaviors and withhold reinforcement or provide punishment for undesired behaviors • Successive approximations • Intensive

26. Behavior Therapies • Operant conditioning – Rewards • Attention • Praise • Token economy

27. Behavior Therapies • Behavior modification critics • How durable are the behaviors? • Wean toward natural reinforcers • Intrinsic rewards can be sufficient • Is it right for one human to control another’s behavior? • Some patients request therapy • Control already exists – just maintain negative patterns • More humane than institutionalization or punishment

28. Cognitive Therapies • Assume our thinking colors our feelings • We learn negative patterns of thinking that can be replaced • Teach new, constructive ways of thinking and reshape internal beliefs • Combine with efforts to modify behavior

29. Cognitive Therapies

30. Cognitive Therapies • Beck’s Therapy for depression • Reverse client’s catastrophizing beliefs • Self, situation, future • Gentle questioning • Reveal irrational thinking

31. Cognitive Therapies • Stress inoculation training: teach people to restructure their thinking in stressful situations (Meichenbaum, 1977, 1985) • Self-talk • Train to dispute negative thoughts Depression-prone children and college students exhibited halved rate of future depression (Seligman, 2002)

32. Cognitive Behavior Therapy • Combines cognitive therapy and behavior therapy • Change self-defeating thinking and behavior • Emotion regulation: replace catastrophizing thinking with more realistic appraisals and practice behaviors that are incompatible with their problem • OCD - re-label and refocus in response to compulsion

33. Group and Family Therapies • +Saves time & money • +No less effective than individual(Fuhriman & Burlingame, 1994) • +Others have similar problems = relief • +Feedback • -Less therapist involvement

34. Group & Family Therapies Family Therapy • Treats the family as a system • Individual’s behavior influenced by, or directed at, other family members • Heal relationships • Mobilize family resources • Open communication • Prevent & resolve conflict • Connection with differentiation

35. Group and Family Therapies Self-help & Support Groups • 14,000 self-help groups found online • Focus on stigmatized or hard-to-discuss illness • AIDS • Anorexia • Hearing loss • Alcoholics Anonymous • >2 million members • More meetings - greater abstinence

36. Evaluating Psychotherapies Clients’ Perceptions • Enter in crisis • Need to believe it is worth the effort • Speak kindly of their therapist • Data do not tend to support these perceptions

37. Evaluating Psychotherapies Clinicians’ Perceptions • Clients justify entering treatment due to unhappiness • Clients justify leaving treatment due to feelings of well-being • Therapist shopping (?)

38. Evaluating Psychotherapies Inflationary perceptions of effectiveness • Placebo effect: healing power of positive expectation • Regression toward the mean: tendency for unusual events or emotions to return to their average state • When we hit bottom, it is likely followed by improvement

39. Evaluating Psychotherapies • Does the client’s improvement following a particular therapy exceed what would be expected from placebo and regression effects alone? • Control groups

40. Evaluating Psychotherapies • Randomized clinical trials • Random assignment to treatment or wait-list • Evaluate everyone • Blind evaluation: evaluator is unaware which group (treatment or control) each participant was in

41. Evaluating Psychotherapies • Meta-analysis: a procedure for statistically combining the results of many different research studies

42. Evaluating Psychotherapies Cost-Effectiveness • Search for other medical treatment drops • Lower medical costs • Improve efficiency • Diminish absenteeism

43. Evaluating Psychotherapies • No one therapy best in all cases • No relationship between clinicians’ experience, training, supervision, & licensing with clients’ outcomes

44. Evaluating Psychotherapies • Behavioral conditioning therapies • Phobias • Compulsions • Sexual disorders • Cognitive therapy • Depression • Reduced suicide risk Therapy is most effective when the problem is clear-cut

45. Evaluating Therapies

46. Evaluating Alternative Therapies • EMDR (eye movement desensitization and reprocessing) • Controlled studies do not support effectiveness • Exposure therapy in safe environment • Placebo effect • Light therapy • Seasonal affect disorder • Effective

47. Benefits Attributed to all Psychotherapies • The expectation that, with commitment from the patient, things can and will get better • Plausible explanation of their symptoms and an alternative way to look at themselves and their worlds • Therapists are empathic people whose care and concern the client feels • Respectful listening, reassurance, advice • Trust and respect

48. Biomedical Therapies • Psychopharmacology: the study of the effects of drugs on mind and behavior • Double-blind: Neither staff nor patient know who is receiving drug or placebo • Eliminates expectation bias

49. Biomedical Therapies • Antipsychotics: control psychotic symptoms (delusions, hallucinations) or disorganized thinking • Occasionally for severe anxiety • May help with very aggressive behavior Chlorpromazine (Thorazine), Thioridazine (Mellaril), Fluphenazine(Prolixin), Trifluoperazine (Stelazine), Thiothixene (Navane), Haloperidol (Haldol) Atypical antipsychotics: Clozapine (Clozaril), Risperidone (Risperdal), Quetiapine (Seroquel), Olanzapine (Zyprexa), Ziprasidone (Zeldox)

50. Biomedical Therapies • Anti-anxiety drugs: reduce severe anxiety • Help people cope with frightening stimuli, with other therapy • Potential physical and psychological dependence Benzodiazapines: Alpraxolam (Xanax), loraxepam (AtivanI), Diazepam (Valium), Clonazepam (Klonopin)