chapter 16-psychological treatment

Analysis of Transference

As client and therapist interact, the relationship between them may become complex and emotionally involved. Often people carry over, and unconsciously apply (or "transfer") to their therapist, attitudes and feelings that they had in their relations with a parent or other person close to them in the past, a process known as transference. Thus, clients may react to their analyst as they did to that earlier person and feel the same love, hostility, or rejection that they felt long ago. If the analyst is operating according to the prescribed role of maintaining an impersonal stance of detached attention, the often affect-laden reactions of the client can be interpreted, it is held, as a type of projection—inappropriate to the present situation yet highly revealing of central issues in the client's life. For example, should the client vehemently (but inaccurately) condemn the therapist for a lack of caring and attention to the client's needs, this would be seen as a "transference" to the therapist of attitudes acquired in childhood interactions with parents or other key individuals. In helping the client to understand and acknowledge the transference relationship, a therapist may provide the client with insight into the meaning of his or her reactions to others. In doing so, the therapist may also introduce a corrective emotional experience by refusing to engage the person on the basis of his or her unwarranted assumptions about the nature of the therapeutic relationship. If the client expects rejection and criticism, for example, the therapist is careful to maintain a neutral manner. In contrast, the therapist may express positive emotions at a point where the client feels particularly vulnerable, thereby encouraging the client to reframe and rethink her or his view of the situation. In this way it may be possible for the client to recognize these assumptions and to "work through" the conflict in feelings about the real parent or perhaps to overcome feelings of hostility and self-devaluation that stem from the earlier parental rejection. In essence, the negative effects of an undesirable early relationship are counteracted by working through a similar emotional conflict with the therapist in a therapeutic setting. A person's reliving of a pathogenic past relationship in a sense re-creates the neurosis in real life, and therefore this experience is often referred to as a transference neurosis. It is not possible here to consider at length the complexities of transference relationships, but a client's attitudes toward his or her therapist usually do not follow such simple patterns as our examples suggest. Often the client is ambivalent—distrusting the therapist and feeling hostile toward him or her as a symbol of authority, but at the same time seeking acceptance and love. In addition, the problems of transference are not confined to the client, for the therapist may also have a mixture of feelings toward the client. This countertransference, wherein the therapist reacts in accord with the client's transferred attributions rather than objectively, must be recognized and handled properly by the therapist. For this reason, it is considered important that therapists have a thorough understanding of their own motives, conflicts, and "weak spots"; in fact, all psychoanalysts undergo psychoanalysis themselves before they begin independent practice. The resolution of the transference neurosis is said to be the key element in effecting a psychoanalytic "cure." Such resolution can occur only if an analyst successfully avoids the pitfalls of countertransference. That is, the analyst needs to keep track of his or her own transference or reaction to a client's behavior. Failure to do so risks merely repeating, in the therapy relationship, the typical relationship difficulties characterizing the client's adult life. Analysis of transference and the phenomenon of countertransference are also part of most psychodynamic derivatives of classical psychoanalysis, to which we now turn.

psychotherapy

The belief that people with psychological problems can change—can learn more adaptive ways of perceiving, evaluating, and behaving—is the conviction underlying all psychotherapy or psychological treatment. Achieving these changes is by no means easy. Sometimes a person's view of the world and her or his self-concept are distorted because of pathological early relationships that have been reinforced by years of negative life experiences. In other instances, environmental factors such as an unsatisfying job, an unhappy relationship, or financial stresses must be the focus of attention in addition to psychotherapy. Because change can be hard, people sometimes find it easier to bear their present problems than to challenge themselves to chart a different life course. Therapy also takes time and offers no magical transformations. Nevertheless, it holds promise even for the most severe mental disorders. Psychotherapeutic interventions have been applied to a wide variety of chronic problems. Even severely disturbed clients with psychosis may profit from a therapeutic relationship that takes into account their level of functioning and maintains therapeutic subgoals that are within their capabilities (e.g., Kendler, 1999; Valmaggia et al., 2008). Moreover, contrary to common opinion, psychotherapy can be less expensive in the long run than alternative modes of intervention Numerous therapeutic approaches have been tried throughout history (some of them cruel and unusual in hindsight), and many exist today (see the following video). However, the era of managed care has prompted new and increasingly stringent demands that the efficacy of treatments be empirically demonstrated. This chapter explores some of the most widely accepted psychological and biological treatment approaches in use today. Although we recognize that different groups of mental health professionals often have their own preferences with respect to the use of the terms client and patient, in this chapter we use the terms interchangeably.

Evidence-Based Treatment

When a pharmaceutical company develops a new drug, it must obtain approval of the drug from the U.S. Food and Drug Administration (FDA) before that drug can be marketed. This involves, among other things, demonstrating through research on human subjects that the drug has efficacy—that is, that the drug cures or relieves some target condition. These tests, using voluntary and informed patients as subjects, are called randomized clinical trials (RCTs) or, more simply, efficacy trials. Although these trials may become quite elaborate, the basic design is one of randomly assigning (e.g., by the flip of a coin) half the patients to the supposedly "active" drug and the other half to a visually identical but physiologically inactive placebo. Usually, neither the patient nor the clinician is informed which is to be administered; that information is recorded in code by a third party. This double-blind study is an effort to ensure that expectations on the part of the patient and prescriber play no role in the study. After a predetermined treatment interval, the code is broken and the active-drug or placebo status of all subjects is revealed. If subjects on the active drug have improved in health significantly more than subjects on the placebo, the investigator has evidence of the drug's efficacy. Obviously, the same design could be modified to compare the efficacy of two or more active drugs, with the option of adding a placebo condition. Thousands of such studies are in progress daily across the country. They usually take place in academic medical settings, and many are financially supported by the pharmaceutical industry. Investigators of psychotherapy outcomes have attempted to apply this research design to their own field of inquiry, with necessary modifications (see Chambless & Ollendick, 2001). A source of persistent frustration has been the difficulty of creating a placebo condition that will appear credible to patients. Most such research has thus adopted the strategy of either comparing two or more purportedly "active" therapies or using a no-treatment ("wait list") control of the same duration as the active-drug treatment. However, withholding treatment from patients in need (even temporarily) by placing them on a wait list sometimes raises ethical concerns. Another problem is that therapists, even those with the same theoretical orientations, often differ markedly in the manner in which they deliver therapy. (In contrast, pills of the same chemical compound and dosage do not vary.) To test a given therapy, it therefore becomes necessary to develop a treatment manual to specify just how the therapy under examination will be delivered. Therapists in the research trial are then trained (and monitored) to make sure that their therapy sessions do not deviate significantly from the procedures outlined in the manual Efforts to "manualize" therapy represent one way that researchers have tried to minimize the variability in patients' clinical outcomes that might result from characteristics of the therapist themselves (such as personal charisma). Although manualized therapies originated principally to standardize psychosocial treatments to fit the RCT paradigm, some therapists recommend extending their use to routine clinical practice after efficacy for particular disorders has been established Efficacy, or RCT, studies of psychosocial treatments are increasingly common. These time-limited studies typically focus on patients who have a single DSM diagnosis (patients with comorbid diagnoses are sometimes excluded) and involve two or more treatment or control (e.g., wait list) conditions, where at least one of the treatment conditions is psychosocial (another could be some biological therapy, such as a particular drug). Client-participants are randomly assigned to these conditions, whose effects, if any, are evaluated systematically with a common battery of assessment instruments, usually administered both before and after treatment. Efficacy studies of the outcomes of specific psychosocial treatment procedures are considered the most rigorous type of evaluation researchers have for establishing that a given therapy "works" for clients with a given diagnosis. Treatments that meet this standard are often described as evidence based or empirically supported. See the following video on assessing treatment effectiveness to learn more.

Neurosurgery

Although neurosurgery was used occasionally in the nineteenth century to treat mental disorders by relieving pressure in the brain (Berrios, 1990), it was not considered a treatment for psychological problems until the twentieth century. In 1935 in Portugal, Antonio Moniz introduced a neurosurgical procedure in which the frontal lobes of the brain were severed from the deeper centers underlying them. This technique eventually evolved into an operation known as prefrontal lobotomy, which stands as an infamous example of the extremes to which professionals have sometimes been driven in their search for effective treatments for the psychoses. In retrospect, it is ironic that this procedure—which results in permanent structural changes in the brain of the patient and has been highly criticized by many within the profession—won Moniz the 1949 Nobel Prize in medicine (although he was later shot by a former patient who was, presumably, less than grateful). From 1935 to 1955 (when antipsychotic drugs became available), tens of thousands of psychiatric patients in the United States and abroad were subjected to prefrontal lobotomies and related neurosurgical procedures. In some settings, as many as 50 patients were treated in a single day (Freeman, 1959). Initial reports of results tended to be enthusiastic, downplaying complications (which included a 1 to 4 percent death rate) and undesirable side effects. It was eventually recognized, however, that the side effects of psychosurgery could be very undesirable indeed. In some instances they included a permanent inability to inhibit impulses, in others an unnatural "tranquility" with undesirable shallowness or absence of feeling. The introduction of the major antipsychotic drugs caused an immediate decrease in the widespread use of psychosurgery, especially prefrontal lobotomy. Such operations are rare today and are used only as a last resort for patients who have not responded to any other form of treatment for a period of 5 years and who are experiencing extreme and disabling symptoms. Modern surgical techniques involve the selective destruction of minute areas of the brain. Psychosurgery is sometimes used for patients with debilitating OCD (Dougherty et al., 2007), treatment-resistant severe self-injury (Price et al., 2001), or even intractable anorexia nervosa (Morgan & Crisp, 2000). However, such approaches carry serious risks. In one study, 25 patients who had received brain lesions to treat severe OCD were followed up an average of 11 years later. Twelve of the 25 patients experienced significant relief from their OCD symptoms after the surgery. They also showed reductions in depression. However, 10 of the patients who showed clinical improvement also showed evidence of frontal lobe dysfunction at follow-up, including impaired executive functioning on cognitive tests, problems with apathy, and disinhibited behavior (Rück et al., 2008). These results highlight the risks of brain surgery even when it is effective in treating the symptoms of OCD. Deep brain stimulation is a different treatment approach that involves surgery but does not result in a permanent lesion being made in the brain.

Evaluating Humanistic-Experiential Therapies

Many of the humanistic-experiential concepts—the uniqueness of each individual, the importance of therapist genuineness, the satisfaction that comes from realizing one's potential, the importance of the search for meaning and fulfillment, and the human capacity for choice and self-direction—have had a major impact on our contemporary views of both human nature and the nature of good psychotherapy. However, humanistic-experiential therapies have been criticized for their lack of agreed-on therapeutic procedures and their vagueness about what is supposed to happen between client and therapist. In response, proponents of such approaches argue against reducing people to abstractions, which can diminish their perceived worth and deny their uniqueness. Because people are so different, they argue, we should expect different techniques to be appropriate for different cases. Controlled research on the outcomes achieved by many forms of humanistic-existential therapy was lacking in the past. However, research in this area is now on the increase. Evidence suggests that these treatment approaches are helpful for patients with a variety of problems including depression, anxiety, trauma, and marital difficulties (Elliot et al., 2004). And, as we have already noted, motivational interviewing is now established as an effective method for promoting behavior change in people with substance abuse problems

Who Provides Psychotherapeutic Services?

Members of many different professions have traditionally provided advice and counsel to individuals in emotional distress. Physicians, in addition to caring for their patients' physical problems, often become trusted advisers in emotional matters as well. Many physicians are trained to recognize psychological problems that are beyond their expertise and to refer patients to psychological specialists or to psychiatrists. Another professional group that deals extensively with emotional problems is the clergy. A minister, priest, or rabbi is frequently the first professional to encounter a person experiencing an emotional crisis. Although some clergy are trained mental health counselors, most limit their counseling to religious matters and spiritual support and do not attempt to provide psychotherapy. Rather, like general-practice physicians, they are trained to recognize problems that require professional management and to refer seriously disturbed people to mental health specialists. Often the first person that someone experiencing an emotional crisis will talk to is a trusted member of his or her religious community. The three types of mental health professionals who most often administer psychological treatment in mental health settings are clinical psychologists, psychiatrists, and psychiatric social workers. In addition to their being able to provide psychotherapy, the medical training and licensure qualifications of psychiatrists enable them to prescribe psychoactive medications and also to administer other forms of medical treatment such as electroconvulsive therapy. In some states, appropriately supervised psychologists and other clinical specialists may prescribe medications if they have received additional training. Although mental health professionals differ with respect to their training and approach to treatment, generally, psychiatrists differ from psychologists insofar as they treat mental disorders using biological approaches (e.g., medications), whereas psychologists treat patients' problems by examining and in some cases changing their patients' behaviors and thought patterns. In a clinic or hospital (as opposed to an individual practice), a wide range of treatment approaches may be used. These range from the use of medications, to individual or group psychotherapy, to home, school, or job visits aimed at modifying adverse conditions in a client's life—for example, helping a teacher become more understanding and supportive of a child-client's needs. Often the latter is as important as treatment directed toward modifying the client's personality, behavior, or both. This willingness to use a variety of procedures is reflected in the frequent use of a team approach to assessment and treatment, particularly in group practice and institutional settings. This approach ideally involves the coordinated efforts of medical, psychological, social work, and other mental health personnel working together as the needs of each case warrant. Also of key importance is the current practice of providing treatment facilities in the community. Instead of considering maladjustment to be an individual's private misery, which in the past often required confinement in a distant mental hospital, this approach integrates family and community resources in a total treatment approach.

SNRI's

More recently, another class of medications has been introduced. These are called serotonin and norepinephrine reuptake inhibitors (SNRIs; Thase, 2009b). Examples of antidepressants in this drug family are venlafaxine (Effexor) and duloxetine (Cymbalta). SNRIs block the reuptake of both norepinephrine and serotonin. They have similar side effects to the SSRIs, and they are relatively safe in overdose. SNRIs seem to help a significant number of patients who have not responded well to other antidepressants, and they are slightly more effective than SSRIs in the treatment of major depression

Nonmedicinal Biological Treatments

Psychotherapy attempts to change the brain by modifying a person's environment and experience (by using words, exposures, role-playing, etc.), whereas all of the biological changes discussed so far try to change the brain by introducing chemicals into the brain. Another type of biological intervention uses a third approach—changing the activity of the brain directly by using electrical activity and/or surgery. As we have discussed, the brain works using electrical signals. Guided by this fact, researchers have begun to use electrical activity to modify the electrical activity of the brain in ways they hope will alleviate mental disorder. Below we review several such approaches, as well as the use of neurosurgery to change the physical structure of the brain.

Couples Therapy

Relationship problems are a major cause of emotional distress. The large numbers of couples seeking help with troubled relationships have made couples counseling a growing field of therapy. Typically the couple is seen together. The primary reasons that couples report for seeking treatment are communication problems and a lack of affection (Doss et al., 2004). As such, improving communication skills and developing more adaptive problem-solving styles are both major foci of clinical attention. Although it is quite routine at the start of therapy for each partner secretly to harbor the idea that only the other will have to do the changing, it is nearly always necessary for both partners to alter their reactions to the other. For many years the gold standard of couple therapy has been traditional behavioral couple therapy (TBCT) (Christensen et al., 2007). TBCT is based on a social-learning model and views marital satisfaction and marital distress in terms of reinforcement. The treatment is usually short term (10 to 26 sessions) and is guided by a manual. The goal of TBCT is to increase caring behaviors in the relationship and to teach partners to resolve their conflicts in a more constructive way through training in communication skills and adaptive problem solving. Traditional behavioral couple therapy is an empirically supported treatment for couple distress (Snyder et al., 2006). Early research established that two-thirds of couples tend to do well and to show improvement in relationship satisfaction (Jacobson et al., 1987). However, it rapidly became apparent that this form of treatment does not work for all couples (Jacobson & Addis, 1993). Moreover, even among couples who do show an improvement in relationship satisfaction, the improvement is not always maintained over time These limitations of TBCT led researchers to conclude that a change-focused treatment approach was not appropriate for all couples. This created the impetus for the development of integrative behavioral couple therapy (IBCT) (Jacobson et al., 2000; Wheeler et al., 2001). Instead of emphasizing change (which sometimes has the paradoxical effect of making people not want to change), IBCT focuses on acceptance and includes strategies that help each member of the couple come to terms with and accept some of the limitations of his or her partner. Of course, change is not forbidden. Rather, within IBCT, acceptance strategies are integrated with change strategies to provide a form of therapy that is more tailored to individual characteristics, relationship "themes" (long-standing patterns of conflicts), and the needs of the couple. Although IBCT is a relative newcomer in the couple therapy field, findings regarding its effectiveness are quite promising. In one early study, improvement rates were 80 percent in the couples treated with IBCT versus 64 percent in couples receiving TBCT (Jacobson et al., 2000). In another, larger study, 70 percent of couples who received IBCT showed clear improvement in their relationship compared with 61 percent of couples receiving TBCT (Christensen et al., 2007). Although these differences are not statistically different from each, other data show that couples who stay together after receiving IBCT are significantly happier than couples who stay together following treatment with TBCT (Atkins et al., 2005). Most recently, ICBT has been translated into a format in which couples can work through therapy via an online self-help website

People who Seek Personal Growth

A final group of people who enter therapy have problems that would be considered relatively normal. That is, they appear to have achieved success, have financial stability, have generally accepting and loving families, and have accomplished many of their life goals. They enter therapy not out of personal despair or impossible interpersonal involvements but out of a sense that they have not lived up to their own expectations and realized their own potential. These people, partly because their problems are more manageable than the problems of others, may make substantial gains in personal growth. It should be clear from these brief descriptions that there is no typical client. Neither is there a model therapy. No currently used form of therapy is applicable to all types of clients. Most authorities agree that client variables such as motivation to change and severity of symptoms are exceedingly important to the outcome of therapy (Clarkin & Levy, 2004). As we will see, the various therapies have relatively greater success when a therapist takes the characteristics of a particular client into account in determining treatment approaches.

Transcranial Magnetic Stimulation

A newer, more targeted approach that uses electricity to change brain functioning is transcranial magnetic stimulation (TMS). TMS is a treatment in which the clinician positions a pulsed magnet over a carefully selected area of the patient's scalp and uses it to create an electrical field that increases or decreases neuronal activity in the brain (see Figure 16.5). Scientists have been using magnets to create electrical fields since the 1830s; however, it wasn't until 1985 that magnets were used for the purposes of brain stimulation (Barker et al., 1985). During the past 30 years, technological advances have led to the ability to carefully control the location, intensity, frequency, and pattern of the electrical currents directed at very specific parts of the brain. At this point, numerous studies have shown that TMS can be used to effectively treat major depression, with additional evidence supporting its use with other conditions TMS is less invasive than surgical interventions and has fewer and less severe side effects than ECT. The most commonly reported side effects from repeated TMS sessions are mild headache and a small risk of seizure. However, there are no impairments in memory or concentration as there are with ECT. Although TMS has shown effectiveness for treating depression and other conditions, it is still a very new approach and typically is only considered after several courses of psychotherapy and antidepressant medication have proven ineffective.

Medication or Psychotherapy?

Advances in psychopharmacology—the use of medications to treat mental disorders—have allowed many people who would otherwise need hospitalization to remain with their families and function in the community. These advances have also reduced the time patients need to spend in the hospital and have made restraints and locked wards largely relics of the past. In short, medication has led to a much more favorable hospital climate for patients and staff alike. Nevertheless, certain issues arise in the use of psychotropic drugs. Aside from possible unwanted side effects, there is the complexity of matching drug and dosage to the needs of each specific patient. It is also sometimes necessary for patients to change medication during the course of treatment. In addition, the use of medications in isolation from other treatment methods may not be ideal for some disorders because drugs themselves generally do not cure disorders. Nonetheless, there is now a national trend toward greater use of psychiatric medications at the expense of psychotherapy. This may be problematic because, as many investigators have pointed out, drugs tend to alleviate symptoms by inducing biochemical changes, not by helping the individual understand and change the personal or situational factors that may be creating or reinforcing maladaptive behaviors. Moreover, when drugs are discontinued, patients may be at risk of relapsing. For many disorders, a variety of evidence-based forms of psychotherapy may produce more long-lasting benefits than medications alone unless the medications are continued indefinitely.

Rebooting Psychotherapy

Although many forms of psychotherapy look pretty similar today to how they looked decades ago (i.e., two people, one office, lots of discussion), there have been some exciting changes in recent years regarding how psychological treatment is studied and practiced. Kazdin and Blaise (2011) have referred to these (and future) changes as a "rebooting" of psychotherapy research and practice. They note that as effective as psychotherapy is, it is not able to meet the enormous demand for treatment in the United States and around the world. Instead, we need to start using advances in technology, and other areas, to become more efficient in how we make assessments and treatments available to the public. There are many examples of how new technologies are being used to enhance the delivery of effective interventions. Effective interventions are being packaged as self-help platforms on the Internet (e.g., Doss et al., 2013). Smartphones are being equipped with programs that can record data about patients' thoughts, feelings, and behaviors in real time (Nock, Prinstein, & Sterba, 2009), as well as actually deliver interventions (Kaplan & Stone, 2013). Socially assistive robots are being used to help deliver psychological interventions to those in need (Rabbitt et al., 2015). These are just a few of the exciting developments happening in the changing landscape of psychological treatment research. It is a truly fascinating time to be learning about, and working in, this field!

Monoamine Oxidase Inhibitors

Although they are used infrequently now, MAOIs were the first antidepressant medications to be developed, in the 1950s. These drugs were being studied for the treatment of tuberculosis when they were found to elevate the mood of patients (Stahl, 2000). They were later shown to be effective in treating depression. Monoamine oxidase inhibitors include isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate), and selegiline (Eldepryl). They inhibit the activity of monoamine oxidase, an enzyme present in the synaptic cleft that helps break down the monoamine neurotransmitters (such as serotonin and norepinephrine) that have been released into the cleft. Patients taking MAOIs must avoid foods rich in the amino acid tyramine (such as salami and Stilton cheese). This limits the drugs' clinical usefulness. Nevertheless, MAOIs are used in certain cases of atypical depression that are characterized by hypersomnia and overeating and do not respond well to other classes of antidepressant medication

Deep Brain Stimulation for Treatment-Resistant Depression

An important development in the treatment of patients with severe and chronic mental health problems is deep brain stimulation. This involves stimulating patients' brains electrically over a period of several months. First, surgeons drill holes into the brain and implant small electrodes (see Figure 16.6). Because this procedure is done under local anesthetic, patients can talk to the doctors about what is happening to them and tell the doctors about the changes they experience. In an early study involving six patients, all reported a response to the electrical stimulation even though they had no cues to tell them when current was being passed through the electrodes or when the current was off (Mayberg et al., 2005). When current was flowing into an area of the brain that is thought to be metabolically overactive in depression (the cingulate region), patients reported that they felt better and had experiences of "sudden calmness or lightness," "connectedness," or "disappearance of the void." After the electrodes have been implanted, patients receive short sessions of deep brain stimulation in which current is passed through the implanted electrodes. Using the reports of the patients as a guide, the researchers can select the settings that will be used to provide stimulation through an implanted pulse device after the patients leave the hospital. How effective is deep brain stimulation as a treatment for unrelenting depression? A total of 20 people who have received this treatment have now been followed up for an average of 3.5 years (Kennedy et al., 2011). The results suggest that this treatment is beneficial for approximately half of the patients. Many of those who responded also returned to work or began to volunteer in their communities. Although a 50 percent response rate may not strike you as very high, keep in mind that only the most chronically ill people are eligible to receive this treatment. Although it is invasive, deep brain stimulation may be able to help a small majority of patients who have failed to show improvement with any other methods.

Analysis of Dreams

Another important, related procedure for uncovering unconscious material is the analysis of dreams. When a person is asleep, repressive defenses are said to be lowered, and forbidden desires and feelings may find an outlet in dreams. For this reason, dreams have been referred to as the "royal road to the unconscious." Some motives, however, are so unacceptable to an individual that even in dreams they are not revealed openly but are expressed in disguised or symbolic form. Thus, a dream has two kinds of content: (1) manifest content, which is the dream as it appears to the dreamer, and (2) latent content, which consists of the actual motives that are seeking expression but are so painful or unacceptable that they are disguised. It is a therapist's task, in conjunction with the associations of the patient, to uncover these disguised meanings by studying the images that appear in the manifest content of a client's dream and in the client's associations to them. For example, a client's dream of being engulfed in a tidal wave may be interpreted by a therapist as indicating that the client feels in danger of being overwhelmed by inadequately repressed fears or hostilities.

Objective Measures

Another widely used objective measure of client change is performance on various psychological tests. A client evaluated in this way takes a battery of tests before and after therapy, and the differences in scores are assumed to reflect progress, or lack of progress, or occasionally even deterioration. However, some of the changes that such tests show may be artifactual, as with regression to the mean, wherein very high (or very low) scores tend on repeated measurement to drift toward the average of their own distributions, yielding a false impression that some real change has been documented. Also, the particular tests selected are likely to focus on the theoretical predictions of the therapist or researcher. Thus, they are not necessarily valid predictors of the changes, if any, that the therapy actually induces or of how the client will behave in real life. And without follow-up assessment, they provide little information on how enduring any change is likely to be. In research settings, functional magnetic resonance imaging (fMRI) can be used to examine brain activity before and after treatment. For example, Nakao and colleagues (Nakao, T., Nakagawa, A., Yoshiura, T., Nakatani, E., Nabeyama, M., Yoshizato, C., et al. 2005) studied 10 outpatients with obsessive-compulsive disorder (OCD). At the start of the study, all the patients received a brain scan while they were engaged in a task that required them to think about words (e.g., sweat, urine, feces) that triggered their obsessions and compulsions. Patients were then treated for 12 weeks either with the SSRI (selective serotonin reuptake inhibitor) fluvoxamine (Luvox) or with behavior therapy. At the end of this treatment period, the brain scanning was repeated. The results showed that, before treatment, certain areas of the brain thought to be involved in OCD (e.g., a brain region in the frontal lobe called the orbitofrontal cortex) were activated during the symptom-provocation task. However, after therapy, these same regions showed much less activation when the patients were challenged to think about the provocative trigger words. In subsequent research these scientists have also shown that, after 12 weeks of behavior therapy, patients with OCD again show changes in several brain regions that are implicated in this disorder (Nabeyama et al., 2008). Research of this type suggests that physiological changes may indeed accompany the clinical gains that occur in psychotherapy

Antianxiety Drugs

Antianxiety drugs are used for conditions in which tension and anxiety are significant components. They do not provide a cure. However, these medications can keep symptoms under control until patients are able to receive other forms of effective psychological treatments. The fact that they are so widely prescribed has caused concern among some leaders in the medical and psychiatric fields because of these drugs' addictive potential and sedating effects. Antianxiety medications have little place in the treatment of psychosis. However, they are often used as supplementary treatments in certain neurological disorders to control such symptoms as convulsive seizures.

Antidepressant Drugs+widely used medications

Antidepressants are the most commonly prescribed psychiatric medications. More than 90 percent of patients being treated for depressive disorders will be given these medications.

Lithium and Other Mood-Stabilizing Drugs

Around 1970, about 20 years later, lithium treatment was introduced in the United States. There were at least two reasons for this delay. First, lithium had been used in the 1940s and 1950s as a salt substitute for patients with hypertension before its toxic side effects were known. Some tragic deaths resulted, making the medical community very wary of using it for any reason. Second, because it is a naturally occurring compound, it is unpatentable. This meant that drug companies did not find it profitable to investigate its effects. Nevertheless, lithium is still widely used for the treatment of bipolar disorder and is marketed as Eskalith and Lithobid. Although lithium has been used for many years, exactly how it brings about its therapeutic effect is still not certain Even though we still do not know exactly how it works, there is no doubt about the effectiveness of lithium. As many as 70 to 80 percent of patients in a clear manic state show marked improvement after 2 to 3 weeks of taking lithium (Keck & McElroy, 2002). In addition, lithium sometimes relieves depression, although probably mainly in patients with bipolar depression (Stahl, 2000). There is increasing evidence that lithium maintenance treatment may be less reliable at preventing future episodes of mania than was once thought. For example, several studies of patients with bipolar disorder maintained on lithium for 5 years or more found that only just over one-third remained in remission. Nevertheless, discontinuation of lithium is also very risky. The probability of relapse is estimated to be 28 times higher after withdrawal than when the patient is on lithium, with about 50 percent relapsing within 6 months Side effects of lithium include increased thirst, gastrointestinal difficulties, weight gain, tremor, and fatigue. In addition, lithium can be toxic if the recommended dose is exceeded or if the kidneys fail to excrete it from the body at a normal rate. Lithium toxicity is a serious medical condition. If not treated swiftly and appropriately, it can cause neuronal damage or even death. Despite the clinical benefits of lithium, not all patients with bipolar disorder take it exactly as prescribed. Many seem to miss the "highs" and the abundance of energy associated with their hypomanic episodes, so when faced with unpleasant side effects and the loss of these highs they may stop taking the drug. Although lithium is still widely used, other drugs are also considered first-line treatments for bipolar disorder (see Table 16.4). These include valproic acid (Depakote) and carbamazepine (Tegretol). Other drugs that are currently being researched and used clinically as treatments for rapid cycling bipolar disorders are gabapentin (Neurontin), lamotrigine (Lamictal), and topiramate (Topamax). Many of these drugs are also used in the treatment of epilepsy and are anticonvulsant agents (Keck & McElroy, 2007). Carbamazepine has been associated with significant side effects including blood problems, hepatitis, and serious skin conditions (Post & Frye, 2009). As with lithium, careful blood monitoring of patients is required. Valproate probably has the fewest and mildest side effects, which can include nausea, diarrhea, sedation, tremor, and weight gain. Abilify, an antipsychotic medication, is also now being marketed as a treatment for bipolar disorder.

Selective Serotonin Reuptake Inhibitors

As is the case for antipsychotic medications, the drugs that were discovered first (so-called classical antidepressants such as monoamine oxidase inhibitors [MAOIs] and tricyclic antidepressants [TCAs]) have now been replaced in routine clinical practice by "second-generation" treatments such as the SSRIs. In 1988 fluoxetine (Prozac) became the first SSRI to be released in the United States. Its pharmacological cousins include sertraline (Zoloft) and paroxetine (Paxil). More recent additions to the SSRI family are fluvoxamine (Luvox), which is used in the treatment of OCD; citalopram (Celexa); and escitalopram (Lexapro). All are equally effective. SSRIs are chemically unrelated to the older TCAs and to the MAOIs. However, most antidepressants work by increasing the availability of serotonin, norepinephrine, or both. As their name implies, the SSRIs serve to inhibit the reuptake of the neurotransmitter serotonin following its release into the synapse. Unlike the tricyclics (which inhibit the reuptake of both serotonin and norepinephrine), SSRIs selectively inhibit the reuptake of serotonin (see Figure 16.2 and the following video on SSRIs). They have become the preferred antidepressant drugs, in large part due to very aggressive advertising by the pharmaceutical companies. SSRIs are also easier to use, have fewer side effects, and are generally not found to be fatal in overdose, as the tricyclics can be. However, there is no compelling evidence that they are more effective than other types of antidepressants Clinical trials with the SSRIs indicate that patients tend to improve after about 3 to 5 weeks of treatment. Patients who show at least a 50 percent improvement in their symptoms are considered to have had a positive response to treatment (see Figure 16.3a). However, although considerably better, such patients are not fully well. When treatment removes all of a patient's symptoms, patients are considered to be in a period of remission (see Figure 16.3b). If this remission is sustained for 6 to 12 months or more, the patient is considered to have recovered. In other words, he or she is fully well again. Side effects of the SSRIs include nausea, diarrhea, nervousness, insomnia, and sexual problems such as diminished sexual interest and difficulty with orgasm (Nemeroff & Schatzberg, 2007). After early reports linked Prozac with increased risk of suicide (e.g., Cole & Bodkin, 1990; Papp & Gorman, 1990), there was a decline in its use. However, Prozac is no more associated with suicide than are other antidepressants (Jick et al., 2004). Recently there has also been concern that, when used during pregnancy, fluoxetine (Prozac) and paroxetine (Paxil) may increase the risk of heart abnormalities in the baby (Diav-Citrin et al., 2008; Malm et al., 2011). For this reason these medications are not recommended as a first option for women planning to become pregnant. It is important to keep in mind, however, that all the risks we have just described are small when weighed against the risks associated with leaving people who are depressed without adequate treatment. Although SSRIs help many people, some people have side effects that are so extreme that they are unable to continue to take their medication as prescribed. Researchers are now exploring the role that genes play in making some people especially susceptible to the adverse effects of specific medications

Modeling

As the name implies, in modeling the client learns new skills by imitating another person, such as a parent or therapist, who performs the behavior to be acquired. A younger client may be exposed to behaviors or roles in peers who act as assistants to the therapist and then be encouraged to imitate and practice the desired new responses. For example, modeling may be used to promote the learning of simple skills such as self-feeding for a child with profound mental retardation or more complex skills such as being more effective in social situations for a shy, withdrawn adolescent. In work with children especially, effective decision making and problem solving may be modeled when the therapist "thinks out loud" about everyday choices that present themselves in the course of therapy Modeling and imitation are adjunctive aspects of various forms of behavior therapy as well as other types of therapy. For example, in an early classic work, Bandura (1964) found that live modeling of fearlessness, combined with instruction and guided exposure, was the most effective treatment for snake phobia, resulting in the elimination of phobic reactions in over 90 percent of the cases treated.

Antipsychotic Drugs

As their name suggests, antipsychotic drugs (also called neuroleptics) are used to treat psychotic disorders such as schizophrenias. You have already read about these medications in the Schizophrenia and Other Psychotic Disorders chapter. The key therapeutic benefit of antipsychotics derives from their ability to alleviate or reduce the intensity of delusions and hallucinations. They do this by blocking dopamine receptors. Studies have found that approximately 60 percent of patients with schizophrenia who are treated with traditional antipsychotic medications have a resolution of their positive symptoms within 6 weeks, compared to only about 20 percent of those treated with placebo (Sharif et al., 2007). These drugs are also useful in treating other disorders with psychotic symptoms such as mania, psychotic depression, and schizoaffective disorder, and they are occasionally used to treat transient psychotic symptoms when these occur in people with borderline personality disorder and schizotypal personality disorder Finally, antipsychotic medications are sometimes used to treat the delusions, hallucinations, paranoia, and agitation that can occur with Alzheimer's disease. However, antipsychotic medications pose great risks to patients with dementia because they are associated with increased rates of death (Sultzer et al., 2008). Because of this, there is now a "black box warning" about using these medications for patients with dementia. (A black box warning is a warning on the outside of a medication package about the potential dangers of that medication that literally appears inside a black box.) Antipsychotic medications are usually administered daily in pill form. However, some patients are not able to remember to take their medications each day. In such cases, depot neuroleptics can be very helpful. These are neuroleptics that can be administered in a long-acting, injectable form. The clinical benefits of one injection can last for up to 4 weeks, which makes depot neuroleptics very valuable for patients who need medication but are unwilling or unable to take drugs every day. Research suggests that patients with schizophrenia who take depot medications do better than those who use oral compounds Tardive (from tardy) dyskinesia is a movement abnormality that is a delayed result of taking antipsychotic medications. Because movement-related side effects are a little less common with atypical antipsychotic medications such as clozapine (Clozaril) and olanzapine (Zyprexa), these medications are often preferred in the clinical management of schizophrenia. Clozapine also seems to be especially beneficial for patients with psychosis who are at high risk of suicide. Even the atypical neuroleptics have side effects, however. Weight gain and diabetes are a major source of clinical concern (Sernyak et al., 2002). You may recall that an even more serious side effect of clozapine is a potentially life-threatening drop in white blood cell count called agranulocytosis, which occurs in 1 percent of patients (Sharif et al., 2007). Accordingly, patients must have their blood tested every week for the first 6 months of treatment and then every 2 weeks thereafter for as long as they are on the medication. Because of this, clozapine is best regarded as a medication to consider after other medications (e.g., some of the other atypical antipsychotic medications) have proved ineffective. Current thinking is that the atypical antipsychotics described above (with the exception of clozapine) are the first-choice treatments for psychosis and that clozapine and conventional antipsychotics (e.g., Haldol) are best considered as second-line therapies.

Psychotherapy and Cultural Diversity

As we have seen, the establishment and maintenance of an effective psychotherapeutic "working alliance" between client and therapist is generally regarded as a crucial and indispensable element in determining the success of the outcome. What does this mean for a client whose background is considerably different from that of the therapist? As yet, there is little or no solid evidence that psychotherapeutic outcomes are diminished when client and therapist differ in race or ethnicity (Beutler et al., 2004; Sue et al., 1994). However, members of minority groups are seriously underrepresented in treatment research studies, and this makes it difficult to fully assess their needs and outcomes (Miranda et al., 2005; Nagayama Hall, 2001). Moreover, racial and ethnic minorities are clearly underserved by the mental health system (Snowden & Yamada, 2005; U.S. Department of Health and Human Services [USDHHS], 2001). However, the factors that are behind these disparities are complex and not well understood. In general, minority patients tend to prefer ethnically similar therapists over European American therapists. Mexican Americans state a strong preference for therapists who share their ethnic background and express the view that such therapists are more "credible" than Anglo therapists would be (Lopez et al., 1991; Ponce & Atkinson, 1989). However, finding an ethnically matched therapist may present difficulties. In one survey, for example, only 2 percent of psychiatrists, 2 percent of psychologists, and 4 percent of social workers said they were African Americans (Holzer et al., 1998). The number of mental health professionals who are representative of other minority groups is no better (USDHHS, 2001). The lack of trained therapists familiar with the issues important to different ethnic groups is a serious drawback, given the unique problems often associated with certain groups. When specialized, culturally adapted interventions are made available in community settings, ethnic minority clients are less likely to drop out of treatment and often do well (Snowden & Yamada, 2005). However, such programs are still lacking in many communities. Also lacking are research investigations designed to understand how culture and ethnicity affect a person's ability to access and receive psychiatric and psychological treatments. Nonetheless, there are encouraging developments. For example, Weisman and colleagues (Weisman, A., Duarte, E., Koneru, V., & Wasserman, S. 2006) are developing culturally informed treatments for the families of patients with schizophrenia. This approach considers the role of family cohesiveness as well as spirituality and religion in the therapy process. Researchers are also developing culturally informed psychotherapy for Hispanic patients with major depression (Markowitz et al., 2009), as well as for African American women who are suicidal and in abusive relationships

Exposure Therapy

As you know, a behavior therapy technique that is widely used in the treatment of anxiety disorders is exposure (see the chapter, Panic, Anxiety, Obsessions, and Their Disorders). If anxiety is learned, then, from the behavior therapy perspective, it can be unlearned. This is accomplished through guided exposure to anxiety-provoking stimuli. During exposure therapy, the patient or client is confronted with the fear-producing stimulus in a therapeutic manner. This can be accomplished in a very controlled, slow, and gradual way, as in systematic desensitization, or in a more extreme manner, as in flooding, in which the patient directly confronts the feared stimulus at full strength. (An example is a housebound patient with agoraphobia being accompanied outdoors by the therapist.) Moreover, the form of the exposure can be real (also known as in vivo exposure) or imaginary (imaginal exposure). The rationale behind systematic desensitization is quite simple: Find a behavior that is incompatible with being anxious (such as being relaxed or experiencing something pleasant) and repeatedly pair this with the stimulus that provokes anxiety in the patient. Because it is difficult if not impossible to feel both pleasant and anxious at the same time, systematic desensitization is aimed at teaching a person, while in the presence (real or imagined) of the anxiety-producing stimulus, to relax or behave in some other way that is inconsistent with anxiety. It may therefore be considered a type of counterconditioning procedure. The term systematic refers to the carefully graduated manner in which the person is exposed to the feared stimulus.' Joseph Wolpe (Wolpe, J., 1958; Rachman & Hodgson, 1980) elaborated on the procedure developed by Jones and coined the phrase systematic desensitization to refer to it. On the assumption that most anxiety-based patterns are, fundamentally, conditioned responses, Wolpe worked out a way to train a client to remain calm and relaxed in situations that formerly produced anxiety. Wolpe's approach is elegant in its simplicity, and his method is equally straightforward. A client is first taught to enter a state of relaxation, typically by progressive concentration on relaxing various muscle groups. Meanwhile, patient and therapist collaborate in constructing an anxiety hierarchy that consists of imagined scenes graded as to their capacity to elicit anxiety. For example, for a patient with a dog phobia, a low-anxiety step might be imagining a small dog in the distance being walked on a leash by its owner. In contrast, a high-anxiety step might be imagining a large and exuberant dog running toward the patient. Therapy sessions consist of the patient's repeatedly imagining, under conditions of deep relaxation, the scenes in the hierarchy, beginning with low-anxiety images and gradually working toward those in the more extreme ranges. Treatment continues until all items in the hierarchy can be imagined without notable discomfort, at which point the client's real-life difficulties typically have shown substantial improvement. Imaginal procedures have some limitations, an obvious one being that not everybody is capable of vividly imagining the required scenes. In an influential early study of clients with agoraphobia, Emmelkamp and Wessels (1975) concluded that prolonged exposure in vivo is superior to imaginal exposure. Since then, therapists have sought to use in vivo exposure whenever practical, encouraging clients to confront anxiety-provoking situations directly. As practicing clinicians, we sometimes receive e-mails from behavior therapists asking for instructions on making concoctions that look like vomit. In these cases the therapist is treating someone who has a vomiting phobia and has a need for something that looks realistic for an in vivo exposure. Of course, in vivo exposure is not possible for all stimuli. In addition, occasionally a client is so fearful that he or she cannot be induced to confront the anxiety-arousing situation directly. Imaginal procedures are therefore a vital part of the therapeutic exposure repertoire. An important development in behavior therapy is the use of virtual reality to help patients overcome their fears and phobias (Rothbaum, Hodges, et al., 2000). Such approaches are obviously needed when the source of the patient's anxiety is something that is not easily reproduced in real life, such as flying. Overall, the outcome record for exposure treatments is impressive. It is also encouraging that the results from virtual reality exposure are comparable to the results obtained from in vivo exposure

Objectifying and Quantifying Change

Attempts at estimating clients' gains in therapy generally depend on one or more of the following sources of information: (1) a client's reports of change in their symptoms or functioning, (2) a clinician's ratings of changes that have occurred, (3) reports from the client's family or friends, (4) comparison of pretreatment and posttreatment scores on instruments designed to measure relevant facets of psychological functioning, and (5) measures of change in selected overt behaviors. Each of these sources has strengths, but also some important limitations.

Aversion Therapy

Aversion therapy involves modifying undesirable behavior by the old-fashioned method of punishment. Probably the most commonly used aversive stimuli today are drugs that have noxious effects, such as Antabuse, which induces nausea and vomiting when a person who has taken it ingests alcohol. In another variant, the client is instructed to wear a substantial elastic band on the wrist and to "snap" it when temptation arises, thus administering self-punishment. In the past, painful electric shock was commonly employed in programs that paired it with the occurrence of the undesirable behavior, a practice that certainly contributed to aversion therapy's negative image among some segments of the public. Although aversive conditioning has been used to treat a wide range of maladaptive behaviors including smoking, drinking, overeating, drug dependence, gambling, sexual deviance, and bizarre psychotic behavior, interest in this approach has declined as other treatment options have become available

Beck's Cognitive Therapy

Beck's cognitive therapy approach was originally developed for the treatment of depression and later for anxiety disorders. Now, however, this form of treatment is used for a broad range of conditions, including eating disorders and obesity, personality disorders, substance abuse, and even schizophrenia (Beck, 2005; Beck & Rector, 2005; Hollon & Beck, 2004). The cognitive model is basically an information-processing model of psychopathology. A fundamental assumption of the cognitive model is that problems result from biased processing of external events or internal stimuli. These biases distort the way that a person makes sense of the experiences that she or he has in the world, leading to cognitive errors. But why do people make cognitive errors at all? According to Beck (Beck, A. T., 2005), underlying these biases is a relatively stable set of cognitive structures or schemas that contain dysfunctional beliefs. When these schemas become activated (by external or internal triggers), they bias how people process information. In the case of depression, people become inclined to make negatively biased interpretations of themselves, their world, and their future. In the initial phase of cognitive therapy, clients are made aware of the connection between their patterns of thinking and their emotional responses. They are first taught simply to identify their own automatic thoughts (such as "This event is a total disaster") and to keep records of their thought content and their emotional reactions (Wright et al., 2006). With the therapist's help, they then identify the logical errors in their thinking and learn to challenge the validity of these automatic thoughts. The errors in the logic behind their thinking lead them (1) to perceive the world selectively as harmful while ignoring evidence to the contrary; (2) to overgeneralize on the basis of limited examples—for example, seeing themselves as totally worthless because they were laid off from work; (3) to magnify the significance of undesirable events—for example, seeing the job loss as the end of the world for them; and (4) to engage in absolutistic thinking—for example, exaggerating the importance of someone's mildly critical comment and perceiving it as proof of their instant descent from goodness to worthlessness. Much of the content of the therapy sessions and homework assignments is analogous to experiments in which a therapist and a client apply learning principles to alter the client's biased and dysfunctional cognitions and continuously evaluate the effects that these changes have on subsequent thoughts, feelings, and overt behavior. It is important to note, however, that in Beck's cognitive therapy, clients do not change their beliefs by debate and confrontation as is common in REBT. Rather, they are encouraged to gather information about themselves. For example, a young man who believes that he will be rejected by any attractive woman he approaches would be led to a searching analysis of the reasons why he holds this belief. The client might then be assigned the task of "testing" this dysfunctional "hypothesis" by actually approaching seemingly appropriate women whom he admires. The results of the "test" would then be discussed with the cognitive therapist, and any cognitive "errors" that may have interfered with a skillful performance would be identified and corrected. In addition, the client is encouraged to discover the faulty assumptions or dysfunctional schemas that may be leading to problem behaviors and self-defeating tendencies (Young et al., 2008). These generally become evident over the course of therapy as the client and the therapist examine the themes of the client's automatic thoughts. Because these dysfunctional schemas are seen as making the person vulnerable (e.g., to depression), this phase of treatment is considered essential in ensuring resistance to relapse when the client faces stressful life events in the future. That is, if the underlying cognitive vulnerability factors are not changed, the client may show only short-term improvement and will still be subject to recurrent depression For disorders other than depression, the general approach is quite similar. However, the nature of the patient's automatic thoughts and underlying beliefs is obviously quite different across disorders. In panic disorder, for example, the focus is on identifying the automatic thoughts about feared bodily sensations and on teaching the client to "decatastrophize" the experience of panic (Craske & Barlow, 2008). In bulimia nervosa, the cognitive approach centers on the person's overvalued ideas about body weight and shape, which are often fueled by low self-esteem and fears of being unattractive. In addition, faulty cognitions about which foods are "safe" and which are "dangerous" are explored

Behavior Therapy

Behavior therapy is a direct and active treatment that recognizes the importance of behavior, acknowledges the role of learning, and includes thorough assessment and evaluation. Instead of exploring past traumatic events or inner conflicts, behavior therapists focus on the presenting problem—the problem or symptom that is causing the patient great distress. A major assumption of behavior therapy is that abnormal behavior is acquired in the same way as normal behavior—that is, by learning. A variety of behavioral techniques have therefore been developed to help patients "unlearn" maladaptive behaviors by one means or another.

Third-Party Ratings

Client change also can be evaluated by third-party raters, meaning people not involved in the treatment. This may include family members or trained independent evaluators. The latter are people who are trained to conduct clinical interviews and to rate the amount of clinical change that has occurred in a patient. Of course, relatives of the client may be inclined to "see" the improvement they had hoped for, although they often seem to be more realistic than either the therapist or the client in their evaluations of outcome. Because of their objectivity and consistency, independent evaluators who are blind to condition (meaning they do not know what kind of treatment a person received and so cannot be biased to say that one form of treatment is more effective than another) are used frequently in rigorous studies of treatment effectiveness.

Evaluating Behavior Therapy

Compared with some other forms of therapy, behavior therapy has some distinct advantages. Behavior therapy usually achieves results in a short period of time because it is generally directed to specific symptoms, leading to faster relief of a client's distress and to lower costs. The methods to be used are also clearly delineated, and the results can be readily evaluated. Overall, the outcomes achieved with behavior therapy compare very favorably with those of other approaches As with other approaches, behavior therapy works better with certain kinds of problems than with others. Generally, the more pervasive and vaguely defined the client's problem, the less likely behavior therapy is to be useful. For example, it appears to be only rarely employed to treat complex personality disorders, although dialectical behavior therapy (see the Personality Disorders chapter) for patients with borderline personality disorder is an exception (Crits-Christoph & Barber, 2007). On the other hand, behavioral techniques remain central to the treatment of anxiety disorders (Barlow et al., 2007; Franklin & Foa, 2007). Because behavioral treatments are often quite straightforward, behavior therapy can be used with patients with psychosis (Kopelowicz et al., 2007). Recent research also shows that behavior therapy is an effective treatment for the vocal and motor tics that are found in people with Tourette's syndrome (Wilhelm et al., 2012). This is welcome news because the alternative treatment approach involves the use of antipsychotic medications. A recent development in the treatment of depression is a brief and structured form of therapy called behavioral activation. In this treatment the patient and the therapist work together to help the patient find ways to become more active and engaged with life. The patient is encouraged to engage in activities that will help improve mood and lead to better ways of coping with specific life problems. Although this sounds quite simple, it is not always that easy to accomplish. However, evidence to date suggests that this form of therapy is very beneficial for patients and can lead to enduring change

Analysis of Resistance

During the process of free association or of associating to dreams, an individual may evidence resistance—an unwillingness or inability to talk about certain thoughts, motives, or experiences. For example, a client may be talking about an important childhood experience and then suddenly switch topics, perhaps stating, "It really isn't that important" or "It is too absurd to discuss." Resistance may also be evidenced by the client's giving a too-glib interpretation of some association, or coming late to an appointment, or even "forgetting" an appointment altogether. Because resistance prevents painful and threatening material from entering awareness, its sources must be sought if an individual is to face the problem and learn to deal with it in a realistic manner

Gestalt Therapy

In German, the term gestalt means "whole," and gestalt therapy emphasizes the unity of mind and body—placing strong emphasis on the need to integrate thought, feeling, and action. Gestalt therapy was developed by Frederick (Fritz) Perls (Perls, F. S., 1969) as a means of teaching clients to recognize the bodily processes and emotions they had been blocking off from awareness. As with the client-centered and humanistic approaches, the main goal of gestalt therapy is to increase the individual's self-awareness and self-acceptance. Although gestalt therapy is commonly used in a group setting, the emphasis is on one person at a time, with whom a therapist works intensively, trying to help identify aspects of the individual's self or world that are not being acknowledged in awareness. The individual may be asked to act out fantasies concerning feelings and conflicts or to represent one side of a conflict while sitting in one chair and then switch chairs to take the part of the adversary. Often the therapist or other group members will ask questions such as "What are you aware of in your body now?" and "What does it feel like in your gut when you think of that?" In Perls' approach to therapy, a good deal of attention is also paid to dreams, but with an emphasis very different from that of classical psychoanalysis. In gestalt theory, all elements of a dream, including seemingly inconsequential, impersonal objects, are considered to be representations of unacknowledged aspects of the dreamer's self. The therapist urges the client to suspend normal critical judgment, to "be" the object in the dream, and then to report on the experience. This is illustrated in the following case study.

Social Values and Psychotherapy

In a broader perspective, there is the complex and controversial issue of the role of values in science. Psychotherapy is not, or at least should not be, a system of ethics; it is a set of tools to be used at the discretion of a therapist in pursuit of a client's welfare. Thus, mental health professionals are confronted with the same kinds of questions that confront scientists in general: Should a physical scientist who helps develop weapons of mass destruction be morally concerned about how they are used? Similarly, should a psychologist or behavioral scientist who develops powerful techniques to influence or control how people behave be concerned about how those techniques are used? Many psychologists and other scientists try to sidestep this issue by insisting that science is value free—that it is concerned only with gathering facts, not with how the facts are applied. Each time therapists decide that one behavior should be eliminated or substituted for another, however, they are making a value judgment. For example, is a therapist to assume that the depression of a young mother who is abused by an alcoholic husband is an internally based disorder requiring "treatment," as once would have been the routine interpretation? Or does the therapist have a larger responsibility to look beyond individual pathology and confront the abnormality of the marital relationship? Therapy takes place in a context that involves the values of the therapist, the client, and the society in which they live. There are strong pressures on a therapist—from parents, schools, courts, and other social institutions—to help people adjust to the world as it is. At the same time, there are many counterpressures, particularly from young people who are seeking support in their (sometimes overdone) attempts to become authentic people rather than blind conformists

Using Antidepressants to Treat Anxiety Disorders, Bulimia Nervosa, and Personality Disorders

In addition to their usefulness in treating depression, the antidepressant drugs are also widely used in the treatment of various other disorders. For example, SSRIs are often used in the treatment of panic disorder, social phobia, and generalized anxiety disorder, as well as OCD (Dougherty et al., 2007; Roy-Byrne & Cowley, 2007). However, some people with panic disorder are greatly bothered by the side effects of these drugs (which create some of the symptoms to which patients with panic disorder are hypersensitive), so they quickly discontinue the medication. SSRIs and TCAs are also used in the treatment of bulimia nervosa. Many studies have shown that these antidepressants are useful in reducing binge eating and purging (Wilson & Fairburn, 2007). Patients with Cluster B personality disorders such as borderline personality disorder may show a decrease in certain symptoms, most notably mood lability, if they take SSRIs

Evaluating Cognitive-Behavioral Therapies

In spite of the widespread attention that Ellis's REBT has enjoyed, it has been less well assimilated into the mainstream than Beck's cognitive therapy (David et al., 2005). Nonetheless, REBT is still very much alive and well. In general, this approach may be most useful in helping basically healthy people to cope better with everyday stress and perhaps in preventing them from developing full-blown anxiety or depressive disorders (Haaga & Davison, 1989). With respect to controlled research studies with carefully diagnosed clinical populations, REBT appears to be inferior to exposure-based therapies in the treatment of anxiety disorders such as agoraphobia, social phobia In contrast, the efficacy of Beck's cognitive treatment methods has been well documented. Research suggests that these approaches are extremely beneficial in alleviating many different types of disorders (Hollon & Beck, 2004). For all but the most severe cases of depression (e.g., psychotic depression), cognitive-behavioral therapy (CBT) is at least comparable to drug treatment. It also offers long-term advantages, especially with regard to the prevention of relapse (Craighead et al., 2007). Cognitive therapy also produces dramatic results in the treatment of panic disorder and generalized anxiety disorder (Hollon & Beck, 2004), and CBT is now the treatment of choice for bulimia (Wilson, 2010; Wilson & Fairburn, 2007). Finally, cognitive approaches have promise in the treatment of conduct disorder in children The combined use of cognitive and behavior therapy approaches is now quite routine. Some disagreement remains about whether the effects of cognitive treatments are actually the result of cognitive changes as the cognitive theorists propose. At least for depression and panic disorder, it does appear that cognitive change is the best predictor of long-term outcome, just as cognitive theory maintains. Exactly what the "active ingredients" of cognitive treatments really are, however, remains a source of debate and research A recent meta-analysis that examined nearly 40 years of data on the use of CBT to treat depression yielded several very interesting findings (Johnsen & Friborg, 2015). The data showed that (1) CBT has been an effective treatment for depression since the 1970s, (2) female patients benefit more from treatment than do men, (3) more experienced clinicians have better treatment effects than less experienced ones, and (4) most alarmingly, the effectiveness of CBT seems to be decreasing over time. This last fact is puzzling; however, there are two leading explanations. One is that as more and more people are getting trained in using CBT over time, more inexperienced clinicians are providing the intervention, and given point (3) above, this is causing CBT to appear less effective than it used to be. Another possibility is that the novelty of CBT led to stronger expectations on the part of both clinician and client early on, but as CBT has become more common, those expectations have decreased, leading to smaller positive changes in depression. Whatever the case, it is comforting to know that CBT is still a powerful and effective treatment!

Motivational Interviewing

People tend to be ambivalent about making changes in their lives. For instance, although there are negative consequences to drinking too much alcohol, there are also some perceived benefits to drinking (e.g., experience of pleasure, social interactions). Motivational interviewing (MI) (Miller & Rollnick, 2012) is a brief form of therapy that can be delivered in one or two sessions. It was developed as a way to help people resolve their ambivalence about change and make a commitment to treatment (Miller, 1983). At its center is a supportive and empathic style of relating to the client that has its origins in the work of Carl Rogers. However, MI differs from client-centered counseling because it employs a more direct approach that explores the client's own reasons for wanting to change. The therapist encourages this "change talk" by asking the client to discuss his or her desire, ability, reasons, and need for change. These are reflected back by the therapist, thus exposing the client to periodic summaries of his or her own motivational statements and thoughts about change. The result is that clients can develop and strengthen their commitment to change in an active, accepting, and supportive atmosphere. Motivational interviewing is most often used in the areas of substance abuse and addiction. When added to the beginning of a treatment program, it appears to benefit patients, perhaps because it facilitates patients' staying in treatment and following the treatment plan. A meta-analysis of the MI literature also has shown that MI has a large effect when it is used with ethnic minorities. In one alcoholism-treatment trial, Native American participants did better if they received four sessions of MI than if they received 12 sessions of CBT or else participated in a 12-step program (Villanueva et al., 2003). Quite possibly, the supportive and nonconfrontational style of MI may be more congruent with the typical and culturally sanctioned communication style of Native Americans and thus represent a culturally appropriate intervention. The collaborative and nonconfrontational style of MI may also make it acceptable to adolescents. Even a very small number of sessions of MI can promote behavior change in adolescents who use drugs and alcohol

Overt Behaviors

Perhaps the most direct way to know if someone has improved in treatment is to observe their behavior directly. For instance, if someone is being treated for a bug phobia, the clinician can observe the client's ability to approach and hold bugs of different sizes before, during, and after treatment to see if the individual's behavior has changed. The advantage of behavioral observation is that it is objective, difficult to "fake," and often reflective of precisely the change that is intended in treatment. The downside is that it may be less appropriate for problems that are less easily observed (e.g., suicidal thoughts).

Psychological Disorders and Stressful Life Circumstances

Perhaps the most obvious candidates for psychological treatment are people experiencing one of the psychological disorders described in this book. Approximately 15 percent of adults in the United States receive mental health care treatment each year, with rates in other countries varying from 1 to 12 percent (see Figure 16.1; WHO World Mental Health Survey Consortium, 2004). Not surprisingly, those with psychological disorders, and especially those with serious conditions in which there is considerable impairment in daily functioning, are much more likely to receive treatment. However, most people who receive treatment do not meet full criteria for a psychological disorder So why would they be seeking treatment? Many people seek therapy due to sudden and highly stressful situations such as a divorce or unemployment—situations that can lead people to feel so overwhelmed by a crisis that they cannot manage on their own.

Freudian Psychoanalysis

Psychoanalysis is a system of therapy that evolved over a period of years during Freud's long career. Four basic techniques are used in this form of therapy: (1) free association, (2) analysis of dreams, (3) analysis of resistance, and (4) analysis of transference.

Psychodynamic Therapies

Psychodynamic therapy is a broad treatment approach that focuses on individual personality dynamics, usually from a psychoanalytic or some psychoanalytically derived perspective. Psychoanalytic therapy is the oldest form of psychological therapy and began with Sigmund Freud. The therapy is mainly practiced in two basic forms: classical psychoanalysis and psychodynamically oriented psychotherapy. As developed by Freud and his immediate followers, classical psychoanalysis is an intensive (at least three sessions per week), long-term procedure for uncovering repressed memories, thoughts, fears, and conflicts presumably stemming from problems in early psychosexual development—and helping individuals come to terms with them in light of the realities of adult life. For example, excessive orderliness and a grim and humorless focus on rigorous self-control would probably be viewed as deriving from difficulties in early toilet training. In psychoanalytically oriented psychotherapy, the treatment and the ideas guiding it may depart substantially from the principles and procedures laid out by orthodox Freudian theory, yet the therapy is still loosely based on psychoanalytic concepts. For example, many psychodynamically oriented therapists schedule less frequent sessions (e.g., once per week) and sit face to face with the client instead of having the latter recline on a couch with the analyst out of sight behind him or her. Likewise, the relatively passive stance of the analyst (primarily listening to the client's "free associations" and rarely offering "interpretations") is replaced with an active conversational style in which the therapist attempts to clarify distortions and gaps in the client's construction of the origins and consequences of his or her problems, thus challenging client "defenses" as they present themselves. It is widely believed that this more direct approach significantly shortens total treatment time. We first examine Freud's original treatment methods, in part because of their historical significance and enormous influence; we then look briefly at some of the contemporary modifications of psychodynamic therapy, which for the most part focus on interpersonal processes.

Reluctant Clients

Some people enter therapy by an indirect route. Perhaps they were court-ordered to do so by a judge because of substance abuse or domestic violence, or maybe they had consulted a physician for their headaches or stomach pains, only to be told that nothing was physically wrong with them. Motivation to enter treatment differs widely among psychotherapy clients. Reluctant clients may come from many situations—for example, a person with a substance abuse problem whose spouse threatens "either therapy or divorce," or a suspected felon whose attorney advises that things will go better at trial if it can be announced that the suspect has "entered therapy." A substantial number of angry parents bring their children to therapists with demands that their child's "problematic behavior," which they view as independent of the family context, be "fixed." These parents may be surprised and reluctant to recognize their own roles in shaping their child's behavior patterns. In general, males are more reluctant to seek help when they are experiencing problems than are females. In the case of depression, far more men than women say that they would never consider seeing a therapist; when men are depressed they are even reluctant to seek informal help from their friends. Moreover, when men do seek professional help, they tend to ask fewer questions than women do (see Addis & Mahalik, 2003). Why would this be? One answer is that men are less able than women to recognize and label feelings of distress and to identify these feelings as emotional problems. In addition, men who subscribe to masculine stereotypes emphasizing self-reliance and lack of emotionality also tend to experience more gender-role conflict when they consider traditional counseling, with its focus on emotions and emotional disclosure. For a man who prides himself on being emotionally stoic, seeking help for a problem like depression may present a major threat to his self-esteem. Seeking help also requires giving up some control and may run counter to the ideology that "a real man helps himself." How can men be encouraged to seek help when they have difficulties? Part of the solution may be to develop new treatment approaches that provide a better fit for men who see little value in talking about their problems. An example here might be the use of virtual reality therapy to treat soldiers with posttraumatic stress disorder (PTSD; see the Stress and Physical and Mental Health chapter). Another strategy is to use more creative approaches to encourage men to seek help and support. For example, television commercials for erectile dysfunction use professional basketball players and football coaches to encourage men with similar problems to "step up to the plate" and talk to their doctors. Making men more aware of other "masculine men" who have been "man enough" to go for help when they needed it may be an important step toward educating those whose adherence to masculine gender roles makes it difficult for them to acknowledge and seek help for their problems.

Systematic Reinforcement

Systematic programs that use reinforcement to increase the frequency of desired behavior have achieved notable success. Often called contingency management programs, these approaches are often used in institutional settings, although this is not always the case. Suppressing problematic behavior may be as simple as removing the reinforcements that support it, provided, of course, that they can be identified. Sometimes identification is relatively easy, as in the following case. In other instances, it may require extremely careful and detailed observation and analysis for the therapist to learn what is maintaining the maladaptive behavior. Billy's was a case in which unwanted behavior was eliminated by eliminating its reinforcers. On other occasions, therapy is administered to establish desired behaviors that are missing. Examples of such approaches are response shaping and use of token economies. In response shaping, positive reinforcement is used to establish, by gradual approximation, a response that is actively resisted or is not initially in an individual's behavioral repertoire. This technique has been used extensively in working with children's behavior problems (Kazdin, 2007). For example, a child who refuses to speak in front of others (selective mutism) may be first rewarded (with praise or a more tangible treat) for making any sound. Later, only complete words, and later again only strings of words, would be rewarded.

Tricyclic Antidepressants

The TCAs operate to inhibit the reuptake of norepinephrine and (to a lesser extent) serotonin once these have been released into the synapse. Their discovery was also serendipitous in that the first TCA—imipramine—was being studied as a possible treatment for schizophrenia when it was found to elevate mood. The theory that these drugs work by increasing norepinephrine activity is now known to be oversimplified. It is also known that when the tricyclics are taken for several weeks, they alter a number of other aspects of cellular functioning including how receptors function and how cells respond to the activation of receptors and the synthesis of neurotransmitters. Because these alterations in cellular functioning parallel the time course for these drugs to exert their antidepressant effects, one or more of these changes are likely to be involved in mediating their antidepressant effects

Free Association

The basic rule of free association (see the Historical and Contemporary Views of Abnormal Behavior chapter) is that an individual must say whatever comes into her or his mind regardless of how personal, painful, or seemingly irrelevant it may be. Usually a client lies in a relaxed position on a couch and gives a running account of all the thoughts, feelings, and desires that come to mind as one idea leads to another. The therapist normally takes a position behind the client so as not to disrupt the free flow of associations in any way. Although such a running account of whatever comes into one's mind may seem random, Freud believed that associations are determined just like other events. The purpose of free association is to explore thoroughly the contents of the preconscious—that part of the mind considered subject to conscious attention but largely ignored. Analytic interpretation involves a therapist's tying together a client's often disconnected ideas, beliefs, and actions into a meaningful explanation to help the client gain insight into the relationship between his or her maladaptive behavior and the repressed (unconscious) events and fantasies that drive it.

Client-Centered Therapy

The client-centered (person-centered) therapy of Carl Rogers (1902-1987) focuses on the natural power of the organism to heal itself (Rogers, 1951,, Rogers, C. R., 1961). Rogers saw therapy as a process of removing the constraints and restrictions that grow out of unrealistic demands that people tend to place on themselves when they believe, as a condition of self-worth, that they should not have certain kinds of feelings such as hostility. By denying that they do in fact have such feelings, they become unaware of their actual "gut" reactions. As they lose touch with their own genuine experience, the result is lowered integration, impaired personal relationships, and various forms of maladjustment. The primary objective of Rogerian therapy is to resolve this incongruence—to help clients become able to accept and be themselves. To this end, client-centered therapists establish a psychological climate in which clients can feel unconditionally accepted, understood, and valued as people. Within this context, the therapist employs nondirective techniques such as empathic reflecting, or a restatement of the client's descriptions of life difficulties. If all goes well, clients begin to feel free, for perhaps the first time, to explore their real feelings and thoughts and to accept hates and angers and ugly feelings as parts of themselves. As their self-concept becomes more congruent with their actual experience, they become more self-accepting and more open to new experiences and new perspectives; in short, they become better-integrated people. In contrast to most other forms of therapy, the client-centered therapist does not give answers, interpret what a client says, probe for unconscious conflicts, or even steer the client toward certain topics. Rather, he or she simply listens attentively and acceptingly to what the client wants to talk about, interrupting only to restate in different words what the client is saying. Such restatements, devoid of any judgment or interpretation by the therapist, help the client to clarify further the feelings and ideas that he or she is exploring—really to look at them and acknowledge them. Pure client-centered psychotherapy, as originally practiced, is rarely used today in North America, although it is still relatively popular in Europe. Motivational interviewing is a new form of therapy that is based on this empathic style.

Sociocultural Perspectives

The criticism has been raised—from both inside and outside the mental health professions—that psychotherapy can be viewed as an attempt to get people adjusted to a "sick" society rather than to encourage them to work toward its improvement. As a consequence, psychotherapy has often been considered the guardian of the status quo. This issue is perhaps easier for us to place in perspective by looking at other cultures. For example, many suggested that psychiatry was used as a means of political control in the former Soviet Union, with those in power using psychiatrists to "diagnose" political opponents with a mental disorder Although few would claim that psychiatry in most industrialized societies is used to gain control over social critics, there is nevertheless the possibility that therapists in some ways play the role of "gatekeepers" of social values.

Cognitive and Cognitive-Behavioral Therapy

The early behavior therapists focused on observable behavior and regarded the inner thoughts of their clients as unimportant. However, starting in the 1970s, a number of behavior therapists began to reappraise the importance of "private events"—thoughts, perceptions, evaluations, and self-statements—and started to see them as processes that mediated the effects of objective stimulus conditions to determine behavior and emotions Cognitive and cognitive-behavioral therapy (terms for the most part used interchangeably) stem from both cognitive psychology (with its emphasis on the effects of thoughts on behavior) and behaviorism (with its rigorous methodology and performance-oriented focus). No single set of techniques defines cognitively oriented treatment approaches. However, two main themes are important: (1) the conviction that cognitive processes influence emotion, motivation, and behavior; and (2) the use of cognitive and behavior-change techniques in a pragmatic (hypothesis-testing) manner. In the following discussion, we briefly describe the rational emotive behavior therapy of Albert Ellis and then focus in more detail on the cognitive therapy approach of Aaron Beck.

Clinician Ratings

The effectiveness of therapy also is often evaluated by the treating clinician. For instance, the Hamilton Rating Scale for Depression is a rating scale used by clinicians to measure the severity of a patient's depression—similar to the Beck Depression Inventory mentioned above, but completed by the clinician rather than the client. Although the clinician may be more objective than the patient, clinicians also may not be the best judge of clients' progress because they may be biased in favor of seeing themselves as competent and successful. In addition, the clinician typically has only a limited observational sample (the client's in-session behavior) from which to make judgments of overall change. Furthermore, clinicians can inflate improvement averages by deliberately or subtly encouraging difficult clients to discontinue therapy.

Rational Emotive Behavior Therapy

The first form of behaviorally oriented cognitive therapy was developed by Albert Ellis and called rational emotive behavior therapy (REBT) (see Ellis & Dryden, 1997). REBT attempts to change a client's maladaptive thought processes, on which maladaptive emotional responses and, thus, behavior are presumed to depend. Ellis posited that a well-functioning individual behaves rationally and in tune with empirical reality. Unfortunately, however, many of us have learned unrealistic beliefs and perfectionistic values that cause us to expect too much of ourselves, leading us to behave irrationally and then to feel that we are worthless failures. For example, a person may continually think, "I should be able to win everyone's love and approval" or "I should be thoroughly adequate and competent in everything I do." Such unrealistic assumptions and self-demands inevitably spell problems. The task of REBT is to restructure an individual's belief system and self-evaluation, especially with respect to the irrational "shoulds," "oughts," and "musts" that are preventing the individual from having a more positive sense of self-worth and an emotionally satisfying, fulfilling life. Several methods are used. One method is to dispute a person's false beliefs through rational confrontation ("Why should your failure to get the promotion you wanted mean that you are worthless?"). REBT therapists also use behaviorally oriented techniques. For example, homework assignments might be given to encourage clients to have new experiences and to break negative chains of behavior. Although the techniques differ dramatically, the philosophy underlying REBT has something in common with that underlying humanistic therapy (discussed later) because both take a clear stand on personal worth and human values. Rational emotive behavior therapy aims to increase an individual's feelings of self-worth and clear the way for self-actualization by removing the false beliefs that have been stumbling blocks to personal growth.

Humanistic-Experiential Therapies

The humanistic-experiential therapies emerged as significant treatment approaches after World War II. In a society dominated by self-interest, mechanization, computerization, mass deception, and mindless bureaucracy, proponents of the humanistic-experiential therapies see psychopathology as stemming in many cases from problems of alienation, depersonalization, loneliness, and a failure to find meaning and genuine fulfillment. Problems of this sort, it is held, are not likely to be solved either by delving into forgotten memories or by correcting specific maladaptive behaviors. The humanistic-experiential therapies are based on the assumption that people have both the freedom and the responsibility to control their own behavior—that they can reflect on their problems, make choices, and take positive action. Humanistic-experiential therapists feel that a client must take most of the responsibility for the direction and success of therapy, with the therapist serving merely as counselor, guide, and facilitator. Although humanistic-experiential therapies differ in their details, their central focus is always expanding a client's "awareness."

Combined Treatments

The integration of medication and psychotherapy remains common in clinical practice, particularly for disorders such as schizophrenia and bipolar disorder. Such integrated approaches are also appreciated and regarded as essential by the patients themselves. The integrative approach is a good example of the biopsychosocial perspective that best describes current thinking about mental disorders and that is reflected throughout this book. Medications can be combined with a broad range of psychological approaches. In some cases, they can help patients benefit more fully from psychotherapy. For example, patients with social anxiety disorder who receive exposure therapy do much better if they are given an oral dose of D-cycloserine before each session. D-cycloserine is an antibiotic used in the treatment of tuberculosis. When taken alone, it has no effect on anxiety. However, D-cycloserine activates a receptor that is critical in facilitating extinction of anxiety. By making the receptor work better, the therapeutic benefits of exposure training are enhanced in people taking D-cycloserine versus placebo Typically, psychosocial interventions are combined with psychiatric medications. This may be especially beneficial for patients with severe disorders (see Gabbard & Kay, 2001). Keller and colleagues (2000) compared the outcomes of 519 patients with depression who were treated with an antidepressant (nefazodone), with psychotherapy (cognitive-behavioral), or with a combination of both of these treatments. In the medication-alone condition, 55 percent of patients did well. In the psychotherapy-alone condition, 52 percent of patients responded to treatment. However, patients for whom the two treatments were combined did even better, with an overall positive response rate of 85 percent. Quite possibly, combined treatment is effective because medications and psychotherapy may target different symptoms and work at different rates. It is important to note that combined treatments are not always superior to single treatments. Adding psychiatric medications does not generally improve the clinical efficacy of psychosocial treatments for anxiety disorders, for example. However, for people suffering from chronic or recurrent depression, combined treatments often result in better clinical outcomes

Object Relations, Attachment-Based Approaches, and Self-Psychology

The most extensive revisions of classical psychoanalytic theory undertaken within recent decades have been related to the object-relations perspective (in psychoanalytic jargon, "objects" are other people) and, to a lesser extent, the attachment and self-psychology perspectives (Prochaska & Norcross, 2003). Whether or not psychotherapy investigators and clinicians use the term object relations (or attachment or self-psychology) to denote their approach, increasing numbers of them describe procedures that focus on interpersonal relationship issues, particularly as they play themselves out in the client-therapist relationship. Interpersonally oriented psychodynamic therapists vary considerably in their time focus, whether they concentrate on remote events of the past, on current interpersonal situations and impasses (including those of the therapy itself), or on some balance of the two. Most seek to expose, bring to awareness, and modify the effects of the remote developmental sources of the difficulties the client is currently experiencing. These therapies generally retain, then, the classical psychoanalytic goal of understanding the present in terms of the past. What they ignore are the psychoanalytic notions of staged libidinal energy transformations and of entirely internal (and impersonal) drives that are channeled into psychopathological symptom formation.

Benzodiazepines

The most important and widely used class of antianxiety (or anxiolytic) drugs are the benzodiazepines. Another class of drugs, the barbiturates (e.g., phenobarbital), is seldom used today except to control seizures or as anesthetics during electroconvulsive therapy. The first benzodiazepines were released in the early 1960s. They are now the drugs of choice for the treatment of acute anxiety and agitation. They are rapidly absorbed from the digestive tract and start to work very quickly. At low doses they help quell anxiety; at higher doses they act as sleep-inducing agents and can be used to treat insomnia. For this reason, people taking these medications are cautioned about driving or operating machinery. One problem with benzodiazepines is that patients can become psychologically and physiologically dependent on them (Roy-Byrne & Cowley, 2007). Patients taking these medications must be "weaned" from them gradually because of the risk of withdrawal symptoms, which include seizures in some cases. Moreover, relapse rates following discontinuation of these drugs are extremely high (Roy-Byrne & Cowley, 2007). For example, as many as 60 to 80 percent of patients with panic disorder relapse following discontinuation of Xanax Benzodiazepines and related anxiolytic medications are believed to work by enhancing the activity of GABA receptors (Stahl, 2000). GABA (gamma aminobutyric acid) is an inhibitory neurotransmitter that plays an important role in the way our brain inhibits anxiety in stressful situations. The benzodiazepines appear to enhance GABA activity in certain parts of the brain known to be implicated in anxiety such as the limbic system.

Other antidepressants

The newest antidepressant, which received FDA approval in 2011, is called Viibryd (vilazodone). It is a novel combination of an SSRI and a serotonin receptor agonist. Studies suggest that vilazodone is safe and well tolerated by patients (Robinson et al., 2011) and that it works better than placebo for patients who are depressed Trazodone (Desyrel) was the first antidepressant to be introduced in the United States that was not lethal when taken in overdose. It specifically inhibits the reuptake of serotonin. Trazodone has heavy sedating properties that limit its usefulness. It is sometimes used in combination with SSRIs and taken at night to help counter the adverse effects the SSRIs often have on sleep. In rare cases, it can produce a condition in men called priapism (Nemeroff & Schatzberg, 2007). Priapism is prolonged erection in the absence of any sexual stimulation. Bupropion (Wellbutrin) is an antidepressant that is not structurally related to other antidepressants. It inhibits the reuptake of both norepinephrine and dopamine. In addition to being an antidepressant medication, bupropion also reduces nicotine cravings and symptoms of withdrawal in people who want to stop smoking. One clinical advantage of bupropion is that, unlike some of the SSRIs, it does not inhibit sexual functioning

Other Antianxiety Medications

The only new class of antianxiety medication that has been released since the early 1960s is buspirone (Buspar), which is completely unrelated to the benzodiazepines and is thought to act in complex ways on serotonergic functioning rather than on GABA. It has been shown to be as effective as the benzodiazepines in treating generalized anxiety disorder (Roy-Byrne & Cowley, 2007), although patients who have previously taken benzodiazepines tend not to respond as well as patients who have never taken them. Buspar has a low potential for abuse, probably because it has no sedative or muscle-relaxing properties and so is less pleasurable for patients. It also does not cause any withdrawal effects. The primary drawback to the use of buspirone is that it takes 2 to 4 weeks to exert any anxiolytic effects. It is therefore not useful in acute situations. Because it is nonsedating, it cannot be used to treat insomnia.

Psychodynamic Therapy Since Freud

The original version of psychoanalysis is practiced only rarely today. Arduous and costly in time, money, and emotional commitment, it may take several years before all major issues in the client's life have been satisfactorily resolved. In light of these heavy demands, psychoanalytic or psychodynamic therapists have worked out modifications in the procedure that are designed to shorten the time and expense required. A good review of some of these approaches can be found in the work of Prochaska and Norcross

Can Therapy Be Harmful?

The outcomes of psychotherapy are not invariably either neutral (no effect) or positive. Some clients are actually harmed by their encounters with psychotherapists (see the World Around Us box). It has been estimated that between 5 and 10 percent of clients deteriorate during treatment (Lambert & Ogles, 2004). Unfortunately, clinicians are often quite bad at recognizing when their clients are not doing well (Whipple & Lambert, 2011). To address this problem, research-based measures to assess clinical deterioration are now being developed. Clinicians who use these measures in their routine clinical practice will be warned when their clients are not progressing in an expected manner. A major hurdle, however, is implementation. We would not be surprised to learn that the least effective therapists are the ones most reluctant to use such patient-monitoring methods. A special case of therapeutic harm concerns what are called boundary violations. This is when the therapist behaves in ways that exploit the trust of the patient or engages in behavior that is highly inappropriate (e.g., taking the patient to dinner, giving the patient gifts). One case involved a patient who had been treated by a psychiatrist for 10 years. During this time the patient gave the therapist gifts of a refrigerator and a dining table and six chairs. She also sold him her Waterford crystal, her china, and a silver service. The silver had an appraised value of $1,600. However, it was purchased by the psychiatrist for only $200. The psychiatrist also sold the patient two of his boats, without her even having seen them (Norris et al., 2003). A sexual relationship between the patient and the therapist represents perhaps the most obvious and extreme example of a serious boundary violation. This is highly unethical conduct. Given the frequently intense and intimate quality of therapeutic relationships, it is not surprising that sexual attraction arises. However, it is the therapist's professional responsibility to maintain the appropriate boundaries at all times. When exploitive and unprofessional behavior on the part of therapists does occur, it results in great harm to patients (Norris et al., 2003). Anyone seeking therapy needs to be sufficiently aware enough to determine that the therapist she or he has chosen is committed to high ethical and professional standards. For the vast majority of therapists, this is indeed the case.

Evaluating Psychodynamic Therapies

The practice of classical psychoanalysis is routinely criticized for being relatively time consuming and expensive; for being based on a questionable and sometimes cult-like approach to human nature; for neglecting a client's immediate problems in the search for unconscious conflicts in the remote past; and for there being no adequate proof of its general effectiveness. Indeed, there have been no rigorous, controlled outcome studies of classical psychoanalysis. This is understandable, given the intensive and long-term nature of the treatment and the methodological difficulties inherent in testing such an approach. Nonetheless, there are some hints that this treatment approach has some value (Gabbard et al., 2002). Psychoanalysts also argue that manualized treatments unduly limit treatment for a disorder. They note that simply because a treatment cannot be standardized does not mean that it is invalid or unhelpful. Whether the clinical benefits justify the time and expense of psychoanalysis, however, remains uncertain. In contrast, much more research has been done on some of the newer psychodynamically oriented approaches. There are signs that psychodynamic approaches may be helpful in the treatment of depression, panic disorder, PTSD, and substance abuse disorders (Gibbons et al., 2008). Recent research also supports the idea that increases in insight ("insight" is a key construct in psychodynamic theory and involves cognitive and emotional understanding of inner conflicts) must occur before there is long-term clinical change Psychoanalytically oriented treatments are also showing promise in the treatment of borderline personality disorder. One example is transference-focused psychotherapy, or TFP. Developed by Kernberg and colleagues (2008), this treatment approach uses such techniques as clarification, confrontation, and interpretation to help the patient understand and correct the distortions that occur in his or her perception of other people, including the therapist. In a clinical trial, patients with borderline personality disorder who received TFP did as well as those who were assigned to receive dialectical behavior therapy (Clarkin et al., 2007). Findings such as these are creating renewed interest in psychodynamic forms of psychotherapy and energizing the field of treatment research.

Thinking Critically about DSM-5 What Are Some of the Clinical Implications of the Recent Changes?

The recent publication of DSM-5 has created a number of new diagnoses. It has also changed the diagnostic criteria for others. Of course, as a diagnostic manual, the DSM does not provide any information about treatment or make recommendations on that topic. However, changes in the DSM always have implications for treatment because a DSM diagnosis is necessary for clinical services to be covered by insurance. Here, we highlight some changes that are likely to have an impact on prevalence rates and medication usage in the years to come. New to DSM-5 is the diagnosis of disruptive mood dysregulation disorder. This disorder is characterized by temper tantrums in a child older than 6 years of age. In order for the diagnosis to be made, the angry outbursts must occur at least three times a week and be inconsistent with the child's developmental level. On the plus side, this diagnosis may allow children with very irritable temperaments to receive specialized help at an early age. However, there is also a risk that many children whose parents might benefit from parental skills training will instead receive powerful tranquilizing medications while their young brains are still maturing and developing. To be diagnosed with attention-deficit/hyperactivity disorder (ADHD) in DSM-IV-TR, symptoms had to develop before the child reached the age of 7. In DSM-5 this age of onset has been raised to age 12. Many children who would not have been eligible to be diagnosed with ADHD (because their symptoms developed when they were age 8, 9, or 10) will now receive the diagnosis. This simple change in the diagnostic criteria will dramatically increase the prevalence of ADHD. And, although it will allow many more children to receive treatment, it will undoubtedly result in many more children being medicated. Another major change that was proposed for DSM-5, but not accepted, was to lower the threshold for the diagnosis of generalized anxiety disorder (GAD). In addition to excessive anxiety and worry, DSM-IV-TR required the presence of three additional symptoms. In DSM-5 it was proposed that only one symptom (either muscle tension or a feeling of being on edge) should be required. This change would undoubtedly have led to a substantial increase in the number of people diagnosed with GAD. Had the change been approved, some people might have been relieved to learn that their worrying reflected a psychiatric disorder. However, had it been accepted, this change would likely have further increased the numbers of people who come to rely on antianxiety medications to get through the day.

The Therapeutic Relationship

The therapeutic relationship evolves out of what both client and therapist bring to the therapeutic situation. The outcome of psychotherapy normally depends on whether the client and therapist are successful in achieving a productive working alliance. The client's major contribution is his or her motivation. Clients who are pessimistic about their chances of recovery or who are ambivalent about dealing with their problems and symptoms respond less well to treatment Although definitions of the therapeutic alliance vary, its key elements are (1) a sense of working collaboratively on the problem, (2) agreement between patient and therapist about the goals and tasks of therapy, and (3) an affective bond between patient and therapist Clear communication is also important. This is no doubt facilitated by the degree of shared experience in the backgrounds of client and therapist. Almost as important as motivation is a client's expectation of receiving help. This expectancy is often sufficient in itself to bring about substantial improvement, perhaps because patients who expect therapy to be effective engage more in the process. Just as a placebo often lessens pain for someone who believes it will do so, a person who expects to be helped by therapy is more likely to benefit. The downside of this fact is that if a therapy or therapist fails for whatever reason to inspire client confidence, the effectiveness of treatment is likely to be compromised. To the art of therapy, a therapist brings a variety of professional skills and methods intended to help people see themselves and their situations more objectively—that is, to gain a different perspective. Besides helping provide a new perspective, most therapy situations also offer a client a safe setting in which he or she is encouraged to practice new ways of feeling and acting, gradually developing both the courage and the ability to take responsibility for acting in more effective and satisfying ways. To bring about such changes, an effective psychotherapist must help the client give up old and dysfunctional behavior patterns and replace them with new, functional ones. Because clients will present varying challenges in this regard, the therapist must be flexible enough to use a variety of interactive styles.

Eclecticism and Integration

The various "schools" of psychotherapy that we have just described once stood more in opposition to one another than they do now. Today, clinical practice is characterized by a relaxation of boundaries and a willingness on the part of therapists to explore differing ways of approaching clinical problems (see Castonguay et al., 2003, for a discussion), a process sometimes called multimodal therapy (Lazarus, 1997). When asked what their orientation is, most psychotherapists today reply "eclectic," which usually means that they try to borrow and combine concepts and techniques from various schools, depending on what seems best for the individual case. This inclusiveness extends to efforts to combine biological and psychosocial approaches as well as individual and family therapies. One example of an eclectic form of therapy is interpersonal psychotherapy (IPT; see also the Mood Disorders and Suicide chapter). Developed by Klerman and colleagues (Klerman, G. L., Weissman, M. M., Rounsaville, B. J., & Chevron, E. S., 1984) as a treatment for depression, IPT focuses on current relationships in the patient's life and has the goals of reducing symptoms and improving functioning. Interpersonal therapy was based on the interpersonal theory of Harry Stack Sullivan as well as on Bowlby's attachment theory. Its central idea is that all of us, at all times, involuntarily invoke schemas acquired from our earliest interactions with others, such as our parents, in interpreting what is going on in our current relationships. Although it is sometimes considered to be a form of psychodynamic psychotherapy, IPT uses techniques from several other treatment approaches. It is also focused and time limited. In addition, the emphasis in treatment is on the present, not the past IPT has shown value in the treatment of depression (de Mello et al., 2005). It has also been adapted for other disorders including bulimia nervosa (Fairburn et al., 1993), anxiety disorders (Stangier et al., 2011), and borderline personality disorder

Family Therapy

Therapy for a family overlaps with couple and marital therapy but has somewhat different roots. Couple therapy developed in response to the large number of clients who came seeking help for relationship problems. Family therapy began with the finding that many people who had shown marked clinical improvement after individual treatment—often in institutional settings—had a relapse when they returned home. As you have already learned, family-based treatment approaches designed to reduce high levels of criticism and family tension have been successful in reducing relapse rates in patients with schizophrenia and mood disorders Another approach to resolving family disturbances is called structural family therapy (Minuchin, 1974). This approach, which is based on systems theory, holds that if the family context can be changed, then the individual members will have altered experiences in the family and will behave differently in accordance with the changed requirements of the new family context. Thus, an important goal of structural family therapy is changing the organization of the family in such a way that the family members will behave more supportively and less pathogenically toward each other. Structural family therapy is focused on present interactions and requires an active but not directive approach on the part of a therapist. Initially, the therapist gathers information about the family—a structural map of the typical family interaction patterns—by acting like one of the family members and participating in the family interactions as an insider. In this way, the therapist discovers whether the family system has rigid or flexible boundaries, who dominates the power structure, who gets blamed when things go wrong, and so on. Armed with this understanding, the therapist then operates as an agent for altering the interaction among the members, which often has transactional characteristics of enmeshment (overinvolvement), overprotectiveness, rigidity, and poor conflict resolution skills. The "identified client" is often found to play an important role in the family's mode of conflict avoidance.

When Therapy Harms

There are many ways in which therapy can be detrimental. For example, a particular therapy might make certain symptoms worse, make a person more concerned about the symptoms they do have, or make the client excessively dependent on the therapist in order to function. Encounters with some therapists or forms of therapy may also make a person less willing to seek therapy in the future. Lilienfeld (Lilienfeld, S. O., 2007) has developed a list of therapies that have potentially harmful consequences. One example is "rebirthing" therapy for children with attachment problems. This approach, which involves therapists wrapping children in blankets, sitting on them, and squeezing them in an attempt to mirror the birth process, has resulted in several children dying of suffocation. Another problematic technique is facilitated communication, which is based on the premise that children with autism can communicate if they have the assistance of a facilitator who helps the child communicate using a computer keyboard. Facilitated communication has been linked to dozens of child sexual abuse allegations against the parents of children with autism. This has exposed these families to a great deal of needless emotional pain and suffering because studies show that the communications in facilitated communication do not come from the children themselves. Rather, they are unknowingly generated by the facilitators themselves as they guide the child's hands over the keyboard. Despite the fact that facilitated communication was debunked more than 20 years ago, many people still use it to this day (Lilienfeld et al., 2015). All practicing clinicians and therapists owe it to their clients (and to the families of their clients) to educate themselves about research on potentially harmful treatments. They should also monitor their own behavior and adhere to high ethical standards of practice. In this way they can minimize the likelihood that they will cause damage to the people who come to them seeking help.

Electroconvulsive Therapy

Using convulsions to treat mental disorders dates back to the Swiss physician and alchemist Paracelsus (1493-1541), who induced a patient with "lunacy" to drink camphor until he experienced convulsions (Abrams, 2002; Mowbray, 1959). However, Ladislas von Meduna, a Hungarian physician, is generally regarded as the modern originator of this treatment approach. Von Meduna noted—erroneously, as it turned out—that schizophrenia rarely occurred in people with epilepsy. This observation caused him to infer that schizophrenia and epilepsy were somehow incompatible and to speculate that one might be able to cure schizophrenia by inducing convulsions. In an early treatment effort, von Meduna used camphor to induce convulsions in a patient with schizophrenia, who relatively quickly regained lucidity after the convulsive therapy. Later, von Meduna began to use a drug called Metrazol to induce convulsions because it operated more rapidly than camphor. Another early approach, adopted by Manfred Sakel in the 1930s, was to cause convulsions by injecting patients with insulin (Fink, 2003). However, these chemical methods gave physicians no control over the induction and timing of the seizures. Then, in 1938, Italian physicians Ugo Cerletti and Lucio Bini tried the simplest method of all—passing an electric current through a patient's head. This method, which became known as electroconvulsive therapy (ECT), is still used today (see the Mood Disorders and Suicide chapter). In the United States, about 100,000 patients are treated with ECT each year The general public often views ECT as a horrific and primitive form of treatment, influenced no doubt by its depiction in movies such as One Flew Over the Cuckoo's Nest. Indeed, a number of malpractice lawsuits have been brought against psychiatrists who use ECT, primarily over the failure to obtain appropriate patient consent, which can be very difficult when patients may not be legally competent to give such consent due to their illness (Abrams, 2002; Leong & Eth, 1991). However, despite the distaste with which some people regard ECT, it is a safe and effective form of treatment. In fact, it is the only way of dealing with some patients who are severely depressed or suicidal—patients who may have failed to respond to other forms of treatment. In addition, it is often the treatment of choice for pregnant women who are severely depressed for whom taking antidepressants may be problematic, as well as for elderly people, who may have medical conditions that make taking antidepressant drugs dangerous Reviews evaluating research on ECT have concluded that it is an effective treatment for patients with severe or psychotic-level depression, as well as for some patients with mania (Prudic, 2009). Properly administered, ECT is not thought to cause structural damage to the brain (Devanand et al., 1994), although this issue remains controversial (Reisner, 2003). Every neurotransmitter system is affected by ECT, and ECT is known to downregulate the receptors for norepinephrine, increasing the functional availability of this neurotransmitter. However, exactly how ECT works is still not fully clear ECT can be administered in one of two ways. In bilateral ECT, electrodes are placed on either side of the patient's head (see Figure 16.4), and brief constant-current electrical pulses of either high or low intensity are passed from one side of the head to the other for up to about 1.5 seconds. In contrast, unilateral ECT (see Figure 16.4) involves limiting current flow to one side of the brain, typically the nondominant side (right side, for most people). A general anesthetic allows the patient to sleep through the procedure, and muscle relaxants are used to prevent the violent contractions that, in the early days of ECT, could be so severe as to cause the patient to fracture bones. A bite block is also used to avoid injury to the teeth. Today, if you were to observe someone receiving ECT, all you might see would be a small twitch of the hand, perhaps, as the convulsions occurred. After the ECT session is over, the patient has amnesia for the period immediately preceding the therapy and is usually somewhat confused for the next hour or so. Normally, a treatment series consists of fewer than a dozen sessions, although occasionally more are needed. Treatments are usually administered two or three times per week Empirical evidence suggests that bilateral ECT is more effective than unilateral ECT. Unfortunately, bilateral ECT is also associated with more severe cognitive side effects and memory problems (Reisner, 2003). For instance, patients often have difficulty forming new memories (anterograde amnesia) for about 3 months after ECT ends. Physicians must therefore weigh the greater clinical benefits of bilateral ECT against its tendency to cause greater cognitive side effects. Some clinicians recommend starting with unilateral ECT and switching to bilateral after five or six treatments if no improvement is seen

Token Economies

Years ago, when behavior therapy was in its infancy, token economies based on the principles of operant conditioning were developed for use with patients experiencing long-term stays in psychiatric hospitals. When they behaved appropriately on the hospital ward, patients earned tokens that they could later use to receive rewards or privileges Token economies have been used to establish adaptive behaviors ranging from elementary responses such as eating and making one's bed to the daily performance of responsible hospital jobs. In the latter instance, the token economy resembles the outside world, where an individual is paid for his or her work in tokens (money) that can later be exchanged for desired objects and activities. Although sometimes the subject of criticism and controversy, token economies remain a relevant treatment approach for individuals with serious mental illness and those with developmental disabilities Similar reinforcement-based methods are now being used to treat substance abuse. In one study, people being treated for cocaine dependence were rewarded with vouchers worth 25 cents if their urine tests came back negative (Higgins, Wong, et al., 2000). Patients could then ask a staff member to purchase for them items from the community with the vouchers they had accumulated. Patients who received the incentive vouchers based on their abstinence from cocaine had better clinical outcomes than a comparison group of patients who also received vouchers but whose vouchers were not contingent on their abstinent behavior.

Client Ratings

clinical settings, there is an emphasis on using client ratings on quantitative measures to determine how much change has occurred. For example, the Beck Depression Inventory (a self-report measure of depression severity) is widely used to measure the degree of severity of a client's depression. It has become almost standard in the pretherapy and posttherapy assessment of depression. Unfortunately, a client is not necessarily a reliable source of information on therapeutic outcomes. Not only may clients want to believe for various personal reasons that they are getting better, but in an attempt to please the therapist they may report that they are being helped. In addition, because therapy often requires a considerable investment of time, money, and sometimes emotional distress, the idea that it has been useless is a dissonant one.

Would Change Occur Anyway?

ways in which people can help each other, it is not surprising that improvement often occurs without professional intervention. Moreover, some forms of psychopathology, such as depressive episodes or brief psychotic disorder, sometimes run a fairly short course with or without treatment. In other instances, disturbed people improve over time for reasons that are not apparent. Even if many people with emotional disturbances tend to improve over time without psychotherapy, psychotherapy can often accelerate improvement or bring about desired behavior change that might not otherwise occur. Most researchers today would agree that psychotherapy is more effective than no treatment. Research suggests that about 50 percent of patients show clinically significant change after 21 therapy sessions. After 40 sessions, about 75 percent of patients have improved. But why do patients improve? Remarkably, we know very little about the mechanisms through which therapeutic change occurs, or about the "active ingredients" of effective therapy. We do know that progress in therapy is not always smooth and linear, however. Sudden gains can occur between one therapy session and another (Tang & DeRubeis, 1999; Tang et al., 2002). These clinical leaps appear to be triggered by cognitive changes that patients experience in critical sessions. Researchers are now actively exploring how such factors as therapist adherence (how well a therapist delivers a particular type of therapy) and therapist competence (how skillfully the therapist administers the therapy) impact how well a patient does