unit 4 topic 4 (therapy)

effectiveness of cognitive-behavioral therapy

(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.

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. -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. -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.

Cognitive and cognitive-behavioral therapy

-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) -Cognitive or cognitive-behavioral therapy attempts to modify a person's self-statements and construal of events in order to change his or her behavior.

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. -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

Social values and psychotherapy

-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. -Although psychotherapy is a set of tools to be used in pursuit of a client's welfare, not an ethics system, therapists are often faced with moral dilemmas in the course of treatment.

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. -males are more reluctant to seek help when they are experiencing problems than are females.

cognitive model

-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.

Why do people seek therapy?

-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 -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 -These include stressful current circumstances, long-standing problems or chronic unhappiness, as well as a search for personal growth and insight into their own lives

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.

elements of therapeutic alliance

(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

-Four basic techniques are used in Freudian psychoanalysis

(1) free association, (2) analysis of dreams, (3) analysis of resistance, and (4) analysis of transference

two main themes of Cognitive and cognitive-behavioral therapy

(1) the conviction that cognitive processes influence emotion, motivation, and behavior; and (2) the use of cognitive and behavior-change techniques in a pragmatic (hypothesistesting) manner.

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 -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. -there are no impairments in memory or concentration as there are with ECT -it is still a very new approach and typically is only considered after several courses of psychotherapy and antidepressant medication have proven ineffective

why do people make cognitive errors at all?

-According to Beck (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

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. -Aside from possible unwanted side effects, there is the complexity of matching drug and dosage to the needs of each specific patient. -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 -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 -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.

other mood-stabilizing drugs

-Although lithium is still widely used, other drugs are also considered first-line treatments for bipolar disorder -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 -Carbamazepine has been associated with significant side effects including blood problems, hepatitis, and serious skin conditions -Valproate probably has the fewest and mildest side effects, which can include nausea, diarrhea, sedation, tremor, and weight gain.

Benzodiazepines

-Another class of drugs, the barbiturates (e.g., phenobarbital), is seldom used today except to control seizures or as anesthetics during electroconvulsive therapy. -benzodiazepines 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 sleepinducing agents and can be used to treat insomnia -One problem with benzodiazepines is that patients can become psychologically and physiologically dependent on them -relapse rates following discontinuation of these drugs are extremely high -Benzodiazepines and related anxiolytic medications are believed to work by enhancing the activity of GABA receptors -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

Antianxiety drugs

-Antianxiety drugs are used for conditions in which tension and anxiety are significant components -They do not provide a cure. -these medications can keep symptoms under control until patients are able to receive other forms of effective psychological treatments -Antianxiety medications have little place in the treatment of psychosis -often used as supplementary treatments in certain neurological disorders to control such symptoms as convulsive seizures

Neurosurgery

-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 -Initial reports of results tended to be enthusiastic, downplaying complications (which included a 1 to 4 percent death rate) and undesirable side effects -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, treatment-resistant severe selfinjury, or even intractable anorexia nervosa. However, such approaches carry serious risks. -Deep brain stimulation is a different treatment approach that involves surgery but does not result in a permanent lesion being made in the brain

Behavior therapy: Aversion therapy

-Aversion therapy involves modifying undesirable behavior by the old-fashioned method of punishment. -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

atypical antipsychotic drugs

-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 (Weight gain and diabetes) -more serious side effect of clozapine is a potentially life-threatening drop in white blood cell count called agranulocytosis, -atypical antipsychotics improve both positive and negative symptoms and have fewer extrapyramidal symptoms (unwanted side effects involving movement) than conventional (first-generation) antipsychotics. -atypical antipsychotics described above (with the exception of clozapine) are the first-choice treatments for psychosis and that clozapine and conventional antipsychotics are best considered as second-line therapies.

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 -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.

Evaluating behavior therapy

-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 more pervasive and vaguely defined the client's problem, the less likely behavior therapy is to be useful. -it appears to be only rarely employed to treat complex personality disorders, although dialectical behavior therapy for patients with borderline personality disorder is an exception -behavioral techniques remain central to the treatment of anxiety disorders -Because behavioral treatments are often quite straightforward, behavior therapy can be used with patients with psychosis -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

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. -trained independent evaluators are people who are trained to conduct clinical interviews and to rate the amount of clinical change that has occurred in a patient -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

Behavior therapy: Exposure therapy

-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 -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 -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 -Imaginal procedures have some limitations, an obvious one being that not everybody is capable of vividly imagining the required scenes. -the results from virtual reality exposure are comparable to the results obtained from in vivo exposure

serotonin and norepinephrine reuptake inhibitors (SNRIs)

-Example 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 -there is no compelling evidence that SSRIs and SNRIs are more effective than the older antidepressants.

Family therapy

-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 -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 -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. -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 -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. -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.

humanistic-experiential therapies: 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 (1969) as a means of teaching clients to recognize the bodily processes and emotions they had been blocking off from awareness. -the main goal of gestalt therapy is to increase the individual's selfawareness 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. -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.

Electroconvulsive therapy

-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 -these chemical methods gave physicians no control over the induction and timing of the seizures. -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 -it is a safe and effective form of treatment. -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. -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 -it is an effective treatment for patients with severe or psychotic-level depression, as well as for some patients with mania -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 -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 -Some clinicians recommend starting with unilateral ECT and switching to bilateral after five or six treatments if no improvement is seen

Client ratings

-In studies aimed at testing the effectiveness of different forms of therapy, and in many clinical settings, there is an emphasis on using client ratings on quantitative measures to determine how much change has occurred. -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.

Cognitive and cognitive-behavioral therapy: Beck's Cognitive Therapy

-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 -With the therapist's help, they then identify the logical errors in their thinking and learn to challenge the validity of these automatic thoughts. -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. -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

couple therapy: integrative behavioral couple therapy (IBCT)

-Instead of emphasizing change (which sometimes has the paradoxical effect of making people not want to change), integrative behavioral couple therapy (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 -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. -couples who stay together after receiving IBCT are significantly happier than couples who stay together following treatment with TBCT

Object relations, attachment-based approaches, and self psychology

-Most seek to expose, bring to awareness, and modify the effects of the remote developmental sources of the difficulties the client is currently experiencing -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 -Many of the newer psychodynamic forms of treatment emphasize the way interpersonal processes are affected by early interactions with parents and other family members.

humanistic-experiential therapies: Motivational interviewing

-Motivational interviewing (MI) 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 -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 -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 -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

Analysis of transference

-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 -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 -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. -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

Overt behaviors

-Perhaps the most direct way to know if someone has improved in treatment is to observe their behavior directly. -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).

Who provides psychotherapeutic services?

-Physicians, in addition to caring for their patients' physical problems, often become trusted advisers in emotional matters -Many physicians are trained to recognize psychological problems that are beyond their expertise and to refer patients to psychological specialists or to psychiatrists -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. -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. -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 -psychiatrists differ from psychologists 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

Humanistic-experiential therapies

-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 -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 -their central focus is always expanding a client's "awareness."

transference-focused psychotherapy, or TFP

-Psychoanalytically oriented treatment for borderline personality disorder -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

Psychodynamic therapies

-Psychodynamic therapy is a broad treatment approach that focuses on individual personality dynamics, usually from a psychoanalytic or some psychoanalytically derived perspective.

Cognitive and cognitive-behavioral therapy: Rational emotive behavior therapy

-REBT attempts to change a client's maladaptive thought processes, on which maladaptive emotional responses and, thus, behavior are presumed to depend -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 -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. -the philosophy underlying REBT has something in common with that underlying humanistic therapy 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

Evaluating cognitive-behavioral therapies

-REBT may be most useful in helping basically healthy people to cope better with everyday stress and perhaps in preventing them from developing fullblown anxiety or depressive disorders -REBT appears to be inferior to exposure-based therapies in the treatment of anxiety disorders such as agoraphobia, social phobia, and probably OCD -Beck's cognitive therapy are extremely beneficial in alleviating many different types of disorders -For all but the most severe cases of depression (e.g., psychotic depression), cognitive-behavioral therapy (CBT) is at least comparable to drug treatment -Cognitive therapy also produces dramatic results in the treatment of panic disorder and generalized anxiety disorder, and CBT is now the treatment of choice for bulimia -cognitive approaches have promise in the treatment of conduct disorder in children, substance abuse, and certain personality disorders

Using antidepressants to treat anxiety disorders, bulimia nervosa, and personality disorders

-SSRIs are often used in the treatment of panic disorder, social phobia, and generalized anxiety disorder, as well as OCD -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. -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

Behavior therapy: 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 -On other occasions, therapy is administered to establish desired behaviors that are missing -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.

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. -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 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. -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

humanistic-experiential therapies: 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 -The primary objective of Rogerian therapy is to resolve this incongruence—to help clients become able to accept and be themselves. -client-centered therapists establish a psychological climate in which clients can feel unconditionally accepted, understood, and valued as people. -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 clientcentered 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.

Clinician ratings

-The effectiveness of therapy also is often evaluated by the treating clinician -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 -the clinician typically has only a limited observational sample (the client's in-session behavior) from which to make judgments of overall change -clinicians can inflate improvement averages by deliberately or subtly encouraging difficult clients to discontinue therapy

Combined treatments

-The integration of medication and psychotherapy remains common in clinical practice, particularly for disorders such as schizophrenia and bipolar disorder -For example, patients with social anxiety disorder who receive exposure therapy do much better if they are given an oraldose 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. -Typically, psychosocial interventions are combined with psychiatric medications -combined treatment is effective because medications and psychotherapy may target different symptoms and work at different rates -Adding psychiatric medications does not generally improve the clinical efficacy of psychosocial treatments for anxiety disorders, for example.

Antipsychotic drugs

-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. -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 -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 -depot neuroleptics 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. -One problematic side effect that can result from treatment with conventional antipsychotic medications such as chlorpromazine is tardive dyskinesia

Psychodynamic therapy since Freud

-The original version of psychoanalysis is practiced only rarely today and there is little empirical support for its efficacy. -psychoanalytic or psychodynamic therapists have worked out modifications in the procedure that are designed to shorten the time and expense required.

Evaluating psychodynamic theories

-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 -There are signs that psychodynamic approaches may be helpful in the treatment of depression, panic disorder, PTSD, and substance abuse disorders -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

Couples therapy: traditional behavioral couple therapy (TBCT)

-The primary reasons that couples report for seeking treatment are communication problems and a lack of affection -the gold standard of couple therapy has been traditional behavioral couple therapy (TBCT) -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 -this form of treatment does not work for all couples -Even among couples who do show an improvement in relationship satisfaction, the improvement is not always maintained over time

The therapeutic relationship

-The therapeutic relationship evolves out of what both client and therapist bring to the therapeutic situation -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 -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 -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. -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. -an effective psychotherapist must help the client give up old and dysfunctional behavior patterns and replace them with new, functional ones

Evidence-based treatment

-These tests, using voluntary and informed patients as subjects, are called randomized clinical trials (RCTs) or, more simply, efficacy trials -double-blind study is an effort to ensure that expectations on the part of the patient and prescriber play no role in the study -Investigators of psychotherapy outcomes have attempted to apply this research design to their own field of inquiry, with necessary modifications - 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. -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). -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

People who seek personal growth

-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

Monoamine oxidase inhibitors

-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). -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

-This involves stimulating patients' brains electrically over a period of several months. -First, surgeons drill holes into the brain and implant small electrodes -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. -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." -How effective is deep brain stimulation as a treatment for unrelenting depression? -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.

Behavior therapy: Token economies

-Token economies have been used to establish adaptive behaviors -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 -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

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 -a dream has two kinds of content: -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. (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.

Bupropion (Wellbutrin)

-an antidepressant that is not structurally related to other antidepressants -It inhibits the reuptake of both norepinephrine and dopamine -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

classical psychoanalysis

-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 -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.

Other antianxiety medications

-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 -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 effect -it takes 2 to 4 weeks to exert any anxiolytic effects -Because it is nonsedating, it cannot be used to treat insomnia.

Eclecticism and integration

-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, a process sometimes called multimodal therapy -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. -One example of an eclectic form of therapy is interpersonal psychotherapy (IPT) -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 -It has also been adapted for other disorders including bulimia nervosa, anxiety disorders, and borderline personality disorder

Why would change occur anyway?

-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 -But why do patients improve? -we know very little about the mechanisms through which therapeutic change occurs, or about the "active ingredients" of effective therapy

bilateral ECT

-electrodes are placed on either side of the patient's head, 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. -Unfortunately, bilateral ECT is also associated with more severe cognitive side effects and memory problems -Empirical evidence suggests that bilateral ECT is more effective than unilateral ECT.

Evaluating humanistic-experiential therapies

-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 -Evidence suggests that these treatment approaches are helpful for patients with a variety of problems including depression, anxiety, trauma, and marital difficulties -effective method for promoting behavior change in people with substance abuse problems

Behavior therapy: Modeling

-in modeling the client learns new skills by imitating another person, such as a parent or therapist, who performs the behavior to be acquired

Lithium

-lithium salts such as lithium carbonate were effective in treating manic disorders -lithium is still widely used for the treatment of bipolar disorder and is marketed as Eskalith and Lithobid -exactly how it brings about its therapeutic effect is still not certain -lithium sometimes relieves depression, although probably mainly in patients with bipolar depression -Side effects of lithium include increased thirst, gastrointestinal difficulties, weight gain, tremor, and fatigue -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.

psychodynamically oriented therapists

-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

why does men ask fewer questions than women do for professional help

-men are less able than women to recognize and label feelings of distress and to identify these feelings as emotional problems -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."

Viibryd (vilazodone)

-newest antidepressant -It is a novel combination of an SSRI and a serotonin receptor agonist. -Studies suggest that vilazodone is safe and well tolerated by patients and that it works better than placebo for patients who are depressed

Selective serotonin reuptake inhibitors

-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. -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 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 -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. -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. -If remission is sustained for 6 to 12 months or more, the patient is considered to have recovered -Side effects of the SSRIs include nausea, diarrhea, nervousness, insomnia, and sexual problems such as diminished sexual interest and difficulty with orgasm -Prozac is no more associated with suicide than are other antidepressants -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

Trazodone (Desyrel)

-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 -In rare cases, it can produce a condition in men called priapism -Priapism is prolonged erection in the absence of any sexual stimulation

How can men be encouraged to seek help when they have difficulties?

-to develop new treatment approaches that provide a better fit for men who see little value in talking about their problem -to use more creative approaches to encourage men to seek help and support

behavioral activation

-treatment of depression - 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.

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

goals of psychotherapy

changing maladaptive behavior, minimizing or eliminating stressful environmental conditions, reducing negative affect, improving interpersonal competencies, resolving personal conflicts, modifying people's inaccurate assumptions about themselves, and fostering a more positive self-image

psychodynamic therapy is mainly practiced in two basic forms

classical psychoanalysis and psychodynamically oriented psychotherapy

unilateral ECT

involves limiting current flow to one side of the brain, typically the nondominant side (right side, for most people)