Chapter 13

Free Association

According to Freud, when you let your mind wander and remove conscious censorship over thoughts—a process called free association—interesting and even bizarre connections seem to spring into awareness (see photo). Freud believed that the first thing to come to a patient's mind is often an important clue to what the person's unconscious wants to conceal. Having the client recline on a couch, with only the ceiling to look at, is believed to encourage free association

Psychiatrists MD (doctor of medicine)

After four years of medical school, an internship and residency in psychiatry are required, which includes supervised practice in psychotherapy techniques and biomedical therapies. In most states in the United States, psychiatrists, because they are M.D.s, are the only mental health specialists who can regularly prescribe drugs.

School psychologists MA (master of arts) PhD (doctor of philosophy) PsyD (doctor of psychology) EdD (doctor of education)

School psychologists generally begin with a bachelor's degree in psychology, followed by graduate training in psychological assessment and counseling for school-related issues and problems.

cognitive restructuring

a process called cognitive restructuring, clients learn to identify and dispute their irrational or maladaptive thought patterns. Do you see how if we first identify our irrational thoughts, then we can logically challenge them, which in turn enables us to become more effective

Cognitive therapies

assume that faulty thoughts (cognitions) are the primary source for problems, and that our thoughts intervene between events and our reactions to them

psychoanalysis

person's psyche (or mind) is analyzed. Traditional psychoanalysis is based on Sigmund Freud's central belief that abnormal behavior is caused by unconscious conflicts among the three parts of the psyche—the id, the ego, and the superego (Chapter 11). During psychoanalysis, these conflicts are brought to consciousness. The individual comes to understand the reasons for his or her dysfunction and realizes that the childhood conditions under which the conflicts developed no longer exist. Once this realization or insight occurs, the conflicts can be resolved, and the client can develop more adaptive behavior patterns

Gender and Therapy In our individualistic Western culture, men and women present different needs and problems to therapists. Research has identified four unique concerns related to gender and psychotherapy Therapists must be sensitive to possible connections between clients' problems and their gender. Rather than just emphasizing drugs to relieve depression, it may be more appropriate for therapists to explore ways to relieve the stresses of multiple roles or poverty for both women and men. an you see how helping a single parent identify parenting resources, such as play groups, parent support groups, and high-quality child care, might be just as effective at relieving depression as prescribing drugs? In the case of men, how might relieving loneliness or depression help decrease their greater problems with substance abuse and aggression? If you've enjoyed this section on cultural and gender issues in therapy, as well as the earlier description of the various forms and formats of psychotherapy, you may be considering a possible career as a therapist

1.Rates of diagnosis and treatment of mental disorders Women are diagnosed and treated for mental illness at a much higher rate than men. Are women "sicker" than men as a group, or are they just more willing to admit their problems? Or are the categories of illness biased against women? More research is needed to answer these questions. 2.Stresses of poverty Women are disproportionately likely to be poor. Poverty contributes to stress, which is directly related to many psychological disorders. 3.Violence against women Rape, incest, and sexual harassment—which are much more likely to happen to women than to men—may lead to depression, insomnia, posttraumatic stress disorder, eating disorders, and other problems. 4.Stresses of multiple roles and gender-role conflict Despite the many changes in gender roles in modern times, restrictive definitions of femininity and masculinity still limit both genders' well-being and human potential. Furthermore, most men and women today serve in many roles, as family members, students, wage earners, and so forth. The conflicting demands of their multiple roles often create special stresses unique to each gender.

Psychodynamic Therapies

A modern derivative of Freudian psychoanalysis, psychodynamic therapies, includes both Freud's theories and those of his major followers— Carl Jung, Alfred Adler, Karen Horney, and Erik Erikson. In contrast to psychoanalysis, psychodynamic therapies are shorter and less intensive (once or twice a week versus several times a week and only for a few weeks or months versus years). Also, the client is treated face-to-face rather than reclining on a couch, and the therapist takes a more directive approach rather than waiting for unconscious memories and desires to slowly be uncovered. In addition, contemporary psychodynamic therapists focus less on unconscious, early-childhood roots of problems and more on conscious processes and current problems (Barber & Solomonov, 2016; Göttken et al., 2014; Short & Thomas, 2015). Such refinements have helped make treatments shorter, more available, and more effective for an increasing number of people. See Figure 13.4 for one of the most popular modern forms of psychodynamic therapies.

self-help group

A variation on group therapy is the self-help group. Unlike other group approaches, self-help groups are not guided by a professional. They are simply circles of people who share a common problem, such as alcoholism, obesity, or breast cancer, and who meet to give and receive support. Programs such as Alcoholics Anonymous, Narcotics Anonymous, and Spenders Anonymous are examples of self-help groups. Although group members don't get the same level of individual attention found in one-on-one therapies, group and self-help therapies provide their own unique advantages (Bateganya et al., 2015; Castillo et al., 2016). They are far less expensive than one-on-one therapies and provide a broader base of social support. Group members also can learn from each other's experiences, share insights and coping strategies, and role-play social interactions together. For example, researchers have studied group sessions in 12-step programs, like Alcoholics Anonymous, and they've found that people suffering from a combination of social anxiety disorders and substance abuse disorders, as well as recovering alcoholics, all show lower rates of relapse than those who don't participate in these self-help groups. This is particularly true if they also provide help to others (Pagano et al., 2013, 2015). In sum, research on self-help groups for alcoholism, obesity, and other disorders suggests that they can be very effective, either alone or in addition to individual psychotherapy (Kendra et al., 2015; McGillicuddy et al., 2015; O'Farrell et al., 2016). Keep in mind that therapists often recommend these alternative formats, such as group therapy, to their clients as an additional resource, while continuing their individual therapy.

Overcoming Irrational Misconceptions

Albert Ellis believed that people often require the help of a therapist to see through their defenses, and to challenge their self-defeating thoughts. For mild, everyday problems, our students have found that they can improve their own irrational beliefs and responses with the following suggestions: 1.Identify and confront your belief system Identify your irrational beliefs by asking yourself why you feel the particular emotions you do. Then, by confronting your thoughts and feelings, you can discover the irrational assumptions creating the problem consequences. 2.Evaluate consequences Rather than perpetuating negative emotions by assuming they must be experienced, focus on whether your reactions make you more effective and enable you to solve your problems. It's gratifying when people you cherish, love you in return. But if they don't, continuing to pursue them, or insisting that they must love you, will only be self-defeating. 3.Practice effective ways of thinking and behaving Imagine and rehearse thoughts and behaviors that are more effective, and outcomes that are more successful.

Beck's Cognitive-Behavior Therapy (CBT)

Another well-known cognitive therapist, Aaron Beck, also believes psychological problems result from illogical thinking and destructive self-talk (Beck, 1976, 2000; Beck & Dozois, 2014; Calkins et al., 2016). But Beck seeks to directly confront and change the behaviors associated with destructive cognitions. Beck's cognitive-behavior therapy (CBT) is designed to reduce both self-destructive thoughts and self-destructive behaviors. Using cognitive-behavior therapy, clients are first taught to recognize and keep track of their thoughts. Next, the therapist trains the client to develop ways to test these automatic thoughts against reality. This approach helps depressed people discover that negative attitudes are largely a product of faulty thought processes. At this point, Beck introduces the second phase of therapy—persuading the client to actively pursue pleasurable activities. Depressed individuals often lose motivation, even for experiences they used to find enjoyable. Simultaneously taking an active rather than a passive role and reconnecting with enjoyable experiences can help in recovering from depression

Psychotherapeutic Drug Treatments for Psychological Disorders: Antianxiety Drugs Medications used to reduce anxiety, and decrease over-arousal in the brain; also known as anxiolytics or minor tranquilizers

Antianxiety drugs lower the sympathetic activity of the brain—the crisis mode of operation—so that anxiety is diminished, and the person is calmer and less tense. Unfortunately, they're also potentially dangerous because they can reduce alertness, coordination, and reaction time. Moreover, they can have a synergistic (intensifying) effect with other drugs, which may lead to severe drug reaction—and even death. Ativan Halcion Klonopin Librium Restoril Tranxene Valium Xanax

Antidepressant Drugs Medications used to treat depression, some anxiety disorders, obsessive-compulsive disorder, posttraumatic stress disorder, and certain eating disorders (such as bulimia).

Antidepressant drugs are used primarily to reduce depression. There are several types of antidepressant drugs, including: selective serotonin reuptake inhibitors (SNRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), norepinephrine and dopamine reuptake inhibitors (NDRIs), and atypical antidepressants. Each class of drugs affects neurochemical pathways in the brain in a slightly different way, increasing or decreasing the availability of certain chemicals. SSRIs (such as Paxil and Prozac) are by far the most commonly prescribed antidepressants. The atypical antidepressants are prescribed for those who fail to respond to, or experience undesirable side effects from, other antidepressants. It's important to note that it can take weeks or months for antidepressants to achieve their full effect. Anafranil Celexa Cymbalta Effexor Elavil Lexapro Nardil Norpramin Parnate Paxil Pristiq Prozac Sarafem Tofranil Wellbutrin Zoloft

How antidepressants affect the brain

Antidepressants are believed to work by increasing the availability of serotonin or norepinephrine, neurotransmitters that normally elevate mood and arousal. Shown here is the action of some of the most popular antidepressants—Prozac, Paxil, and other selective serotonin reuptake inhibitors (SSRIs)

Antipsychotic Drugs Medications used to diminish or eliminate symptoms of psychosis; also known as neuroleptics or major tranquilizers

Antipsychotic drugs reduce the agitated behaviors, hallucinations, delusions, and other symptoms associated with psychotic disorders, such as schizophrenia. Traditional antipsychotics work by decreasing activity at the dopamine receptors in the brain. A large number of clients markedly improve when treated with antipsychotic drugs. Clozaril Geodon Invega Latuda Haldol Risperdal Seroquel Thorazine Zyprexa

Freud's free association

As shown in this popular cartoon, psychoanalysis is oft en portrayed as a client lying on a couch engaging in free association. Freud believed that this arrangement—with the client relaxed and the therapist out of his or her view—helps the client let down his or her defenses, making the unconscious more accessible.

Can Watching Movies Prevent Divorce?

As we all know, roughly half of all U.S. marriages end in divorce. Numerous secular and religious institutions have attempted to reduce this rate with various early marriage intervention programs. To examine whether simple self-help strategies, such as watching and discussing movies about relationships, might offer some of the same benefits as these professionally led intervention programs, researchers randomly assigned 174 couples to one of four groups (Rogge et al., 2013): Group 1 (control) received no training or instructions. Group 2 (conflict management) learned active listening strategies to help discuss heated issues. Group 3 (compassion and acceptance training) learned strategies for finding common ground and showing empathy. Group 4 (minimal intervention—movie and talk) attended a 10-minute lecture on relationship awareness and how watching couples in movies could help increase awareness of their own behaviors. Following this initial assignment to groups, Group 1 received no training at all, but members of this group were similar to those in the three other groups in terms of age, education, ethnicity, relationship satisfaction, and other dimensions. Groups 2 and 3 attended weekly lectures, completed homework assignments, and met with a trained therapist periodically. In contrast, Group 4 only attended a 10-minute lecture, watched a romantic comedy, and then discussed 12 questions about the screen couple's interactions (such as, "Did they try using humor to keep things from getting nasty?"). They were then sent home with a list of 47 relationship-oriented movies and allowed to choose their favorite one to watch and discuss once a week for the next month. The researchers then followed up with all couples 3 years later to see which of these approaches was most effective for preventing divorce. Much to their surprise, couples in all three of the intervention groups were much less likely to get divorced compared to those in the control group. Specifically, 24% of couples in the control group were divorced, compared to only 11% of those in any of the other three groups. Even more surprising, this study shows that a simple self-help strategy of watching and discussing five relationship movies over 1 month's time can be just as effective at reducing the divorce or separation rate as more intensive early marriage counseling programs led by trained psychologists. Do you see how this study has exciting wide-scale, national applications? If "movie date night" can double as therapy, many U.S. couples might be saved from the very high emotional and financial costs of divorce. What about your own current or future relationships? If simply sharing and discussing a relationship movie now and then with your romantic partner might strengthen that relationship, why not try it? You can learn more about this study (and see a list of recommended movies with guided discussion questions) at: www.couples-research.com.

Operant Conditioning

As we discovered in Chapter 6, consequences are the heart of operant conditioning. Using a form of therapy called behavior modification, therapists provide reinforcement as a consequence for appropriate behaviors, and they withhold reinforcement for inappropriate behaviors. To develop complex behaviors, they often use shaping, which provides immediate rewards for successive approximations of the target behavior. Therapists have found this technique particularly successful in developing language skills in children with autism. First, the child is rewarded for connecting pictures or other devices with words; later, rewards are given only for using the pictures to communicate with others. This type of shaping can even be helpful if you suffer from the common problem of excessive shyness For clients in an inpatient treatment facility, adaptive behaviors can be taught or increased with techniques that provide immediate reinforcement in the form of tokens, which are objects or symbols that can be later exchanged for primary rewards, such as food, TV time, a private room, or outings. Clients might at first be given tokens for merely attending group therapy sessions. Later they will be rewarded only for actually participating in the sessions. Eventually, the tokens can be discontinued when the client receives the reinforcement of being helped by participation in the therapy sessions

Evaluating Psychoanalysis

As you can see, psychoanalysis is largely rooted in the assumption that repressed memories and unconscious conflicts actually exist. But, as we noted in Chapters 7 and 11, this assumption is the subject of heated, ongoing debate. Critics also point to two other problems with psychoanalysis 1. Limited applicability Psychoanalysis is time-consuming (often lasting several years with four to five sessions a week) and expensive. In addition, critics suggest that it applies only to a select group of highly motivated, articulate clients with less severe disorders and not to more complex disorders, such as schizophrenia. 2. Lack of scientific credibility According to critics, it is difficult, if not impossible, to scientifically document the major tenets of psychoanalysis. How do we prove or disprove the existence of an unconscious mind or the meaning of unconscious conflicts and symbolic dream images? espite these criticisms, research shows that traditional psychoanalysis can be effective for those who have the time and money

Protecting Your Mental Health

As you've seen throughout this text, psychology focuses on three major areas—thoughts, feelings, and actions. Therefore, to increase your everyday well-being and protect your mental health, consider the following research-based positive psychology tips for each area: 1.Recognize and control your thoughts. Would you like to be happier and more often in a great mood? You might start by reviewing and implementing the suggestions in the PositivePsych happiness section in Chapter 10. In addition, as discussed earlier, the 3 Cs of Beck's cognitive therapy (catching, challenging, and changing our faulty thought processes) are key to successful therapy—as well as in everyday life. Research also finds that having a positive view of the future and an optimistic, attributional style are important to mental health Depressed people often suffer from a depressive attribution style of thinking, which means that they typically attribute negative events to internal, stable, and global causes. For example, "I failed because I'm unlucky, I have been throughout my life, and it affects all parts of my life." The good news is that social connections with others, which we discuss later in this list, can reduce this type of thinking (Cruwys et al., 2015). In addition, there is a wealth of research on the power of meditation in recognizing and gaining control of your thought processes. As discussed in Chapter 3, mindfulness-based stress reduction (MBSR) is linked with numerous health benefits, from better concentration and physical health to improved mental well-being 2.Acknowledge and express your feelings. Although we all have negative emotions and conflicts that often need to be acknowledged and resolved, as a general rule, recognizing and expressing your positive emotions, particularly feelings of gratitude, has been found to be an important avenue to mental health (see again Chapter 10's PositivePsych happiness feature). Noting what you're thankful for — from your significant other to catching the bus or subway before the doors close—will definitely improve your ability to cope with life's challenges. Being grateful also tends to increase your personal self-esteem and overall well-being (Lin, 2015). Interestingly, well-being therapy (WBT), which focuses on personal growth and noticing and savoring the positive aspects of our lives, has been successful in promoting overall mental health, as well as in increasing resilience and sustained recovery from several psychological disorders Empathy is equally important. As you recall from our earlier discussion of Roger's client-centered therapy, empathy involves being a sensitive listener who understands and shares another's inner experience. The good news is that when you're being empathic, you're not only improving another person's self-acceptance and mental health, but also your own. In fact, providing emotional support (empathy) to another is more important than practical, instrumental support in increasing the provider's well-being (Morelli et al., 2015). In short, compassionate sharing of feelings and experiences benefits both parties. Perhaps because it helps all of us to feel accepted and less alone during life's inevitable ups and downs. Finally, love for yourself may be the most important emotional key to protecting your mental health. Self-care and self-compassion are not "selfish!" Self-compassion refers to a kind and nurturing attitude toward yourself, and research shows that it is positively linked with psychological flexibility and well-being In other words, prioritize your well-being. When you're feeling frustrated and overwhelmed, allow yourself to say "no." Along with all the resources for coping mentioned in Chapter 3, keep in mind that "no" is a complete sentence. You don't have to explain your reasons for taking care of and loving yourself. 3.Recognize and change your behaviors.As discussed in several chapters of this text, "simply" eating the right food, getting enough exercise and sleep, and spending time in nature are all important to our well-being and may help protect our mental health (Bell et al., 2015; Song et al., 2016; Wassing et al., 2016). For example, research finds that even moderate exercise—20 to 30 minutes of walking a day—can prevent episodes of depression in the long term (Mammen & Faulkerner, 2013). Other research suggests that moderate exercise may be as helpful as psychotherapy or antidepressants (Craft & Perna, 2004). A second behavioral change that increases psychological health is to make someone else feel good. Studies show that volunteering and expressing kindness to others has a cyclical effect— doing a good deed for others makes them happier, which in turns makes you happier (Anik et al., 2011; Xi et al., 2016)! As previously mentioned, spending time in nature is important to mental health, but it also unexpectedly increases our willingness to help. In a very simple field experiment, confederates (people who were part of the experiment) accidentally dropped a glove while walking in an urban green park filled with large trees, lawns, and flowers (Guéguen & Stefan, 2016). Researchers found that passersby who saw the dropping of the glove after walking through the park were far more likely to help by picking up the glove than those who had not yet entered the park. Perhaps the most important action you can take to protect your mental health is to enjoy and maintain your social connections. For example, research shows that people who feel more connected to others have lower rates of anxiety and depression (McLeigh, 2015). For this and many other reasons, we need to remind ourselves to spend as much time as possible with our friends and loved ones, whether it's going on vacation or just watching a movie together.

Do Psychedelic Drugs Cause Psychosis?

Beginning in the 1960s, there was considerable debate and widespread reports of "acid casualties," and increased incidents of mental health disorders among people who experimented with popular psychedelics, such as LSD, psilocybin (the active ingredient in "magic mushrooms"), and mescaline (found in the peyote cactus). As you may know, these drugs have been illegal in the United States since 1970 and are classified as schedule 1 drugs—"the most dangerous drugs" with no medicinal use. In addition to correcting imbalances in the brain's neurotransmitters, other studies suggest that psychotherapeutic drugs, primarily antidepressants, may relieve depression and thoughts of suicide in three additional ways. They increase neurogenesis, the production of new neurons, or synaptogenesis, the production of new synapses, and/or they stimulate activity in various areas of the brain (

Classical Conditioning

Behavior therapists use the principles of classical conditioning to decrease maladaptive behaviors by creating new associations to replace the faulty ones (see the cartoon). We will explore two techniques based on these principles: systematic desensitization and aversion therapy.

Evaluating Cognitive Therapies

Cognitive therapies are highly effective treatments for depression, as well as anxiety disorders, bulimia nervosa, anger management, addiction, and even some symptoms of schizophrenia and insomnia (Hundt et al., 2016; Palermo et al., 2016; Sankar et al., 2015). However, both Beck and Ellis have been criticized for ignoring or denying the client's unconscious dynamics, overemphasizing rationality, and minimizing the importance of the client's past (Granillo et al., 2013; Hammack, 2003). Other critics suggest that cognitive therapies are successful because they employ behavior techniques, not because they change the underlying cognitive structure (Bandura, 1969, 2008; Granillo et al., 2013; Walker & Lampropoulos, 2014). Imagine that you sought treatment for depression and learned to curb your all-or-nothing thinking, along with identifying activities and behaviors that lessened your depression. You can see why it's difficult to identify whether changing your cognitions or changing your behavior was the most significant therapeutic factor. But to clients who have benefited, it doesn't matter. CBT combines both, and it has a proven track record for lifting depression!

Evaluating Cognitive Therapies 2

Cognitive therapies are highly effective treatments for depression, as well as anxiety disorders, bulimia nervosa, anger management, addiction, and even some symptoms of schizophrenia and insomnia (Hundt et al., 2016; Palermo et al., 2016; Sankar et al., 2015). However, both Beck and Ellis have been criticized for ignoring or denying the client's unconscious dynamics, overemphasizing rationality, and minimizing the importance of the client's past (Granillo et al., 2013; Hammack, 2003). Other critics suggest that cognitive therapies are successful because they employ behavior techniques, not because they change the underlying cognitive structure (Bandura, 1969, 2008; Granillo et al., 2013; Walker & Lampropoulos, 2014). Imagine that you sought treatment for depression and learned to curb your all-or-nothing thinking, along with identifying activities and behaviors that lessened your depression. You can see why it's difficult to identify whether changing your cognitions or changing your behavior was the most significant therapeutic factor. But to clients who have benefited, it doesn't matter. CBT combines both, and it has a proven track record for lifting depression!

Although most therapists work with clients in several of these areas, the emphasis varies according to the therapist's training and whether it is psychodynamic, cognitive, humanistic, behaviorist, or biomedical. Clinicians who regularly borrow freely from various theories are said to take an eclectic approach.

Does therapy work? After years of controlled studies and meta-analysis—a method of statistically combining and analyzing data from many studies—researchers have fairly clear evidence that it does. As you can see in Figure 13.17, early meta-analytic reviews combined studies of almost 25,000 people and found that the average person who received treatment was better off than 75% of the untreated control clients The average person who receives therapy is better off after it than a similar person who does not get treatment . An analysis of more than 435 studies on the effectiveness of therapy for treating psychological disorders in children and adolescents revealed that therapy can lead to improvements in many different types of psychological disorders, including anxiety, autism, depression, disruptive behavior, eating problems, substance use, and traumatic stress Studies also show that short-term treatments can sometimes be as effective as long-term treatments and that most therapies are equally effective for various disorders. Even informal therapy techniques, like watching romantic comedies, have led to increased marital satisfaction

Psychopharmacology

Drug therapy has been criticized on several grounds. First, although drugs may relieve symptoms for some people, they seldom provide cures and some individuals become physically dependent. In addition, psychiatric medications can cause a variety of side effects, ranging from mild fatigue to severe impairments in memory and movement. It's important to note that drug therapy is more effective when combined with talk therapy. For example, researchers have examined whether children and teenagers experiencing clinical depression would benefit from receiving cognitive behavioral therapy (CBT) along with medication to treat this disorder. In one study, 75 youths (ages 8 to 17) received either an antidepressant alone, or an antidepressant along with CBT for 6 months (Kennard et al., 2014). Of those who received only the drug, 26.5% experienced depression, compared to only 9% of those who received the drug as well as CBT. In modern times, psychotherapeutic drugs have led to revolutionary changes in mental health. Before the use of drugs, some patients were destined to spend a lifetime in psychiatric institutions. Today, most improve enough to return to their homes and lead successful lives—if they continue to take their medications to prevent relapse.

Analysis of Resistance

During free association or dream analysis, Freud found that clients often show an inability or unwillingness to discuss or reveal certain memories, thoughts, motives, or experiences. For example, if the client suddenly "forgets" what he or she was saying or completely changes the subject, it is the therapist's job to identify these possible cases of resistance and then help the client face his or her problems and learn to deal with them more realistically.

Observational learning

During modeling therapy, a client might learn how to interview for a job by first watching the therapist role-play the part of the interviewee. The client then imitates the therapist's behavior and plays the same role. Over the course of several sessions, the client becomes gradually desensitized to the anxiety of interviews

Emphasizing Interdependence

In Japanese Naikan therapy, clients sit quietly from 5:30 a.m. to 9:00 p.m. for seven days and are visited by an interviewer every 90 minutes. During this time, they reflect on their relationships with others in order to discover personal guilt for having been ungrateful and troublesome and to develop gratitude toward those who have helped them (

ECT

ECT currently serves as a valuable last-resort treatment for severe depression. However, similar benefits may be available through the latest advances in repetitive transcranial magnetic stimulation (rTMS), which uses an electromagnetic coil placed on the scalp. Unlike ECT, which uses electricity to stimulate parts of the brain, rTMS uses magnetic pulses (Figure 13.14). To treat depression, the coil is usually placed over the prefrontal cortex, a region linked to deeper parts of the brain that regulate mood. Currently, rTMS's advantages over ECT are still unclear, but studies have shown marked improvement in depression, and clients experience fewer side effects

As we've just seen, some studies find that most therapies are equally effective for various disorders. However, other studies suggest that certain disorders are better treated with specific approaches. For example, anxiety disorders seem to respond best to exposure-based CBT, whereas symptoms of schizophrenia can be significantly relieved with medication.

Finally, in recent years, the empirically supported, or evidence-based practice (EBP), movement has been gaining momentum because it seeks to identify which therapies have received the clearest research support for particular disorders. Like all other movements, it has been criticized, but this type of empirically based research promises to be helpful for therapists and clients alike in their treatment decisions.

Analysis of Transference

Freud believed that during psychoanalysis, clients disclose intimate feelings and memories, and the relationship between the therapist and client may become complex and emotionally charged. As a result, clients often apply, or transfer, some of their unresolved emotions and attitudes from past relationships onto the therapist. For example, a client might interact with the therapist as if the therapist were a lover or parent.

Sigmund Freud (1856-1939)

Freud believed that during psychoanalysis, the therapist's (or psychoanalyst's) major goal was to bring unconscious conflicts into consciousness.

Evaluating Behavior Therapies Criticisms of behavior therapy fall into two major categories:

Generalizability Critics argue that in the real world, clients are not consistently reinforced, and their newly acquired behaviors may disappear. To deal with this possibility, behavior therapists work to encourage clients to better recognize existing external real world rewards and to generate their own internal reinforcements, which they can then apply at their own discretion. Ethics Critics contend that it is unethical for one person to control another's behavior. Behaviorists, however, argue that rewards and punishments already control our behaviors. Behavior therapy actually increases our freedom by making these controls overt and by teaching people how to change their own behavior. Despite these criticisms, behavior therapy is generally recognized as one of the most effective treatments for numerous problems, including phobias, obsessive-compulsive disorder, eating disorders, sexual dysfunctions, autism, intellectual disabilities, and delinquency

Marital and Family Therapies

Given that a family or marriage is a system of interdependent parts, the problem of any one individual inevitably affects everyone. Therefore, all members are potential beneficiaries of therapy. The line between family and marital or couples therapy is often blurred. Here, our discussion will focus on family therapy, in which the primary aim is to change maladaptive family interaction patterns (Figure 13.18). All members of the family attend therapy sessions, though at times the therapist may see family members individually or in twos or threes. Many families initially come into therapy believing that one member is the cause of all their problems. However, family therapists often find that this "identified client" is a scapegoat for deeper disturbances. How could changing ways of interacting within the family system promote the health of individual family members and the family as a whole? Family therapy is useful in treating a number of disorders and clinical problems. For example, the therapist can help families improve their communication styles and reframe their problems as a family issue versus an individual one. It can also be the most favorable setting for the treatment of adolescent substance abuse and eating disorders

Psychosurgery

Given that all forms of psychosurgery are generally irreversible and potentially dangerous with serious or even fatal side effects, some critics say that it should be banned altogether. For these reasons, psychosurgery is considered experimental and remains a highly controversial treatment. Recently, psychiatrists have been experimenting with a much more limited and precise neurosurgical procedure called deep brain stimulation (DBS). The surgeon drills two tiny holes into the skull, and implants electrodes in the area of the brain believed to be associated with a specific disorder (Figure 13.15). These electrodes are then connected to a "pacemaker" implanted in the chest or stomach that sends low-voltage electricity to the problem areas in the brain. Over time, this repeated stimulation can bring about significant improvement in Parkinson's disease, epilepsy, major depression, and other disorders (Fields, 2015; Kim et al., 2016; Lipsman et al., 2015). Research has also shown that clients who receive DBS along with antidepressants show lower rates of depression than those who receive either treatment alone

Major Therapy Techniques-

Rogerian therapists create a therapeutic relationship by focusing on four important qualities of communication: empathy, unconditional positive regard, genuineness, and active listening.

Therapy Formats. The therapies described earlier in this chapter are conducted primarily in a face-to-face, therapist-to-client format. In this section, we focus on several major alternatives: group, family, and marital therapies, which treat multiple individuals simultaneously, and telehealth/electronic therapy, which treats individuals via the Internet, e-mail, and/or smartphones.

Group Therapies In group therapies, multiple people meet together to work toward therapeutic goals. Typically, a group of 8 to 10 people meet with a therapist on a regular basis to talk about problems in their lives.

How do the four categories differ? Antianxiety drugs generally create feelings of tranquility and relaxation, while also decreasing over-arousal in the brain. In contrast, antipsychotic drugs are designed to diminish or eliminate symptoms of psychosis, such as hallucinations. And mood-stabilizer drugs attempt to level off the emotional highs and lows of bipolar disorder. Interestingly, antidepressants were originally designed to lift depression—hence their name. However, they're now being successfully used in the treatment of some anxiety disorders, obsessive-compulsive disorder, posttraumatic stress disorder, and certain eating disorders.

How do drug treatments actually work? For most psychotherapeutic medications, including antidepressants, the best understood action of the drugs is to correct an imbalance in the levels of neurotransmitters in the brain (Figure 13.12). Surprisingly, recent research has found that the drug ketamine, a dangerous date rape/party drug, called "Special K," also works to manage the symptoms of major depression, suicidal behaviors, and bipolar disorders. Widely known in the medical field for its anesthetic properties, ketamine changes the levels of brain neurotransmitters and appears to decrease thoughts of suicide because it targets parts of the brain responsible for executive and emotional processing (Lee et al., 2016). Due to its antisuicide effects, rapid onset, high efficacy, and good tolerability, ketamine shows promise as a potential treatment for depression and bipolar disorders (Kishimoto et al., 2016; Li et al., 2016; Reardon, 2015). However, it remains controversial due to the relative lack of empirical evidence, some serious side effects, and the potential for abuse

Choosing a Therapist

How do you find a good therapist for your specific needs? If you have the time (and money) to explore options, there are several steps you can take to find a therapist best suited to your specific goals. First, you might consult your psychology instructor, college counseling system, or family physician for specific referrals. In addition, most HMOs and health insurers provide lists of qualified professionals. Next, call the referred therapists and ask for an opportunity to discuss some questions. You could ask what their training was like, what approach they use, what their fees are, and whether they participate in your insurance plan. Finding a therapist takes time and energy. If you need immediate help—you're having suicidal thoughts or are the victim of abuse—you should see if your community is one of the many that have medical hospital emergency services and telephone hotlines that provide counseling services on a 24-hour basis. In addition, most colleges and universities have counseling centers that provide immediate, short-term therapy to students free of charge. Finally, if you're concerned about a friend or family member who might need therapy, you can follow the tips above to help locate a therapist and then possibly offer to go with him or her on their first appointment. If the individual refuses help and the problem affects you, it is often a good idea to seek therapy yourself. You will gain insights and skills that will help you deal with the situation more effectively. For general help in locating a skilled therapist, identifying what types of initial questions to ask, learning how to gain the most benefits during therapy, and so on, consult the American Psychological Association (APA) website. Think Critically

Genuineness

Humanists believe that when therapists use genuineness and honestly share their thoughts and feelings with their clients, the clients will in turn develop self-trust and honest self-expression

Interpersonal therapy (IPT)

IPT, a variation of psychodynamic therapy, focuses on current relationships, with the goal of relieving immediate symptoms and teaching better ways to solve interpersonal problems. Research shows that it's effective for a variety of disorders, including depression, marital conflict, eating disorders, and drug addiction

REBT example

If you receive a poor performance evaluation at work, you might directly attribute your bad mood to the negative feedback. Psychologist Albert Ellis would argue that your self-talk ("I always mess up") between the event and the feeling is what actually upsets you. Furthermore, ruminating on all the other times you've "messed up" in your life maintains your negative emotional state and may even lead to anxiety disorders, depression, and other psychological disorders. To treat these problems, Ellis developed an A-B-C-D approach: A stands for activating event, B the person's belief system, C the emotional consequences, and D the act of disputing erroneous beliefs. During therapy, Ellis helped his clients identify the A, B, C's underlying their irrational beliefs by actively arguing with, cajoling, and teasing them—sometimes in very blunt, confrontational language. Once clients recognized their self-defeating thoughts, he worked with them on how to dispute those beliefs and create and test out new, rational ones. These new beliefs then changed the maladaptive emotions—thus breaking the vicious cycle. (Note the arrow under D that goes backwards to B.)

Using Active Listening Personally and Professionally

If you want to try active listening in your personal life, keep in mind that to reflect is to hold a mirror in front of the person, enabling that person to see him- or herself. To paraphrase is to summarize in different words what the other person is saying. To clarify is to check that both the speaker and listener are on the same wavelength. When a professional uses active listening, he or she might notice a client's furrowed brow and downcast eyes while he is discussing his military experiences and then might respond, "It sounds like you're angry with your situation and feeling pretty miserable right now." Can you see how this statement reflects the client's anger, paraphrases his complaint, and gives feedback to clarify the communication? This type of attentive, active listening is a relatively simple and well-documented technique that you can use to improve your communication with virtually anyone—professors, employers, friends, family, and especially your love partner.

aversion therapy

In contrast to systematic desensitization, aversion therapy uses classical conditioning techniques to create unpleasant (aversive) associations and responses rather than to extinguish them. People who engage in excessive drinking, for example, build up a number of pleasurable associations with alcohol. These pleasurable associations cannot always be prevented. Therefore, aversion therapy provides negative associations to compete with the pleasurable ones The goal of aversion therapy is to create an undesirable, or aversive, response to a stimulus a person would like to avoid, such as alcohol.

humanistic therapies

In contrast to the psychoanalytic and psychodynamic focus on the unconscious, the humanistic approach emphasizes conscious processes and present versus past experiences. The name humanistic therapies reflects this focus on the human characteristics of a person's potential for self-actualization, free will, and self-awareness. Humanistic therapists assume that people with problems are suffering from a disruption of their normal growth potential and, hence, their self-concept. When obstacles are removed, the individual is free to become the self-accepting, self-actualized person everyone is capable of being

systematic desensitization pt 2

In systematic desensitization, the therapist and client together construct a fear hierarchy, a ranked listing of 10 or so related anxiety-arousing images—from the least fearful to the most. Then, while in a state of relaxation, the client mentally visualizes, or physically experiences, mildly anxiety-producing items at the lowest level of the hierarchy. After becoming comfortable with the mild stimulus, the client then works his or her way up to the most anxiety-producing items at the top. In sum, each progressive step on the fear hierarchy is repeatedly paired with relaxation, until the fear response or phobia is extinguished How does relaxation training desensitize someone? Recall from Chapter 2 that the parasympathetic nerves control autonomic functions when we are relaxed. Because the opposing sympathetic nerves are dominant when we are anxious, it is physiologically impossible to be both relaxed and anxious at the same time. The key to success is teaching the client how to replace his or her fear response with relaxation when exposed to the fearful stimulus, which explains why these and related approaches are often referred to as exposure therapies. Modern virtual reality technology also uses systematic desensitization to expose clients to feared situations right in a therapist's office

Careers in Mental Health Most colleges have counseling or career centers with numerous resources and trained staff to help you with your career choices. To give you an overview of the general field of psychotherapy, we've included a brief summary of the major types of mental health professionals, their degrees, required education beyond the bachelor's degree, job description, and type of training.

MAJOR TYPES OF MENTAL HEALTH PROFESSIONALS

Mood-Stabilizer Drugs Medications used to treat the combination of manic episodes and depression characteristics of bipolar disorders.

Mood-stabilizer drugs help steady mood swings, particularly for those suffering from bipolar disorder, a condition marked by extremes of both mania and depression. Because these drugs generally require up to three or four weeks to take effect, their primary use is in preventing future episodes, and helping to break the manic-depressive cycle. Depakote Eskalith CR Lamictal Lithium Neurontin Tegretol Topamax Trileptal

Clinical psychologists PhD (doctor of philosophy) PsyD (doctor of psychology)

Most clinical psychologists have a doctoral degree with training in research and clinical practice, and a supervised one-year internship in a psychiatric hospital or mental health facility. As clinicians, they work with client suffering from mental disorders, but many also work in colleges and universities as teachers and researchers, in addition to having their own private practice.

Counseling psychologists MA (master of arts) PhD (doctor of philosophy) PsyD (doctor of psychology) EdD (doctor of education)

Most clinical psychologists have a doctoral degree with training in research and clinical practice, and a supervised one-year internship in a psychiatric hospital or mental health facility. As clinicians, they work with client suffering from mental disorders, but many also work in colleges and universities as teachers and researchers, in addition to having their own private practice.

Therapy Goals and Effectiveness All major forms of therapy are designed to help the client in five specific areas The five most common goals of therapy

Most therapies focus on one or more of these five goals. Can you identify which would be of most interest to psychodynamic, humanistic, cognitive, and behavioristic therapists?

Ellis's Rational-Emotive Behavior Therapy (REBT)

One of the best-known cognitive therapists, Albert Ellis, suggested that irrational beliefs are the primary culprit in problem emotions and behaviors. He proposed that most people mistakenly believe they are unhappy or upset because of external, outside events, such as receiving a bad grade on an exam. Ellis suggested that, in reality, these negative emotions result from faulty interpretations and irrational beliefs (such as interpreting the bad grade as a sign of your incompetence and an indication that you'll never qualify for graduate school or a good job).

client-centered therapy

One of the best-known humanistic therapists is Carl Rogers (see photo), who developed an approach that encouraged people to actualize their potential and to relate to others in genuine ways. His approach is referred to as client-centered therapy (Figure 13.5). (Rogers used the term client because he believed the label patient implied that someone was sick or mentally ill rather than responsible and competent.) Client-centered therapy, like psychoanalysis and psychodynamic therapies, explores thoughts and feelings as a way to obtain insight into the causes of behaviors. For Rogerian therapists, however, the focus is on providing an accepting atmosphere and encouraging healthy emotional experiences. Clients are responsible for discovering their own maladaptive patterns.

A Cognitive Approach to Lifting Depression

One of the most successful applications of Beck's CBT is in the treatment of depression (Beck et al., 2012, 2015; Dobson, 2016; Hundt et al., 2016). Beck identified several thinking patterns believed to be common among depression-prone people. Recognizing these patterns in our own thought processes may help prevent or improve the occasional bad moods we all experience. Clients are first taught the three Cs—to Catch (identify), Challenge, and Change their irrational or maladaptive thought patterns. Here we provide an example of how to label the three C's for the first problem of selective perception. Then try to do the same for the other four maladaptive patterns. Aaron Beck (1921-present) Clem Murray/MCT/NewsCom Selective perception Focusing selectively on negative events while ignoring positive events. (Catch the thought = "Why am I the only person alone at this party?"; Challenge it = "I notice four other single people at this party"; Change it = "Being single has several advantages. I'll bet some of the couples are actually envying my freedom.") Overgeneralization Drawing sweeping, global, negative conclusions based on one incident, and then assuming that conclusion applies to unrelated areas of life. "My girlfriend yelled at me for not picking her up on time. I'm so forgetful. I'll never succeed in a professional career." Magnification and minimization Exaggerating the importance of small, undesirable events and grossly underestimating larger, positive ones. Despite having earned high grades in all her classes, an A student concludes: "This B on my last organic chemistry quiz means that I can't go on to med school, so I should just drop out of college right now." Personalization Taking responsibility and blame for events that are actually unrelated to the individual. "My adult child is unmarried and doesn't want to have children. I must have been a bad parent." All-or-nothing thinking Seeing things as black-or-white categories—where everything is either totally good or bad, right or wrong, a success or a failure. ("If I don't get straight A's, I'll never get a good job.")

Pastoral counselor None MA (master of arts) PhD (doctor of philosophy) DD (doctor of divinity)

Pastoral counselors combine spiritual advice and psychotherapy, and generally must hold a license and at least a master's or doctoral degree in their field of study. They typically work for counseling centers, churches, community programs, and hospitals.

Psychiatric nurses RN (registered nurse) MA (master of arts) PhD (doctor of philosophy)

Psychiatric nurses usually have a bachelor's or master's degree in nursing, followed by advanced training in the care of patients in hospital settings, and clients in mental health facilities.

Psychiatric social workers MSW (master's in social work) DSW (doctor of social work) PhD (doctor of philosophy)

Psychiatric social workers usually have a master's degree in social work, followed by advanced training and experience in hospitals or outpatient settings working with people who have psychological problems.

Virtual reality therapy

Rather than use mental imaging or actual physical experiences of a fearful situation, virtual-reality headsets and data gloves allow a client with a fear of heights, for example, to have experiences ranging from climbing a stepladder all the way to standing on the edge of a tall building.

systematic desensitization

Recall from Chapter 6 that classical conditioning occurs when a neutral stimulus (NS) becomes associated with an unconditioned stimulus (US) to elicit a conditioned response (CR). Sometimes a classically conditioned fear response becomes so extreme that we call it a "phobia." To treat phobias, behavior therapists often use systematic desensitization, which begins with relaxation training, followed by imagining or directly experiencing various versions of a feared object or situation while remaining deeply relaxed See Figure 13.8 for a description of systematic desensitization useful for overcoming a driving phobia. Similarly, if you or a friend suffers from a spider phobia, you may be amazed to know that after just two or three hours of therapy, starting with simply looking at photos of spiders (see the photo), and then moving next to a tarantula in a glass aquarium, clients are able to eventually pet and hold the spider with their bare hands

Nurturing growth

Recall how you've felt when you've been with someone who considers you to be a worthy and good person with unlimited potential, a person who believes that your "real self" is unique and valuable. These are the feelings that are nurtured in humanistic therapy.

Uliconditional Positive Regard

Regardless of the clients' problems or behaviors, humanistic therapists offer them unconditional positive regard, a genuine caring and nonjudgmental attitude toward people based on their innate value as individuals. They avoid evaluative statements such as "That's good" and "You did the right thing" because such comments imply that the therapist is judging the client. Rogers believed that most of us receive conditional acceptance from our parents, teachers, and others, which leads to poor self-concepts and psychological disorders Unconditional versus conditional positive regard According to Rogers, clients need to feel unconditionally accepted by their therapists in order to recognize and value their own emotions, thoughts, and behaviors. As this cartoon sarcastically implies, some parents withhold their love and acceptance unless the child lives up to their expectations.

Overcoming Shyness

Shaping can help people acquire social skills and greater assertiveness. If you are painfully shy, for example, a clinician might first ask you to role-play simply saying hello to someone you find attractive. Then you might practice behaviors that gradually lead you to suggest a get-together or date. During such role-playing, or behavior rehearsal, the clinician gives you feedback and reinforcement for each successive step you take toward the end goal.

psychopharmacology

Since the 1950s, the field of psychopharmacology has effectively used drugs to relieve or control the major symptoms of psychological disorders. In some instances, using a psychotherapeutic drug is similar to administering insulin to people with diabetes, whose own bodies fail to manufacture enough. In other cases, drugs have been used to relieve or suppress the symptoms of psychological disturbances even when the underlying cause was not thought to be biological. As shown in Table 13.2, psychotherapeutic drugs are classified into four major categories: antianxiety, antipsychotic, mood stabilizer, and antidepressant.

Biomedical Therapies

Some problem behaviors seem to be caused, at least in part, by chemical imbalances or disturbed nervous system functioning, and, as such, they can be treated with biomedical therapies. Psychiatrists or other medical personnel are generally the only ones who use biomedical (biological) therapies. However, in some states, licensed psychologists can prescribe certain medications, and they often work with clients receiving biomedical therapies. In this section, we will discuss three aspects of biomedical therapies: psychopharmacology, electroconvulsive therapy (ECT), and psychosurgery.

Evaluating Humanistic Therapies

Supporters say that there is empirical evidence for the efficacy of client-centered therapy, whereas critics argue that outcomes such as self-actualization and self-awareness are difficult to test scientifically. Furthermore, research on specific humanistic techniques has had mixed results

Interpretation

The core of all psychoanalytic therapy is interpretation. During free association, dream analysis, resistance, and transference, the analyst listens closely and tries to find patterns and hidden conflicts. At the right time, the therapist explains or interprets the underlying meanings to the client.

psychosurgery lobotomy

The most extreme, and least used, biomedical therapy is psychosurgery—brain surgery performed to reduce serious debilitating psychological problems. Attempts to change disturbed thoughts, feelings, and behavior by altering the brain have a long history. In Roman times, for example, it was believed that a sword wound to the head could relieve insanity. In 1936, Portuguese neurologist Egaz Moniz first treated uncontrollable psychoses with a form of psychosurgery called a lobotomy, in which he cut the nerve fibers between the frontal lobes (where association areas for monitoring and planning behavior are found) and the thalamus and hypothalamus. Although these surgeries did reduce emotional outbursts and aggressiveness, some clients were left with debilitating brain damage.

behavior therapies

The previously discussed talk therapies are often called "insight therapies" because they focus on self-awareness, but sometimes having insight into a problem does not automatically solve it. In behavior therapies, the focus is on the problem behavior itself rather than on any underlying causes. Although the person's feelings and interpretations are not disregarded, they're also not emphasized. The therapist diagnoses the problem by listing maladaptive behaviors that occur and adaptive behaviors that are absent. The therapist then attempts to shift the balance of the two, drawing on the learning principles of classical conditioning, operant conditioning, and observational learning

Cultural Issues in Therapy

The therapies described in this chapter are based on Western European and North American culture. Does this mean they are unique? Or do these psychotherapists accomplish some of the same things that, say, a native healer or shaman does? When we look at therapies in all cultures, we find that they have certain key features in common Naming the problem People often feel better just knowing that others experience the same problem and that the therapist has had experience with it. Demonstrating the right qualities Clients must feel that the therapist is caring, competent, approachable, and concerned with finding solutions to their problems. Establishing credibility Word-of-mouth testimonials and status symbols, such as diplomas on the wall, establish a therapist's credibility. A native healer may earn credibility by serving as an apprentice to a revered healer. Placing the problem in a familiar framework Some cultures believe evil spirits cause psychological disorders, so therapy is directed toward eliminating these spirits. Similarly, in cultures that emphasize the importance of early childhood experiences and the unconscious mind as the cause of mental disorders, therapy will be framed around these familiar issues. Applying techniques to bring relief In all cultures, therapy includes action. Either the client or the therapist must do something, and what the therapist does must fit the client's expectations—whether it is performing a ceremony to expel demons or talking with the client about his or her thoughts and feelings. Meeting at a special time and place The fact that therapy occurs outside the client's everyday experiences seems to be an important feature of all therapies. Although there are basic similarities in therapies across cultures, there are also important differences. In the traditional Western European and North American model, the emphasis is on the client's self and on his or her having independence and control over his or her life—qualities that are highly valued in individualistic cultures. In collectivist cultures, however, the focus of therapy is on interdependence and the acceptance of life realities Not only does culture affect the types of therapy that are developed, but it also influences the perceptions of the therapist. What one culture considers abnormal behavior may be quite common—and even healthy—in others. For this reason, recognizing cultural differences is very important for building trust between therapists and clients and for effecting behavioral change

transference

The therapist uses this process of transference to help the client "relive" painful past relationships in a safe, therapeutic setting so that he or she can move on to healthier relationships.

Electroconvulsive Therapy and Psychosurgery

There is a long history of using electrical stimulation to treat psychological disorders. In electroconvulsive therapy (ECT), also known as electroshock therapy (EST), a moderate electrical current is passed through the brain. This can be done by placing electrodes on the outside of both sides of the head (bilateral ECT), or on only one side of the head (unilateral ECT). The current triggers a widespread firing of neurons, or brief seizures. ECT can quickly reverse symptoms of certain mental illnesses and often works when other treatments have been unsuccessful. The electric current produces many changes in the central and peripheral nervous systems, including activation of the autonomic nervous system, increased secretion of various hormones and neurotransmitters, and changes in the blood-brain barrier Modern ECT treatments are conducted with considerable safety precautions, including muscle-relaxant drugs that dramatically reduce muscle contractions, and medication to help clients sleep through the procedure. Note, however, that ECT is used less often today, and generally only when other treatments have failed, due to possibly serious side effects.

Telehealth/Electronic Therapy

Today millions of people are receiving advice and professional therapy in newer, electronic formats, such as the Internet, e-mail, virtual reality (VR), and interactive web-based conference systems such as Skype. This latest form of electronic therapy, often referred to as telehealth, allows clinicians to reach more clients and provide them with greater access to information regarding their specific problems

A Modern Alternative to Lobotomies

Two of the most notable examples of the damage from early lobotomies are Rosemary Kennedy, the sister of President John F. Kennedy, and Rose Williams, sister of American playwright Tennessee Williams. Both women were permanently incapacitated from lobotomies performed in the early 1940s. Thankfully, in the mid-1950s, when antipsychotic drugs came into use, psychosurgery virtually stopped.

Major Therapy Techniques

Unfortunately, according to Freud, the ego has strong defense mechanisms that block unconscious thoughts from coming to light. Thus, to gain insight into the unconscious, the ego must be "tricked" into relaxing its guard. To meet that goal, psychoanalysts employ five major methods: free association, dream analysis, analyzing resistance, analyzing transference, and interpretation

Active Listening

Using active listening, which includes reflecting, paraphrasing, and clarifying what the client is saying, the clinician communicates that he or she is genuinely interested and paying close attention

Studies have long shown that therapy outcomes improve with increased client contact, and the electronic/telehealth format may be the easiest and most cost-effective way to increase this contact (Acierno et al., 2016; Bush et al., 2015; Gray et al., 2015). For example, when the effectiveness of cognitive behavioral therapy delivered over the telephone was compared to the effectiveness of in-person visits for clients with major depressive disorder, researchers found that those who received phone therapy showed less improvement than those who received face-to-face therapy. However, the phone therapy clients were more likely to continue with therapy over time

Using electronic options such as the Internet and smartphones does provide alternatives to traditional one-on-one therapies, but, as you might expect, these unique approaches also raise concerns. Professional therapists fear, among other things, that without interstate and international licensing, or a governing body to regulate this type of therapy, there are no means to protect clients from unethical practices or incompetent therapists. What do you think? Would you be more likely to participate in therapy if it were offered via your smartphone, e-mail, or a website? Or is this too impersonal for you?

Empathy

Using the technique of empathy, a sensitive understanding and sharing of another person's inner experience, therapists pay attention to body language and listen for subtle cues to help them understand the emotional experiences of clients. To further help clients explore their feelings, the therapist uses open-ended statements such as "You found that upsetting" or "You haven't been able to decide what to do about this" rather than asking questions or offering explanations.

Dream Analysis

according to Freud, our psychological defenses are lowered during sleep. Therefore, our forbidden desires and unconscious conflicts are supposedly more freely expressed during dreams. Even while dreaming, however, we recognize these feelings and conflicts as unacceptable and must disguise them as images that have deeper symbolic meaning. Thus, using Freudian dream analysis, a dream of riding a horse or driving a car might be analyzed as just the surface description, or manifest content. In contrast, the hidden, underlying meaning, or latent content, might be analyzed as a desire for, or concern about, sexual intercourse.

The chapter begins with what's known as

talk therapies, including psychoanalysis/psychodynamic, humanistic, and cognitive. Next we look at behavior therapies and the roles of classical conditioning, operant conditioning, and observational learning. Then we examine biomedical (or biological) therapies, including the topics of psychopharmacology, electroconvulsive therapy, and psychosurgery. Our final section looks at psychotherapy in perspective—its goals and effectiveness, its formats, and its cultural and gender issues.

psychotherapy

to help us improve our overall psychological functioning and adjustment to life, and to assist people suffering from one or more psychological disorders. Due to the common stereotype and stigma that therapy is only for deeply disturbed individuals, it's important to note that therapy provides an opportunity for everyone to have their specific problems addressed, as well as to learn better thinking, feeling, and behavioral skills useful in their everyday lives.