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PSY 451

Psychotherapy

Dr. Ark Verma

The Elements

there are a wide range of psychotherapeutic approaches


that are being used, & hence a unitary definition may
not be available.

however, there are a few important features:

a helping relationship.

a professional with special training ( the therapist) &

a person who needs help (the client).

Treatment: Subtypes

Kazdin (1994) estimates that there may be over 400 distinct


types of therapies.

However they may be classified into categories:

Insight Therapies: basically talk therapy. Remember


Freud?

clients engage in complex verbal interactions with their


therapists. the goal in these discussions is to pursue
increased insight regarding the nature of the clients
difficulties and to sort through possible solutions.

Behaviour Therapies: are based on the principles of


learning and conditioning. instead of emphasising on
personal insights, behaviour therapists male direct
efforts to alter problematic responses (phobic
behaviours etc.) & maladaptive habits (e.g. drug abuse).
Behaviour therapists work on changing clients overt
behaviors, different procedures are used for different
kinds of problems.

Biomedical Therapies: these involve interventions into a


persons physiological functioning. the most widely
used procedures are drug therapy & electroconvulsive
therapy.

these treatments have traditionally been provided by


physicians with a medical degree (psychiatrists).

Clients:

Acc. to the 1999 U.S. Surgeon Generals report on mental


health, about 15% of the U.S. population use mental health
services in a given year.

these people bring to therapy the full range of human


problems:

anxiety, depression, unsatisfactory interpersonal relations,


troublesome habits, poor self control, low self-esteem,
marital conflicts, self-doubt, a sense of emptiness & feelings
of personal stagnation. with anxiety & depression (Narrow
et al., 1993).

Wang, Berglund et al., (2005) found that the median delay in


seeking treatment was around 6 years for bipolar disorder & for
drug dependence, 8 years for depression, 9 years for generalised
anxiety disorder & 10 years for panic disorder.

about only half of the people who use mental health services in a
given year meet the criteria for a full-fledged mental disorder
(Kessler et al., 2005).

interestingly, even when people perceive a need for professional


assistance, only 59% actually seek professional help (Mojitabai,
Olson, & Mechanic, 2002).

also, many people who need therapy dont receive it (Kessler,


2005).

Therapists

psychologists & psychiatrists are the principle therapy


providers.

therapy is also provided by social workers, psychiatric


nurses & counselors.

Psychologists: clinical psychologists and counselling


psychologists specialise in the diagnosis and treatment
of psychological disorders and everyday behavioural
problems.

Psychiatrists: psychiatrists are physicians who specialise


in the treatment of psychological disorders.

Other mental health professionals like psychiatric social


workers & psychiatric nurses often work as a part of the
treatment team.

Insight Therapies

insight therapies involve verbal interactions intended to


enhance clients self knowledge and thus promote
healthy changes in personality & behaviour.

Psychoanalysis: is an insight therapy that emphasizes


the recovery of unconscious conflicts, motives, and
defences through techniques such as free association,
dream analysis, and transference.

was developed by through a painstaking process of


trial & error for the treatment of psychological
disorders & distress.

probing the unconscious: the idea is to probe the murky depths of the
unconscious to discover the unresolved conflicts causing the clients
neurotic behaviour. To explore the unconscious, he or she relies on two
techniques:

in free association, clients spontaneous express their thoughts and


feelings exactly as they occur, with as little censorship as possible.

in dream analysis, the therapist interprets the symbolic meaning of the


clients dreams.

for Freud, dreams were the royal road to the unconscious the most direct
means of access to the patients inner most conflicts, wishes, impulses etc.

clients are encouraged and trained to remember their dreams, which


they describe in therapy. the therapist, then analyses the symbolism in
these dreams to interpret their meaning.

Mr. N. reports a fragment of a dream. All that he can remember


is that he is waiting for a red traffic light to change when he feels
that someone has bumped into him from behind. the
associations led to Mr. Ns love of cars, especially sports cars. He
loved the sensation, in particular of whizzing by those fat, old,
expensive cars..His father always hinted that he had been a great
athlete, but he never substantiated it..Mr. N doubted whether
his father could perform. His father would flirt with a waitress
in a cafe or make sexual remarks about women passing by, but
he seemed to be showing off.

the therapist saw sexual overtones in the dream


fragment, where Mr. N was bumped from behind. The
therapist also inferred that Mr. N had a competitive
orientation towards his father, based on the free
association about whizzing by fat, old, expensive cars.
etc

Interpretations: involves the therapists attempts to


explain the inner significance of the clients thoughts,
feelings, memories, and behaviours.

analysts move forward inch by inch, offering


interpretations that should be just out of clients own
reach (Samberg & Marcus, 2005). Mr. Ns therapist
offered the following interpretation.

I said to Mr. N near the end of the hour that I felt he was
struggling with his feelings about his fathers sexual life. He
seemed to be saying that his father was sexually not a very potent
man He also recalls that he once found a packet of condoms
under his fathers pillow when he was an adolescent and he though
My father must be going to prostitutes. I then intervened and
pointed out that the condoms under his fathers pillow seemed to
indicate more obviously that his father used the condoms with his
mother, who slept in the same bed. However, Mr. N wanted to
believe his wish- fulfilling fantasy: mother doesnt want sex with
father and father is not very potent. The patient was silent and the
hour ended.

resistance: resistance involves largely unconscious


defensive manoeuvres intended to hinder the progress
of therapy. e.g. Mr. Ns therapist noted that after the
session just described, the next day he began by telling
me that he was furious with me.

transference: transference occurs when clients start


relating to their therapists in ways that mimic critical
relationships in their lives.

for e.g. a client might start relating to a therapist as if


the therapist were an overprotective mother, rejecting
brother, or a passive spouse.

In a sense, the client transfers the conflicting feelings


about the important people onto the therapist. for e.g.
Mr N transfered some of the competitive hostility
towards his father onto the therapist.

psychoanalysts some times encourage transference so


that the clients begin to reenact relations with crucial
people in the context of the therapy, & bring to surface
repressed feelings and conflicts, allowing the client to
work through them.

the therapists handling of transference is complex and


difficult as transference may arouse confusing & highly
charges emotions in the client.

Client Centred Therapy

Carl Rogers (1951,1986) devised client centred therapy in


the 1940s & 1950s.

Client Centred Therapy: is an insight therapy that


emphasises providing a supportive emotional climate
for clients, who play a major role in determining the
pace and direction of their therapy.

Why the client?

It is the client who knows what hurts, what directions to go,


what problems are crucial, what experiences have been deeply
buried. It began to occur to me that unless I had a need to
demonstrate my own cleverness & learning, I would do better to
rely upon the client for the direction of movement in the process.
(pp 11-12), Rogers (1961).

Does any of you remember the central idea of Rogers


theory?

incongruence!: makes people feel threatened by realistic


feedback about themselves by others. e.g. if you
incorrectly view yourself as a hardworking person, you
will feel threatened by contradictory feedback from your
employer, or friends etc.

So, client centred therapists help clients to realise that they


do not have to worry constantly about pleasing others and
winning acceptance.

they encourage clients to respect their own feelings &


values and help people restructure their self-concept and
correspond better to reality.

The Process: therapeutic climate

In client centred therapy, the process of therapy is not as


important as the emotional climate, in which the therapy
takes place.

Acc. to Rogers, it is critical for the therapist to provide a


warm, supportive, accepting climate in which clients
can confront their shortcomings without feeling
threatened.

to create an atmosphere of emotional support, Rogers believed that


client-centred therapists must provide three conditions:

genuineness: the therapist should communicate with the client in


an honest & spontaneous manner; without being fake or
defensive.

unconditional positive regard: the therapist must also show


complete, nonjudgmental acceptance of the client as a person. the
therapist should provide warmth, & caring for the clients without
any conditions. importantly, the therapist can disapprove of the
clients behaviour at instances, but still value the individual.

empathy: the therapist must provide accurate empathy for the


client, i.e. the therapist must understand the clients world from
the clients perspective.

therapeutic process

in client centred therapy, the client & the therapist work as equals!

the therapist provides relatively little


interpretation & advice to a minimum.

primarily, the therapist provides feedback to help clients sort out


their feelings.

the therapists key task is clarification.

guidance

and

keeps

to try to function like a human mirror, reflecting statements back


to their clients with enhanced clarity & help clients become more
aware of their true feelings by highlighting themes that may be
obscure in the clients rambling discourse.

clarifying clients feelings helps the therapists to buil


towards more far-reaching insights.

they try to help clients become more self-aware of their


genuine selves.

client-centred therapy resembles psychoanalysis in that


both seek to achieve a major reconstruction of a clients
personality.

Positive Psychology

positive psychology maintains that therapy has historically


focussed far too heavily on pathology, weakness, & suffering
(and how to heal these conditions) rather than health &
resilience.

it is argued that more research needs to be conducted on


contentment, well-being, human strengths, & positive emotions.

well being therapy (Fava, 1999): seeks to enhance clients selfacceptance, purpose in life, autonomy & personal growth. has
been used successfully in the treatment of mood disorders &
anxiety disorders (Fava et al., 2005).

positive psychotherapy ( Seligman, Rashid & Parks,


2006) attempts to get clients to recognise their strengths,
appreciate their blessings, saver positive experiences,
forgive those who have wronged them and find
meaning in their lives. can be an effective treatment in
depression.

e.g. compared to treatment as usual (with/without


medication) positive psychotherapy group showed
lowest depression scores (Seligman et al., 2006).

Group Therapy: is the simultaneous treatment of several


clients in a group. the use of group therapy appears likely
to grow because of economic pressures in health care.

Participants Roles: a therapy group typically consists


of 4-12 people, with 6-8 participants regarded as an
ideal number (Cox et al., 2008).

the therapist usually screens the participants, excluding


anyone who seems likely to be disruptive, judicious
selection of participants is crucial (Salvendy, 1993).

the therapists responsibilities include selecting participants,


setting goals for the group, initiating and maintaining the
therapeutic process & protecting the clients from harm.

the therapist often plays a relatively subtle role, staying in


the back ground and focusing mainly on promoting group
cohesiveness.

the therapist retains a special status, though maintains an


equal footing with the client.

the leader of the group, expresses emotions, shares feelings


and copes with challenges from group members
(Burlingame & Mc Clendon, 2008).

in group therapy, essentially the participants function as


therapists for each other (Stone, 2003). Group members
describe their problems, trade viewpoints, share
experiences and discuss coping strategies.

most importantly, they provide acceptance, & emotional


support for each other.

As members come to value each others opinions, they


tend to work hard to display healthy changes & win the
groups approval.

Advantages of Group Therapy:

saves time & money.

for most patients it is as effective as individual therapy


(Alonso et al., 2003).

Yalom (1995) has described some advantages:

participants come to realize that their misery is not unique!

participants can work on their social skills in a safe


environment!

certain kinds of problem are actually well suited to group


treatment. e.g. Alcoholics Anonymous!

Evaulating Insight Therapies

while evaluating the effectiveness for any approach to


treatment is a complex challenge (Hill & Lambert, 2004),
evaluating insight therapies is especially complex
(Strauss & Stiles, 2005).

how would you evaluate: by what you feel? by your


behaviour? by asking the therapist? etc.

research into outcomes of a wide variety of treatment


approaches examining a broad range of clinical problems has
been conducted, which indicates insight therapy as a method is
superior to no treatment or treatment with placebo
treatments, and also that the therapy effects are reasonably
durable (Kopta et al., 1999).

insight therapies show equal efficacy to that of drug


treatments (Arkowitz & Lilienfeld, 2007).

studies generally find the greatest improvement early in


treatment (the first 13-18 weekly sessions) with gains
gradually diminishing over time (Lambert, Bergin & Garfield,
2004).

but HOW does insight therapy help?

there is considerable debate over the mechanisms of action


underlying the positive effects of insight therapies (Kazdin,
2007).

different therapies achieve similar benefits through different


processes (Chambless & Hollon, 1998).

another view says, that different therapies may have


common factors, which may account for the improvement
experienced by the clients (Frank & Frank, 1991).

recent evidence supports the common factors view


(Duncan & Miller, 2008).

What are these common factors?

the development of a therapeutic alliance with a professional


helper.

the provision of emotional support & empathic understanding


by the therapist.

the cultivation of hope & positive expectations in the client.

the provision of a rationale for the clients problems and a


plausible method for solving them.

the opportunity to express feelings, confront problems, gain


new insights & learn new patterns of behaviour (Weinberger,
1995).

Behavior Therapies

Behaviour therapists believe that insights arent


necessary in order to produce constructive change.

therapist simply designs a program to eliminate the


compulsive behaviour.

So, behaviour therapies involve the application of the


principles of learning to direct efforts to change clients
maladaptive behaviours.

Systematic Desensitization: is a behaviour therapy used


to reduce clients anxiety responses through
counterconditioning.

the goal of desensitization is to weaken the association


between the conditioned stimulus (the bridge) and the
conditioned response of anxiety.

systematic desensitization involves three steps:

the therapist helps the client build an anxiety


hierarchy. e.g. the client ranks different stimuli from
the least anxiety arousing to the most anxiety arousing.

the second step involves training the client in deep


muscle relaxation.

this phase may begin during early sessions, while


the client & the therapist are still constructing the
anxiety hierarchy.

it is important that the client learns to engage in


deep & thorough relaxation on command from the
therapist.

in the third step, the client tries to work through the


hierarchy, learning to remain relaxed while imagining
each stimulus.

starting with the least anxiety arousing stimulus,


the client imagines the situation as vividly as
possible, while relaxing.

if the client experiences strong anxiety , he or she


drops the scene & concentrates on the relaxation
process, until he/she can imagine the scene with
little or no anxiety.

as the clients conquer the imaginary phobic stimuli, they are


encouraged to confront the real stimuli.

contemporary therapists generally follow up desensitization with


direct exposures to the real anxiety arousing stimuli
(Emmelkamp, 2004).

behavioural interventions emphasising direct exposures to


anxiety arousing stimuli have become therapists choice of
treatment for phobic & other anxiety disorders (Rachman, 2009).

Acc. to Wolpe (1990), the principle in systematic desensitisation is


simple: anxiety & relaxation are incompatible responses.

the trick is to recondition the people so that the conditioned


stimulus elicits relaxation instead of anxiety.

Aversion Therapy: is a behaviour therapy in which an


aversive stimulus is paired with a stimulus that elicits an
undesired response. e.g. alcoholics have had drug-induced
nausea paired with their favourite drinks during therapy
sessions (Landabaso et al., 1999).

aversive therapy takes advantage through classical


conditioning.

troublesome behaviors treated with aversion therapy


include: drug & alcohol abuse, sexual deviance,
gambling, shoplifting, stuttering, smoking etc.
(Bordnick et al., 2004).

Social Skills Training: is a behaviour therapy designed to


improve the interpersonal skills that emphasises shaping,
modelling, & behaviour rehearsal.

the therapist uses to modeling by asking clients to watch


socially skilled friends, so that the clients can acquire responses
through observation.

in behavioral rehearsal , the client tries to practice social


techniques in structured role-playing exercises.

shaping is used with clients that are gradually asked to handle


more complicated & delicate social situations. e.g. a nonassertive client may begin by working on making requests of
friends.

Cognitive
Behavioral
Treatments:
use
varied
combinations of verbal interventions and behavioural
modifications to help clients maladaptive patterns of
thinking.

Aaron Becks Cognitive therapy (Beck, 1976): uses


specific strategies to correct habitual thinking errors that
underlie various types of disorders. e.g. depression.

Cognitive therapy was originally devised as a


treatment for depression, but in recent years it has
been applied fruitfully to a wide range of disorders
(Wright, Thase, & Beck, 2008) & it has proven
particularly valuable as a therapy for anxiety
disorders (Rachman, 2009).

Acc. to cognitive therapists, depression is caused by errors in


thinking.

depression prone people tend to:

blame their setbacks on personal


considering circumstantial explanations

inadequacies

without

focus selectively on negative events while ignoring positive ones

make unduly pessimistic projections about the future

& draw negative conclusions about their worth as a person based


on insignificant events.

the goal of cognitive therapy is to change clients negative thoughts


& maladaptive beliefs (Kellogg & Young, 2008).

to begin with, clients are taught to detect their automatic negative thoughts,
the sorts if self-defeating arguments that people are prone to make when
analysing problems. e.g. No one really likes me. or Its all my fault. etc.

clients are then trained to subject these automatic thoughts to reality testing.
the therapist helps them to see how unrealistically negative the thoughts
are.

Cognitive therapy uses a wide variety of behavioural techniques, including


modelling, systematic monitoring of ones behaviour & behavioural
rehearsal (Wright et al., 2003).

Clients are given homework assignments that focus on changing their overt
behaviours. eg. one shy, insecure young man in cognitive therapy was told
to go to a singles bar & engage three different women in conversations for
up to 5 minutes each.

Biomedical Therapies

biomedical therapies are physiological interventions


intended to reduce systems associated with
psychological disorders.

Treatment with drugs: psychopharmaotherapy is the


treatment of mental disorders with medication.

Antianxiety drugs: antianxiety drugs, which relieve tension,


apprehension & nervousness. e.g. valium & xanax which are the trade
names that companies use for diazepam & alprazolam respectively.

Valium, Xanax & other drugs in the benzodiazepine family are often
called tranquilisers. & given to millions of people who simply suffer
from chronic nervous tension.

anti-anxiety drugs exert their effects almost immediately, they can


be fairly effective in alleviating feelings of anxiety (Dubovsky, 2009).

however, their effect is measured in hours & hence is relatively


short lived.

common side-effects include drowsiness, depression, nausea &


confusion.

a new anti-anxiety drug called BUSPAR (buspirone)


appears useful in the treatment of generalized anxiety
disorder (Levitt, Schaffer, & Lanctot, 2009). Unlike
Valium, Buspar is slow-acting, exerting its effects in
1-3 weeks and has fewer sedative side effects (Ninan,
& Muntasser, 2004).

Antipsychotic Drugs: antipsychotic drugs are used to gradually


reduce psychotic symptoms, including hyperactivity, mental
confusion, hallucinations & delusions.

studies suggest that antipsychotics reduce psychotic symptoms


in about 70% of the patients, albeit invidious degrees (Kane,
Stroup, & Marder, 2009).

patients usually begin to respond in 1-3 weeks, but


considerably variability in responsiveness is seen (Emsley,
Rabinowitz & Medori, 2006).

many schizophrenic patients are placed on antipsychotic drugs


because these can reduce the likelihood of a release into an
active schizophrenic episode (Dolder, 2008).

However, common side-effects include drowsiness, constipation, &


cotton mouth. patients may also experience tremors, muscular
rigidity, & impaired coordination.

in extreme cases patients can experience tardive dyskinesia, i.e a


neurological disorder marked by chronic tremors & involuntary
spastic movements.

Currently psychiatrists are enthusiastic about a new class of second


generation antipsychotic drugs.

these drugs can help patients who do not respond to


conventional antipsychotic medications (Volavka et al., 2002).

these have fewer unpleasant side-effects & lower risk of tardive


dyskinesia.

Antidepressant drugs: these gradually elevate mood &


help to bring people out of depression.

there were two principal types of antidepressants: tricyclics


and MAO inhibitors.

these two sets of drugs affect neurochemical activity in


different ways & tend to work with different patients.

overall, they are beneficial for about two-thirds of


depressed patients.

tricyclics have notably fewer problems as compared to


MAO inhibitors and hence are used as first choice.

today psychiatrists are more likely to prescribe a newer class


of antidepressants, called selective serotonin repute
inhibitors (SSRIs), which slow the repute process at serotonin
synapses.

these drugs, which include Prozac (fluoxetine), Paxil


(paroxetine), & Zoloft (sertraline), yield therapeutic gains
similar to the tricyclics in the treatment of depression
( Shelton & Lester, 2006) while producing fewer side - effects.

SSRIs have proven to be useful in the treatment of obsessive


compulsive disorders, panic disorders & other anxiety
disorders (Matthew, Hoffman, & Charney, 2009).

A major concern in recent years have been evidence


from a number of studies that SSRIs may increase the
risk for suicide, primarily among adolescents and
young adults (Healy & Whitaker, 2003).

Mood Stabilizers: are drugs used to control mood swings in


patients with bipolar mood disorders.

for many years, lithium was the only effective drug in this
category. Lithium has proven valuable in preventing
future episodes of both mania & depression in patients
with bipolar illness (Post & Altshuler, 2009).

sideffects could include kidney & thyroid gland


complications; high levels of lithium in blood may be fatal.

more recently, an anticonvulsant agent called valproate has


become more widely used than lithium in the treatment of
bipolar disorders (Thase & Denko, 2008).

Electroconvulsive Therapy (ECT)

electroconvulsive therapy (ECT) is a biomedical treatment in which electric shock


is used to produce a cortical seizure accompanied by convulsions.

in ECT, electrodes are attached to the skull over one or both temporal lobes
of the brain.

a light anaesthesia is induced, and the patient is given a variety of drugs to


minimize the likelihood of complications, such as spinal fractures.

an electric current is then applied for about a second.

this current should trigger a brief (5 - 20 seconds) seizure, during which the
patient usually loses consciousness.

patients normally awaken in an hour or two.

patients typically receive between 6-12 treatments in about a month.

proponents of ECT maintain that it is a remarkably


effective treatment for major depression (Prudic, 2009).

also, they note that many patients who do not benefit


from antidepressant medication improve in response to
ECT (Nobler, & Sackeim, 2006).

however, opponents of ECT argue that the available


studies are flawed and argue that ECT is no more
effective than a placebo (Rose et al., 2003).

Risks with ECT:

ECT patients may experience memory losses,


impaired attention, & other cognitive deficits
commonly.

While the ECT proponents maintain that these effects


are mild & disappear usually in about a month, the
opponents claim that these effects are significant &
sometimes permanent.

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