3.3 Types of Treatment

PSYCHOTHERAPY TECHNIQUES: PSYCHOANALYSIS

   Psychoanalysis was developed by Sigmund Freud and was the first form of psychotherapy. It was the dominant therapeutic technique in the early 20th century, but other orientations are generally more popular today. Freud believed most of our psychological problems are the result of repressed impulses and trauma experienced in childhood, and he believed psychoanalysis would help uncover long-buried feelings. In a psychoanalyst’s office, you might see a patient lying on a couch speaking of dreams or childhood memories, and the therapist using various Freudian methods such as free association and dream analysis. In free association, the patient relaxes and then says whatever comes to mind at the moment. However, Freud felt that the ego would at times try to block, or repress, unacceptable urges or painful conflicts during free association. Consequently, a patient would demonstrate resistance to recalling these thoughts or situations. In dream analysis, a therapist interprets the underlying meaning of dreams.

Psychoanalysis is a therapy approach that can take years. Over the course of time, the patient reveals a great deal about themselves to the therapist. Freud suggested that during this patient-therapist relationship, the patient comes to develop strong feelings concerning the therapist—maybe positive feelings, maybe negative feelings. Freud called this transference: the patient transfers all the positive or negative emotions associated with the patient’s other relationships to the psychoanalyst. For example, Crystal is seeing a psychoanalyst. During the years of therapy, she comes to see her therapist as a father figure. She transfers her feelings about her father onto her therapist, perhaps in an effort to gain the love and attention she did not receive from her own father.

This is the famous couch in Freud’s consulting room. Patients were instructed to lie comfortably on the couch and to face away from Freud in order to feel less inhibited and to help them focus. Today, psychotherapy clients are not likely to lie on a couch; instead, clients are more likely to sit facing the therapist (Prochaska & Norcross, 2010). (credit: Robert Huffstutter)

Today, Freud’s psychoanalytical perspective has been expanded upon by the developments of subsequent theories and methodologies to create the psychodynamic orientation. This approach to therapy remains centered on the role of people’s internal drives and forces, but treatment is less intensive in some ways than Freud’s original model.

PSYCHOTHERAPY: BEHAVIOR THERAPY

   In behavior therapy, a therapist employs principles of learning to help clients change undesirable behaviors. Therapists with this orientation believe that dysfunctional behaviors, like phobias and bedwetting, can be changed by teaching clients new, more constructive behaviors. Behavior therapy employs both classical and operant conditioning techniques to change behavior.

One type of behavior therapy utilizes classical conditioning techniques. Therapists using these techniques believe that dysfunctional behaviors are conditioned responses. Applying the conditioning principles developed by Ivan Pavlov, these therapists seek to recondition their clients and thus change their behavior. Emmie is eight years old, and frequently wets her bed at night. She’s been invited to several sleepovers, but she won’t go because of her problem. Using a type of conditioning therapy, Emmie begins to sleep on a liquid-sensitive bed pad that is hooked to an alarm. When moisture touches the pad, it sets off the alarm, waking up Emmie. When this process is repeated enough times, Emmie develops an association between urinary relaxation and waking up, and this stops the bedwetting. Emmie has now gone three weeks without wetting her bed and is looking forward to her first sleepover this weekend.

One commonly used classical conditioning therapeutic technique is counterconditioning: a client learns a new response to a stimulus that has previously elicited an undesirable behavior. Two counterconditioning techniques are aversive conditioning and exposure therapy. Aversive conditioning uses an unpleasant stimulus to stop an undesirable behavior. Therapists apply this technique to eliminate addictive behaviors, such as smoking, nail biting, and drinking. In aversion therapy, clients will typically engage in a specific behavior (such as nail biting) and at the same time are exposed to something unpleasant, such as a bad taste. After repeated associations between the unpleasant stimulus and the behavior, the client can learn to stop the unwanted behavior.

Aversion therapy has been used effectively for years in the treatment of alcoholism (Davidson, 1974; Elkins, 1991; Streeton & Whelan, 2001). One common way this occurs is through a chemically based substance known as Antabuse. When a person takes Antabuse and then consumes alcohol, uncomfortable side effects result including nausea, vomiting, increased heart rate, heart palpitations, severe headache, and shortness of breath. Antabuse is repeatedly paired with alcohol until the client associates alcohol with unpleasant feelings, which decreases the client’s desire to consume alcohol. Antabuse creates a conditioned aversion to alcohol because it replaces the original pleasure response with an unpleasant one.

In exposure therapy, a therapist seeks to treat clients’ fears or anxiety by presenting them with the object or situation that causes their problem, with the idea that they will eventually get used to it. This can be done via reality, imagination, or virtual reality. Exposure therapy was first reported in 1924 by Mary Cover Jones, who is considered the mother of behavior therapy. Jones worked with a boy named Peter who was afraid of rabbits. Her goal was to replace Peter’s fear of rabbits with a conditioned response of relaxation, which is a response that is incompatible with fear. How did she do it? Jones began by placing a caged rabbit on the other side of a room with Peter while he ate his afternoon snack. Over the course of several days, Jones moved the rabbit closer and closer to where Peter was seated with his snack. After two months of being exposed to the rabbit while relaxing with his snack, Peter was able to hold the rabbit and pet it while eating (Jones, 1924).

Exposure therapy seeks to change the response to a conditioned stimulus (CS). An unconditioned stimulus is presented over and over just after the presentation of the conditioned stimulus. This figure shows conditioning as conducted in Mary Cover Jones’ 1924 study.

   Thirty years later, Joseph Wolpe (1958) refined Jones’s techniques, giving us the behavior therapy technique of exposure therapy that is used today. A popular form of exposure therapy is systematic desensitization, wherein a calm and pleasant state is gradually associated with increasing levels of anxiety-inducing stimuli. The idea is that you can’t be nervous and relaxed at the same time. Therefore, if you can learn to relax when you are facing environmental stimuli that make you nervous or fearful, you can eventually eliminate your unwanted fear response (Wolpe, 1958).

This person suffers from arachnophobia (fear of spiders). Through exposure therapy he is learning how to face his fear in a controlled, therapeutic setting. (credit: “GollyGforce – Living My Worst Nightmare”/Flickr)

   How does exposure therapy work? Jayden is terrified of elevators. Nothing bad has ever happened to him on an elevator, but he’s so afraid of elevators that he will always take the stairs. That wasn’t a problem when Jayden worked on the second floor of an office building, but now he has a new job—on the 29th floor of a skyscraper in downtown Los Angeles. Jayden knows he can’t climb 29 flights of stairs in order to get to work each day, so he decided to see a behavior therapist for help. The therapist asks Jayden to first construct a hierarchy of elevator-related situations that elicit fear and anxiety. They range from situations of mild anxiety such as being nervous around the other people in the elevator, to the fear of getting an arm caught in the door, to panic-provoking situations such as getting trapped or the cable snapping. Next, the therapist uses progressive relaxation. She teaches Jayden how to relax each of his muscle groups so that he achieves a drowsy, relaxed, and comfortable state of mind. Once he’s in this state, she asks Jayden to imagine a mildly anxiety-provoking situation. Jayden is standing in front of the elevator thinking about pressing the call button.

If this scenario causes Jayden anxiety, he lifts his finger. The therapist would then tell Jayden to forget the scene and return to his relaxed state. She repeats this scenario over and over until Jayden can imagine himself pressing the call button with much less or no anxiety. Over time the therapist and Jayden use progressive relaxation and imagination to proceed through all of the situations on Jayden’s hierarchy until he becomes desensitized to each one. After this, Jayden and the therapist begin to practice what he only previously envisioned in therapy, gradually going from pressing the button to actually riding an elevator. The goal is that Jayden will be able to take the elevator all the way up to the 29th floor of his office, even if he still feels a little anxious.

Sometimes, it’s too impractical, expensive, or embarrassing to re-create anxiety-producing situations, so a therapist might employ virtual reality exposure therapy by using a simulation to help conquer fears. Virtual reality exposure therapy has been used effectively to treat numerous anxiety disorders such as the fear of public speaking, claustrophobia (fear of enclosed spaces), aviophobia (fear of flying), and post-traumatic stress disorder (PTSD), a trauma and stressor-related disorder (Gerardi, Cukor, Difede, Rizzo, & Rothbaum, 2010). A new virtual reality exposure therapy is being used to treat PTSD in soldiers. Virtual Iraq is a simulation that mimics Middle Eastern cities and desert roads with situations similar to those soldiers experienced while deployed in Iraq. This method of virtual reality exposure therapy has been effective in treating PTSD for combat veterans. Approximately 80% of participants who completed treatment saw clinically significant reduction in their symptoms of PTSD, anxiety, and depression (Rizzo et al., 2010).

PSYCHOTHERAPY: COGNITIVE THERAPY

   Cognitive therapy is a form of psychotherapy that focuses on how a person’s thoughts lead to feelings of distress. The idea behind cognitive therapy is that how you think determines how you feel and act. Cognitive therapists help their clients change dysfunctional thoughts in order to relieve distress. They help a client see how they misinterpret a situation (cognitive distortion). For example, a client may overgeneralize. Because Ray failed one test in his Psychology 101 course, he feels he is stupid and worthless. These thoughts then cause his mood to worsen. Therapists also help clients recognize when they blow things out of proportion. Because Ray failed his Psychology 101 test, he has concluded that he’s going to fail the entire course and probably flunk out of college altogether. These errors in thinking have contributed to Ray’s feelings of distress. His therapist will help him challenge these irrational beliefs, focus on their illogical basis, and correct them with more logical and rational thoughts and beliefs.

Cognitive therapy was developed by psychiatrist Aaron Beck in the 1960s. His initial focus was on depression and how a client’s self-defeating attitude served to maintain a depression despite positive factors in her life (Beck, Rush, Shaw, & Emery, 1979). Through questioning, a cognitive therapist can help a client recognize dysfunctional ideas, challenge catastrophizing thoughts about themselves and their situations, and find a more positive way to view things (Beck, 2011).

Your emotional reactions are the result of your thoughts about the situation rather than the situation itself. For instance, if you consistently interpret events and emotions around the themes of loss and defeat, then you are likely to be depressed. Through therapy, you can learn more logical ways to interpret situations.

PSYCHOTHERAPY: COGNITIVE-BEHAVIORAL THERAPY

   Cognitive-behavioral therapists focus much more on present issues than on a patient’s childhood or past. One of the first forms of cognitive-behavioral therapy (CBT) was rational emotive therapy (RET), which was founded by Albert Ellis (Daniel, n.d.). Behaviorists such as Joseph Wolpe also influenced Ellis’s therapeutic approach (National Association of Cognitive-Behavioral Therapists, 2009).  CBT is one of the most popular and widely researched types of therapy today.

CBT helps clients examine how their thoughts affect their behavior. It aims to change cognitive distortions and self-defeating behaviors. In essence, this approach is designed to change the way people think as well as how they act. It is similar to cognitive therapy in that CBT attempts to make individuals aware of their irrational and negative thoughts and helps people replace them with new, more positive ways of thinking. It is also similar to behavior therapies in that CBT teaches people how to practice and engage in healthier and more positive approaches to daily situations. In total, hundreds of studies have shown the effectiveness of cognitive-behavioral therapy in the treatment of numerous psychological disorders such as depression, PTSD, anxiety disorders, eating disorders, bipolar disorder, and substance abuse (Beck Institute for Cognitive Behavior Therapy, n.d.). For example, CBT has been found to be effective in decreasing levels of hopelessness and suicidal thoughts in previously suicidal teenagers (Alavi, Sharifi, Ghanizadeh, & Dehbozorgi, 2013). Cognitive-behavioral therapy has also been effective in reducing PTSD in specific populations, such as transit workers (Lowinger & Rombom, 2012).

Cognitive-behavioral therapy aims to change cognitive distortions and self-defeating behaviors using techniques like the ABC model. With this model, there is an Action (sometimes called an activating event), the Belief about the event, and the Consequences of this belief. Let’s say, Jon and Joe both go to a party. Jon and Joe each have met a young woman at the party: Jon is talking with Megan most of the party, and Joe is talking with Amanda. At the end of the party, Jon asks Megan for her phone number and Joe asks Amanda. Megan tells Jon she would rather not give him her number, and Amanda tells Joe the same thing. Both Jon and Joe are surprised, as they thought things were going well. What can Jon and Joe tell themselves about why the women were not interested? Let’s say Jon tells himself he is a loser or he is ugly. Jon then gets depressed and decides not to go to another party, which starts a cycle that keeps him depressed. Joe tells himself that she simply may not have been interested in dating anyone at that time, goes to another party, and meets someone new.

Jon’s belief about what happened results in a consequence of further depression, whereas Joe’s belief does not. Jon is internalizing the attribution or reason for the rebuffs, which triggers his depression. On the other hand, Joe is externalizing the cause, so his thinking does not contribute to feelings of depression. Cognitive-behavioral therapy examines specific maladaptive and automatic thoughts and cognitive distortions. Some examples of cognitive distortions are all-or-nothing thinking, overgeneralization, and jumping to conclusions. In overgeneralization, someone takes a small situation and makes it huge—for example, instead of saying, “This particular person was not interested in me,” an individual might say, “I am ugly, a loser, and no one is ever going to be interested in me.”

All or nothing thinking, which is a common type of cognitive distortion for people suffering from depression, reflects extremes. In other words, everything is black or white. After being turned down for a date, Jon begins to think, “No one will ever go out with me. I’m going to be alone forever.” He begins to feel anxious and sad as he contemplates his future.

The third kind of distortion involves jumping to conclusions—assuming that people are thinking negatively about you or reacting negatively to you, even though there is no evidence. Consider the example of Savannah and Hillaire, who recently met at a party. They have a lot in common, and Savannah thinks they could become friends. She calls Hillaire to invite her for coffee. Since Hillaire doesn’t answer, Savannah leaves her a message. Several days go by and Savannah never hears back from her potential new friend. Maybe Hillaire never received the message because she lost her phone or she is too busy to return the phone call. But if Savannah believes that Hillaire didn’t like Savannah or didn’t want to be her friend, she is demonstrating the cognitive distortion of jumping to conclusions.

PSYCHOTHERAPY: HUMANISTIC THERAPY

   Humanistic psychology focuses on helping people achieve their potential. So it makes sense that the goal of humanistic therapy is to help people become more self-aware and accepting of themselves. In contrast to psychoanalysis, humanistic therapists focus on conscious rather than unconscious thoughts. They also emphasize the patient’s present and future, as opposed to exploring the patient’s past.

Psychologist Carl Rogers developed a therapeutic orientation known as Rogerian, or client-centered therapy. Note the change from patients to clients. Rogers (1951) felt that the term patient suggested the person seeking help was sick and looking for a cure. Since this is a form of nondirective therapy, a therapeutic approach in which the therapist does not give advice or provide interpretations but helps the person to identify conflicts and understand feelings, Rogers (1951) emphasized the importance of the person taking control of his own life to overcome life’s challenges.

In client-centered therapy, the therapist uses the technique of active listening. In active listening, the therapist acknowledges, restates, and clarifies what the client expresses. Therapists also practice what Rogers called unconditional positive regard, which involves not judging clients and simply accepting them for who they are. Rogers (1951) also felt that therapists should demonstrate genuineness, empathy, and acceptance toward their clients because this helps people become more accepting of themselves, which results in personal growth.

EVALUATING VARIOUS FORMS OF PSYCHOTHERAPY

   How can we assess the effectiveness of psychotherapy? Is one technique more effective than another? For anyone considering therapy, these are important questions. According to the American Psychological Association, three factors work together to produce successful treatment. The first is the use of evidence-based treatment that is deemed appropriate for your particular issue. The second important factor is the clinical expertise of the psychologist or therapist. The third factor is your own characteristics, values, preferences, and culture. Many people begin psychotherapy feeling like their problem will never be resolved; however, psychotherapy helps people see that they can do things to make their situation better. Psychotherapy can help reduce a person’s anxiety, depression, and maladaptive behaviors. Through psychotherapy, individuals can learn to engage in healthy behaviors designed to help them better express emotions, improve relationships, think more positively, and perform more effectively at work or school.

Many studies have explored the effectiveness of psychotherapy. For example, one large-scale study that examined 16 meta-analyses of CBT reported that it was equally effective or more effective than other therapies in treating PTSD, generalized anxiety disorder, depression, and social phobia (Butler, Chapman, Forman, & Beck, 2006). Another study found that CBT was as effective at treating depression (43% success rate) as prescription medication (50% success rate) compared to the placebo rate of 25% (DeRubeis et al., 2005). Another meta-analysis found that psychodynamic therapy was also as effective at treating these types of psychological issues as CBT (Shedler, 2010). While much research has been done comparing different psychotherapies, researchers do not agree on whether any one therapy appears to be superior to another (e.g., Marcus, O’Connell, Norris, & Sawaqdeh, 2014; Wampold et al., 1997; Wampold et al., 2017).

BIOMEDICAL THERAPIES

   Individuals can be prescribed biologically based treatments or psychotropic medications that are used to treat mental disorders. While these are often used in combination with psychotherapy, they also are taken by individuals not in therapy. This is known as biomedical therapy. Medications used to treat psychological disorders are called psychotropic medications and are prescribed by medical doctors, including psychiatrists. In New Mexico, Louisiana, Illinois, Iowa, and Idaho, psychologists are also able to prescribe some types of these medications (American Psychological Association, 2017).

Different types and classes of medications are prescribed for different disorders. A person with depression might be given an antidepressant, an individual with bipolar disorder might be given a mood stabilizer, and an individual with schizophrenia might be given an antipsychotic. These medications are used to try to treat the symptoms of a psychological disorder. They can help people feel better so that they can function on a daily basis, but they do not cure the disorder. Some people may only need to take a psychotropic medication for a short period of time. Others with severe disorders like bipolar disorder or schizophrenia may need to take psychotropic medication for a long time. Still other individuals may decide not to take medications for personal reasons, such as cost or inability to tolerate harmful side effects. The table below shows types of medication and how they are used.

Another biologically based treatment that continues to be used, although infrequently, is electroconvulsive therapy (ECT)(formerly known as electroshock therapy). It involves using an electrical current to induce seizures to help alleviate the effects of severe depression. The exact mechanism is unknown, although it does help alleviate symptoms for people with severe depression who have not responded to traditional drug therapy (Pagnin, de Queiroz, Pini, & Cassano, 2004). About 85% of people treated with ECT improve (Reti, n.d.). However, the memory loss associated with repeated administrations has led to it being implemented as a last resort (Donahue, 2000; Prudic, Peyser, & Sackeim, 2000). A more recent alternative is transcranial magnetic stimulation (TMS), a procedure approved by the FDA in 2008 that uses magnetic fields to stimulate nerve cells in the brain to improve depression symptoms; it is used when other treatments have not worked (Mayo Clinic, 2012).