1. ©2015 Cengage Learning. All Rights Reserved. Chapter 15 Psychotherapy

2. ©2015 Cengage Learning. All Rights Reserved. The Treatment Process, continued Treatments: How many types are there? Therapeutic Relationship: essential There are three main categories of therapy: 1.Insight therapies 2.Behavior therapies 3.Psychiatric: Medication —As shown in Figure 15.1, many are treated with medication only.

4. ©2015 Cengage Learning. All Rights Reserved. The Treatment Process, continued Clients: Who seeks therapy? Coping with loss: deaths, loss, relationships Anxiety, Depression, Substance Abuse Women People with medical insurance

6. ©2015 Cengage Learning. All Rights Reserved. The Treatment Process, continued Clients: Who seeks therapy?, continued Many who need therapy, do not get it Common barriers to seeking treatment include: – Lack of health insurance. – The “stigma” associated with receiving mental health services. What is the stigma associated with treatment?

7. ©2015 Cengage Learning. All Rights Reserved. The Treatment Process, continued Therapists: Who provides treatment? Psychologists and psychiatrists are the most common providers of treatment. However, therapy is also provided by other professionals, including: – Social Workers (LCSW) – Psychiatric nurses (LVM) – Counselors: Marriage-Family Therapist

8. ©2015 Cengage Learning. All Rights Reserved. The Treatment Process, continued Therapists, continued Clinical psychologists and counseling psychologists “specialize in the diagnosis and treatment of psychological disorders and everyday behavioral problems." Both require a doctoral degree (Ph.D., Psy.D., or Ed.D). Psychologists also conduct psychological testing and carry out research. Do not prescribe medication in California

9. ©2015 Cengage Learning. All Rights Reserved. The Treatment Process, continued Therapists, continued Psychiatrists “are physicians who specialize in the treatment of psychological disorders." Treat with medication only Treat a wide variety of mental illnesses: Anxiety, PTSD, OCD, Schizophrenia, Depression.

10. ©2015 Cengage Learning. All Rights Reserved. The Treatment Process, continued Therapists, continued Other mental health professionals – Psychiatric social workers – They have a master’s degree and usually help patients integrate back into the community. Discharged hospitalized patients Homeless population – Psychiatric nurses : are able to prescribe medication with the support of a Psychiatrist – See Figure 15.3 for a full list.

12. ©2015 Cengage Learning. All Rights Reserved. Insight Therapies, continued Insight therapies : Explore the impact of early family dynamics on adult issues and relationships Insight therapies include: – Psychoanalysis: Freud – Client-centered therapy: Carl Rogers – Group therapy

13. ©2015 Cengage Learning. All Rights Reserved. Insight Therapies, continued Psychoanalysis – Probing the unconscious: look for unconscious conflicts Therapists use two techniques : – In free association: clients spontaneously express their thoughts and feelings exactly as they occu – In dream analysis, interpret the symbolic meaning in dreams – interpret the clues that these methods provide about unconscious conflicts.

14. ©2015 Cengage Learning. All Rights Reserved. Insight Therapies, continued Psychoanalysis, continued – Interpretation “involves the therapist’s attempts to explain the inner significance of the client’s thoughts, feelings, memories, and behaviors." – Resistance “unconscious defensive maneuvers intended to hinder the progress of therapy." o Clients may resist by “forgetting” appointments or being hostile toward the therapist.

16. ©2015 Cengage Learning. All Rights Reserved. Insight Therapies, continued Psychoanalysis, continued – Transference clients start relating to their therapists in ways that mimic significant relationships in their lives: Therapist as mother, father, ex-boyfriend, etc. psychodynamic approaches: newer therapies in psychoanalytic tradition

17. ©2015 Cengage Learning. All Rights Reserved. Insight Therapies, continued Client-centered therapy : A safe and accepting relationship is curative Carl Rogers: Therapist is collaborative not the expert as with Psychoanalysis Use of reflection as primary intervention: – Therapist reflects back and clarifies what the client states

18. ©2015 Cengage Learning. All Rights Reserved. Insight Therapies, continued Client-centered therapy, continued Therapeutic climate 1.Genuineness (honest communication) 2.Unconditional positive regard (therapist remains supportive, non-judgmental) 3.Empathy (therapist understands issues from client’s point of view)

19. ©2015 Cengage Learning. All Rights Reserved. Insight Therapies, continued Group therapy : Self-help or Clinician led -several or more clients (typically five to ten people) in a group." Participants’ roles – Participants share and provide support – Share their experiences and insight (exp: share about interventions that worked, insights into how to manage an ill family member, etc.)

20. ©2015 Cengage Learning. All Rights Reserved. Insight Therapies, continued Group therapy, continued Advantages of the group experience 1.Do not feel alone 2.Social support: key to health and recovery 3.Types: 1.Grief Support 2.Alcoholics Anonymous, Narcotics Anonymous 3.Depression Support Group 4.Sexual Abuse Support Group

21. ©2015 Cengage Learning. All Rights Reserved. Insight Therapies, continued Couples and family therapy Couples, or marital therapy –The focus is on the relationship conflict or distress Family therapy “involves the treatment of a family unit as a whole May be part of individual therapy or couples therapy

23. ©2015 Cengage Learning. All Rights Reserved. Insight Therapies, continued What makes therapy effective? 1.Good therapeutic relationship with therapist 2.Emotional support and empathic 3.The cultivation of hope, positive expectations. 4.Express feelings, receive insights and clarity

24. ©2015 Cengage Learning. All Rights Reserved. Behavior Therapies, continued Insight therapists believe that behaviors are symptoms of underlying psychological issues. behavior therapies : – Treat the symptoms – Stay in the here and now – Have a structure and direction to treatment

25. ©2015 Cengage Learning. All Rights Reserved. Behavior Therapies, continued Systematic desensitization “is a behavior therapy used to reduce clients’ anxiety responses through counterconditioning." Phobia a result of pairing anxiety with a neutral stimulus (exp. Spider) Goal: Associate Relaxation with Neutral Stimulus

26. ©2015 Cengage Learning. All Rights Reserved. Behavior Therapies, continued Systematic desensitization, continued Before beginning, the therapist helps the client build a anxiety hierarchy, or a list of progressively more frightening versions of the conditioned stimulus. Then, the client is trained in deep muscle relaxation. Gradually expose to the stimulus while staying relaxed and calm. – In vivo or imaginary or virtual

27. ©2015 Cengage Learning. All Rights Reserved. Behavior Therapies, continued Cognitive-behavioral treatments blend verbal and behavioral interventions. Cognitive therapy “is a treatment that emphasizes recognizing and changing negative thoughts and maladaptive beliefs." It emerged from the work of two former psychoanalysts: Albert Ellis and Aaron Beck (this chapter will focus on the work of Aaron Beck).

28. ©2015 Cengage Learning. All Rights Reserved. Behavior Therapies, continued Cognitive therapy, continued “Depression is errors in thinking”: 1.Irrational self-blame 2.Selective recall of negative memories 3.Negative about self, others, and future

29. ©2015 Cengage Learning. All Rights Reserved. Behavior Therapies, continued Cognitive therapy, continued Goal: change the way clients think. Teach client to become aware of their negative thinking and actively challenge it -Test their negative assumptions or beliefs -Actively “talk back” to negative self-talk

31. ©2015 Cengage Learning. All Rights Reserved. Behavior Therapies, continued Evaluating behavior / cognitive therapies Recommended Treatment Approach for: (good empirical support) – Depression, anxiety problems, phobias, OCD, and schizophrenia. – Sexual dysfunction. – Drug-related problems and eating disorders. – Hyperactivity. – Autism and mental retardation.

32. ©2015 Cengage Learning. All Rights Reserved. Biomedical Therapies LEARNING OBJECTIVES Describe the principal drug therapies used in the treatment of psychological disorders, and summarize evidence regarding their efficacy. Identify some of the problems associated with drug therapies and drug research. Describe ECT, and discuss its efficacy and risks.

33. ©2015 Cengage Learning. All Rights Reserved. Biomedical Therapies, continued Biomedical therapies “are physiological interventions intended to reduce symptoms associated with psychological disorders." Two prominent biomedical therapies are: – Drug therapy – Electroconvulsive (ECT)

34. ©2015 Cengage Learning. All Rights Reserved. Biomedical Therapies, continued: Treatment with drugs Psychopharmacotherapy (or drug therapy) “is the treatment of mental disorders with medication." Therapeutic drugs fall into four main categories: 1.Antianxiety drugs 2.Antipsychotic drugs 3.Antidepressant drugs 4.Mood stabilizers

35. ©2015 Cengage Learning. All Rights Reserved. Biomedical Therapies, continued Treatment with drugs, continued Antianxiety drugs “relieve tension, apprehension, and nervousness." Two common antianxiety drugs are Valium and Xanax. These drugs provide fast relief. However there is the risk for abuse, dependency, overdose, and withdrawal effects.

36. ©2015 Cengage Learning. All Rights Reserved. Biomedical Therapies, continued Treatment with drugs, continued Antipsychotic drugs “are used to gradually reduce psychotic symptoms, including hyperactivity, mental confusion, hallucinations, and delusions." They are typically used to treat schizophrenics or other patients in a delusional state. Traditional antipsychotics include Thorazine, Mellaril, and Haldol.

37. ©2015 Cengage Learning. All Rights Reserved. Biomedical Therapies, continued Treatment with drugs, continued Antipsychotics work gradually (one to three weeks), and reduce symptoms in about 70% of patients. They do have unpleasant side effects, however, including: – Dry mouth, constipation – Drowsiness – Tremors, muscular rigidity, and impaired coordination

38. ©2015 Cengage Learning. All Rights Reserved. Biomedical Therapies, continued Treatment with drugs, continued A more serious, but rare, side effect is a condition called tardive dyskinesia, “a neurological disorder marked by chronic tremors and involuntary spastic movements”, which is irreversible. Atypical antipsychotics are a newer class of drugs with a lower risk of these side effects. – However, these drugs may increase risk for diabetes and cardiovascular disease.

39. ©2015 Cengage Learning. All Rights Reserved. Biomedical Therapies, continued Treatment with drugs, continued Antidepressant drugs “gradually elevate mood and help bring people out of a depression." Reliance on antidepressants has increased dramatically in the past 15 years. – They are the most frequently prescribed medication in the U.S. The most commonly used antidepressants today are SSRIs (selective serotonin reuptake inhibitors) that work by affecting the brain chemical, serotonin (e.g., Zoloft).

40. ©2015 Cengage Learning. All Rights Reserved. Biomedical Therapies, continued Treatment with drugs, continued SSRIs also work for some anxiety disorders. Side effects of SSRIs include: – Weight gain – Sleep problems – Sexual dysfunction More recently, research has raised concern that SSRIs may possibly increase the risk for suicide, especially in adolescents. Effective within 12 weeks or less

41. ©2015 Cengage Learning. All Rights Reserved. Biomedical Therapies, continued Treatment with drugs, continued Mood stabilizers “are drugs used to control mood swings in patients with bipolar mood disorders." Lithium, Depakote – Toxicity or death at high concentrations – Kidney and thyroid gland problems Important to have regular blood monitor

42. ©2015 Cengage Learning. All Rights Reserved. Biomedical Therapies, continued Electroconvulsive therapy (ECT) “is a biomedical treatment in which electric shock is used to produce a cortical seizure accompanied by convulsions." ECT is primarily used to treat depression. Patients are given a light anesthetic and muscle relaxers to prevent spinal fractures. Electric current is applied for about a second, which triggers a brief seizure. Typically, patients receive 3 treatments a week, over two to seven weeks.

43. ©2015 Cengage Learning. All Rights Reserved. Biomedical Therapies, continued ECT, continued Effectiveness of ECT Proponents of ECT claim it is very effective for depression in patients that do not respond to medication. Opponents argue that it is not more effective than placebo and carries serious risks. In addition, relapse rates are very high. – In one well-controlled study, 64% of patients relapsed within 6 months (Prudic et al. 2004).

44. ©2015 Cengage Learning. All Rights Reserved. Biomedical Therapies, continued ECT, continued Risks associated with ECT ECT proponents admit that memory loss and impaired attention are mild, temporary side effects of the treatment. Critics argue that these cognitive problems are more serious and sometimes permanent.

45. ©2015 Cengage Learning. All Rights Reserved. Current Trends and Issues, continued Blending approaches to treatment Increasingly, therapists describe their theoretical approach as eclectic (see Figure 15.13). Eclectic therapists “borrow ideas, insights, and techniques from a variety of sources while tailoring their intervention strategy to the unique needs of each client." Eclectic approaches are particularly common when a treatment team provides therapy. Studies show that there is, indeed, merit to this idea.

46. Based on data from Norcross, Hedges, & Castle, 2002

47. ©2015 Cengage Learning. All Rights Reserved. Current Trends and Issues, continued Increasing multicultural sensitivity in treatment Minority groups are especially unlikely to seek and utilize therapy. 1.Cultural barriers – Some cultures emphasize assistance from family, clergy, etc., over mental health professionals. – Some cultures have difficulty trusting the medical (and mental health) establishment.

48. ©2015 Cengage Learning. All Rights Reserved. Current Trends and Issues, continued Increasing multicultural sensitivity, continued 2.Language barriers –Effective communication is critical to therapy, and cultural differences in language can act as a barrier to treatment. 3.Institutional barriers –Most therapists have only been trained to interact with white, middle-class clients and are unfamiliar with the cultural backgrounds of various ethnic groups.

49. ©2015 Cengage Learning. All Rights Reserved. Current Trends and Issues, continued Increasing multicultural sensitivity, continued What can be done? –Recruit and train minority therapists. –Train therapists how to work more effectively with a culturally diverse clientele. –Research how to modify current approaches so that they are more compatible with a diverse clientele.

50. ©2015 Cengage Learning. All Rights Reserved. Application: Looking for a Therapist LEARNING OBJECTIVES Discuss where to seek therapy and the importance of a therapist’s gender and professional background. Evaluate the importance of a therapist’s theoretical approach and understand what one should expect from therapy.

51. ©2015 Cengage Learning. All Rights Reserved. Application: Looking for a Therapist, continued Where do you find therapeutic services? Contrary to popular belief, most therapists do not operate in private practice. In fact, many work in: – Institutional settings (such as community mental health centers) – Human service agencies – See Figure 15.15 for more information

53. ©2015 Cengage Learning. All Rights Reserved. Application: Looking for a Therapist, continued Is therapy always expensive? – Not necessarily. Costs can be reduced by: Seeking treatment from providers who are not in private practice (e.g., human service agencies). Using health insurance.

54. ©2015 Cengage Learning. All Rights Reserved. Application: Looking for a Therapist, continued Is the therapist’s theoretical approach important? For certain types of problems, certain theoretical approaches are a better fit. For example: – Cognitive therapy is best for panic disorders. – Behavior therapy (systematic desensitization) is best for phobias. – OCD is best treated with behavior therapy and medication.

55. ©2015 Cengage Learning. All Rights Reserved. Application: Looking for a Therapist, continued What is therapy like? It is important to have realistic expectations about therapy. Therapy is usually a slow process. Therapy is hard work. Your therapist is only a facilitator. Ultimately, you have to make changes in your behavior or personality in order to see improvement.