12 Clinical Psychology
STEP 4 Review the Knowledge You Need to Score High
No one approach for treating people with psychopathologies has been shown to be ideal. Multiple approaches can often be more helpful than using one specific approach. For example, a depressed patient might benefit from cognitive therapy, social skills training, and antidepressant drugs. Research is being conducted to determine the most effective (efficacious) treatments for clients with different disorders. One method for evaluating outcome research is meta-analysis. Meta-analysis, the systematic statistical method for synthesizing the results of numerous research studies dealing with the same variables, indicates that clients who receive psychotherapy are better off than most of those who receive no treatment. Treatments that appear more effective than others for particular disorders are noted in the following sections. See Table 12.2.
Table 12.2 Therapy/Cause/Goal
Insight therapies include psychoanalysis, psychodynamic therapy, and interpersonal psychotherapy; humanistic client-centered; and Gestalt psychotherapy. They all agree that their goal is to help clients develop insight about the cause of their problems and that insight will lead to behavior change; problems will decrease as self-awareness increases.
Sigmund Freud believed that abnormal behavior was the result of unconscious conflicts from early childhood trauma experienced during the psychosexual stages of development. He thought that the way to relieve the anxieties is to resolve the unconscious conflicts, which are covered by layers of experience. Psychoanalysis involves going back to discover the roots of problems, then changing one’s misunderstandings and emotions after identifying the problem. His treatment plan to bring the conflict into the conscious mind, enabling the client to gain insight and achieve personality change, includes the techniques of free association and dream interpretation.
In traditional psychoanalysis, the client participates in several sessions every week for 2 or 3 years, during which the therapist sits behind the patient and asks him or her to say whatever comes to mind, called free association. If clients do not censor what they say, key thoughts will make unconscious conflicts accessible. Since threatening experiences and feelings can be revealed when controls of the ego and superego are relaxed during sleep, the analyst may ask the client to recall his or her dreams. The recalled dream—the surface meaning—is called the manifest content. The therapist works with the client to find the hidden, underlying meaning (the latent content), by analyzing symbols within the dream. Hypnosis and Freudian slips, Freud’s “faulty actions,” for which his editor/translator adopted the term parapraxes, may also reveal hidden conflicts. Resistance—blocking of anxiety-provoking feelings and experiences, evidenced by behavior such as talking about trivial issues or coming late for sessions—is a sign that the client has reached an important issue that needs to be discovered. Although the analyst’s behavior is neutral, the client may respond to the analyst as though he or she is a significant person in the client’s emotional life. Known as transference, this behavior can allow the client to replay previous experiences and reactions, enabling him or her to gain insight about current feelings and behaviors. Catharsis, the release of emotional tension after remembering or reliving an emotionally charged experience from the past, may ultimately result in relief of anxiety. Traditional psychoanalysis requires too much time and is too expensive for the vast majority of people seeking help.
Psychodynamic and Interpersonal Psychotherapy
Psychoanalytic theory influences modern psychodynamic psychotherapy, which is typically shorter in duration, less frequent, and involves the client sitting up and talking to the therapist. The more active therapist is likely to point out and interpret relevant associations and help the client uncover unresolved conflict more directly to gain insight into the problem and work through feelings. Although psychodynamic therapists think that anxieties are rooted in past experiences, they do not necessarily assume the problems arose in infancy and early childhood.
Even shorter interpersonal psychotherapy aims to enable people to gain insight into the causes of their problems, but it focuses on current relations to relieve present symptoms.
Humanistic therapies include client-centered or person-centered therapies, and Gestalt therapy. Humanists think that problems arise because the client’s inherent goodness and potential to grow emotionally have been stifled by external psychosocial constraints. The goal of client-centered therapy is to provide an atmosphere of acceptance (unconditional positive regard), understanding (empathy), and sharing that permits the client’s inner strength and qualities to surface so that personal growth can occur and problems can be eliminated, ultimately resulting in self-actualization. According to humanist Carl Rogers, the greater the difference between the ideal self and the real self, the greater the problems of the client. His emphasis on developing a more positive self-concept through unconditional positive regard, active listening, and showing both sensitivity and genuineness is a central focus of nondirective Rogerian psychotherapy. Nondirective therapy encourages the client to take the lead in determining the direction of therapy. Rogers’s technique of active listening involves echoing, restating, and seeking clarification of what the client says and does and acknowledging feelings.
Influenced by Gestalt psychology, which emphasized that people organize their view of the world to make meaning, psychoanalyst Fritz Perls said that people create their own reality and continue to grow psychologically only as long as they perceive, stay aware of, and act on their true feelings. He developed Gestalt therapy. The therapist’s goal is to push clients to decide whether they will allow past conflicts to control their future or whether they will choose right now to take control of their own destiny. In contrast to client-centered therapy, Gestalt therapists are directive in questioning and challenge clients to help them become aware of their feelings and problems, and to discard feelings and values that are not their own. Similar to psychoanalysts, Gestalt therapists use dream interpretation to help the client gain a better understanding of the whole self. Through role playing, the therapist gets the client to express his or her true feelings. Like other humanistic therapies, the emphasis is on present behavior, feelings, and thoughts to get the client aware of how these factors interact to affect his or her whole being.
Insight therapies have been demonstrated to be effective for treating eating disorders, depressive disorders, and marital discord.
B. F. Skinner and other behaviorists discount the insight therapies. To Skinner, abnormal behavior is a result of maladaptive behavior learned through faulty rewards and punishment. The goal of behavior therapy is to extinguish unwanted behavior and replace it with more adaptive behavior. Therapies are based on the learning principles of classical conditioning, operant conditioning, and observational or social learning theory.
Classical Conditioning Therapies
After Watson conditioned Baby Albert to fear a rat, he planned to remove the fear, but Albert was taken away. Soon thereafter, Mary Cover Jones worked with a young child who feared white rabbits, rats, and similar stimuli. Over several months, she gradually introduced a rabbit closer and closer to the child while he ate and played. The boy’s fear was gradually eliminated. Joseph Wolpe dubbed her “the mother of behavior therapy.”
Classical conditioning therapies involving reconditioning include the counterconditioning techniques of systematic desensitization, flooding, and aversive conditioning.
• Originally called reciprocal inhibition, systematic desensitization is a behavior therapy founded on the idea that an anxiety response is inhibited by an incompatible relaxation response. Joseph Wolpe explained systematic desensitization as reconditioning so that the crucial conditioned stimulus elicits the new conditioned response. The procedure has three steps. First, the client is taught progressive relaxation. Next, the therapist and client create an anxiety hierarchy of all associated fears from the least-feared to the most-feared stimulus. For example, for school phobia, they may list the following situations: thinking about going to school, seeing a picture of the school, getting on the school bus, walking toward the school, opening the school door, and finally sitting in the classroom. Third, the therapist has the student imagine each of the fearful associations beginning with the least-feared stimulus, the mere thought of going to school, and pairs it with relaxation. After the student can relax with this fear, the process is repeated, finally ascending to the most fear-provoking stimulus of actually sitting in the classroom. When the student can sit in the classroom and be completely relaxed, the relaxation response is effective for inhibiting the fear response. Systematic desensitization is typically accomplished within 10 sessions.
• Flooding is an exposure technique, another classical conditioning treatment for phobias and other anxiety disorders, that extinguishes the conditioned response. As a result of the client directly confronting the anxiety-provoking stimulus, extinction is achieved; the feared stimulus (the conditioned stimulus) is repeatedly presented without the reason for being afraid (the unconditioned stimulus). For example, if someone afraid of dogs is repeatedly exposed to friendly dogs that do not bite, the fear associated with the dogs will eventually be extinguished.
• Yet another form of behavior therapy based on the principles of classical conditioning, aversive conditioning, trains the client to associate physical or psychological discomfort with behaviors, thoughts, or situations he or she wants to stop or avoid. One example of aversive conditioning uses a drug called Antabuse (US) to discourage the use of alcohol. By itself, the drug has no chemical effect, but when paired with alcohol (CS), the combination causes extreme nausea (CR). Similar to taste aversions discussed in Chapter 8, after very few pairings of Antabuse and alcohol, the client learns to avoid alcohol. Without an occasional pairing of the Antabuse with the alcohol again, this new response can easily be extinguished.
Operant Conditioning Therapies
Operant conditioning therapies include contingency management techniques of behavior modification and token economies designed to change behavior by modifying its consequences. In both, rewards are used to reinforce target behaviors.
• In behavior modification, the client selects a goal and, with each step toward it, receives a small reward until the intended goal is finally achieved.
• In token economies, positive behaviors are rewarded with secondary reinforcers (tokens, points, etc.), which can eventually be exchanged for extrinsic rewards, such as food. Token economies are often used in institutions to encourage socially acceptable behaviors and to discourage socially unacceptable ones.
Other Behavior Therapies
Social skills training is a behavior therapy, based on operant conditioning and Albert Bandura’s social learning theory, to improve interpersonal skills by using modeling, behavioral rehearsal, and shaping. With modeling, the client is encouraged to observe socially skilled people in order to learn appropriate behaviors. In behavioral rehearsal, the client practices the appropriate social behaviors through role-playing in structured situations. The therapist helps the client by providing positive reinforcement and corrective feedback. Shaping involves reinforcement of more and more complex social situations. Through social skills training, people with social phobias learn to make friends or date, and former mental patients learn to deal normally with people outside of the hospital.
Biofeedback training is a widely used behavioral therapy that involves giving the individual immediate information about the degree to which he or she is able to change anxiety-related responses such as heart rate, muscle tension, and skin temperature to facilitate improved control of the physiological process and, therefore, lessen physiological arousal.
Behavior therapies have been found effective for treating anxiety disorders (generalized anxiety disorder, panic disorder), obsessive-compulsive disorder, post-traumatic stress disorder, alcohol and drug addictions, bed-wetting, sexual dysfunctions, and autism spectrum disorder.
Psychoanalysts discount the quick cure offered by behaviorists. Since behaviorists are unconcerned with the cause of anxiety, analysts believe that it will resurface in a new form. Until the unconscious conflict is made conscious, the behaviorist is only “curing” the symptom of the problem; so through symptom substitution, a new problem will occur. The so-called cured smoker suddenly begins another compulsive habit, like eating or drinking.
Cognitive therapists, sometimes called cognitive-behavioral therapists, think that abnormal behavior is the result of faulty thought patterns. Many psychologists consider cognitive therapy to be an insight therapy. Cognitive-behavior therapy helps clients change both the way they think and the way they behave. Through cognitive restructuring, or turning the faulty, disordered thoughts into more realistic thoughts, the client may change abnormal behavior.
Rational Emotive Behavior Therapy
Albert Ellis developed Rational Emotive Therapy (RET), which is also called rational emotive behavior therapy (REBT), based on the idea that anxiety, guilt, depression, and other psychological problems result from self-defeating thoughts. The therapist has the client confront irrational thoughts by discussing his or her actions, his or her beliefs about those actions, and finally the consequences of those beliefs. The actions, beliefs, and consequences he called the ABCs of treatment. For instance, a young man is feeling guilty about not having helped his mother more before she died. Ellis might have confronted this guilty belief with a statement like “And you were the only person in the entire universe who could have helped her, right?” While defending these beliefs, the client may see how absurd they truly are. Ellis believed that much of this thinking involves the tyranny of the “shoulds,” what we believe we must do, rather than what is actually realistic or necessary.
Cognitive Triad Therapy
Aaron Beck also developed a cognitive therapy to alleviate faulty and negative thoughts. His cognitive triad looks at what a person thinks about his or her self, his or her world, and his or her future. Depressed individuals tend to have negative perceptions in all three areas. As noted by Martin Seligman, depressed individuals tend to think they caused the negative events, the negative events will affect everything they do, and the negative events will last forever. Such thoughts and beliefs lead to low self-esteem, depression, and anxiety. The goal of therapy is to help them change these irrationally negative beliefs into more positive and realistic views so that failures are attributed to things outside their control and successes are seen as personal accomplishments. Beck suggests specific tactics, including evaluating the evidence the client has for and against automatic thoughts, reattributing the blame to situational factors rather than the client’s incompetence, and discussing alternative solutions to the problem. For example, instead of blaming yourself for being stupid when the entire class does poorly on a math exam, you might substitute the thought that you didn’t have an adequate opportunity to study and that the test may not have been valid.
Cognitive therapies have been demonstrated to be effective in treating depressive disorders, eating disorders, chronic pain, marital discord, and anxiety disorders (generalized anxiety disorder, panic disorder, agoraphobia, and social phobia).