Clinical Psychology: Treatment
Part V: Content Review for the AP Psychology Exam
The various disordered behaviors described in the previous chapter can be viewed from varying perspectives. Often, insight into the true nature of a disorder can be derived from examining the strategy that is most effective in treating the disorder.
Insight Therapies: Psychoanalytic and Humanistic Approaches
The psychoanalytic approach to the treatment of disordered behavior is rooted in the concept of insight. Insight into the cause of the problem, according to this theory, is the primary key to eliminating the problem.
Psychoanalysis, or psychoanalytic therapy, as it is sometimes called, was first developed by Freud and focuses on probing past defense mechanisms of repression and rationalization to understand the unconscious cause of a problem. A primary tool for revealing the contents of the unconscious is free association, in which the patient reports any and all conscious thoughts and ideas. Within the pattern of free associations are hints to the nature of the unconscious conflict. The insight process does not occur quickly, however, as patients exhibit resistance to the uncovering of repressed thoughts and feelings.
In psychoanalytic therapy, the therapist strives to remain detached from the patient, resisting emotional or personal involvement. This detachment is intended to encourage transference, which occurs when the patient shifts thoughts and feelings about certain people or events onto the therapist. This process is thought to help reveal the nature of the patient’s conflicts. Countertransference may occur if the therapist transfers his or her own feelings onto the patient. In order to avoid countertransference, psychotherapists have typically undergone analysis themselves and many continue to do so while practicing therapy.
Freud and Dreams
According to psychoanalytic theory, another window into the unconscious is provided by dreams. Freud believed that the images and occurrences in dreams—the manifest content of dreams—are actually symbols representing the latent, or truly meaningful, content of dreams.
The humanistic school of psychology takes a related, yet different approach to the treatment of disordered behavior. Rather than treating the person seeking help as a patient, the humanistic approach treats the individual as a client. Client-centered therapy was invented by Carl Rogers and involves the assumption that clients can be understood only in terms of their own reality. This approach differs from the Freudian approach in its focus on the client’s present perception of reality, rather than the past and its analysis of conscious, instead of unconscious, motives. The goal of the therapy is to help the client realize full potential through self-actualization. In order to accomplish this, the client-centered therapist takes a somewhat different approach from that of the Freudian. Rather than remaining detached, the therapist is open, honest, and expressive of feelings with the client (an active listener). Rogers referred to this way of relating to the client as genuineness.
The next key for successful client-centered therapy, according to Rogers, is unconditional positive regard. You may recall from previous chapters that Rogers believed that unconditional positive regard for the child by the parent was critical for healthy development. The therapist provides this unconditional positive regard to help the client reach a state of unconditional self-worth.
The final key to successful therapy is accurate empathic understanding. Rogers used this term to describe the therapist’s ability to view the world from the eyes of the client. This empathy is critical to successful communication between the therapist and client.
A different type of approach toward treatment is Gestalt therapy, which combines both physical and mental therapies. Fritz Perls developed this approach to blend an awareness of unconscious tensions with the belief that one must become aware of and deal with those tensions by taking personal responsibility. Clients may be asked to physically “act out” psychological conflicts in order to make them aware of the interaction between mind and body.
Behavioral therapy stands in dramatic contrast to the insight therapies. First, behavioral therapy is a short-term process, whereas the insight approaches are extended over long periods of time, often spanning years. Secondly, behavior therapy treats symptoms because, in this school of thought, there is no deep underlying cause of the problem. The disordered behavior itself is both the problem and symptom. To change behavior, behavioral therapists use specific techniques with clearly defined methods of application and clear ways to evaluate their efficacy.
Counterconditioning is a technique in which a response to a given stimulus is replaced by a different response. For example, if a patient seeks behavioral therapy to stop drinking alcohol, the therapist must take the learned responses, the positive feelings generated by drinking alcohol, and replace them with a new reaction, namely, negative feelings concerning alcohol.
Counterconditioning can be accomplished in a few ways. One is to use aversion therapy, in which an aversive stimulus is repeatedly paired with the behavior that the client wishes to stop. So, to use our alcohol example, the therapist might administer a punishment to the patient each time the patient drinks alcohol.
Alcoholics and Aversion Therapy
This approach is sometimes used in treating alcoholism. Patients are administered a drug called Antabuse, which makes them violently ill if they consume alcohol.
Another method used for counterconditioning is systematic desensitization. This technique involves replacing one response, such as anxiety, with another response, such as relaxation. In order to achieve this goal, a therapist constructs, with the help of the client, a hierarchical set of mental images related to the stressful stimulus. These mental images are laid out in an order such that each one is slightly more anxiety-inducing than the previous one. The patient then learns a deep-relaxation technique. Next, the therapist asks the patient to bring to mind the least stressful of the mental images. As the client imagines the scene, he or she may become anxious. The client is instructed to practice the relaxation technique the moment the feelings of anxiety begin and to continue using the relaxation technique until he or she feels fully relaxed while imagining the scene. The therapist, over time, systematically helps the client work up the hierarchy until he or she is able to imagine the most stressful scene in the hierarchy without experiencing anxiety. This technique relies on learning mechanisms to associate the formerly anxiety-provoking stimuli with relaxation.
Changing It Up
A variation of systematic desensitization can occur when a therapist introduces the client to increasingly more anxiety-inducing stimuli instead of relying solely on his or her imagination.
Other forms of behavioral therapy involve extinction procedures, which are designed to weaken maladaptive responses. One way of trying to extinguish a behavior is called flooding. Flooding involves exposing a client to the stimulus that causes the undesirable response. If, for example, a client has come to a therapist to try to overcome a fear of spiders, the therapist will actually expose the client to spiders. Of course, the client will have a high anxiety level, but after a few minutes of being near the spider without any negative consequences, the client will presumably realize that the situation is not dangerous. Implosion is a similar technique, in which the client imagines the disruptive stimuli rather than actually confronting them.
Operant conditioning is a behavior-control technique that we discussed in the chapter on learning. A related approach is behavioral contracting, in which the therapist and the client draw up a contract by which they both agree to abide. The client must, according to the contract, act in certain ways, such as not exhibiting undesirable behaviors; meanwhile, the therapist must provide stated rewards if the client holds up his or her end of the bargain.
Modeling is a therapeutic approach based on Bandura’s social learning theory. This technique is based on the principle of vicarious learning. Clients watch someone act in a certain way and then receive a reward. Presumably, the client will then be disposed to imitate that behavior.
Cognitive approaches to the treatment of disordered behavior rely on changing cognitions, or the ways people think about situations, in order to change behavior. One such approach is rational-emotive behavior therapy (REBT) (sometimes called simply RET, for rational-emotive therapy), formulated by Albert Ellis. REBT is based on the idea that when confronted with situations, people recite statements to themselves that express maladaptive thoughts. The maladaptive thoughts result in maladaptive emotional responses. The goal of REBT is to change the maladaptive thoughts and emotional responses by confronting the irrational thoughts directly. Incorrect thoughts are changed in a simple way: the patient is told that he or she is incorrect and why. An example of a maladaptive thought is, “I always have to be perfect in everything I do” or “Other people’s opinions are crucial to my happiness.”
Another cognitive approach is cognitive therapy, formulated by Aaron Beck, in which the focus is on maladaptive schemas. These schemas cause the client to experience cognitive distortions, which in turn lead them to feel worthless or incompetent. Beck asserted that there is a negative triad of depression that involves a negative view of self, of the world, and of the future. This view is learned through experiences and then becomes a cycle of response that needs to be addressed through cognitive therapy. Maladaptive schemas include arbitrary inference, in which a person draws conclusions without evidence, and dichotomous thinking, which involves all-or-none conceptions of situations. An example might be that of a person, faced with the stress of a job interview, who thinks, “If I don’t get this job, I’ll be a complete failure.” The goal of cognitive therapy is to eliminate or modify the individual’s maladaptive schemas.
Biological therapies are medical approaches to behavioral problems. Biological therapies are typically used in conjunction with one of the previously mentioned forms of treatment.
Electroconvulsive therapy (ECT) is a form of treatment in which fairly high voltages of electricity are passed across a patient’s head. This treatment causes temporary amnesia and can result in seizures. It has been successful in the treatment of major depression, but today it is used only when all other means of treating depression have failed because of the risks involved with memory loss.
Another form of biological treatment is psychosurgery. Perhaps the most well-known form of psychosurgery is the prefrontal lobotomy, in which parts of the frontal lobes are cut off from the rest of the brain. This surgery was a popular treatment for violent patients from the 1930s to the 1950s. It frequently left patients in a zombie-like or catatonic state. Its use marked a controversial chapter in the history of psychotherapy.
Psychopharmacology is the treatment of psychological and behavioral maladaptations with drugs. There are four broad classes of psychotropic, or psychologically active drugs: antipsychotics, antidepressants, anxiolytics, and lithium salts.
Antipsychotics like Clozapine, Thorazine, and Haldol reduce the symptoms of schizophrenia by blocking the neural receptors for dopamine. You may recall that dopamine is implicated in schizophrenia and in movement disorder. Unfortunately, jerky movements, tremors, and muscle stiffness are among the side effects of these drugs. The clinician must decide which is worse—the psychological disorder being treated or the side effects of the drugs.
Antidepressants can be grouped into three types: monoamine oxidase (MAO) inhibitors, tricyclics, and selective reuptake inhibitors. MAO inhibitors, like Eutron, work by increasing the amount of serotonin and norepinephrine in the synaptic cleft. They produce this increase by blocking monoamine oxidase, which is responsible for the breakdown of many neurotransmitters. These drugs are effective but toxic and require special dietary modifications. Tricyclics, like Norpramin, Amitriptyline, and Imipramine increase the amount of serotonin and norepinephrine.
The third class of antidepressants, selective reuptake inhibitors (often called the selective serotonin reuptake inhibitors, or SSRIs, for the neurotransmitter most affected by them) also work by increasing the amount of neurotransmitter at the synaptic cleft, in this case by blocking the reuptake mechanism of the cell that released the neurotransmitters. Prozac (Fluoxetine) is one example of such a drug. The indirect mechanism of action of these drugs means that they have fewer side effects. They are the most frequently prescribed class of antidepressant drugs in the United States.
Anxiolytics depress the central nervous system and reduce anxiety while increasing feelings of well-being and reducing insomnia. A commonly prescribed anti-anxiety medication is Xanax. Anxiolytics also include barbiturates, which are rarely used because of their potential for addiction and their danger when mixed with other drugs. Benzodiazepines, which also include Valium (Diazepam) and Librium (Chlordiazepoxide), cause muscle relaxation and a feeling of tranquility.
Lithium carbonate, a salt, is effective in the treatment of bipolar disorder. The mechanism of action is not known, however.
MODES OF THERAPY
Not all forms of therapy involve an individual client seeing a therapist. Group therapy, in which clients meet together with a therapist as an interactive group, has some advantages over individual therapy. It is less expensive, and the group dynamic may be therapeutic in and of itself. Of course, the psychological effect of the therapist also may be diluted across the members of the group because attention is focused on the group rather than on a specific individual. One area in which group therapy has gained popularity is in the treatment of substance abuse. Twelve-step programs are one form of group therapy, although they are usually not moderated by professional psychotherapists. These programs, modeled after Alcoholics Anonymous, are a combination of spirituality and group therapy. The twelve-step programs focus on a strong social support system of people who are experiencing or who have experienced addictions or other types of maladaptive adjustments to life.
Another therapy in which there is more than a single client is couples or family therapy. This type of treatment arose out of the simple observation that some dysfunctional behavior affects the afflicted person’s loved ones. Couples therapy approaches the couple dyad as a system that involves complex interactions. Family therapy has distinct advantages in that it allows family members to express their feelings to one another and to the therapist simultaneously. This behavior, in turn, encourages family members to listen to one another in a way that might not occur in other settings.
unconditional positive regard
accurate empathetic understanding
rational-emotive behavior therapy (REBT) / rational-emotive therapy (RET)
electroconvulsive therapy (ECT)
selective reuptake inhibitors (SSRIs)
Modes of Therapy
Chapter 17 Drill
See Chapter 19 for answers and explanations.
1.The concept of accurate empathic understanding is most closely associated with which of the following therapeutic approaches?
2.Behavioral therapeutic approaches, such as systematic desensitization, have been most often used with those experiencing or diagnosed with
3.A psychoanalytically oriented therapist would most likely be in accord with which of the following criticisms regarding behaviorally oriented therapies?
(A)Behaviorally oriented therapies often take years to complete and create an onerous financial burden for the patient.
(B)Behaviorally oriented therapies are concerned solely with the modification of troubling behavioral symptoms and do not address the underlying problems which may have produced those symptoms.
(C)Behaviorally oriented therapies can be performed only by therapists who have had the longest and most rigorous training and, as a result, can never impact as many people as can other treatment approaches.
(D)Behaviorally oriented therapies are relatively uninterested in the development of an egalitarian client-therapist relationship and miss opportunities to promote emotional growth and empowerment.
(E)Behaviorally oriented therapies avoid the technique of role-playing and may not be suitable for group or family therapy situations.
4.The cognitively oriented therapeutic approach known as rational-emotive behavior therapy is most closely associated with
5.Which of the following is NOT a major class of drugs used for psychotherapeutic effect?
(C)Monoamine oxidase inhibitors
(E)Selective reuptake inhibitors
6.Judy has acrophobia, a fear of heights. A behavioral therapist creates a treatment plan to take her to the top of the Empire State Building on the first session, where she will remain until her reaction to the stimulus subsides. This technique is known as
7.A behavioral therapist uses which of the following techniques?
(E)Unconditional positive regard
8.Selective Serotonin Reuptake Inhibitors, more commonly known as SSRIs, are generally effective in treating which of the following?
(D)Feeding and eating disorders
9.A psychotherapist would most likely use which of the following therapies?
10.Carl Rogers is most closely identified with which of the following therapy perspectives?
(D)Cognitive behavioral therapy
Respond to the following questions:
· Which topics in this chapter do you hope to see on the multiple-choice section or essay?
· Which topics in this chapter do you hope not to see on the multiple-choice section or essay?
· Regarding any psychologists mentioned, can you pair the psychologists with their contributions to the field? Did they contribute significant experiments, theories, or both?
· Regarding any theories mentioned, can you distinguish between differing theories well enough to recognize them on the multiple-choice section? Can you distinguish them well enough to write a fluent essay on them?
· Regarding any figures given, if you were given a labeled figure from within this chapter, would you be able to give the significance of each part of the figure?
· Can you define the key terms at the end of the chapter?
· Which parts of the chapter will you review?
· Will you seek further help, outside of this book (such as a teacher, Princeton Review tutor, or AP Students), on any of the content in this chapter—and, if so, on what content?