ENDURING ISSUES IN THERAPIES
The underlying assumption behind therapy for psychological disorders is the belief that people are capable of changing (Stability-Change). Throughout this chapter you will have many opportunities to think about whether people suffering from psychological disorders can change significantly and whether they can change without intervention. In the discussion of biological treatments for psychological disorders, we again encounter the issue of mind-body. Finally, the enduring issue of diversity-universality will arise when we discuss the challenges therapists face when treating people from cultures other than their own.
INSIGHT THERAPIES
Although the details of various insight therapies differ, their common goal is to give people a better awareness and understanding of their feelings, motivations, and actions in the hope that this will lead to better adjustment. In this section, we consider two major insight therapies: psychoanalysis and client-centered therapy.
Psychoanalysis
In Freudian psychoanalysis, the client is instructed to talk about whatever comes to mind. This process is called free association. Freud believed that the resulting "stream of consciousness" would provide insight into the person's unconscious mind. During the early stages of psychoanalysis, the analyst remains impassive, mostly silent, and out of the person's sight. The analyst's silence serves as a "blank screen" onto which the person projects unconscious thoughts and feelings.
Eventually, clients may test their analyst by talking about desires and fantasies that they have never revealed to anyone else. When clients discover that their analyst is not shocked or disgusted by their revelations, they are reassured and transfer to their analyst feelings they have toward authority figures from their childhood. This process is known as transference. It is said to be positive transference when the person feels good about the analyst.
As people continue to expose their innermost feelings, they being to feel increasingly vulnerable. Threatened by their analyst's silence and by their own thoughts, clients may feel cheated and perhaps accuse their analyst of being a money grabber. Or they may suspect that their analyst is really disgusted by their disclosures or is laughing at them behind their backs. This negative transference is thought to be a crucial step in psychoanalysis, for it presumably reveals negative feelings toward authority figures and resistance to uncovering repressed emotions.
As therapy progresses, the analyst takes a more active role and begins to interpret or suggest alternative meanings for clients' feelings, memories, and actions. The goal of interpretation is to help people to gain insight - to become aware of what was formerly outside their awareness. As what was unconscious becomes conscious, clients may come to see how their childhood experiences have determined how they currently feel and act. By working through old conflicts, clients have a chance to review and revise the feelings and beliefs that underlie their problems. In the example of a therapy session that follows, the woman discovers a link between her current behaviors and childhood fears regarding her mother, which she has transferred to the analyst.
THERAPIST: (summarizing and restating) It sounds as if you would like to let loose with me, but you are afraid of what my response would be.
PATIENT: I get so excited by what is happening here. I feel I'm being held back by needing to be nice. I'd like to blast loose sometimes, but I don't dare.
THERAPIST: Because you fear my reaction?
PATIENT: The worst thing would be that you wouldn't like me. You wouldn't speak to me friendly; you wouldn't smile; you'd feel you can't treat me and discharge me from treatment. But I know this isn't so; I know it.
THERAPIST: Where do you think these attitudes come from?
PATIENT: When I was 9 years old, I read a lot about great men in history. I'd quote them and be dramatic. I'd want a sword at my side; I'd dress like an Indian. Mother would scold me, "Don't frown; don't talk so much. Sit on your hands," over and over again. I did all kinds of things. I was a naughty child. She told me I'd be hurt. Then, at 14, I fell off a horse and broke my back. I had to be in bed. Mother told me that day not to go riding. I'd get hurt because the ground was frozen. I was a stubborn, self-willed child. Then I went against her will and suffered an accident that changed my life: a fractured back. Her attitude was, "I told you so." I was put in a cast and kept in bed for months.
THERAPIST: You were punished, so to speak, by this accident.
PATIENT: But I gained attention and love from Mother for the first time. I felt so good. I'm ashamed to tell you this: Before I healed, I opened the cast and tried to walk, to make myself sick again so I could stay in bed longer.
THERAPIST: How does that connect with your impulse to be sick now and stay in bed so much?
PATIENT: Oh.... (pause)
THERAPIST: What do you think?
PATIENT: Oh, my God, how infantile, how ungrownup (pause). It must be so. I want people to love me and feel sorry for me. Oh, my God. How completely childish. It is, is that. My mother must have ignored me when I was little, and I wanted so to be loved.
THERAPIST: So that it may have been threatening to go back to being self-willed and unloved after you got out of the cast (interpretation).
PATIENT: It did. My life changed. I became meek and controlled. I couldn't get angry or stubborn afterward.
THERAPIST: Perhaps if you go back to being stubborn with me, you would be returning to how you were before, that is, active, stubborn, but unloved.
PATIENT: (excitedly) And, therefore, losing your love. I need you, but after all, you aren't going to reject me. But the pattern is so established now that the threat of the loss of love is too overwhelming with everybody, and I've got to keep myself from acting selfish or angry (Wolberg, 1977, pp. 560-561)
A relatively small percentage of people who seek therapy go into traditional psychoanalysis, as this woman did. As Freud recognized, analysis requires great motivation to change and an ability to deal rationally with whatever the analysis uncovers. Moreover, since traditional analysis takes a long time, not everyone can afford this kind of treatment, and fewer still possess the verbal and analytical skills necessary to discuss thoughts and feelings in this detailed way. And many want more immediate help for their problems. Finally, for those with severe disorders, psychoanalysis is ineffective.
Since Freud's invention around the turn of the 20th century, psychodynamic personality theory has changed significantly. Many of these changes have led to modified psychoanalytic techniques as well as to different therapeutic approaches (McCullough & Magill, 2009; Monti & Sabbadini, 2005; Safran, 2012; VandenBos, Meidenbauer, & Frank-McNeil, 2014). Freud felt that to understand the present we must understand the past, but most neo-Freudians encourage clients to cope directly with current problems in addition to addressing unresolved conflicts from the past. Neo-Freudians also favor face-to-face discussions, and most take an active role in analysis by interpreting their client's statements freely and suggesting discussion topics.
Client-Centered Therapy
Carl Rogers, the founder of the client-centered (or person-centered) therapy, took pieces of the neo-Freudians' views and revised them into a radically different approach to therapy.
Rogers' therapy is one example of humanistic therapies which share a common goal: to help people become fully functioning, to open them up to all of their experiences and to all of themselves. Such inner awareness is a form of insight, but for Rogers, insight into current feelings was more important than insight into unconscious wishes with roots in the distant past. Rogers called his approach to therapy client centered because he placed the responsibility for change on the person with the problem. Rogers believed that people's defensiveness, anxiety, and other signs of discomfort stem from their experiences of conditioned positive regard. They have learned that love and acceptance are contingent on conforming to what other people want them to be. By contrast, the cardinal rule in person-centered therapy is for the therapist to express unconditional positive regard - that is, to show true acceptance of clients no matter what they may say or do (Bozarth, 2007). Rogers felt that this was a crucial first step toward clients' self-acceptance.
Rogerian therapists try to understand things from the clients' point of view. They are emphatically nondirective. They do not suggest reasons for a client's feelings or how they might better handle a difficult situation. Instead, they try to reflect clients' statements, sometimes asking questions or hinting at feelings that clients have not articulated (VandenBos, Meidenbauer, & Frank-McNeil, 2014). Rogers felt that when therapists provide an atmosphere of openness and genuine respect, clients can find themselves, as portrayed in the following session.
CLIENT: I guess I do have problems at school.... You see, I'm chairman of the Science Department, so you can imagine what kind of a department it is.
THERAPIST: You sort of feel that if you're in something that it can't be too good. Is that...
CLIENT: Well, it's not that I... It's just that I'm... I don't think that I could run it.
THERAPIST: You don't have any confidence in yourself?
CLIENT: No confidence, no confidence in myself. I never had any confidence in myself. I - like I told you - like even when I was a kid I didn't feel I was capable and I always wanted to get back with the intellectual group.
THERAPIST: This has been a long-term thing, then. It's gone on a long time.
CLIENT: Yeah, the feeling is - even though I know it isn't, it's the feeling that I have that - that I haven't got it, that - that - that - people will find out that I'm dumb or - or...
THERAPIST: Masquerade.
CLIENT: Superficial, I'm just superficial. There's nothing below the surface. Just superficial generalities, that...
THERAPIST: There's nothing really deep and meaningful to you (Hersher, 1970, pp. 29-32).
Rogers wanted to discover those processes in client-centered therapy that were associated with positive results. Rogers's interest in the process of therapy resulted in important and lasting contributions to the field; research has shown that a therapist's emphasis on empathy, warmth, and understanding increase success, no matter what therapeutic approach is used (Bike, Norcross, & Schatz, 2009; Kirschenbaum & Jourdan, 2005).
A number of variations on person-centered therapy have been developed. However, they all share several common features: the therapist must provide empathy and unconditional positive regard, and the belief that clients are resourceful persons capable of finding their own directions and solutions to their problems (Cain, 2010).
Recent Developments
Although Freud, Rogers, and Perls originated the three major forms of insight therapy, others have developed hundreds of variations on this theme. Most involve a therapist who is far more active and emotionally engaged with clients than traditional psychoanalysts thought fit. These therapists give clients direct guidance and feedback, commenting on what they are told rather than just neutral listening.
Another general trend in recent years is toward shorter-term "dynamic therapy." For most people, this usually means meeting once a week for a fixed period. In fact, short-term psychodynamic therapy is increasingly popular among both clients and mental health professionals (Abbass, Joffres, & Ogrodniczuk, 2008; Levenson, 2010; McCullough & Magill, 2009; VandenBos, Meidenbauer, & Frank-McNeil, 2014). Insight remains the goal, but the course of treatment is usually limited - for example, to 25 sessions. With the trend to a time-limited framework, insight therapies have become more problem- or symptom-oriented, with greater focus on the person's current life situation and relationships. Although contemporary insight therapists do not discount childhood experiences, they view people as being less at the mercy of early childhood events than Freud did.
Perhaps the most dramatic and controversial change in insight therapies is virtual therapy. For a hundred years or so, people who wanted to see a therapist have literally gone to see a therapist - they have traveled to the therapist's office, sat down, and talked through their problems. In recent years, however, some people have started connecting with their therapists by telephone (S. Williams, 2000). Others pay their visits via cyberspace. The delivery of health care over the Internet or through other electronic means is part of a rapidly expanding field known as telehealth (Kaufman, 2014).
Although most therapists believe that online therapy is no substitute for face-to-face interactions (Almer, 2000; Rabasca, 2000c), evidence suggests that telehealth may provide cost-effective opportunities for delivery of some mental health services (J. E. Barnett & Scheetz, 2003; T. J. Kim, 2011). Telehealth is a particularly appealing alternative for people who live in remote or rural areas and for those with mild to moderate disorders (Hammond et al., 2012). For example, a university-based telehealth system in Kentucky provides psychological services to rural schools (Thomas Miller et al., 2003), and video-conferencing therapy has been used successfully to treat posttraumatic stress disorder in rural Wyoming (Hassija & Gray, 2009). Another study, this time in Canada, demonstrated that psychotherapy delivered by video-conference was as effective as face-to-face therapy in treating posttraumatic stress disorder (Germain, Marchand, Bouchard, Drouin, & Guay, 2009). Though these preliminary results are encouraging, more research is needed to determine under what circumstances virtual therapy is effective, as such services are likely to proliferate in the future (Melnyk, 2008; Zur, 2007). Not all medical plans reimburse for telehealth services. However, in anticipation of more widespread use of telehealth, in 2013, a joint task force was created by the American Psychological Association and issued guidelines to educate and guide psychologists using this technique (Joint Task Force for the Development of Telepsychology Guidelines for Psychologists, 2013).
Even more notable than the trend toward short-term and virtual therapy has been the proliferation of behavior therapies during the past few decades. In the next section, we examine several types.
BEHAVIOR THERAPIES
Behavior therapies sharply contrast with insight-oriented therapies. Behavior therapies are based on the belief that all behavior, both normal and abnormal, is learned. People suffering from hypochondriasis learn that they get attention when they are sick; people with paranoid personalities learn to be suspicious of others. Behavior therapists also assume that maladaptive behaviors are the problem, not symptoms of deeper underlying causes. If behavior therapists can teach people to behave in more appropriate ways, they believe that they have cured the problem. The therapist does not know exactly how or why a client learned to behave abnormally in the first place. The job of the therapist is simply to teach the person new, more satisfying ways of behaving on the basis of scientifically studied principles of learning, such as classical conditioning, operant conditioning, and modeling (Anthony & Roemer, 2011; VandenBos, Meidenbauer, & Frank-McNeil, 2014; Zinbarg & Griffith, 2008).
Therapies Based on Classical Conditioning
Classical conditioning involves the repressed pairing of a neutral stimulus with one that evokes a certain reflex response. Eventually, the formerly neutral stimulus alone comes to elicit the same response. The approach is one of learned stimulus-response associations. Several variations on classical conditioning have been used to treat psychological problems.
Desensitization, Extinction, and Flooding
Systematic desensitization, a method for gradually reducing fear and anxiety, is one of the oldest behavior therapy techniques (Wolpe, 1990). The method works by gradually associated a new response (relaxation) with anxiety-causing stimuli. For example, an aspiring politician might seek therapy because she is anxious about speaking to crowds. The therapist explores the kinds of crowds that are most threatening: Is an audience of 500 worse than one of 50? Is it harder to speak to men than it is to women? Is there more anxiety facing strangers than a roomful of friends? From this information the therapist develops a hierarchy of fears - a list of situations from the least to the most anxiety provoking. The therapist then teaches techniques for relaxation, both mentally and physically. once the client has mastered deep relaxation, she or he begins work at the bottom of the hierarchy of fears. The person is told to relax while imagining the least threatening situation on the list, then the next most threatening, and so on, until the most fear-arousing one is reached and the client can still remain calm.
Numerous studies show that systematic desensitization helps many people overcome their fears and phobias (Hazel, 2005; D. W. McNeil & Zvolensky, 2000). However, the key to success may not be the learning of a new conditioned relaxation response, but rather the extinction of the old fear response through mere exposure. Recall that in classical conditioning, extinction occurs when the learned, conditioned stimulus is repeatedly presented without the unconditioned stimulus following it. Thus, if a person repeatedly imagines a frightening situation without encountering danger, the associated fear should gradually decline. Desensitization is most effective when clients gradually confront their fears in the real world rather than merely in their imaginations.
The technique of flooding is a less familiar desensitization method. It involves full-intensity exposure to a feared stimulus for a prolonged period of time (Moulds & Nixon, 2006; Wolpe, 1990). Someone with a fear of snakes might be forced to handle dozens of snakes. Though flooding may seem unnecessarily harsh, remember how debilitating many untreated anxiety disorders can be.
Aversive Conditioning
Another classical conditioning technique is aversive conditioning, in which pain and discomfort are associated with the behavior that the client wants to unlearn. Aversive conditioning has been used with limited success to treat alcoholism, obesity, smoking, and some psychosexual disorders. For example, the taste and smell of alcohol are sometimes paired with drug-induced nausea and vomiting. Before long, clients feel sick just seeing a bottle of liquor. A follow-up study of nearly 800 people who completed alcohol-aversion treatment found that 63% had maintained continuous abstinence for at least 12 months (Sharon Johnson, 2003; Wiens & Menustik, 1983). The long-term effectiveness of this technique has been questioned; if punishment no longer follows, the undesired behavior may reemerge.
Therapies Based on Operant Conditioning
In operant conditioning, a person learns to behave a certain way because the behavior is reinforced. One therapy based on the principle of reinforcement is called behavior contracting. The therapist and the client agree on behavioral goals and on the reinforcement that the client will receive when he or she teaches those goals. These goals and reinforcements are often written in a contract that "legally" binds both the client and the therapist. A contract to help a person stop smoking might read: "For each day that I smoke fewer than 20 cigarettes, I will earn 30 minutes of time to go bowling. For each day that I exceed the goal, I will lose 30 minutes from the time that I have accumulated."
Another therapy based on operant conditioning is called the token economy. Token economies are usually used in schools and hospitals, where controlled conditions are most feasible (Boniecki & Moore, 2003; Comaty, Stasio, & Advokat, 2001). People are rewarded with tokens or points for appropriate behaviors, which can be exchanged for desired items and privileges. In a mental hospital, for example, improved grooming habits might earn points that can be used to purchase special foods or weekend passes. The positive changes in behavior, however, do not always generalize to everyday life outside the hospital or clinic, where adaptive behavior is not always reinforced and maladaptive behavior is not always punished.
Therapies Based on Modeling
Modeling - learning a behavior by watching someone else perform it - can also be used to treat problem behaviors. In a now classic demonstration of modeling, Albert Bandura and colleagues helped people to overcome a snake phobia by showing films in which models gradually moved closer and closer to snakes (Bandura, Blanchard, & Ritter, 1969). Modeling techniques have also been successfully used as part of job training programs (P.J. Taylor, Russ-Eft, & Chan, 2005) and have been used extensively with people with mental retardation to teach job and independent living skills (Cannella-Malone et al., 2006; Farr, 2008).
COGNITIVE THERAPIES
Cognitive therapies are based on the belief that if people can change their distorted ideas about themselves and the world, they can also change their problem behaviors and make their lives more enjoyable. Three popular forms of cognitive therapy are stress-inoculation therapy, rational-emotive therapy, and Aaron Beck's cognitive approach.
Stress-Inoculation Therapy
As we go about our lives, we talk to ourselves constantly - proposing courses of action, commenting on our performance, expressing wishes, and so on. Stress-inoculation therapy makes use of this self-talk to help people cope with stressful situations. The client is taught to suppress any negative, anxiety-evoking thoughts and to replace them with positive, "coping" thoughts. A student facing anxiety with an exam may think, "Another test; I'm so nervous. I'm sure I won't know the answers. If only I'd studied more. If I don't get through this course, I'll never graduate!" This pattern of thought is dysfunctional because it only makes anxiety worse. With the help of a cognitive therapist, the student learns a new pattern of self-talk: "I studied hard, and I know the material well. I looked at the textbook last night and reviewed my notes. I should be able to do well. If some questions are hard, they won't all be, and even if it's tough, my whole grade doesn't depend on just one test." Then the person tries the new strategy in a real situation, ideally one of only moderate stress (like a short quiz). Finally, the person is ready to use the strategy in a more stressful situation, like a final exam (Sheehy & Horan, 2004). Stress-inoculation therapy works by turning the client's thought patterns into a kind of vaccine against stress-induced anxiety.
Rational-Emotive Therapy
Another type of cognitive therapy, rational-emotive therapy (RET), developed by Albert Ellis (1973, 2001), is based on the view that most people in need of therapy hold a set of irrational and self-defeating beliefs (Ellis & Ellis, 2011). They believe that they should be competent at everything, always treated fairly, quick to find solutions to every problem, and so forth. Such beliefs involve absolutes - "musts" and "shoulds" - and make no room for mistakes. When people with such irrational beliefs come up against real-life struggles, they often experience excessive psychological distress.
Rational-emotive therapists confront such dysfunctional beliefs vigorously, using a variety of techniques, including persuasion, challenge, commands, and theoretical arguments (Ellis & Ellis, 2011; VandenBos, Meidenbauer, & Frank-McNeil, 2014). Studies have shown that RET often enables people to reinterpret negative beliefs and experiences more positively, decreasing the likelihood of depression (Blatt, Zuroff, Quinlan, & Pilkonis, 1996; Bruder et al., 1997).
Beck's Cognitive Therapy
One of the most important and promising forms of cognitive therapy for treating depression is known simply as cognitive therapy (J. Cahill et al., 2003). Sometimes it is referred to as "Beck's cognitive therapy," after developer Aaron Beck (1967), to distinguish between the broader category of cognitive therapies.
Beck believes that depression results from inappropriately self-critical patterns of thought. Self-critical people have unrealistic expectations, magnify failures, make sweeping negative generalizations based on little evidence, notice only negative feedback from the outside world, and interpret anything less than total success as failure. Although Beck's assumptions about the cause of depression are very similar to those underlying RET, the style of treatment differs considerably. Cognitive therapists are much less challenging and confrontational than rational-emotive therapists (Dozois, Frewen, & Covin, 2006). Instead, they try to help clients examine each dysfunctional thought in a supportive, but objectively scientific manner ("Are you sure your whole life will be totally ruined if you break up with Frank? What is your evidence for that? Didn't you once tell me how happy you were before you met him?") (Dobson, 2012; VandenBos, Meidenbauer, & Frank-McNeil, 2014). Like RET, Beck's cognitive therapy tries to lead the person to more realistic and flexible ways of thinking.
GROUP THERAPIES
Some therapists believe that treating several people simultaneously is preferable to individual treatment. Group therapy uses this approach (Burlingame & McClendon, 2008; Yalom & Leszcz, 2005). It allows both client and therapist to see how the person acts around others. If a person is painfully anxious and tongue-tied, chronically self-critical, or hostile, these tendencies show up quickly in a group. Group therapies also have the advantage of social support - a feeling that one is not the only person in the world with problems. Group members can help one another learn useful new behaviors, like how to disagree without antagonizing others. Group interactions can lead people toward insights into their own behavior, such as why they are defensive or feel compelled to complain constantly. Because group therapy consists of several clients "sharing" a therapist, it is also less expensive than individual therapy.
There are many kinds of group therapy. Some groups follow the general outlines of the therapies we have already mentioned. Others are oriented toward a specific goal, such as stopping smoking or drinking. Others may have a more open-ended goal - for example, a happier family or romantic relationship.
Family Therapy
Family therapy is one form of group therapy. Family therapists believe that if one person in the family is having problems, it's a signal that the entire family needs assistance. Therefore, it would be a mistake to treat a client without attempting to meet the person's parents, spouse, or children. Family therapists do not try to reshape the personalities of family members (Gurman & Kniskern, 1991), rather, they attempt to change relational interactions by improving communication, encouraging empathy, sharing responsibilities, and reducing family conflict (Lebow, 2014; VandenBos, Meidenbauer, & Frank-McNeil, 2014). To achieve these goals, all family members must believe that they will benefit from behavioral changes.
Although family therapy is appropriate when there are problems between husband and wife or parents and children, it is increasingly used when only one family member has a clear psychological disorder (Keitner, Archambault, Ryan, & Miller, 2003; Mueser, 2006). The goal of treatment in these circumstances is to help mentally healthy members of the family cope more effectively with the impact of the disorder on the family unit, which, in turn, helps the troubled person. Family therapy is also called for when a person's progress in individual therapy is slowed by the family (often because other family members have trouble adjusting to that person's improvement) (Clark, 2009).
Couple Therapy
Another form of group therapy is couple therapy, which is designed to assist partners who are having relationship difficulties. Previously termed marital therapy, the term "couple therapy" is considered more appropriate today because it captures the broad range of partners who may seek help (Lebow, 2014; Sheras & Koch-Sheras, 2006).
Most couple therapists concentrate on improving patterns of communication and mutual expectations. In empathy training, each member of the couple is taught to share inner feelings and to listen and to understand the partner's feelings before responding. This technique requires more time spent on listening, grasping what is really being said, and less time in self-defensive rebuttal. Other couple therapists use behavioral techniques, such as helping a couple develop a schedule for exchanging specific caring actions, like helping with chores or making time to share a special meal together. This approach may not sound romantic, but proponents say it can break a cycle of dissatisfaction and hostility in a relationship, and hence, it is an important step in the right direction (N. B. Epstein, 2004). Couple therapy for both partners is generally more effective than therapy for just one (Fraser & Solovey, 2007; Susan Johnson, 2003).
Self-Help Groups
An estimated 57 million Americans suffer from some kind of psychological problem (Kessler, Chiu, Demler, & Walters, 2005). Since individual treatment can be expensive, more and more people faced with life crises are turning to low-cost self-help groups. Most groups are small, local gatherings of people who share a common problem and who provide mutual support. Alcoholics Anonymous is perhaps the best-known self-help group, but self-help groups are available for virtually every life problem.
Do these self-help groups work? In many cases, they apparently do. Alcoholics Anonymous has developed a reputation for helping people cope with alcoholism. Most group members express strong support for their groups, and studies have demonstrated that they can indeed be effective (Galanter, Hayden, Castaneda, & Franco, 2005; Kurtz, 2004; McKellar, Stewart, & Humphreys, 2003).
Such groups also help to prevent more serious psychological disorders by reaching out to people who are near the limits of their ability to cope with stress. The social support they offer is particularly important in an age when divorce, geographic mobility, and other factors have reduced the ability of the family to comfort people.
EFFECTIVENESS OF PSYCHOTHERAPY
We have noted that some psychotherapies are generally effective, but how much better are they than no treatment at all? And how are we to decide whether a therapy is, in fact, effective (Norcross, Beutler, & Levant, 2006). Researchers have found that roughly twice as many people (two-thirds) improve with formal therapy than with no treatment at all (Borkovec & Costello, 1993; M. J. Lambert, 2001). Furthermore, many people who do not receive formal therapy get therapeutic help from friends, clergy, physicians, and teachers. Thus, the recovery rate for people who receive no therapeutic help at all is quite possibly even less than one-third. Other studies concur on psychotherapy's effectiveness (Hartmann & Zepf, 2003; M. J. Lambert & Archer, 2006; Leichsenring & Leibing, 2003). However, the effectiveness of psychotherapy appears to be related to a number of other factors. For instance, psychotherapy works best for relatively mild psychological problems (Kopta, Howard, Lowry, & Beutler, 1994) and seems to provide the greatest benefits to people who really want to change (Orlinsky & Howard, 1994).
One very extensive study designed the evaluate the effectiveness of psychotherapy was reported by Consumer Reports. Largely under the direction of psychologist Martin E. P. Seligman (1995), this investigation surveyed 180,000 Consumer Reports subscribers on everything from automobiles to mental health. Approximately 7,000 people from the total sample responded to the mental health section of the questionnaire that assessed satisfaction and improvement in people who had received psychotherapy, with the following results.
First, the vast majority of respondents reported significant overall improvement after therapy (Seligman, 1995). Second, there was no difference in the overall improvement score among people who had received therapy alone and those who had combined psychotherapy and medication. Third, no differences were found between the various forms of psychotherapy. Fourth, no differences in effectiveness were indicated among psychologists, psychiatrists, and social workers, although marriage counselors were seen as less effective. Fifth, people who received long-term therapy reported more improvement than those who received short-term therapy. Though the Consumer Reports study lacked the scientific rigor of more traditional investigations designed to assess psychotherapeutic efficacy, it does provide broad support for the idea that psychotherapy works (Jacobson & Christensen, 1996; Seligman, 1995, 1996).
Which Type of Therapy is Best for Which Disorder?
An important question is whether some forms of psychotherapy are more effective than others (Lyddon & Jones, 2001). Is behavior therapy, for example, more effective than insight therapy? In general, the answer seems to be "not much" (J. A. Carter, 2006; Hanna, 2002; Wampold et al., 1997). Most of the benefits of treatment seem to come from being in some kind of therapy, regardless of the particular type.
As we have seen, the various forms of psychotherapy are based on very different views about what causes mental disorders and, at least on the surface, approach the treatment of mental disorders in different ways. Why, then, is their no difference in their effectiveness? To answer this question, some psychologists have focused their attention on what the various forms of psychotherapy have in common, rather than emphasizing their differences (J. A. Carter, 2006; A. H. Roberts, Kewman, Mercer, & Hovell, 1993):
1. All forms of psychotherapy provide people with an explanation for their problems. Along with this explanation often comes a new perspective, providing people with specific actions to help them cope more effectively.
2. Most forms of psychotherapy offer people hope. Because most people who seek therapy have low self-esteem and feel demoralized and depressed, hope and the expectation for improvement increase their feelings of self-worth.
3. All major types of psychotherapy engage the client in a therapeutic alliance with a therapist. Although their therapeutic approaches may differ, effective therapists are warm, empathetic, and caring people who understand the importance of establishing a strong emotional bond with their clients that is built on mutual respect and understanding (Norcross, 2002; Wampold, 2001).
Together, these nonspecific factors common to all forms of psychotherapy appear to help explain why most people who receive any form of therapy show some benefits, compared with those who receive none at all.
Some kinds of psychotherapy seem to be particularly appropriate for certain people and problems (Norcross, Beutler, & Levant, 2006). Insight therapy, for example, though reasonably effective with a wide range of mental disorders (de Maat, de Jonghe, Schoevers, & Dekker, 2009), seems to be best suited to people seeking profound self-understanding, relief of inner conflict and anxiety, or better relationships with others. It has also been found to improve the basic life skills of people suffering from schizophrenia (Maxine Sigman & Hassan, 2006). Behavior therapy is apparently most appropriate for treating specific anxieties or other well-defined behavioral problems, such as sexual dysfunctions. Couple therapy is generally more effective than individual counseling for the treatment of drug abuse (Fals-Stewart & Lam, 2008; Liddle & Rowe, 2002).
Cognitive therapies have been shown to be effective treatments for depression (Hamdan-Mansour, Puskar, & Bandak, 2009; Leahy, 2004), anxiety disorders (M. A. Stanley et al., 2009), posttraumatic stress disorders (Foa, Gillihan, & Bryant, 2013), and even show some promise in reducing suicide (Wenzel, Brown, & Beck, 2009). In addition, cognitive therapies have been used effectively to treat people with personality disorders by helping them change their core beliefs and reducing their automatic acceptance of negative thoughts (McMain & pos, 2007; S. Palmer et al., 2006; Tarrier, Taylor, & Gooding, 2008). The trend in psychotherapy is toward eclecticism - that is, toward recognition of the value of a broad treatment package, rather than commitment to a single form of therapy (J. A. Carter, 2006; Slife & Reber, 2001).
BIOLOGICAL TREATMENTS
Biological treatments - a group of approaches including medication, electroconvulsive therapy, and neurosurgery - may be used to treat psychological disorders in addition to, or instead of, psychotherapy. Clients and therapists opt for biological treatments for several reasons. First, some people are too agitated, disoriented, or unresponsive to be helped by psychotherapy. Second, biological treatment is virtually always used for disorders with a strong biological component. Third, biological treatment is often used for people who are dangerous to themselves and to others. Fourth, insurance company reimbursement rates encourage brief encounters between therapists and clients rather than the longer sessions associated with the various talk therapies.
Traditionally, the only mental health professionals licensed to offer biological treatments were psychiatrists, who are physicians. However, an increasing number of states now permit specially trained psychologists to prescribe drugs (Fox et al., 2009). Therapists without such training often work with physicians who prescribe medication for their clients. In many cases where biological treatments are used, psychotherapy is also recommended; medication and psychotherapy used together generally are more effective for treating major depression and for preventing a recurrence then either treatment used alone (M. B. Keller et al., 2000; Manber et al., 2008).
Drug Therapies
Two major reasons for the widespread use of drug therapies today are the development of several very effective psychoactive medications and the fact that drug therapies can cost less than psychotherapy. Critics suggest, however, that another reason is our society's "pill mentality," or belief that we can take a medicine to fix any problem.
Antipsychotic Drugs
Before the mid-1950s, drugs were not widely used to treat psychological disorders, because the only available sedatives induced sleep as well as calm. Then the major tranquilizers reserpine and the phenothiazines were introduced. In addition to alleviating anxiety and aggression, both drugs reduce psychotic symptoms, such as hallucinations and delusions; for that reason, they are called antipsychotic drugs. Antipsychotic drugs are prescribed primarily for very severe psychological disorders, particularly schizophrenia. They are very effective for treating schizophrenia's "positive symptoms," like hallucinations, but less effective for the "negative symptoms," like social withdrawal. The most widely prescribed antipsychotic drugs are known as neuroleptics, which work by blocking the brain's receptors for dopamine, a major neurotransmitter (Leuner & Muller, 2006; Oltmanns & Emery, 2006). The success of antipsychotic drugs in treating schizophrenia supports the notion that schizophrenia is linked in some way to an excess of this neurotransmitter in the brain.
Antipsychotic medications sometimes have dramatic effects. People with schizophrenia who take them can go from being perpetually frightened, angry, confused, and plagued by auditory and visual hallucinations to being totally free of such symptoms. It is important to note that these drugs do not cure schizophrenia; they only alleviate the symptoms while the person is taking the drug (Oltmanns & Emery, 2006; P. Thomas et al., 2009). Moreover, antipsychotic drugs can have a number of undesirable side effects (H. Y. Lane et al., 2006; Roh, Ahn, & Nam, 2006). Blurred vision, weight gain, and constipation are among the common complaints, as are temporary neurological impairments such as muscular rigidity or tremors. A very serious potential side effect is tardive dyskinesia, a permanent disorder of motor control, particularly of the face (uncontrollable smacking of the lips, for instance), which can be only partially alleviated with other drugs (Chong, Tay, Subramaniam, Pek, & Machin, 2009; Eberhard, Lindstrom, & Levander, 2006). In addition, some of the antipsychotic medications that are effective with adults are not as well tolerated by children who experience an increased risk for many of the side effects described above (Kumra et al., 2008). Another problem is that antipsychotics are of little value in treating the problems of social adjustment that people with schizophrenia face outside the institutional setting. Because many discharged people fail to take their medications, relapse is common. However, the relapse rate can be reduced if drug therapy is effectively combined with psychotherapy.
Antidepressant Drugs
A second group of drugs, known as antidepressants, is used to combat depression. Until the end of the 1980s, there were only two main types of antidepressant drugs: monoamine oxidase inhibitors (MAO inhibitors) and tricyclics. Both drugs work by increasing the concentration of the neurotransmitters serotonin and norepinephrine in the brain. Both are effective for most people with serious depression, but both produce a number of serious and troublesome side effects.
In 1988, Prozac (fluoxetine) came onto the market. This drug works by reducing the uptake of serotonin in the nervous system, thus increasing the amount of serotonin active in the brain at any given moment. For this reason, Prozac is part of a group of psychoactive drugs known as selective serotonin reuptake inhibitors (SSRIs). Today, a number of second-generation SSRIs are available to treat depression, including Paxil (paroxetine), Zoloft (sertraline), and Effexor (venlafaxine HCI). For many people, correcting the imbalance in these chemicals in the brain reduces their symptoms of depression and also relieves the associated symptoms of anxiety. Moreover, because these drugs have fewer side effects than do MAO inhibitors or tricyclics (Nemeroff & Schatzberg, 2002), they have been heralded in the popular media as "wonder drugs" for the treatment of depression.
Today, antidepressant drugs are not only used to treat depression, but also have shown promise in treating generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, social phobia, and posttraumatic stress disorder (M. H. Pollack & Simon, 2009; Ralat, 2006). Antidepressant drugs such as the SSRIs do not work for everyone, however. At least a quarter of the patients with major depressive disorder do not respond to antidepressant drugs (Shelton & Hollon, 2000). Moreover, for some patients, these drugs produce unpleasant side effects, including nausea, weight gain, insomnia, headaches, anxiety, and impaired sexual functioning (Demyttenaere & Jaspers, 2008). They can also cause severe withdrawal symptoms in patients who abruptly stop taking them (Kotzalidis et al., 2007).
Lithium
Bipolar disorder is frequently treated with lithium carbonate. Lithium is not a drug, but a naturally occurring salt that is generally quite effective in treating bipolar disorder (Gnanadesikan, Freeman, & Gelenberg, 2003) and in reducing the incidence of suicide in bipolar patients (Grandjean & Aubry, 2009). We do not know exactly how lithium works, but recent studies with mice indicate that it may act to stabilize the levels of specific neurotransmitters (Dixon & Hokin, 1998) or alter the receptivity of specific synapses (G. Chen & Manji, 2006). Unfortunately, some people with bipolar disorder stop taking lithium when their symptoms improve - against the advice of their physicians; this leads to a relatively high relapse rate (Gershon & Soares, 1997; M. Pope & Scott, 2003).
Other Medications
Several other medications can be used to alleviate the symptoms of various psychological problems. Psychostimulants heighten alertness and arousal. Some psychostimulants, such as Ritalin, are commonly used to treat children with attention-deficit hyperactivity disorder (Ghuman, Arnold, & Anthony, 2008). In these cases they have a calming, rather than stimulating effect. Antianxiety medications, such as Valium and Xanax, are commonly prescribed as well. Quickly producing a sense of calm and mild euphoria, they are often used to reduce general tension and stress. Because they are potentially addictive, however, they must be used with caution. Sedatives produce both calm and drowsiness, and are used to treat agitation or to induce sleep. These drugs, too, can become addictive.
Electroconvulsive Therapy
Electroconvulsive therapy (ECT) is most often used for cases of prolonged and life-threatening depression that do not respond to other forms of treatment (Birkenhaeger, Pluijims, & Lucius, 2003; Tess & Smetana, 2009). The technique involves briefly passing a mild electric current through the brain or, more recently, through only one of its hemispheres (S. G. Thomas & Kellner, 2003). Treatment normally consists of 10 or fewer sessions of ECT.
No one exactly knows why ECT works, but its effectiveness has been clearly demonstrated. In addition, the fatality rate for ECT is markedly lower for people taking antidepressant drugs (Henry, Alexander, & Sener, 1995). Still, ECT has many critics and its use remains controversial (Krystal, Holsinger, Weiner, & Coffey, 2000; Shorter & Healy, 2007). Side effects include brief confusion, disorientation, and memory impairment, though research suggests that unilateral ECT produces fewer side effects and is only slightly less effective than the traditional method (Bajbouj et al., 2006). In view of the side effects, ECT is usually considered a "last-resort" treatment after still other methods have failed (Lilienfeld & Arkowitz, 2014). A more recent version of brain stimulation appears to hold promise for the treatment of depression without the side effects of ECT. Transcranial direct current stimulation (tDCS) uses a very low level current administered to specific parts of the brain over as much as a half hour (Alonzo, Chan, Martin, Mitchell, & Loo, 2013; Brunoni et al., 2013).
Neurosurgery
Neurosurgery refers to brain surgery performed to change a person's behavior and emotional state. This is a drastic step, especially because the effects of neurosurgery are difficult to predict. In a prefrontal lobotomy, the frontal lobes of the brain are severed from the lower brain centers (chiefly the thalamus and hypothalamus, which are important to emotions). Unfortunately, lobotomies often result in permanent, undesirable side effects, such as the inability to inhibit impulses or a near-total absence of feeling. Thus, prefrontal lobotomies are rarely performed today (Greely, 2007).
However, as we learn more about the links between the brain and behavior, it is becoming possible to pinpoint specific neural circuits that control such conditions as severe obsessive-compulsive disorders (OCD) and depression (Shawanda Anderson & Booker, 2006; Weingarten & Cummings, 2001). For example, one area toward the front of the cingulate gyrus is known to be overactive in people with severe OCD. Thin wires can be threaded into that area to destroy bits of tissue, reducing the overactivity. it is also possible to insert wires permanently, connect them to a kind of pacemaker, and periodically stimulate a particular area of the brain (Cusin et al., 2010; Howeland, 2008; Sachdev & Chen, 2009). While these experimental procedures are promising, they do not work in many cases and often there are undesirable side effects (Juckel, Uhl, Padberg, Brune, & Winter, 2009). Thus researchers are proceeding with great caution (Kringelbach & Aziz, 2009).
INSTITUTIONALIZATION AND ITS ALTERNATIVES
For persons with severe mental illness, hospitalization has been the treatment of choice in the United States for the past 150 years. Several different kinds of hospitals offer such care. General hospitals admit many affected people, usually for short-term stays until they can be released to their families or to other institutional care. Private hospitals - some nonprofit and some for profit - offer services to people with adequate insurance. Veterans Administration hospitals admit veterans with psychological disorders.
When most people think of "mental hospitals," however, large, state-run institutions come to mind. These public hospitals, many with beds for thousands of patients, were often built in rural areas in the 19th century. The idea was that a country setting would calm patients and help to restore their mental health. Despite the good intentions behind the establishment of these hospitals, in general they have not provided adequate care or therapy for their residents, as they are perpetually underfunded and understaffed. Except for new arrivals who were often intensively treated in the hope of quickly discharging them, patients received little therapy besides drugs; and most spent their days watching television or staring into space. Under these conditions, many patients became completely apathetic and accepted a permanent "sick role."
The development of effective drug therapies starting in the 1950s led to a number of changes in state hospitals. First, people who were agitated could now be sedated with drugs, which was considered an improvement over the use of physical restraints. The second major, and more lasting, result of the new drug therapies was the widespread release of people with severe psychological disorders back into the community - a policy called deinstitutionalization.
Deinstitutionalization
The practice of placing people in smaller, more humane facilities or returning them under medication to care within the community intensified during the 1960s and 1970s. By 1975, 600 regional mental health centers accounted for 1.6 million cases of outpatient care.
In recent years, however, deinstitutionalization has created serious challenges (Torrey, 2013). Discharged people often find poorly funded community mental health centers - or none at all. Many are not prepared to live in the community and they receive little guidance in coping with the mechanics of daily life. Those who return home can become a burden to their families, especially when follow-up care is inadequate. The quality of residential centers such as halfway houses can vary, with many providing poor care and minimal contact with the outside world. Insufficient sheltered housing forces many former patients into nonpsychiatric facilities - often rooming houses located in dirty, unsafe, isolated neighborhoods. The patients are further burdened by the social stigma of mental illness, which may be the largest single obstacle to their rehabilitation. Many released patients have been unable to obtain follow-up care or housing and are incapable of looking after their own needs. Consequently, many have ended up literally on the streets. Without supervision, they have stopped taking the drugs that made their release possible in the first place and their psychotic symptoms have returned. Perhaps one of the most tragic outcomes of the deinstitutionalization movement is the increase in the suicide rate among deinstitutionalized patients (Goldney, 2003). In addition, surveys indicate that nearly 40% of homeless people are mentally ill (Burt et al., 1999). Clearly, providing adequate mental health care to the homeless presents many challenges (Bhui, Shanahan, & Harding, 2006).
Alternative Forms of Treatment
For several decades, Charles Kiesler (1934-2002) argued for a shift from the focus on institutionalization to forms of treatment that avoid hospitalization all together (Kiesler & Simpkins, 1993). Kiesler (1982b) examined 10 controlled studies in which seriously disturbed people were randomly assigned either to hospitals or to an alternative program. The alternative programs took many forms: training patients living at home to cope with daily activities; assigning patients to a small, homelike facility in which staff and residents share responsibility for residential life; placing patients in a hostel, offering therapy and crisis intervention; providing family-crisis therapy and day-care treatment; providing visits from public-health nurses combined with medication; and offering intensive outpatient counseling combined with medication. All alternatives involved daily professional contact and skillful preparation of the community to receive the patients. Even though the hospitals to which some people in these studies were assigned provided very good patient care - probably substantially above average for institutions in the United States - 9 out of the 10 studies found that the outcome was more positive for alternative treatments than for the more expensive hospitalization. More recently, Kazdin & Kabbitt (2013) have described a half dozen novel ways of delivering mental health services that could reach many individuals who are not currently receiving treatment.
Prevention
Another approach to managing mental illness is attempting prevention. This requires finding and eliminating the conditions that cause or contribute to mental disorders and substituting conditions that foster well-being (Biglan, Flay, Embry, & Sandler, 2012). Prevention takes three forms: primary, secondary, and tertiary.
Primary prevention refers to efforts to improve the overall environment so that new cases of mental disorders do not develop. Family planning and genetic counseling are two examples of primary prevention programs. Other primary prevention programs aim at increasing personal and social competencies in a wide variety of groups. For example, there are programs designed to help mothers encourage problem-solving skills in their children and programs to enhance competence and adjustment among elderly persons. Current campaigns to educate young people about drugs, alcohol abuse, violence, and date rape are examples of primary preventions (Foxcroft, Ireland, Lister, Lowe, & Breen, 2003; Schinke, Schwinn, 2005).
Secondary prevention involves identifying high risk groups - for example, abused children, people who have recently divorced, those who have been laid off from their jobs, veterans, and victims of terrorist incidents. Interaction is the main thrust of secondary prevention - that is, detecting maladaptive behavior early and treating it promptly. One form of intervention is crisis intervention, which includes such programs as suicide hotlines or short-term crisis facilities where therapists can provide face-to-face counseling and support.
The main objective of tertiary prevention it to help people adjust to community life after release from a mental hospital. For example, hospitals often grant passes to encourage people to leave the institution for short periods of time before their release. Other tertiary prevention measures are halfway houses, where people find support and skills training during the period of transition between hospitalization and full integration into the community, and nighttime and outpatient programs that provide supportive therapy while people live at home and hold down full-time jobs. Tertiary prevention also includes community education.
Prevention has been the ideal of the mental health community since at least 1970, when the final report of the Joint Commission on Mental Health of Children called for a new focus on prevention in mental health work. Ironically, because preventive programs are usually long range and indirect, they are often the first to be eliminated in times of economic hardship. However, a 2009 report from the National Research Council and Institute of Medicine concluded that intervention with children and adolescents could improve the well-being of millions of children and save the nation as much as $247 billion dollars a year (O'Connell, Boat, & Warner, 2009). Subsequently, specific recommendations were made for minimizing the effects of poverty on children and youths (Yoshikawa, Aber, & Beardslee, 2012) and for preventing major depression (Munoz, Beardslee, & Leykin, 2012).
CLIENT DIVERSITY AND TREATMENT
A major topic is the wide range of differences that exist in human beings. Do such human differences affect the treatment of psychological problems? The American Psychological Association (APA) believes so: in 2012, the APA devoted a special issue of the journal American Psychologist to "Ethnic Disparities in Mental Health Care" ("Ethnic Disparities," 2012).
The importance of considering individual differences is reflected in the fact that there have been eight National Multicultural Conferences and Summits, the most recent held in January, 2015. Two areas that researchers have explored to answer this question are gender differences and cultural differences.
Gender and Treatment
There are significant gender differences in the prevalence of many psychological disorders. In part, this is because women have traditionally been more willing than men to admit that they have psychological problems and need help to solve them (Addis & Mahalik, 2003; Cochran & Rabinowitz, 2003), and because psychotherapy is more socially accepted for women than for men (Mirkin, Suyemoto, & Okun, 2005). However, the number of males willing to seek psychotherapy and counseling has increased (W. S. Pollack & Levant, 1998). Researchers attribute this growth to the changing roles of men in today's society: Men are increasingly expected to provide emotional as well as financial support for their families.
If gender differences exist in the prevalence of psychological disorders, are there gender differences in their treatment as well? In most respects, the treatment given to women is the same as that given to men, a fact that has become somewhat controversial in recent years (Ogrodniczuk, Piper, & Joyce, 2004; Ogrodniczuk & Staats, 2002). Critics of "equal treatment" have claimed that women in therapy are often encouraged to adopt traditional, male-oriented views of what is "appropriate"; male therapists may urge women to adapt passively to their surroundings. They may also be insufficiently sensitive to the fact that much of the stress that women experience comes from trying to cope with a world in which they are not treated equally (Tone, 2007). In response to this, the number of "feminist therapists" has increased (Brown, 2009). These therapists help their female clients to become more aware of the extent to which their problems derive from external controls and inappropriate sex roles, to become more conscious of and attentive to their own needs and goals, and to develop a sense of pride in their womanhood, rather than passively accepting or identifying with the status quo. Consistent with this position, the American Psychological Association has developed a detailed set of guidelines to help psychologists meet the special needs of female patients, which includes exposure to interpersonal victimization and violence, unrealistic media images, and work inequities (American Psychological Association, 2007).
Culture and Treatment
When a client and a therapist come from different cultural backgrounds or belong to different racial or ethnic groups, misunderstandings can arise in therapy.
This example shows how culture bound our ideas of what constitutes normal behavior are. When psychotherapist and client come from different cultures, misunderstandings of speech, body language, and customs are almost inevitable (Comas-Diaz, 2012; Hays, 2008). Even when client and therapist are of the same nationality and speak the same language, there can be striking differences if they belong to different racial and ethnic groups (Casas, 1995). Some Black people, for example, are wary of confiding in a White therapist - so much so that their wariness is sometimes mistaken for paranoia. In addition, Black patients often perceive Black therapists as being more understanding and accepting to their problems than White therapists (V. L. S. Thompson & Alexander, 2006). For this reason, many Black people seek out a Black therapist, a tendency that is becoming more common as larger numbers of Black middle-class people enter therapy (Diala et al., 2000; Snowden & Yamada, 2005).
One of the challenges for U.S. therapists in recent years has been to treat immigrants, many of whom have fled such horrifying circumstances that they arrive in the United States exhibiting posttraumatic stress disorder (Paunovic & Oest, 2001). These refugees must overcome the effects of post trauma, and the new stresses of settling in a strange country - separation from their families, ignorance of the English language, and inability to practice their traditional occupations. Therapists in such circumstances must learn something of their clients' culture. Often they have to conduct interviews through an interpreter - hardly an ideal circumstance for therapy.
Therapists need to recognize that some disorders that afflict people from other cultures may not exist in Western culture at all. For example, taijin kyofusho involves a morbid fear that one's body or actions may be offensive to others. Because this disorder is rarely seen outside Japan, American therapists require specialized training to identify it.
Ultimately, the best solution to the difficulties of serving a multicultural population is to train therapists of many different backgrounds so that members of ethnic, cultural, and racial minorities can choose therapists of their own group if they wish to do so (Bernal & Castro, 1994). Research has shown that psychotherapy is more likely to be effective when the client and the therapist share a similar cultural background (Gibson & Mitchell, 2003; Pedersen & Carey, 2003). Similarly, efforts aimed at preventing mental illness in society must also be culturally aware.