Gateway THEME Psychotherapies are based on a common core of therapeutic principles. Medical therapies treat the physical causes of psychological disorders. In many cases, these approaches are complementary.

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Joe stared at some ducks through the blinds in his psychology professor’s office. They were quacking as they explored the campus pond. As psychologists, we meet many students with personal problems. Still, Joe’s teacher was surprised to see him at her office door. His excellent work in class and his healthy, casual appearance left her unprepared for his first words. “I feel like I’m losing my mind,” he said. “Can I talk to you?”

Over the next hour, Joe described his own personal hell. In a sense, he was like the ducks outside, appearing peaceful on the surface, but madly paddling underneath. He was working hard to hide a world of crippling fear, anxiety, and depression. At work, he was deathly afraid of talking to coworkers and cus- tomers. His social phobia led to frequent absenteeism and embarrassing behavior. At school, Joe felt “dif- ferent” and was sure that other students could tell he was “weird.” Several disastrous romances had left him terrified of women. Lately, he had been so depressed that he thought of suicide.

Joe’s request for help was a turning point. At a time when he was becoming his own worst enemy, Joe realized he needed help. In Joe’s case, that person was a talented clinical psychologist to whom his teacher referred him. With psychotherapy (and some temporary help from an antidepression medication), the psy- chologist was able to help Joe come to grips with his emotions and regain his balance.

This chapter discusses methods used to alleviate problems like Joe’s. We will begin with a look at the origins of modern therapy before describing therapies that emphasize the value of viewing personal prob- lems with insight and changing thought patterns. Then, we will focus on behavior therapies, which directly change troublesome actions. After that, we will explore medical therapies, which are based on psychiatric drugs and other physical treatments. We conclude with a look at some contemporary issues in therapy.

Gateway QUESTIONS 15.1 How did psychotherapy originate? 15.2 Is Freudian psychoanalysis still used? 15.3 How do psychotherapies differ? 15.4 What are the major humanistic therapies? 15.5 How does cognitive therapy change thoughts

and emotions? 15.6 What is behavior therapy? 15.7 What role do operant principles play in

behavior therapy?

15.8 How do psychiatrists treat psychological disorders?

15.9 Are various psychotherapies effective, and what do they have in common?

15.10 What will therapy be like in the future? 15.11 How are behavioral principles applied to

everyday problems and how could a person find professional help?

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Therapies

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Chapter 15512

Origins of Therapy— Bored Out of Your Skull

Gateway Question 15.1: How did psychotherapy originate? Fortunately, the odds are that you will not experience problems as serious as those of Joe, the student we just met. But if you did, what help is available? In most cases, it would be some form of psycho- therapy, a psychological technique that can bring about positive changes in personality, behavior, or personal adjustment. It might, as with Joe, also include a medical therapy. Let’s begin with a brief history of mental health care, including a discussion of psychoanaly- sis, the first fully developed psychotherapy.

Early treatments for mental problems give good reasons to appreciate modern therapies (Sharf, 2012). Archaeological find- ings dating to the Stone Age suggest that most primitive approaches were marked by fear and superstitious belief in demons, witchcraft, and magic. If Joe were unlucky enough to have been born several thousand years ago, his “treatment” might have left him feeling “bored.” You see, one of the more dramatic “cures” practiced by primitive “therapists” was a process called trepanning (treh-PAN- ing), also sometimes spelled trephining (Terry, 2006). In modern usage, trepanning is any surgical procedure in which a hole is bored in the skull. In the hands of primitive therapists, it meant boring, chipping, or bashing holes in a patient’s head. Presumably, this was done to relieve pressure or release evil spirits (• Figure 15.1).

Joe would not have been much better off during the Middle Ages. Then, treatments for mental illness in Europe focused on demonology, the study of demons and persons plagued by spirits. Medieval “therapists” commonly blamed abnormal behavior on supernatural forces, such as possession by the devil, or on curses from witches and wizards. As a cure, they used exorcism to “cast out evil spirits.” For the fortunate, exorcism was a religious ritual. More often, physical torture was used to make the body an inhospitable place for the devil to reside.

One reason for the rise of demonology may lie in ergot- ism (AIR-got-ism), a psychotic-like condition caused by ergot poisoning. In the Middle Ages, rye (grain) fields were often infested with ergot fungus. Ergot, we now know, is a natural source of LSD and other mind-altering chemicals. Eating tainted bread could have caused symptoms that were easily mistaken for bewitchment or madness. Pinch- ing sensations, muscle twitches, facial spasms, delirium, and hallucinations are all signs of ergot poisoning (Matossian, 1982). Modern analyses of “demonic possession” suggest that many victims may have been suffering from epilepsy, schizophrenia (Mirsky & Duncan, 2005), dissociative dis- orders (van der Hart, Lierens, & Goodwin, 1996), and depression (Thase, 2006). Thus, many people “treated” by demonologists may have been doubly victimized.

Then, in 1793, a French doctor named Philippe Pinel changed the Bicêtre Asylum in Paris from a squalid “mad- house” into a mental hospital by unchaining the inmates (Harris, 2003). Finally, the emotionally disturbed were

regarded as “mentally ill” and given compassionate treatment. Although it has been more than 200 years since Pinel began more humane treatment, the process of improving care continues today.

When was psychotherapy developed? The first true psychother- apy was created by Sigmund Freud little more than 100 years ago ( Jacobs, 2003). As a physician in Vienna, Freud was intrigued by cases of hysteria. People suffering from hysteria have physical symptoms (such as paralysis or numbness) for which no physical causes can be found.

Such problems are now called somatoform disorders, as discussed in Chapter 14, pages 499–501.

BRIDGES

• Figure 15.1 Primitive “treatment” for mental disorders sometimes took the form of boring a hole in the skull. This example shows signs of healing, which means the “patient” actually survived the treatment. Many didn’t.

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Therapies 513

Psychotherapy Any psychological technique used to facilitate positive changes in a person’s personality, behavior, or adjustment.

Demonology In medieval Europe, the study of demons and the treatment of persons “possessed” by demons.

Hysteria (now called somatoform disorders) An outdated term describing people with physical symptoms (such as paralysis or numbness) for which no physical causes can be found.

Psychoanalysis A Freudian therapy that emphasizes the use of free association, dream interpretation, resistances, and transference to uncover unconscious conflicts.

Free association In psychoanalysis, the technique of having a client say anything that comes to mind, regardless of how embarrassing or unimportant it may seem.

Resistance A blockage in the flow of free association; topics the client resists thinking or talking about.

Slowly, Freud became convinced that hysteria was related to deeply hidden unconscious conflicts and developed psychoanalysis in order to help patients gain insight into those conflicts (Knafo, 2009). Because it is the “granddaddy” of more modern therapies, let’s examine psychoanalysis in some detail.

Psychoanalysis—Expedition into the Unconscious

Gateway Question 15.2: Is Freudian psychoanalysis still used? Isn’t psychoanalysis the therapy for which the patient lies on a couch? Freud’s patients usually reclined on a couch during therapy, while Freud sat out of sight taking notes and offering interpretations. This procedure was supposed to encourage a free flow of thoughts and images from the unconscious. However, it is the least impor- tant element of psychoanalysis, and many modern analysts have abandoned it.

How did Freud treat emotional problems? Freud’s theory stressed that “neurosis” and “hysteria” are caused by repressed memories, motives, and conflicts—particularly those stemming from instinctual drives for sex and aggression. Although they are hidden, these forces remain active in the personality and cause some people to develop rigid ego defenses and compulsive, self- defeating behavior. Thus, the main goal of psychoanalysis is to reduce internal conflicts that lead to emotional suffering (Fayek, 2010).

Freud developed four basic techniques to uncover the uncon- scious roots of neurosis (Freud, 1949). These are free association, dream analysis, analysis of resistance, and analysis of transference.

Free Association The basis for free association is saying whatever comes to mind without worrying whether ideas are painful, embarrassing, or illogical. Thoughts are simply allowed to move freely from one idea to the next, without self-censorship. The purpose of free associa- tion is to lower defenses so that unconscious thoughts and feelings can emerge (Hoffer & Youngren, 2004).

Dream Analysis Freud believed that dreams disguise consciously unacceptable feel- ings and forbidden desires in dream form (Rock, 2004). The psy- choanalyst can use this “royal road to the unconscious” to help the patient work past the obvious, visible meaning of the dream (its manifest content) to uncover the hidden, symbolic meaning (its latent content). This is achieved by analyzing dream symbols (images that have personal or emotional meanings).

Suppose that a young man dreams of pulling a pistol from his waistband and aiming at a target as his wife watches. The pistol repeatedly fails to discharge, and the man’s wife laughs at him. Freud might have seen this as an indication of repressed feelings of sexual impotence, with the gun serving as a disguised image of the penis.

See Chapter 5, pages 178–179 and 198–199, for more information of Freudian dream theory.

BRIDGES

Analysis of Resistance When free associating or describing dreams, patients may resist talking about or thinking about certain topics. Such resistances (blockages in the flow of ideas) reveal particularly important unconscious conflicts. As analysts become aware of resistances, they bring them to the patient’s awareness so the patient can deal with them realistically. Rather than being roadblocks in therapy, resistances can be clues and challenges (Engle & Arkowitz, 2006).

Pioneering psychotherapist Sigmund Freud’s famous couch.

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Chapter 15514

Analysis of Transference Transference is the tendency to “transfer” feelings to a therapist similar to those the patient had for important persons in his or her past. At times, the patient may act as if the analyst is a rejecting father, an unloving or overprotective mother, or a former lover, for example. As the patient re-experiences repressed emotions, the therapist can help the patient recognize and understand them. Troubled persons often provoke anger, rejection, boredom, criti- cism, and other negative reactions from others. Effective therapists learn to avoid reacting as others do and playing the patient’s habit- ual resistance and transference “games.” This, too, contributes to therapeutic change (Fayek, 2010).

Psychoanalysis Today What is the status of psychoanalysis today? Traditional psychoanalysis was open-ended, calling for three to five therapy sessions a week, often for many years. Today, most patients are seen only once or twice per week, but treatment may still go on for years (Friedman et al., 1998). Because of the huge amounts of time and money this requires, psychoanalysts have become relatively rare. Nevertheless, psycho- analysis made a major contribution to modern therapies by highlight- ing the importance of unconscious conflicts (Friedman, 2006).

Many therapists have switched to doing time-limited brief psy- chodynamic therapy, which uses direct questioning to reveal unconscious conflicts (Binder, 2004). Modern therapists also actively provoke emotional reactions that will lower defenses and provide insights. Interestingly, brief therapy appears to accelerate recovery. Patients seem to realize that they need to get to the heart of their problems quickly (Messer & Kaplan, 2004).

Interpersonal Psychotherapy One example of a brief dynamic therapy is interpersonal psycho- therapy (IPT), which was first developed to help depressed people improve their relationships with others (Teyber & McClure, 2011). Research has confirmed that IPT is effective for depressive disorders, as well as eating disorders, substance abuse, social pho- bias, and personality disorders (Fiore et al., 2008; Hoffart, 2005; Prochaska & Norcross, 2010; Talbot & Gamble, 2008).

Liona’s therapy is a good example of IPT (Brown & Barlow, 2011). Liona was suffering from depression that a therapist helped her trace to a conflict with her parents. When her father was absent, Liona adopted the role of her mother’s protector and friend. How- ever, when her father was home, she was expected to resume her role as a daughter. She was angry with her father for frequently abandon- ing her mother and upset about having to switch roles so often. Liona’s IPT sessions (which sometimes included her mother) focused on clarifying Liona’s family roles. Her mood improved a lot after her mother urged her to “stick to being herself.”

Is Traditional Psychoanalysis Effective? The development of newer, more streamlined dynamic therapies is in part due to questions about whether traditional psychoanalysis “works.” In a classic criticism, Hans Eysenck (1994) suggested that

psychoanalysis simply takes so long that patients experience a spontaneous remission of symptoms (improvement due to the mere passage of time).

How seriously should the possibility of spontaneous remission be taken? It’s true that problems ranging from hyperactivity to anxiety do improve with the passage of time. Regardless, researchers have confirmed that psychoanalysis does, in fact, produce improvement in a majority of patients (Doidge, 1997).

The real value of Eysenck’s critique is that it encouraged psy- chologists to try new ideas and techniques. Researchers began to ask, “When psychoanalysis works, why does it work? Which parts of it are essential and which are unnecessary?” Modern therapists have given surprisingly varied answers to these questions. Let’s move on to survey some of the ways modern therapies differ. Later, we will acquaint you with some of the therapies currently in use.

Dimensions of Therapy— Let Me Count the Ways

Gateway Question 15.3: How do psychotherapies differ? In contrast to medical therapies, which are physical in nature, psychotherapy refers to any psychological technique that can bring about positive changes in personality, behavior, or personal adjustment. Psychotherapy is usually based on a dialogue between therapists and their clients, although some therapists also use learning principles to directly alter troublesome behaviors (Corsini & Wedding, 2011).

Therapists have many approaches to choose from: psycho- analysis, which we just discussed, as well as client-centered ther- apy, Gestalt therapy, cognitive therapy, and behavior therapy—to name but a few. As we will see throughout the chapter, each therapy emphasizes different concepts and methods. For this reason, the best approach for a particular person or problem may vary (Prochaska & Norcross, 2010).

Dimensions of Psychotherapy The terms in the list that follows describe some basic aspects of various psychotherapies (Prochaska & Norcross, 2010; Sharf, 2012). Notice that more than one term may apply to a particular therapy. For example, it is possible to have a directive, action- oriented, open-ended group therapy or a nondirective, individual, insight-oriented, time-limited therapy:

• Insight vs. action therapy: Does the therapy aim to bring clients to a deeper understanding of their thoughts, emotions, and behavior? Or is it designed to bring about direct changes in troublesome thoughts, habits, feelings, or behavior, without seeking insight into their origins or meanings?

• Directive vs. nondirective therapy: Does the therapist provide strong guidance and advice? Or does the therapist merely assist clients, who are responsible for solving their own problems?

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Therapies 515

Transference The tendency of patients to transfer feelings to a therapist that correspond to those the patient had for important persons in his or her past.

Brief psychodynamic therapy A modern therapy based on psychoanalytic theory but designed to produce insights more quickly.

Interpersonal psychotherapy (IPT) A brief dynamic psychotherapy designed to help people by improving their relationships with other people.

Spontaneous remission Improvement of symptoms due to the mere passage of time.

• Individual vs. group therapy: Does the therapy involve one therapist with one client? Or do several clients participate at the same time?

• Open-ended vs. time-limited therapy: Is the therapy open- ended? Or is it begun with the expectation that it will last only a limited number of sessions?

Myths Psychotherapy has often been depicted as a complete personal transformation—a sort of “major overhaul” of the psyche. But therapy is not equally effective for all problems. Chances of improvement are fairly good for phobias, low self-esteem, some sexual problems, and marital conflicts. More complex problems can be difficult to solve and may, as in Joe’s case, require medical treatment as well. The most extreme cases may not respond to psychotherapy at all, leaving a medical therapy as the only viable treatment option.

In short, it is often unrealistic to expect psychotherapy to undo a person’s entire past. For many people, the major benefit of psy- chotherapy is that it provides comfort, support, and a way to make constructive changes (Bloch, 2006; Burns, 2010). Yet, even when problems are severe, therapy may help a person gain a new perspec- tive or learn behaviors to better cope with life. Psychotherapy can be hard work for both clients and therapists, but when it succeeds, few activities are more worthwhile.

It’s also a mistake to think that psychotherapy is used only to solve problems or end a crisis. Even if a person is already doing well, therapy can be a way to promote personal growth (Bloch, 2006). Therapists in the positive psychology movement are developing ways to help people make use of their personal strengths. Rather than trying to fix what is “wrong” with a person, they seek to nur- ture positive traits and actively solve problems (Compton, 2005). ■ Table 15.1 lists some of the elements of positive mental health that therapists seek to restore or promote. Before we dig deeper into some of the different types of psychotherapy, let’s enhance your positive academic health with a short review.

Elements of Positive Mental Health

• Personal autonomy and independence

• A sense of identity

• Feelings of personal worth

• Skilled interpersonal communication

• Sensitivity, nurturance, and trust

• Genuineness and honesty with self and other

• Self-control and personal responsibility

• Committed and loving personal relationships

• Capacity to forgive others and oneself

• Personal values and a purpose in life

• Self-awareness and motivation for personal growth

• Adaptive coping strategies for managing stresses and crises

• Fulfillment and satisfaction in work

• Good habits of physical health

■ TABLE 15.1

Adapted from Bergin, 1991; Bloch, 2006.

Knowledge Builder Treating Psychological Distress

RECITE 1. One modern scientific explanation of medieval “possessions” by

“demons” is related to the effects of a. ergot poisoning b. trepanning c. exorcism

d. unconscious transference 2. Pinel is famous for his use of exorcism. T or F? 3. In psychoanalysis, an emotional attachment to the therapist is

called: a. free association b. manifest association c. resistance

d. transference Match:

4. _____ Directive therapies A. Change behavior 5. _____ Action therapies B. Place responsibility on the client 6. _____ Insight therapies C. The client is guided strongly 7. _____ Nondirective therapies D. Seek understanding

8. An approach that is incompatible with insight therapy is a. individual therapy b. action therapy c. nondirective

therapy d. time-limited psychotherapy

REFLECT Think Critically

9. According to Freud’s concept of transference, patients “transfer” their feelings onto the psychoanalyst. In light of this idea, to what might the term countertransference refer?

Self-Reflect

The use of trepanning, demonology, and exorcism all implied that the mentally ill are “cursed.” To what extent are the mentally ill rejected and stigmatized today?

Try to free associate (aloud) for 10 minutes. How difficult was it? Did anything interesting surface?

Can you explain, in your own words, the role of dream analysis, resistances, and transference in psychoanalysis?

Make a list describing what you think it means to be mentally healthy. How well does your list match the items in ■ Table 15.1?

Answers: 1. a 2. F 3. d 4. C 5. A 6. D 7. B 8. d 9. Psychoanalysts (and therapists in general) are also human. They may transfer their own unresolved, unconscious feelings onto their patients. This sometimes hampers the effectiveness of therapy (Kim & Gray, 2009).

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Chapter 15516

Humanistic Therapies— Restoring Human Potential

Gateway Question 15.4: What are the major humanistic therapies? When most people picture psychotherapists at work, they imagine them talking with their clients. Let’s sample a variety of talk- oriented approaches. Humanistic therapies tend to be insight thera- pies intended to help clients gain deeper insight into their thoughts, emotions, and behavior. In contrast, cognitive therapies tend to be action therapies less concerned with insight than with helping peo- ple change harmful thinking patterns. Let’s start with some insight.

Better self-knowledge was the goal of traditional psychoanaly- sis. However, Freud claimed that his patients could expect only to change their “hysterical misery into common unhappiness”! Humanistic therapists are more optimistic, believing that humans have a natural urge to seek health and self-growth. Most assume that it is possible for people to use their potentials fully and live rich, rewarding lives. In this section, we’ll discuss three of the most common humanistic therapies: client-centered therapy, existential therapy, and Gestalt therapy.

Client-Centered Therapy What is client-centered therapy? How is it different from psychoanaly- sis? Whereas psychoanalysis is directive and based on insights from the unconscious, client-centered therapy (also called person- centered therapy) is nondirective and based on insights from con- scious thoughts and feelings (Brodley, 2006; Wampold, 2007). The psychoanalyst tends to take a position of authority, stating what dreams, thoughts, or memories “mean.” In contrast, Carl Rogers (1902–1987), who originated client-centered therapy, believed that what is right or valuable for the therapist may be wrong for the cli- ent. (Rogers preferred the term “client” to “patient” because “patient” implies that a person is “sick” and needs to be “cured.”) Conse- quently, in client-centered therapy, the client determines what will be discussed during each session.

If the client runs things, what does the therapist do? The therapist cannot “fix” the client. Instead, the client must actively seek to solve his or her problems (Whitton, 2003). The therapist’s job is to create a safe “atmosphere of growth” by providing opportunities for change.

How do therapists create such an atmosphere? Rogers believed that effective therapists maintain four basic conditions. First, the therapist offers the client unconditional positive regard (unshak- able personal acceptance). The therapist refuses to react with shock, dismay, or disapproval to anything the client says or feels. Total acceptance by the therapist is the first step to self-acceptance by the client.

Second, the therapist attempts to achieve genuine empathy by trying to see the world through the client’s eyes and feeling some part of what the client is feeling.

As a third essential condition, the therapist strives to be authen- tic (genuine and honest). The therapist must not hide behind a professional role. Rogers believed that phony fronts destroy the growth atmosphere sought in client-centered therapy.

Fourth, the therapist does not make interpretations, propose solutions, or offer advice. Instead, the therapist reflects (rephrases, summarizes, or repeats) the client’s thoughts and feelings. This enables the therapist to act as a psychological “mirror” so clients can see themselves more clearly. Rogers theorized that a person armed with a realistic self-image and greater self-acceptance will gradually discover solutions to life’s problems.

Existential Therapy According to the existentialists, “being in the world” (existence) creates deep anxiety. Each of us must deal with the realities of death. We must face the fact that we create our private world by making choices. We must overcome isolation on a vast and indif- ferent planet. Most of all, we must confront feelings of meaning- lessness (Schneider, Galvin, & Serlin, 2009).

What do these concerns have to do with psychotherapy? Existen- tial therapy focuses on the problems of existence, such as meaning, choice, and responsibility. Like client-centered therapy, it pro- motes self-knowledge. However, there are important differences. Client-centered therapy seeks to uncover a “true self ” hidden behind a screen of defenses. In contrast, existential therapy empha- sizes free will, the human ability to make choices. Accordingly, existential therapists believe you can choose to become the person you want to be.

Existential therapists try to give clients the courage to make rewarding and socially constructive choices. Typically, therapy focuses on death, freedom, isolation, and meaninglessness, the “ulti- mate concerns” of existence (van Deurzen & Kenward, 2005). These universal human challenges include an awareness of one’s mortality, the responsibility that comes with freedom to choose, being alone in your own private world, and the need to create meaning in your life.

One example of existential therapy is Victor Frankl’s logother- apy, which emphasizes the need to find and maintain meaning in

Psychotherapist Carl Rogers, who originated client- centered therapy.

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Therapies 517

Client-centered (or person-centered) therapy A nondirective therapy based on insights gained from conscious thoughts and feelings; emphasizes accepting one’s true self.

Unconditional positive regard An unqualified, unshakable acceptance of another person.

Empathy A capacity for taking another’s point of view; the ability to feel what another is feeling.

Authenticity In Carl Rogers’s terms, the ability of a therapist to be genuine and honest about his or her own feelings.

Reflection In client-centered therapy, the process of rephrasing or repeating thoughts and feelings expressed by clients so they can become aware of what they are saying.

Existential therapy An insight therapy that focuses on the elemental problems of existence, such as death, meaning, choice, and responsibility; emphasizes making courageous life choices.

Gestalt therapy An approach that focuses on immediate experience and awareness to help clients rebuild thinking, feeling, and acting into connected wholes; emphasizes the integration of fragmented experiences.

Cognitive therapy A therapy directed at changing the maladaptive thoughts, beliefs, and feelings that underlie emotional and behavioral problems.

life. Frankl (1904–1997) based his approach on experiences he had as a prisoner in a Nazi concentration camp. In the camp, Frankl saw countless prisoners break down as they were stripped of all hope and human dignity (Frankl, 1955). Those who sur- vived with their sanity did so because they managed to hang on to a sense of meaning (logos). Even in less dire circumstances, a sense of purpose in life adds greatly to psychological well-being (Prochaska & Norcross, 2010).

What does the existential therapist do? The therapist helps clients discover self-imposed limitations in personal identity. To be suc- cessful, the client must fully accept the challenge of changing his or her life (Bretherton & Orner, 2004). Interestingly, Buddhists seek a similar state that they call “radical acceptance” (Brach, 2003).

A key aspect of existential therapy is confrontation, in which clients are challenged to be mindful of their values and choices and to take responsibility for the quality of their existence (Claessens, 2009). An important part of confrontation is the unique, intense, here-and-now encounter between two human beings. When existential therapy is successful, it brings about a renewed sense of purpose and a reappraisal of what’s important in life. Some clients even experience an emotional rebirth, as if they had survived a close brush with death. As Marcel Proust wrote, “The real voyage of discovery consists not in seeing new landscapes but in having new eyes.”

Gestalt Therapy Gestalt therapy is based on the idea that perception, or awareness, is disjointed and incomplete in maladjusted persons. The German word Gestalt means “whole,” or “complete.” Gestalt therapy helps people rebuild thinking, feeling, and acting into connected wholes. This is achieved by expanding personal awareness; by accepting responsibility for one’s thoughts, feelings, and actions; and by fill- ing in gaps in experience (Masquelier, 2006).

What are “gaps in experience”? Gestalt therapists believe that we often shy away from expressing or “owning” upsetting feelings. This creates a gap in self-awareness that may become a barrier to personal growth. For example, a person who feels anger after the death of a parent might go for years without fully expressing it. This and similar threatening gaps may impair emotional health.

The Gestalt approach is more directive than client-centered or existential therapy, and it is less insight-oriented and instead emphasizes immediate experience. Working either one-to-one or in a group setting, the Gestalt therapist encourages clients to become more aware of their moment-to-moment thoughts, per- ceptions, and emotions (Staemmler, 2004). Rather than discussing why clients feel guilt, anger, fear, or boredom, the therapist encour- ages them to have these feelings in the “here and now” and become fully aware of them. The therapist promotes awareness by drawing attention to a client’s posture, voice, eye movements, and hand gestures. Clients may also be asked to exaggerate vague feelings until they become clear. Gestalt therapists believe that expressing such feelings allows people to “take care of unfinished business” and break through emotional impasses (O’Leary, 2006).

Gestalt therapy is often associated with the work of Fritz Perls (1969). According to Perls, emotional health comes from knowing what you want to do, not dwelling on what you should do, ought to do, or should want to do (Brownell, 2010). In other words, emo- tional health comes from taking full responsibility for one’s feel- ings and actions. For example, it means changing “I can’t” to “I won’t,” or “I must” to “I choose to.”

How does Gestalt therapy help people discover their real wants? Above all else, Gestalt therapy emphasizes present experience (Yontef, 2007). Clients are urged to stop intellectualizing and talking about feelings. Instead, they learn to live now; live here; stop imagining; experience the real; stop unnecessary thinking; taste and see; express rather than explain, justify, or judge; give in to unpleasantness and pain just as to pleasure; and surrender to being as you are. Gestalt therapists believe that, paradoxically, the best way to change is to become who you really are (Brownell, 2010).

Cognitive Therapy—Think Positive!

Gateway Question 15.5: How does cognitive therapy change thoughts and emotions? Whereas humanistic therapies usually seek to foster insight, cogni- tive therapies usually try to directly change what people think, believe, and feel, and, as a consequence, how they act. In general, cognitive therapy helps clients change thinking patterns that lead to troublesome emotions or behaviors (Davey, 2008; Power, 2010).

In practice, how does cognitive therapy differ from humanistic therapy? Janice is a hoarder whose home is crammed full with things she has acquired over two decades. If she seeks help from a therapist concerned with insight, she will try to better understand why she began collecting stuff. In contrast, if she seeks help from a cognitive

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Chapter 15518

therapist, she may spend little time examining her past. Instead, she will work to actively change her thoughts and beliefs about hoard- ing. With either approach, the goal is to give up hoarding. Further, in practice, humanistic therapies often also result in active change and cognitive therapies often also yield deeper insight.

Cognitive therapy has been successfully used as a remedy for many problems, ranging from generalized anxiety disorder and post- traumatic stress disorder to marital distress and anger (Butler et al., 2006). For example, compulsive hand washing can be greatly reduced by changing a client’s thoughts and beliefs about dirt and contamina- tion (Jones & Menzies, 1998). Cognitive therapy has been especially successful in treating depression (Hollon, Stewart, & Strunk, 2006). Joe’s clinical psychologist relied on cognitive therapy to help lift Joe (who could forget Joe?) out of his depression.

Cognitive Therapy for Depression As you may recall from Chapter 13, cognitive psychologists believe that negative, self-defeating thoughts underlie depression. According to Aaron Beck (1991), depressed persons see them- selves, the world, and the future in negative terms because of major distortions in thinking. The first is selective perception, which refers to perceiving only certain stimuli in a larger array. If five good things and three bad things happen during the day, depressed people focus only on the bad. A second thinking error in depression is overgeneralization, the tendency to think that an upsetting event applies to other, unrelated situations. An example would be Joe’s considering himself a total failure, or completely worthless, if he were to lose a part-time job or fail a test. To com- plete the picture, depressed persons tend to magnify the impor- tance of undesirable events by engaging in all-or-nothing think- ing: they see events as completely good or bad, right or wrong, and themselves as either successful or failing miserably (Lam & Mok, 2008).

How do cognitive therapists alter such patterns? Cognitive thera- pists make a step-by-step effort to correct negative thoughts that lead to depression or similar problems. At first, clients are taught to recognize and keep track of their own thoughts. The client and therapist then look for ideas and beliefs that cause depression, anger, and avoidance. For example, here’s how Joe’s therapist began to challenge his all-or-nothing thinking:

Joe: I’m feeling really depressed today. No one wants to hire me, and I can’t even get a date. I feel completely incompetent!

Therapist: I see. The fact that you are currently unemployed and don’t have a girlfriend proves that you are completely and utterly incompetent?

Joe: Well…I can see that doesn’t add up.

Next, clients are asked to gather information to test their beliefs. For instance, a depressed person might list his or her activities for a week. The list is then used to challenge all-or-nothing thoughts, such as “I had a terrible week” or “I’m a complete failure.” With more coaching, clients learn to alter their thoughts in ways that improve their moods, actions, and relationships.

Cognitive therapy is at least as effective as drugs for treating many cases of depression (Butler et al., 2006; Eisendrath, Chartier, & McLane, 2011). More importantly, people who have adopted new thinking patterns are less likely to become depressed again—a benefit that drugs can’t impart (Dozois & Dobson, 2004; Hollon, Stewart, & Strunk, 2006).

In an alternate approach, cognitive therapists look for an absence of effective coping skills and thinking patterns, not for the presence of self-defeating thoughts (Dobson, Backs-Dermott, & Dozois, 2000). The aim is to teach clients how to cope with anger, depression, shyness, stress, and similar problems. Stress inocula- tion, which was described in Chapter 13, is a good example of this approach. Joe used it to weaken his social phobia.

Cognitive therapy is a rapidly expanding specialty. Before we leave the topic, let’s explore another widely used cognitive therapy.

Rational-Emotive Behavior Therapy Rational-emotive behavior therapy (REBT) attempts to change irrational beliefs that cause emotional problems. According to Albert Ellis (1913–2007), the basic idea of REBT is as easy as A-B-C (Ellis, 1995, Ellis & Ellis, 2011). Ellis assumes that people become unhappy and develop self-defeating habits because they have unrealistic or faulty beliefs.

How are beliefs important? Ellis analyzes problems in this way: The letter A stands for an activating experience, which the person assumes to be the cause of C, an emotional consequence. For instance, a person who is rejected (the activating experience) feels depressed, threatened, or hurt (the consequence). Rational-emotive behavior therapy shows the client that the real problem is what comes between A and C: In between is B, the client’s irrational and unrealistic beliefs. In this example, an unrealistic belief leading to unnecessary suffering is, “I must be loved and approved by every- one at all times.” REBT holds that events do not cause us to have feelings. We feel as we do because of our beliefs (Dryden, 2011; Kottler & Shepard, 2011). (For some examples, see “Ten Irrational Beliefs—Which Do You Hold?”)

The REBT explanation of emotional distress is related to the effects of emotional appraisals. See Chapter 10, pages 359–360.

BRIDGES

Ellis (1979, Ellis & Ellis, 2011) says that most irrational beliefs come from three core ideas, each of which is unrealistic:

1. I must perform well and be approved of by significant others. If I don’t, then it is awful, I cannot stand it, and I am a rotten person.

2. You must treat me fairly. When you don’t, it is horrible, and I cannot bear it.

3. Conditions must be the way I want them to be. It is terrible when they are not, and I cannot stand living in such an awful world.

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Therapies 519

Selective perception Perceiving only certain stimuli among a larger array of possibilities.

Overgeneralization Blowing a single event out of proportion by extending it to a large number of unrelated situations.

All-or-nothing thinking Classifying objects or events as absolutely right or wrong, good or bad, acceptable or unacceptable, and so forth.

Rational-emotive behavior therapy (REBT) An approach that states that irrational beliefs cause many emotional problems and that such beliefs must be changed or abandoned.

It’s easy to see that such beliefs can lead to much grief and needless suffering in a less than perfect world. Rational-emotive behavior therapists are very directive in their attempts to change a client’s irrational beliefs and “self-talk.” The therapist may directly attack clients’ logic, challenge their thinking, confront them with evidence contrary to their beliefs, and even assign “homework.” Here, for instance, are some examples of statements that dispute irrational beliefs (adapted from Dryden, 2011; Ellis & Ellis, 2011; Kottler & Shepard, 2011):

• “Where is the evidence that you are a loser just because you didn’t do well this one time?”

• “Who said the world should be fair? That’s your rule.” • “What are you telling yourself to make yourself feel so upset?” • “Is it really terrible that things aren’t working out as you would like? Or is

it just inconvenient?”

Many of us would probably do well to give up our irrational beliefs. Improved self-acceptance and a better tolerance of daily annoyances are the benefits of doing so (see “Overcoming the Gambler’s Fallacy”).

The value of cognitive approaches is further illustrated by three techniques (covert sensitization, thought stopping, and covert rein- forcement) described in this chapter’s Psychology in Action section. A little later you can see what you think of them.

Ten Irrational Beliefs—Which Do You Hold?Discovering Psychology

Rational-emotive behavior therapists have identified numerous beliefs that com- monly lead to emotional upsets and con- flicts. See if you recognize any of the following irrational beliefs:

1. I must be loved and approved by almost every significant person in my life or it’s awful and I’m worthless.

Example: “One of my classmates doesn’t seem to like me. I must be a big loser.”

2. I should be completely competent and achieving in all ways to be a worthwhile person.

Example: “I don’t understand my physics class. I guess I really am just stupid.”

3. It’s terribly upsetting when things don’t go my way.

Example: “I should have gotten a B in that class. The teacher is a total creep.”

4. It’s not my fault I’m unhappy; I can’t control my emotional reactions.

Example: “You make me feel awful. I would be happy if it weren’t for you.”

5. I should never forget it if something un- pleasant happens.

Example: “I’ll never forget the time my boss insulted me. I think about it every day at work.”

6. It is easier to avoid difficulties and re- sponsibilities than to face them.

Example: “I don’t know why my girl- friend is angry. Maybe it will just pass if I ignore it.”

7. A lot of people I have to deal with are bad. I should severely punish them for it.

Example: “The students renting next door are such a pain. I’m going to play my stereo even louder the next time they complain.”

8. I should depend on others who are stronger than me.

Example: “I couldn’t survive if she left me.”

9. Because something once strongly af- fected me, it will do so forever.

Example: “My girlfriend dumped me during my junior year in college. I can never trust a woman again.”

10. There is always a perfectly obvious solu- tion to human problems, and it is im- moral if this solution is not put into practice.

Example: “I’m so depressed about poli- tics in this country. It all seems hopeless.”*

If any of the listed beliefs sound familiar, you may be creating unnecessary emotional distress for yourself by holding on to unreal- istic expectations.

*Adapted from Dryden, 2011; Ellis & Ellis, 2011; Teyber & McClure, 2011).

Knowledge Builder Humanistic and Cognitive Therapies

RECITE Match: 1. _____ Client-centered therapy A. Changing thought patterns 2. _____ Gestalt therapy B. Unconditional positive regard 3. _____ Existential therapy C. Gaps in awareness 4. _____ REBT D. Choice and becoming 5. The Gestalt therapist tries to reflect a client’s thoughts and feelings.

T or F? 6. Confrontation and encounter are concepts of existential therapy.

T or F? 7. According to Beck, selective perception, overgeneralization, and

_________________________ thinking are cognitive habits that underlie depression.

Continued

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Chapter 15520

Therapies Based on Classical Conditioning—Healing by Learning

Gateway Question 15.6: What is behavior therapy? Jay repeatedly and vividly imagined himself going into a store to steal something. He then pictured himself being caught and turned over to the police, who handcuffed him and hauled him off to jail. Once there, he imagined calling his wife to tell her he had been arrested for shoplifting. He became very distressed as he faced her anger and his son’s disappointment (Kohn & Antonuccio, 2002).

Why would anyone imagine such a thing? Jay’s behavior is not as strange as it may seem. His goal was self-control: Jay is a kleptoma- niac (a compulsive thief ). The method he chose (called covert sensitization) is a form of behavior therapy (Prochaska & Norcross, 2010).

In general, how does behavior therapy work? A breakthrough occurred when psychologists realized they could use learning principles to solve human problems. Behavior therapy is an action therapy that uses learning principles to make constructive changes in behavior. Behavior therapists believe that deep insight into one’s problems is often unnecessary for improvement. Instead, they try to directly alter troublesome actions and thoughts. Jay

Overcoming the Gambler’s FallacyThe Clinical File

Seventeen-year-old Jonathan just lost his shirt again. This time, he did it playing on- line Blackjack. Jonathan started out making $5 bets and then doubled his bet over and over. Surely, he thought, his luck would eventually change. However, he ran out of money after just eight straight hands, having lost more than $1000. Last week, he lost a lot of money playing Texas Hold ‘Em. Now Jonathan is in tears—he has lost most of his summer earnings, and he is worried about having to drop out of school and tell his par- ents about his losses. Jonathan has had to admit that he is part of the growing ranks of underage gambling addicts (LaBrie & Shaf- fer, 2007; Wilber & Potenza, 2006).

Like many problem gamblers, Jonathan suffers from several cognitive distortions re- lated to gambling. Here are some of his mis- taken beliefs (adapted from adapted from Toneatto, 2002; Wickwire, Whelan, & Meyers, 2010):

Magnified gambling skill: Your self- confidence is exaggerated, despite the fact that you lose persistently.

Attribution errors: You ascribe your wins to skill but blame losses on bad luck.

Gambler’s fallacy: You believe that a string of losses soon must be followed by wins.

Selective memory: You remember your wins but forget your losses.

Overinterpretation of cues: You put too much faith in irrelevant cues such as bodily sensations or a feeling that your next bet will be a winner.

Luck as a trait: You believe that you are a “lucky” person in general.

Probability biases: You have incorrect beliefs about randomness and chance events.

Do you have any of these mistaken beliefs? Taken together, Jonathan’s cognitive distor- tions created an illusion of control. That is, he believed that if he worked hard enough, he could figure out how to win. Fortunately, a cog- nitive therapist helped Jonathan cognitively restructure his beliefs. He now no longer be- lieves he can control chance events. Jonathan still gambles a bit, but he does so only recre- ationally, keeping his losses within his budget and enjoying himself in the process.

Gambling addiction is a growing problem among young people (LaBrie & Shaffer, 2007).

8. The B in the A-B-C of REBT stands for a. behavior b. belief c. being d. Beck

REFLECT Think Critically

9. How might using the term patient affect the relationship between an individual and a therapist?

1 0. In Aaron Beck’s terms, a belief such as “I must perform well or I am a rotten person” involves two thinking errors. What are they?

Self-Reflect

You are going to play the role of a therapist for a classroom demonstration. How would you act if you were a client-centered therapist? An existential therapist? A Gestalt therapist?

What would an existential therapist say about the choices you have made so far in your life? Should you be choosing more “courageously”?

We all occasionally engage in negative thinking. Can you remember a time recently when you engaged in selective perception? Overgeneralization? All-or-nothing thinking?

Answers: 1. B 2. C 3. D 4. A 5. F 6. T 7. all-or-nothing 8. b 9. The terms doctor and patient imply a large gap in status and authority between the individual and his or her therapist. Client-centered therapy attempts to narrow this gap by making the person the final authority concerning solutions to his or her problems. Also, the word patient implies that a person is “sick” and needs to be “cured.” Many regard this as an inappropriate way to think about human problems. 10. Overgeneralization and all-or-nothing thinking.

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Therapies 521

Behavior therapy Any therapy designed to actively change behavior. Behavior modification The application of learning principles to change

human behavior, especially maladaptive behavior. Aversion therapy Suppressing an undesirable response by associating it

with aversive (painful or uncomfortable) stimuli.

didn’t need to probe into his past or his emotions and conflicts; he simply wanted to break his shoplifting habit. This and the next section describe some innovative—and very successful—behav- ioral therapies.

Behavior therapists assume that people have learned to be the way they are. If they have learned responses that cause problems, then they can change them by relearning more appropriate behav- iors. Broadly speaking, behavior modification refers to any use of classical or operant conditioning to directly alter human behavior (Miltenberger, 2011; Spiegler & Guevremont, 2010). (Some therapists prefer to call this approach applied behavior analysis.) Behavioral approaches include aversion therapy, desen- sitization, token economies, and other techniques (Forsyth & Savsevitz, 2002).

How does classical conditioning work? I’m not sure I remember. Perhaps a brief review would be helpful. Classical conditioning is a form of learning in which simple responses (especially reflexes) are associated with new stimuli. In classical conditioning, a neutral stimulus is followed by an unconditioned stimulus (US) that consis- tently produces an unlearned reaction, called the unconditioned response (UR). Eventually, the previously neutral stimulus begins to produce this response directly. The response is then called a condi- tioned response (CR), and the stimulus becomes a conditioned stimulus (CS). Thus, for a child the sight of a hypodermic needle (CS) is followed by an injection (US), which causes anxiety or fear (UR). Eventually, the sight of a hypodermic (the conditioned stimulus) may produce anxiety or fear (a conditioned response) before the child gets an injection.

For a more thorough review of classical conditioning, return to Chapter 6, pages 207–212.

BRIDGES

What does classical conditioning have to do with behavior modi- fication? Classical conditioning can be used to associate discom- fort with a bad habit, as Jay did to deal with his kleptomania. More powerful versions of this approach are called aversion therapy.

Aversion Therapy Imagine that you are eating an apple. Suddenly, you discover that you just bit a large green worm in half. You vomit. Months later, you cannot eat an apple again without feeling ill. It’s apparent that you have developed a conditioned aversion to apples. (A condi- tioned aversion is a learned dislike or negative emotional response to some stimulus.)

How are conditioned aversions used in therapy? In aversion therapy, an individual learns to associate a strong aversion to an undesirable habit such as smoking, drinking, or gambling. Aver- sion therapy has been used to cure hiccups, sneezing, stuttering, vomiting, nail-biting, bed-wetting, compulsive hair-pulling, alco- holism, and the smoking of tobacco, marijuana, or crack cocaine. Actually, aversive conditioning happens every day. For example, not many physicians who treat lung cancer patients are smokers, nor do many emergency room doctors drive without using their seat belts (Eifert & Lejuez, 2000).

Puffing Up an Aversion The fact that nicotine is toxic makes it easy to create an aversion that helps people give up smoking. Behavior therapists have found that electric shock, nauseating drugs, and similar aversive stimuli are not required to make smokers uncomfortable. All that is needed is for the smoker to smoke—rapidly, for a long time, at a forced pace. During rapid smoking, clients are told to smoke con- tinuously, taking a puff every 6 to 8 seconds. Rapid smoking con- tinues until the smoker is miserable and can stand it no more. By then, most people are thinking, “I never want to see another ciga- rette for the rest of my life.”

Rapid smoking has long been known as an effective behavior therapy for smoking (McRobbie & Hajek, 2007). Nevertheless, anyone tempted to try rapid smoking should realize that it is very unpleasant. Without the help of a therapist, most people quit too soon for the procedure to succeed. In addition, rapid smoking can be dangerous. It should be done only with professional supervi- sion. (An alternative method that is more practical is described in the Psychology in Action section of this chapter.)

Aversive Therapy for Drinking Another excellent example of aversion therapy was pioneered by Roger Vogler and his associates (1977). Vogler worked with alco- holics who were unable to stop drinking and for whom aversion therapy was a last chance. While drinking an alcoholic beverage, clients receive a painful (although not injurious) electric shock to the hand. Most of the time, these shocks occur as the client is beginning to take a drink of alcohol.

These response-contingent shocks (shocks that are linked to a response) obviously take the pleasure out of drinking. Shocks also

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Chapter 15522

cause the alcohol abuser to develop a conditioned aversion to drinking. Normally, the misery caused by alcohol abuse comes long after the act of drinking—too late to have much effect. But if alco- hol can be linked with immediate discomfort, then drinking will begin to make the individual very uncomfortable.

Is it really acceptable to treat clients this way? People are often disturbed (shocked?) by such methods. However, clients usually volunteer for aversion therapy because it helps them overcome a destructive habit. Indeed, commercial aversion programs for over- eating, smoking, and alcohol abuse have attracted many willing customers. More important, aversion therapy can be justified by its long-term benefits. As behaviorist Donald Baer put it, “A small number of brief, painful experiences are a reasonable exchange for the interminable pain of a lifelong maladjustment.”

Desensitization How is behavior therapy used to treat phobias, fears, and anxieties? Suppose you want to help Curtis overcome fear of the high diving board. How might you proceed? Directly forcing Curtis off the high board could be a psychological disaster. A better approach would be to begin by teaching him to dive off the edge of the pool. Then he could be taught to dive off the low board, followed by a platform 6 feet above the water and then an 8-foot platform. As a last step, Curtis could try the high board.

Who’s Afraid of a Hierarchy? This rank-ordered series of steps (called a hierarchy) allows Curtis to undergo adaptation. Gradually, he adapts to the high dive and overcomes his fear. When Curtis has conquered his fear, we can say that desensitization (dee-SEN-sih-tih-ZAY-shun) has occurred (Spiegler & Guevremont, 2010).

Desensitization is also based on reciprocal inhibition (using one emotional state to block another) (Heriot & Pritchard, 2004).

For instance, it is impossible to be anxious and relaxed at the same time. If we can get Curtis onto the high board in a relaxed state, his anxiety and fear will be inhibited. Repeated visits to the high board should cause fear to disappear in this situation. Again, we would say that Curtis has been desensitized. Typically, systematic desen- sitization (a guided reduction in fear, anxiety, or aversion) is attained by gradually approaching a feared stimulus while main- taining relaxation.

What is desensitization used for? Desensitization is used primar- ily to help people unlearn phobias (intense, unrealistic fears) or strong anxieties. For example, each of these people might be a can- didate for desensitization: a teacher with stage fright; a student with test anxiety; a salesperson who fears people; or a newlywed with an aversion to sexual intimacy.

Feeling a Little Tense? Relax!Discovering Psychology

The key to desensitization is relaxation. To inhibit fear, you must learn to relax. One way to voluntarily relax is by using the tension-release method. To achieve deep muscle relaxation, try the following exercise:

Tense the muscles in your right arm until they tremble. Hold them tight as you slowly count to ten and then let go. Allow your hand and arm to go limp and to relax completely. Repeat the procedure. Releasing tension two or three times will allow you to feel whether your arm

muscles have relaxed. Repeat the tension– release procedure with your left arm. Compare it with your right arm. Repeat until the left arm is equally relaxed. Apply the tension–release technique to your right leg; to your left leg; to your abdomen; to your chest and shoulders. Clench and release your chin, neck, and throat. Wrinkle and release your forehead and scalp. Tighten and release your mouth and face mus- cles. As a last step, curl your toes and tense your feet. Then release.

If you carried out these instructions, you should be noticeably more relaxed than you were before you began. Practice the tension- release method until you can achieve com- plete relaxation quickly (5 to 10 minutes). After you have practiced relaxation once a day for a week or two, you will begin to be able to tell when your body (or a group of muscles) is tense. Also, you will begin to be able to relax on command. This is a valuable skill that you can apply in any situation that makes you feel tense or anxious.

Programs for treating fears of flying combine relaxation, systematic desensitiza- tion, group support, and lots of direct and indirect exposure to airliners. Many such programs conclude with a brief flight, so that participants can “test their wings.”

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Therapies 523

Hierarchy A rank-ordered series of higher and lower amounts, levels, degrees, or steps.

Reciprocal inhibition The presence of one emotional state can inhibit the occurrence of another, such as joy preventing fear or anxiety inhibiting pleasure.

Systematic desensitization A reduction in fear, anxiety, or aversion brought about by planned exposure to aversive stimuli.

Tension-release method A procedure for systematically achieving deep relaxation of the body.

Vicarious desensitization A reduction in fear or anxiety that takes place vicariously (“secondhand”) when a client watches models perform the feared behavior.

Virtual reality exposure Use of computer-generated images to present fear stimuli. The virtual environment responds to a viewer’s head movements and other inputs.

Eye movement desensitization and reprocessing (EMDR) A technique for reducing fear or anxiety; based on holding upsetting thoughts in mind while rapidly moving the eyes from side to side.

Performing Desensitization How is desensitization done? First, the client and the therapist construct a hierarchy. This is a list of fear- provoking situations, arranged from least disturbing to most frightening. Second, the client is taught exer- cises that produce deep relaxation (see “Feeling a Little Tense? Relax!”). Third, once the client is relaxed, she or he tries to perform the least disturbing item on the list. For a fear of heights (acrophobia), this might be: “(1) Stand on a chair.” The first item is repeated until no anxiety is felt. Any change from complete relaxation is a signal that clients must relax again before continuing. Slowly, clients move up the hierar- chy: “(2) Climb to the top of a small stepladder”; “(3) Look down a flight of stairs”; and so on, until the last item is performed without fear: “(20) Fly in an airplane.”

For many phobias, desensitization works best when people are directly exposed to the stimuli and situa- tions they fear (Bourne, 2010; Miltenberger, 2011). For something like a simple spider phobia, this expo- sure can even be done in groups. Also, for some fears (such as fear of riding an elevator, or fear of spiders) desensitiza- tion may be completed in a single session (Müller et al., 2011; Sturges & Sturges, 1998).

Vicarious Desensitization What if it’s not practical to directly act out the steps of a hierarchy? For a fear of heights, the steps of the hierarchy might be acted out. However, if this is impractical, as it might be in the case of a fear of flying, the problem can be handled by having clients observe mod- els who are performing the feared behavior (Eifert & Lejuez, 2000; Bourne, 2010; • Figure 15.2). A model is a person (either live or filmed) who serves as an example for observational learning. If such vicarious desensitization (secondhand learning) can’t be used, there is yet another option. Fortunately, desensitization works almost as well when a person vividly imagines each step in the hierarchy (Yahnke, Sheikh, & Beckman, 2003). If the steps can be visualized without anxiety, fear in the actual situation is reduced. Because imagining feared stimuli can be done at a therapist’s office, it is the most common way of doing desensitization.

Virtual Reality Exposure Desensitization is an exposure therapy. Similar to other such thera- pies, it involves exposing people to feared stimuli until their fears extinguish. In an important recent development, psychologists are now also using virtual reality to treat phobias. Virtual reality is a computer-generated, three-dimensional “world” that viewers enter by wearing a head-mounted video display. Virtual reality expo- sure presents computerized fear stimuli to clients in a realistic, yet carefully controlled fashion (Wiederhold & Wiederhold, 2005; Riva, 2009). It has already been used to treat fears of flying, driv- ing, and public speaking as well as acrophobia (fear of heights),

claustrophobia, and spider phobias (Arbona et al., 2004; Giuseppe, 2005; Lee et al., 2002; Meyerbröker & Emmelkamp, 2010; Müller et al., 2011; see • Figure 15.3.). Virtual reality exposure has also been used to create immersive distracting environments for help patients reduce the experience of pain (Malloy & Milling, 2010).

Desensitization has been one of the most successful behavior therapies. A relatively new technique may provide yet another way to lower fears, anxieties, and psychological pain.

Eye Movement Desensitization Traumatic events produce painful memories. Disturbing flash- backs often haunt victims of accidents, disasters, molestations, muggings, rapes, or emotional abuse. To help ease traumatic mem- ories and post-traumatic stress, Dr. Francine Shapiro developed eye movement desensitization and reprocessing (EMDR).

• Figure 15.2 Treatment of a snake phobia by vicarious desensitization. These classic photo- graphs show models interacting with snakes. To overcome their own fears, phobic subjects observed the models (Bandura, Blanchard, & Ritter, 1969).

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Chapter 15524

In a typical EMDR session, the client is asked to visualize the images that most upset her or him. At the same time, a pencil (or other object) is moved rapidly from side to side in front of the person’s eyes. Watching the moving object causes the person’s eyes to dart swiftly back and forth. After about 30  seconds, clients describe any memories, feelings, and thoughts that emerged and discuss them with the therapist. These steps are repeated until troubling thoughts and emotions no longer surface (Shapiro, 2001; Shapiro & Forrest, 2004).

A number of studies suggest that EMDR lowers anxieties and takes the pain out of traumatic memories (Seidler & Wagner, 2006). However, EMDR is highly controversial (Albright & Thyer, 2010). Some studies, for example, have found that eye movements

add nothing to the treatment. The apparent success of EMDR may simply be based on gradual exposure to upsetting stimuli, as in other forms of desensitization (Davidson & Parker, 2001). On the other hand, some researchers continue to find that EMDR is superior to traditional therapies (Greenwald, 2006; Solomon, Solomon, & Heide, 2009).

Is EMDR a breakthrough? Given the frequency of traumas in modern society, it shouldn’t be long before we find out.

Operant Therapies—All the World Is a Skinner Box?

Gateway Question 15.7: What role do operant principles play in behavior therapy? Aversion therapy and desensitization are based on classical condition- ing. Where does operant conditioning fit in? As you may recall, oper- ant conditioning refers to learning based on the consequences of making a response. The operant principles most often used by behavior therapists to deal with human behavior are:

1. Positive reinforcement. Responses that are followed by re- inforcement tend to occur more frequently. If children whine and get attention, they will whine more frequently. If you get A’s in your psychology class, you may become a psychology major.

2. Nonreinforcement and Extinction. A response that is not followed by reinforcement will occur less frequently. If a response is not followed by reward after it has been repeated many times, it will extinguish entirely. After winning three times, you pull the handle on a slot machine 30 times more without a payoff. What do you do? You go away. So does the response of handle pulling (for that particular machine, at any rate).

3. Punishment. If a response is followed by discomfort or an undesirable effect, the response will be suppressed (but not necessarily extinguished).

4. Shaping. Shaping means reinforcing actions that are closer and closer approximations to a desired response. For example, to reward an intellectually disabled child for saying “ball,” you might begin by reinforcing the child for saying anything that starts with a b sound.

5. Stimulus control. Responses tend to come under the control of the situation in which they occur. If you set your clock 10 minutes fast, it may be easier to leave the house on time in the morning. Your departure is under the stimulus control of the clock, even though you know it is fast.

6. Time out. A time-out procedure usually involves removing the individual from a situation in which reinforcement occurs. Time out is a variation of response cost: It pre- vents reward from following an undesirable response. For example, children who fight with each other can be sent to separate rooms and allowed out only when they are able to behave more calmly.

• Figure 15.3 (top) Dr. Larry Hodges (in the head-mounted display) and Dr. Page Anderson show how a virtual reality system is used to expose people to feared stimuli. (bottom) A computer image from a virtual Iraq or Afghanistan. Veterans suf- fering from post-traumatic stress disorder (PTSD) can re-experience their traumas. For example, someone whose Humvee was destroyed by an improvised explosive device can relive that moment complete with sights, sounds, vibrations, and even smells. Successive exposures result in a reduction of PTSD symptoms (Gerardi et al., 2008).

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Therapies 525

Token economy A therapeutic program in which desirable behaviors are reinforced with tokens that can be exchanged for goods, services, activities, and privileges.

For a more thorough review of operant learning, return to Chapter 6, pages 212–229.

BRIDGES

As simple as these principles may seem, they have been used very effectively to overcome difficulties in work, home, school, and industrial settings. Let’s see how.

Nonreinforcement and Extinction An extremely overweight mental patient had a persistent and dis- turbing habit: She stole food from other patients. No one could persuade her to stop stealing or to diet. For the sake of her health, a behavior therapist assigned her a special table in the ward dining room. If she approached any other table, she was immediately removed from the dining room. Any attempt to steal from others caused the patient to miss her own meal (Ayllon, 1963). Because her attempts to steal food went unrewarded, they rapidly disappeared.

What operant principles did the therapist in this example use? The therapist used nonreward to produce extinction. The most frequently occurring human behaviors lead to some form of reward. An unde- sirable response can be eliminated by identifying and removing the rewards that maintain it. But people don’t always do things for food, money, or other obvious rewards. Most of the rewards maintaining human behavior are subtler. Attention, approval, and concern are common yet powerful reinforcers for humans (• Figure 15.4).

Nonreward and extinction can eliminate many problem behav- iors, especially in schools, hospitals, and institutions. Often, diffi-

culties center on a limited number of particularly disturbing responses. Time out is a good way to remove such responses, usu- ally by refusing to pay attention to a person who is misbehaving. For example, 14-year-old Terrel periodically appeared in the nude in the activity room of a training center for disturbed adolescents. This behavior always generated a great deal of attention from staff and other patients. As an experiment, the next time he appeared nude, counselors and other staff members greeted him normally and then ignored him. Attention from other patients rapidly sub- sided. Sheepishly, he returned to his room and dressed.

Reinforcement and Token Economies A distressing problem therapists sometimes face is how to break through to severely disturbed patients who won’t talk. Conven- tional psychotherapy offers little hope of improvement for such patients.

What can be done for them? One widely used approach is based on tokens (symbolic rewards that can be exchanged for real rewards). Tokens may be printed slips of paper, check marks, points, or gold stars. Whatever form they take, tokens serve as rewards because they may be exchanged for candy, food, cigarettes, recreation, or privileges, such as private time with a therapist, out- ings, or watching television. Tokens are used in mental hospitals, halfway houses, schools for the intellectually disabled, programs for delinquents, and ordinary classrooms. They usually produce improvements in behavior (Dickerson, Tenhula, & Green-Paden, 2005; Matson & Boisjoli, 2009).

Tokens provide an effective way to change behavior because they are secondary reinforcers. See Chapter 6, pages 218–220.

BRIDGES

By using tokens, a therapist can immediately reward positive responses. For maximum impact, therapists select specific target behaviors (actions or other behav- iors the therapist seeks to modify). Target behaviors are then reinforced with tokens. For example, a mute mental patient might first be given a token each time he or she says a word. Next, tokens may be given for speaking a complete sentence. Later, the patient could gradually be required to speak more often, then to answer questions, and eventually to carry on a short conversation in order to receive tokens. In this way, deeply withdrawn patients have been returned to the world of normal communication.

The full-scale use of tokens in an institutional set- ting produces a token economy. In a token economy,

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• Figure 15.4 This graph shows extinction of self-destructive behavior in two autistic boys. Before extinction began, the boys received attention and concern from adults for injuring them- selves. During extinction, the adults were taught to ignore the boys’ self-damaging behavior. As you can see, the number of times that the boys tried to injure themselves declined rapidly. (Adapted from Lovaas & Simmons, 1969.)

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Chapter 15526

patients are rewarded with tokens for a wide range of socially desirable or productive activities (Spiegler & Guevremont, 2010). They must pay tokens for privileges and when they engage in problem behaviors (• Figure 15.5). For example, tokens are given to patients who dress themselves, take required medication, arrive for meals on time, and so on. Constructive activities, such as gardening, cooking, or cleaning, may also earn tokens. Patients must exchange tokens for meals and private rooms, movies, passes, off-ward activities, and other privi- leges. They are charged tokens for disrobing in public, talking to themselves, fighting, crying, and similar target behaviors (Morisse et al., 1996; Spiegler & Guevremont, 2010).

Token economies can radically change a patient’s overall adjustment and morale. Patients are given an incentive to change, and they are held responsible for their actions. The use of tokens may seem manip- ulative, but it actually empowers patients. Many “hopelessly” intellectually disabled, mentally ill, and delinquent people have been returned to productive lives by means of token economies (Field et al., 2004).

By the time they are ready to leave, patients may be earning tokens on a weekly basis for maintaining sane, responsible, and productive behavior (Miltenberger, 2011). Typically, the most effective token economies are those that gradually switch from tokens to social rewards such as praise, recognition, and approval. Such rewards are what patients will receive when they return to family, friends, and community.

OXNARD DAY TREATMENT CENTER CREDIT INCENTIVE SYSTEM

EARN CREDITS BY SPEND CREDITS FOR MONITOR DAILY MENU PLANNING CHAIRMAN

PARTICIPATE

BUY FOOD AT STORE COOK FOR/PREPARE LUNCH WIPE OFF KITCHEN TABLE WASH DISHES DRY AND PUT AWAY DISHES MAKE COFFEE AND CLEAN URN CLEAN REFRIGERATOR ATTEND PLANNING CONFERENCE OT PREPARATION COMPLETE OT PROJECT RETURN OT PROJECT DUST AND POLISH TABLES PUT AWAY GROCERIES

CLEAN TABLE CLEAN 6 ASH TRAYS CLEAN SINK CARRY OUT CUPS & BOTTLES CLEAN CHAIRS CLEAN KITCHEN CUPBOARDS ASSIST STAFF ARRANGE MAGAZINES NEATLY BEING ON TIME

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• Figure 15.5 Shown here is a token used in one token economy system. In this instance, the token is a card that records the number of credits earned by a patient. Also pictured is a list of credit values for various activities. Tokens may be exchanged for items or for privileges listed on the board. (After photographs by Robert P. Liberman.)

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Knowledge Builder Behavior Therapies

RECITE 1. What two types of conditioning are used in behavior modification?

______________________ and ______________________ 2. Shock, pain, and discomfort play what role in conditioning an

aversion? a. conditioned stimulus b. unconditioned response

c. unconditioned stimulus d. conditioned response 3. If shock is used to control drinking, it must be ___________________

contingent. 4. When desensitization is carried out through the use of live or filmed

models, it is called a. cognitive therapy b. flooding c. covert desensitization

d. vicarious desensitization 5. The three basic steps in systematic desensitization are: constructing

a hierarchy, flooding the person with anxiety, and imagining relaxation. T or F?

6. In EMDR therapy, computer-generated virtual reality images are used to expose clients to fear-provoking stimuli. T or F?

7. Behavior modification programs aimed at extinction of an undesirable behavior typically make use of what operant principles? a. punishment and stimulus control b. punishment and shaping

c. nonreinforcement and time out d. stimulus control and time out

8. Attention can be a powerful ______________________ for humans. 9. Tokens basically allow the operant shaping of desired responses or

“target behaviors.” T or F?

REFLECT Think Critically

1 0. Alcoholics who take a drug called Antabuse become ill after drinking alcohol. Why, then, don’t they develop an aversion to drinking?

1 1. A natural form of desensitization often takes place in hospitals. Can you guess what it is?

Self-Reflect

Can you describe three problems for which you think behavior therapy would be an appropriate treatment?

A friend of yours has a dog that goes berserk during thunderstorms. You own a CD of a thunderstorm. How could you use the CD to desensitize the dog? (Hint: The CD player has a volume control.)

Have you ever become naturally desensitized to a stimulus or situation that at first made you anxious (for instance, heights, public speaking, or driving on freeways)? How would you explain your reduced fear?

See if you can give a personal example of how the following principles have affected your behavior: positive reinforcement, extinction, punishment, shaping, stimulus control, and time out.

Answers: 1. classical (or respondent), operant 2. c 3. response 4. d 5. F 6. F 7. C 8. reinforcer 9. T 10. Committed alcoholics may actually “drink through it” and learn to tolerate the nauseating effects. 11. Doctors and nurses learn to relax and remain calm at the sight of blood and other bodily fluids because of their frequent exposure to them.

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Therapies 527

Somatic therapy Any bodily therapy, such as drug therapy, electroconvulsive therapy, or psychosurgery.

Pharmacotherapy The use of drugs to treat psychopathology. Anxiolytics Drugs (such as Valium) that produce relaxation or reduce

anxiety. Antidepressants Mood-elevating drugs. Antipsychotics (major tranquilizers) Drugs that, in addition to having

tranquilizing effects, also tend to reduce hallucinations and delusional thinking.

Medical Therapies— Psychiatric Care

Gateway Question 15.8: How do psychiatrists treat psychological disorders? Psychotherapy may be applied to anything from a brief crisis to a full-scale psychosis. However, most psychotherapists do not treat patients with major depressive disorders, schizophrenia, or other severe conditions. Major mental disorders are more often treated medically, although combinations of medication and psychother- apy are also often helpful (Beck, et al., 2009).

Three main types of somatic (bodily) therapy are pharmaco- therapy, electrical stimulation therapy, and psychosurgery. Somatic

therapy is often done in the context of psychiatric hospitalization. All the somatic approaches have a strong medical slant and are typically administered by psychiatrists, who are trained as medical doctors.

Drug Therapies The atmosphere in psychiatric wards and mental hospitals changed radically in the mid-1950s with the widespread adoption of pharmacotherapy (FAR-meh-koe-THER-eh-pea), the use of drugs to treat psychopathology. Drugs may relieve the anxiety attacks and other discomforts of milder psychological disorders. More often, however, they are used to combat schizophrenia and major mood disorders ( Julien, 2008).

What sort of drugs are used in pharmacotherapy? Three major types of drugs are used. All achieve their effects by influencing the activity of different brain neurotransmitters (Freberg, 2010). Anxiolytics (ANG-zee-eh LIT-iks), such as Valium, produce relaxation or reduce anxiety. Antidepressants, such as Prozac, are mood-elevating drugs that combat depression. Antipsychot- ics (also called major tranquilizers), such as Risperdal, have tranquilizing effects and reduce hallucinations and delusions. See ■ Table 15.2 for examples of each class of drugs.

Are drugs a valid approach to treatment? Yes. Drugs have short- ened hospital stays, and they have greatly improved the chances that people will recover from major psychological disorders. Drug therapy has also made it possible for many people to return to the community, where they can be treated on an outpatient basis.

Limitations of Drug Therapy Regardless of their benefits, all drugs involve risks as well. For example, 15 percent of patients taking major tranquilizers for long periods develop a neurological disorder that causes rhythmic facial

Commonly Prescribed Psychiatric Drugs

Class Examples (Trade Names) Effects Main Mode of Action

Anxiolytics (minor tranquilizers)

Ativan, Halcion, Librium, Restoril, Valium, Xanax

Reduce anxiety, tension, fear Enhance effects of GABA

Antidepressants Anafranil, Elavil, Nardil, Norpramin, Parnate, Paxil, Prozac, Tofranil, Zoloft

Counteract depression Enhance effects of sero- tonin or dopamine

Antipsychotics (major tranquilizers)

Clozaril, Haldol, Mellaril, Navane, Risperdal, Thorazine

Reduce agitation, delusions, hallucinations, thought disorders

Reduce effects of dopamine

■ TABLE 15.2

Source: Adapted from Freberg, 2010; Julien, 2008; Kalat, 2009.

The work of artist Rodger Casier illustrates the value of psychiatric care. Despite having a form of schizophrenia, Casier produces artwork that has received public acclaim and has been featured in professional journals.

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Chapter 15528

and mouth movements (Chakos et al., 1996). Similarly, although the drug clozapine (Clozaril) can relieve the symptoms of schizo- phrenia, 2 out of 100 patients taking the drug suffer from a poten- tially fatal blood disease (Ginsberg, 2006).

Is the risk worth it? Many experts think it is, because chronic schizophrenia robs people of almost everything that makes life worth living. It’s possible, of course, that newer drugs will improve the risk/benefit ratio in the treatment of severe problems like schizophrenia. For example, the drug risperidone (Risperdal) appears to be as effective as Clozaril, without the same degree of lethal risk.

But even the best new drugs are not cure-alls. They help some people and relieve some problems, but not all. It is noteworthy that for serious mental disorders a combination of medication and psychotherapy almost always works better than drugs alone (Manber et al., 2008). Nevertheless, when schizophrenia and major mood disorders are concerned, drugs will undoubtedly remain the primary mode of treatment (Vasa, Carlino, & Pine, 2006; Walker et al., 2004).

Electrical Stimulation Therapy In contrast to drug therapies, electrical stimulation therapies achieve their effects by altering the electrical activity of the brain. Electroconvulsive therapy is the first, and most dramatic, of these therapies. Widely used since the 1940s, it remains controversial to this day (Hirshbein & Sarvananda, 2008).

Electroshock In electroconvulsive therapy (ECT), a 150-volt electrical current is passed through the brain for slightly less than a second. This rather drastic medical treatment for depression triggers a convul- sion and causes the patient to lose consciousness for a short time. Muscle relaxants and sedative drugs are given before ECT to soften its impact. Treatments are given in a series of sessions spread over several weeks or months.

How does shock help? Actually, it is the seizure activity that is believed to be helpful. Proponents of ECT claim that shock- induced seizures alter or “reset” the biochemical and hormonal balance in the brain and body, bringing an end to severe depression and suicidal behavior (Medda et al., 2009) as well as improving long-term quality of life (McCall et al., 2006). Others have charged that ECT works only by confusing patients so they can’t remember why they were depressed.

Not all professionals support the use of ECT. However, most experts seem to agree on the following: (1) At best, ECT produces only temporary improvement—it gets the patient out of a bad spot, but it must be combined with other treatments; (2) ECT can cause memory loss in some patients (Sienaert et al., 2010); (3) ECT should be used only after other treatments have failed; and (4) to lower the chance of a relapse, ECT should be followed by antide- pressant drugs (Sackeim et al., 2001). All told, ECT is considered by many to be a valid treatment for selected cases of depression— especially when it rapidly ends wildly self-destructive or suicidal behavior (Medda et al., 2009; Pagnin et al., 2004). It’s interesting to note that most ECT patients feel that the treatment helped them. Most, in fact, would have it done again (Bernstein et al., 1998; Smith et al., 2009).

Implanted Electrodes Unlike ECT, implanting electrodes requires surgery but allows for electrical stimulation of precisely targeted brain regions. In some studies, depressed patients who hadn’t benefited from drug therapy and ECT improved when a specific brain region was stimulated (Mayberg et al., 2005; Sartorius et al., 2010). Stimulating pleasure centers in the brains of another group of patients also relieved depression (Schlaepfer et al., 2008). Also, unlike ECT, implanted electrodes can be used to treat disorders other than depression, such as obsessive-compulsive disorder (Haq et al., 2010).

Electrical stimulation of the brain is one of several methods used to investigate the brain’s inner workings. For more information, see Chapter 2, pages 60–63.

BRIDGES

Psychosurgery Psychosurgery (any surgical alteration of the brain) is the most extreme medical treatment. The oldest and most radical psycho- surgery is the lobotomy. In prefrontal lobotomy, the frontal lobes are surgically disconnected from other brain areas. This procedure was supposed to calm persons who didn’t respond to any other type of treatment.

When the lobotomy was first introduced in the 1940s, there were enthusiastic claims for its success. But later studies suggested that some patients were calmed, some showed no change, and some became mental “vegetables.” Lobotomies also produced a high rate of undesirable side effects, such as seizures, blunted emotions, major personality changes, and stupor. At about the same time that

In electroconvulsive therapy, electrodes are attached to the head and a brief electrical current is passed through the brain. ECT is used in the treat- ment of severe depression.

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Therapies 529

Electroconvulsive therapy (ECT) A treatment for severe depression, consisting of an electric shock passed directly through the brain, which induces a convulsion.

Psychosurgery Any surgical alteration of the brain designed to bring about desirable behavioral or emotional changes.

Mental hospitalization Placing a person in a protected, therapeutic environment staffed by mental health professionals.

Partial hospitalization An approach in which patients receive treatment at a hospital during the day, but return home at night.

Deinstitutionalization Reduced use of full-time commitment to mental institutions to treat mental disorders.

such problems became apparent, the first antipsychotic drugs became available. Soon after, the lobotomy was abandoned (Mashour, Walker, & Martuza, 2005).

To what extent is psychosurgery used now? Psychosurgery is still considered valid by many neurosurgeons. However, most now use deep lesioning, in which small target areas are destroyed in the brain’s interior. The appeal of deep lesioning is that it can have value as a remedy for some very specific disorders (Mashour, Walker, & Martuza, 2005). For instance, patients suffering from a severe type of obsessive-compulsive disorder may be helped by psychosurgery (Dougherty et al., 2002).

Deep lesioning is another method used to study the brain.