What comes to mind when you think about therapy for psychological problems? You might picture someone lying on a couch talking about his childhood while the therapist sits and takes notes, à la Sigmund Freud. But can you envision a therapy session in which someone is wearing virtual reality headgear to conquer a fear of snakes?

In this chapter, you will see that approaches to therapy include both psychological and biological interventions, all with the goal of alleviating distress. Because psychological problems can originate from various sources—biology, genetics, childhood experiences, conditioning, and sociocultural influences—psychologists have developed many different therapeutic techniques and approaches. For example, some psychologists believe that psychotherapy should involve a close personal relationship between therapist and client, while others believe their main responsibility is to help the patient change behavior. The Ocean Therapy program shown in Figure 1 uses multiple approaches to support the mental health of veterans in the group.

Mental Health

It was once believed that people with psychological disorders, or those exhibiting strange behavior, were possessed by demons. These people were forced to take part in exorcisms, were imprisoned, or executed. Later, asylums were built to house the mentally ill, but the patients received little to no treatment, and many of the methods used were cruel. Philippe Pinel and Dorothea Dix argued for more humane treatment of people with psychological disorders. In the mid-1960s, the deinstitutionalization movement gained support and asylums were closed, enabling people with mental illness to return home and receive treatment in their own communities. Some did go to their family homes, but many became homeless due to a lack of resources and support mechanisms.

Today, instead of asylums, there are psychiatric hospitals run by state governments and local community hospitals, with the emphasis on short-term stays. However, most people suffering from mental illness are not hospitalized. A person suffering symptoms could speak with a primary care physician, who most likely would refer him to someone who specializes in therapy. The person can receive outpatient mental health services from a variety of sources, including psychologists, psychiatrists, marriage and family therapists, school counselors, clinical social workers, and religious personnel. These therapy sessions would be covered through insurance, government funds, or private (self) pay.

Mental Health Treatment in the Past

For much of history, the mentally ill have been treated very poorly. It was believed that mental illness was caused by demonic possession, witchcraft, or an angry god (Szasz, 1960). For example, in medieval times, abnormal behaviors were viewed as a sign that a person was possessed by demons. If someone was considered to be possessed, there were several forms of treatment to release spirits from the individual. The most common treatment was exorcism, often conducted by priests or other religious figures: Incantations and prayers were said over the person’s body, and she may have been given some medicinal drinks. Another form of treatment for extreme cases of mental illness was trephining: A small hole was made in the afflicted individual’s skull to release spirits from the body. Most people treated in this manner died. In addition to exorcism and trephining, other practices involved execution or imprisonment of people with psychological disorders. Still others were left to be homeless beggars. Generally speaking, most people who exhibited strange behaviors were greatly misunderstood and treated cruelly. The prevailing theory of psychopathology in earlier history was the idea that mental illness was the result of demonic possession by either an evil spirit or an evil god because early beliefs incorrectly attributed all unexplainable phenomena to deities deemed either good or evil.

From the late 1400s to the late 1600s, a common belief perpetuated by some religious organizations was that some people made pacts with the devil and committed horrible acts, such as eating babies (Blumberg, 2007). These people were considered to be witches and were tried and condemned by courts—they were often burned at the stake. Worldwide, it is estimated that tens of thousands of mentally ill people were killed after being accused of being witches or under the influence of witchcraft (Hemphill, 1966)

By the 18th century, people who were considered odd and unusual were placed in asylums (Figure 2). Asylums were the first institutions created for the specific purpose of housing people with psychological disorders, but the focus was ostracizing them from society rather than treating their disorders. Often these people were kept in windowless dungeons, beaten, chained to their beds, and had little to no contact with caregivers.

In the late 1700s, a French physician, Philippe Pinel, argued for more humane treatment of the mentally ill. He suggested that they be unchained and talked to, and that’s just what he did for patients at La Salpêtrière in Paris in 1795 (Figure 3). Patients benefited from this more humane treatment, and many were able to leave the hospital.

In the 19th century, Dorothea Dix led reform efforts for mental health care in the United States (Figure 4). She investigated how those who are mentally ill and poor were cared for, and she discovered an underfunded and unregulated system that perpetuated abuse of this population (Tiffany, 1891). Horrified by her findings, Dix began lobbying various state legislatures and the U.S. Congress for change (Tiffany, 1891). Her efforts led to the creation of the first mental asylums in the United States.

Despite reformers’ efforts, however, a typical asylum was filthy, offered very little treatment, and often kept people for decades. At Willard Psychiatric Center in upstate New York, for example, one treatment was to submerge patients in cold baths for long periods of time. Electroshock treatment was also used, and the way the treatment was administered often broke patients’ backs; in 1943, doctors at Willard administered 1,443 shock treatments (Willard Psychiatric Center, 2009). (Electroshock is now called electroconvulsive treatment, and the therapy is still used, but with safeguards and under anesthesia. A brief application of electric stimulus is used to produce a generalized seizure. Controversy continues over its effectiveness versus the side effects.) Many of the wards and rooms were so cold that a glass of water would be frozen by morning (Willard Psychiatric Center, 2009). Willard’s doors were not closed until 1995. Conditions like these remained commonplace until well into the 20th century.

Starting in 1954 and gaining popularity in the 1960s, antipsychotic medications were introduced. These proved a tremendous help in controlling the symptoms of certain psychological disorders, such as psychosis. Psychosis was a common diagnosis of individuals in mental hospitals, and it was often evidenced by symptoms like hallucinations and delusions, indicating a loss of contact with reality. Then in 1963, Congress passed and John F. Kennedy signed the Mental Retardation Facilities and Community Mental Health Centers Construction Act, which provided federal support and funding for community mental health centers (National Institutes of Health, 2013). This legislation changed how mental health services were delivered in the United States. It started the process of deinstitutionalization, the closing of large asylums, by providing for people to stay in their communities and be treated locally. In 1955, there were 558,239 severely mentally ill patients institutionalized at public hospitals (Torrey, 1997). By 1994, by percentage of the population, there were 92% fewer hospitalized individuals (Torrey, 1997).

Link to Learning

View this timeline showing the history of mental institutions in the United States.

Try It

Mental Health Treatment Today

With many different treatment options available, approximately how many people receive mental health treatment per year? According to the Substance Abuse and Mental Health Services Administration (SAMHSA), in 2008, 13.4% of adults received treatment for a mental health issue (NIMH, n.d.-b). These percentages, shown in Figure 5, reflect the number of adults who received care in inpatient and outpatient settings and/or used prescription medication for psychological disorders. The “2016 State of Mental Health in America” report showed that 57% of adults with mental illnesses do not receive any treatment. Stigmas about mental illness, cost, insurance concerns, awareness, and accessibility are all contributing factors as to why more do not receive treatment (MHA).

Children and adolescents also receive mental health services. The Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey (NHANES) found that approximately half (50.6%) of children with mental disorders had received treatment for their disorder within the past year (NIMH, n.d.-c). However, there were some differences between treatment rates by category of disorder (Figure 6). For example, children with anxiety disorders were least likely to have received treatment in the past year, while children with ADHD or a conduct disorder were more likely to receive treatment. Can you think of some possible reasons for these differences in receiving treatment?

Considering the many forms of treatment for mental health disorders available today, how did these forms of treatment emerge? Let’s take a look at the history of mental health treatment from the past (with some questionable approaches in light of modern understanding of mental illness) to where we are today.

Treatment Today

Today, there are community mental health centers across the nation. They are located in neighborhoods near the homes of clients, and they provide large numbers of people with mental health services of various kinds and for many kinds of problems. Unfortunately, part of what occurred with deinstitutionalization was that those released from institutions were supposed to go to newly created centers, but the system was not set up effectively. Centers were underfunded, staff was not trained to handle severe illnesses such as schizophrenia, there was high staff burnout, and no provision was made for the other services people needed, such as housing, food, and job training. Without these supports, those people released under deinstitutionalization often ended up homeless. Even today, a large portion of the homeless population is considered to be mentally ill (Figure 7). Statistics show that 26% of homeless adults living in shelters experience mental illness (U.S. Department of Housing and Urban Development [HUD], 2011).

Another group of the mentally ill population is involved in the corrections system. According to a 2006 special report by the Bureau of Justice Statistics (BJS), approximately 705,600 mentally ill adults were incarcerated in the state prison system, and another 78,800 were incarcerated in the federal prison system. A further 479,000 were in local jails. According to the study, “people with mental illnesses are overrepresented in probation and parole populations at estimated rates ranging from two to four times the general population” (Prins & Draper, 2009, p. 23). The Treatment Advocacy Center reported that the growing number of mentally ill inmates has placed a burden on the correctional system (Torrey et al., 2014).

Today, instead of asylums, there are psychiatric hospitals run by state governments and local community hospitals focused on short-term care. In all types of hospitals, the emphasis is on short-term stays, with the average length of stay being less than two weeks and often only several days. This is partly due to the very high cost of psychiatric hospitalization, which can be about $800 to $1000 per night (Stensland, Watson, & Grazier, 2012). Therefore, insurance coverage often limits the length of time a person can be hospitalized for treatment. Usually individuals are hospitalized only if they are an imminent threat to themselves or others.

Most people suffering from mental illnesses are not hospitalized. If someone is feeling very depressed, complains of hearing voices, or feels anxious all the time, he or she might seek psychological treatment. A friend, spouse, or parent might refer someone for treatment. The individual might go see his primary care physician first and then be referred to a mental health practitioner.

Some people seek treatment because they are involved with the state’s child protective services—that is, their children have been removed from their care due to abuse or neglect. The parents might be referred to psychiatric or substance abuse facilities and the children would likely receive treatment for trauma. If the parents are interested in and capable of becoming better parents, the goal of treatment might be family reunification. For other children whose parents are unable to change—for example, the parent or parents who are heavily addicted to drugs and refuse to enter treatment—the goal of therapy might be to help the children adjust to foster care and/or adoption (Figure 8).

Some people seek therapy because the criminal justice system referred them or required them to go. For some individuals, for example, attending weekly counseling sessions might be a condition of parole. If an individual is mandated to attend therapy, she is seeking services involuntarily. Involuntary treatment refers to therapy that is not the individual’s choice. Other individuals might voluntarily seek treatment. Voluntary treatment means the person chooses to attend therapy to obtain relief from symptoms.

Psychological treatment can occur in a variety of places. An individual might go to a community mental health center or a practitioner in private or community practice. A child might see a school counselor, school psychologist, or school social worker. An incarcerated person might receive group therapy in prison. There are many different types of treatment providers, and licensing requirements vary from state to state. Besides psychologists and psychiatrists, there are clinical social workers, marriage and family therapists, and trained religious personnel who also perform counseling and therapy.

A range of funding sources pay for mental health treatment: health insurance, government, and private pay. In the past, even when people had health insurance, the coverage would not always pay for mental health services. This changed with the Mental Health Parity and Addiction Equity Act of 2008, which requires group health plans and insurers to make sure there is parity of mental health services (U.S. Department of Labor, n.d.). This means that co-pays, total number of visits, and deductibles for mental health and substance abuse treatment need to be equal to and cannot be more restrictive or harsher than those for physical illnesses and medical/surgical problems.

Finding treatment sources is also not always easy: there may be limited options, especially in rural areas and low-income urban areas; waiting lists; poor quality of care available for indigent patients; and financial obstacles such as co-pays, deductibles, and time off from work. Over 85% of the l,669 federally designated mental health professional shortage areas are rural; often primary care physicians and law enforcement are the first-line mental health providers (Ivey, Scheffler, & Zazzali, 1998), although they do not have the specialized training of a mental health professional, who often would be better equipped to provide care. Availability, accessibility, and acceptability (the stigma attached to mental illness) are all problems in rural areas. Approximately two-thirds of those with symptoms receive no care at all (U.S. Department of Health and Human Services, 2005; Wagenfeld, Murray, Mohatt, & DeBruiynb, 1994). At the end of 2013, the U.S. Department of Agriculture announced an investment of $50 million to help improve access and treatment for mental health problems as part of the Obama administration’s effort to strengthen rural communities.

Try It

Think It Over

• Do you think there is a stigma associated with mentally ill persons today? Why or why not?
• What are some places in your community that offer mental health services? Would you feel comfortable seeking assistance at one of these facilities? Why or why not?

Try It

Types of Treatment

There’s no one way to treat a mental disorder, but psychotherapy or medicine, or a combination of the two are the most common treatment methods. Psychotherapy does not necessarily mean employing Freud’s psychoanalytical approach (although that is one method), but instead refers a variety of therapy methods that psychologists, psychiatrists, and counselors use to help their patients.  In this section, you’ll learn about the following types of psychotherapy:

• Psychoanalysis was developed by Sigmund Freud. Freud’s theory is that a person’s psychological problems are the result of repressed impulses or childhood trauma. The goal of the therapist is to help a person uncover buried feelings by using techniques such as free association and dream analysis.
• Play therapy is a psychodynamic therapy technique often used with children. The idea is that children play out their hopes, fantasies, and traumas, using dolls, stuffed animals, and sandbox figurines.
• In behavior therapy, a therapist employs principles of learning from classical and operant conditioning to help clients change undesirable behaviors. Counterconditioning is a commonly used therapeutic technique in which a client learns a new response to a stimulus that has previously elicited an undesirable behavior via classical conditioning. Principles of operant conditioning can be applied to help people deal with a wide range of psychological problems. Token economy is an example of a popular operant conditioning technique.
• Cognitive therapy is a technique that focuses on how thoughts lead to feelings of distress. The idea behind cognitive therapy is that how you think determines how you feel and act. Cognitive therapists help clients change dysfunctional thoughts in order to relieve distress. Cognitive-behavioral therapy explores how our thoughts affect our behavior. Cognitive-behavioral therapy aims to change cognitive distortions and self-defeating behaviors.
• Humanistic therapy focuses on helping people achieve their potential. One form of humanistic therapy developed by Carl Rogers is known as client-centered or Rogerian therapy. Client-centered therapists use the techniques of active listening, unconditional positive regard, genuineness, and empathy to help clients become more accepting of themselves.

Often in combination with psychotherapy, people can be prescribed biologically based treatments such as psychotropic medications and/or other medical procedures such as electro-convulsive therapy.

Autobiography in Five Short Chapters by Portia Nelson (1993)

Chapter One

I walk down the street.
There is a deep hole in the sidewalk.
I fall in. I am lost. . . . I am helpless.
It isn’t my fault.
It takes forever to find a way out.

Chapter Two

I walk down the same street.
There is a deep hole in the sidewalk.
I pretend I don’t see it.
I fall in again.
I can’t believe I am in this same place.
But, it isn’t my fault.
It still takes a long time to get out.

Chapter Three

I walk down the same street.
There is a deep hole in the sidewalk.
I see it is there.
I still fall in . . . it’s a habit . . . but,
my eyes are open.
I know where I am.
It is my fault.
I get out immediately.

Chapter Four

I walk down the same street.
There is a deep hole in the sidewalk.
I walk around it.

Chapter Five

I walk down another street.

Two types of therapy are psychotherapy and biomedical therapy. Both types of treatment help people with psychological disorders, such as depression, anxiety, and schizophrenia. Psychotherapy is a psychological treatment that employs various methods to help someone overcome personal problems, or to attain personal growth. Biomedical therapy involves medication and/or medical procedures to treat psychological disorders. First, we will explore the various psychotherapeutic orientations outlined in Table 1 (many of these orientations were discussed in the Introduction module). In addition to psychotherapy and the biomedical approach, there is also a social approach to treatment, which focuses on family or group therapies.

Psychotherapy Techniques: Psychoanalysis

Psychoanalysis was developed by Sigmund Freud and was the first form of psychotherapy. It was the dominant therapeutic technique in the early 20th century, but it has since waned significantly in popularity. Freud believed most of our psychological problems are the result of repressed impulses and trauma experienced in childhood, and he believed psychoanalysis would help uncover long-buried feelings. In a psychoanalyst’s office, you might see a patient lying on a couch speaking of dreams or childhood memories, and the therapist using various Freudian methods such as free association and dream analysis (Figure 9). In free association, the patient relaxes and then says whatever comes to mind at the moment. However, Freud felt that the ego would at times try to block, or repress, unacceptable urges or painful conflicts during free association. Consequently, a patient would demonstrate resistance to recalling these thoughts or situations. In dream analysis, a therapist interprets the underlying meaning of dreams.

Psychoanalysis is a therapy approach that typically takes years. Over the course of time, the patient reveals a great deal about himself to the therapist. Freud suggested that during this patient-therapist relationship, the patient comes to develop strong feelings for the therapist—maybe positive feelings, maybe negative feelings. Freud called this transference: the patient transfers all the positive or negative emotions associated with the patient’s other relationships to the psychoanalyst. For example, Crystal is seeing a psychoanalyst. During the years of therapy, she comes to see her therapist as a father figure. She transfers her feelings about her father onto her therapist, perhaps in an effort to gain the love and attention she did not receive from her own father.

Today, Freud’s psychoanalytical perspective has been expanded upon by the developments of subsequent theories and methodologies: the psychodynamic perspective. This approach to therapy remains centered on the role of people’s internal drives and forces, but treatment is less intensive than Freud’s original model.

Try It

Psychotherapy: Cognitive and Cognitive-Behavioral Therapy

Cognitive therapy is a form of psychotherapy that focuses on how a person’s thoughts lead to feelings of distress. The idea behind cognitive therapy is that how you think determines how you feel and act. Cognitive therapists help their clients change dysfunctional thoughts in order to relieve distress. They help a client see how they misinterpret a situation (cognitive distortion). For example, a client may overgeneralize. Because Ray failed one test in his Psychology 101 course, he feels he is stupid and worthless. These thoughts then cause his mood to worsen. Therapists also help clients recognize when they blow things out of proportion. Because Ray failed his Psychology 101 test, he has concluded that he’s going to fail the entire course and probably flunk out of college altogether. These errors in thinking have contributed to Ray’s feelings of distress. His therapist will help him challenge these irrational beliefs, focus on their illogical basis, and correct them with more logical and rational thoughts and beliefs.

Cognitive therapy was developed by psychiatrist Aaron Beck in the 1960s. His initial focus was on depression and how a client’s self-defeating attitude served to maintain a depression despite positive factors in her life (Beck, Rush, Shaw, & Emery, 1979)(Figure 10). Through questioning, a cognitive therapist can help a client recognize dysfunctional ideas, challenge catastrophizing thoughts about themselves and their situations, and find a more positive way to view things (Beck, 2011).

One of the first forms of cognitive-behavior therapy was rational emotive therapy (RET), which was founded by Albert Ellis and grew out of his dislike of Freudian psychoanalysis (Daniel, n.d.). Behaviorists such as Joseph Wolpe also influenced Ellis’s therapeutic approach (National Association of Cognitive-Behavioral Therapists, 2009). During the 1980s and 1990s, cognitive and behavioral techniques were merged into cognitive-behavioral therapy. Pivotal to this merging was the successful development of treatments for panic disorder by David M. Clark in the UK and David H. Barlow in the U.S. Over time, cognitive-behavioral therapy came to be known not only as a therapy, but as an umbrella category for all cognitive-based psychotherapies.

Cognitive-behavioral therapy (CBT) helps clients examine how their thoughts affect their behavior. It aims to change cognitive distortions and self-defeating behaviors. For example, if it’s your first time meeting new people, you may have the automatic thought, “These people won’t like me because I have nothing interesting to share.” That thought itself is not what’s troublesome; the appraisal (or evaluation) that it might have merit is what’s troublesome. The goal of CBT is to help people make adaptive, instead of maladaptive, appraisals (e.g., “I do know interesting things!”). This technique of reappraisal, or cognitive restructuring, is a fundamental aspect of CBT. With cognitive restructuring, it is the therapist’s job to help point out when a person has an inaccurate or maladaptive thought, so that the patient can either eliminate it or modify it to be more adaptive. In essence, this approach is designed to change the way people think as well as how they act.

In total, hundreds of studies have shown the effectiveness of cognitive-behavioral therapy in the treatment of numerous psychological disorders such as depression, PTSD, anxiety disorders, eating disorders, bipolar disorder, and substance abuse (Beck Institute for Cognitive Behavior Therapy, n.d.). For example, CBT has been found to be effective in decreasing levels of hopelessness and suicidal thoughts in previously suicidal teenagers (Alavi, Sharifi, Ghanizadeh, & Dehbozorgi, 2013). Cognitive-behavioral therapy has also been effective in reducing PTSD in specific populations, such as transit workers (Lowinger & Rombom, 2012).

Cognitive-behavioral therapy aims to change cognitive distortions and self-defeating behaviors using techniques like the ABC model. With this model, there is an Action (sometimes called an activating event), the Belief about the event, and the Consequences of this belief. Let’s say, Jon and Joe both go to a party. Jon and Joe each have met a young woman at the party: Jon is talking with Megan most of the party, and Joe is talking with Amanda. At the end of the party, Jon asks Megan for her phone number and Joe asks Amanda. Megan tells Jon she would rather not give him her number, and Amanda tells Joe the same thing. Both Jon and Joe are surprised, as they thought things were going well. What can Jon and Joe tell themselves about why the women were not interested? Let’s say Jon tells himself he is a loser, or is ugly, or “has no game.” Jon then gets depressed and decides not to go to another party, which starts a cycle that keeps him depressed. Joe tells himself that he had bad breath, goes out and buys a new toothbrush, goes to another party, and meets someone new.

Jon’s belief about what happened results in a consequence of further depression, whereas Joe’s belief does not. Jon is internalizing the attribution or reason for the rebuffs, which triggers his depression. On the other hand, Joe is externalizing the cause, so his thinking does not contribute to feelings of depression. Cognitive-behavioral therapy examines specific maladaptive and automatic thoughts and cognitive distortions. Some examples of cognitive distortions are all-or-nothing thinking, overgeneralization, and jumping to conclusions. In overgeneralization, someone takes a small situation and makes it huge—for example, instead of saying, “This particular woman was not interested in me,” the man says, “I am ugly, a loser, and no one is ever going to be interested in me.”

All or nothing thinking, which is a common type of cognitive distortion for people suffering from depression, reflects extremes. In other words, everything is black or white. After being turned down for a date, Jon begins to think, “No woman will ever go out with me. I’m going to be alone forever.” He begins to feel anxious and sad as he contemplates his future.

The third kind of distortion involves jumping to conclusions—assuming that people are thinking negatively about you or reacting negatively to you, even though there is no evidence. Consider the example of Savannah and Hillaire, who recently met at a party. They have a lot in common, and Savannah thinks they could become friends. She calls Hillaire to invite her for coffee. Since Hillaire doesn’t answer, Savannah leaves her a message. Several days go by and Savannah never hears back from her potential new friend. Maybe Hillaire never received the message because she lost her phone or she is too busy to return the phone call. But if Savannah believes that Hillaire didn’t like Savannah or didn’t want to be her friend, she is demonstrating the cognitive distortion of jumping to conclusions.

How effective is CBT? One client said this about his cognitive-behavioral therapy:

I have had many painful episodes of depression in my life, and this has had a negative effect on my career and has put considerable strain on my friends and family. The treatments I have received, such as taking antidepressants and psychodynamic counseling, have helped [me] to cope with the symptoms and to get some insights into the roots of my problems. CBT has been by far the most useful approach I have found in tackling these mood problems. It has raised my awareness of how my thoughts impact on my moods. How the way I think about myself, about others and about the world can lead me into depression. It is a practical approach, which does not dwell so much on childhood experiences, whilst acknowledging that it was then that these patterns were learned. It looks at what is happening now, and gives tools to manage these moods on a daily basis. (Martin, 2007, n.p.)

Try It

Behavior Therapy: How Does it Work?

Meet Miriam. She is smart, ambitious, creative, and full of energy. She is studying at a university, majoring in business. During the next few years, after she graduates, she wants to live in interesting places and get solid training and experience with a good corporation. Her dream is to start her own company, to be her own boss, and to do things that she can take pride in. For her, financial success and doing something worthwhile must go hand-in-hand.

But Miriam has a secret. She is terrified of speaking in front of people who are not her close friends. She has fought these fears for a long time, but she has never been able to conquer them. She is also aware of the fact that she will need to be able to speak to strangers comfortably and convincingly if she is going to meet her goals in business.

Now that you and your client have agreed upon your goals, it is time to choose a particular technique for the therapy. As a behavioral therapist, you are looking for a method to allow Miriam to learn a new response to the thought of public speaking. Now the idea terrifies her. After therapy is over, she should no longer be terrified and she may even look forward to the opportunity to speak in front of other people.

You know that everyone is not the same and different problems may call for different approaches to therapy. For these reasons, you have been trained in a variety of techniques that you can use to customize Miriam’s therapy to meet her particular needs. It is time to decide how you are going to help Miriam.

Try It

Systematic desensitization works by gradually—step-by-step—exposing the person to situations that are increasingly more anxiety-producing. This is called “progressive exposure.” By learning to cope with anxiety with less-threatening situations first, the person is better prepared to handle the more-threatening situations. Even more important for treatment, the mind learns that nothing horrible happens. This retraining of the subconscious mind means that the situation actually becomes less threatening.

The first steps in systematic desensitization is the development of a “hierarchy of fears.” This simply means that you must help your Miriam create a list of situations related to her fear of public speaking. Then you create a hierarchy. This means that you have her organize the situations from the least frightening to the most frightening.

For the next step in this exercise, you will need to take on Miriam’s role as the client. Imagine that you have developed a list of frightening situations, from ones that make you only slightly uncomfortable to ones that nearly make you sick with anxiety.

Try It

Remember that systematic desensitization works by putting the person in a series of situations. The early ones are not threatening or are only mildly threatening. However, as soon as your client learns to cope with each situation, you start working on the next most frightening situation.

So we’re ready to start, right? Wrong!

Behavioral therapy teaches the client to cope with an anxiety-producing situation by replacing fear with an alternative response. A common alternative response is relaxation. This idea is that fear and anxiety cannot coexist with relaxation—if you are relaxed, you can’t be fully afraid.

However, most people are not very good at relaxing on command. So the behavioral therapist will teach the client how to relax effectively. The techniques are ones often used in meditation—slow breathing and focus on positive thoughts. Psychologist Kevin Arnold explains a deep breathing technique in this video.

Miriam’s Treatment

Miriam is an imaginary person, but behavioral therapy is used by thousands of therapist with their clients every day. Review Table 2 to discover how Miriam’s therapy progressed. Her story is based on a fairly typical series of therapy sessions, though please understand that each person’s course of therapy is unique.

You just learned about Systematic Desensitization, a form of exposure therapy. Flooding is another type of exposure therapy. To understand how it works, let’s review a few points from Systematic Desensitization.

Try It

In flooding therapy, you would skip the earliest situations described in systematic desensitization and you would move directly to highly threatening situations. Right after Miriam had mastered relaxation, your first session would require Miriam to give an actual talk. You would probably not start with the most extreme situation, but your goal would be to start Miriam in situations that she would immediately rate as 9 or 10 on the anxiety scale.

Flooding has the potential to be more traumatic for Miriam (for your client), so it must be arranged carefully. But the same principles of learning work for flooding that work for systematic desensitization:

• The person consciously works to replace anxiety and fear with relaxation.
• The unconscious parts of the mind learn that the situation does not result in horrible outcomes. New expectations replace old fears.
• Learning does not just happen immediately. Homework and repeated practice reinforce the new positive response to situations that once produced fear.

Try It

Psychotherapy: Humanistic Therapy

Humanistic psychology focuses on helping people achieve their potential. So it makes sense that the goal of humanistic therapy is to help people become more self-aware and accepting of themselves. In contrast to psychoanalysis, humanistic therapists focus on conscious rather than unconscious thoughts. They also emphasize the patient’s present and future, as opposed to exploring the patient’s past.

Psychologist Carl Rogers developed a therapeutic orientation known as Rogerian, or client-centered therapy (also sometimes called person-centered therapy or PCT). Note the change from patients to clients. Rogers (1951) felt that the term patient suggested the person seeking help was sick and looking for a cure. Since this is a form of nondirective therapy, a therapeutic approach in which the therapist does not give advice or provide interpretations but helps the person to identify conflicts and understand feelings, Rogers (1951) emphasized the importance of the person taking control of his own life to overcome life’s challenges.

In client-centered therapy, the therapist uses the technique of active listening. In active listening, the therapist acknowledges, restates, and clarifies what the client expresses. Therapists also practice what Rogers called unconditional positive regard, which involves not judging clients and simply accepting them for who they are. Rogers (1951) also felt that therapists should demonstrate genuineness, empathy, and acceptance toward their clients because this helps people become more accepting of themselves, which results in personal growth.

Try It

Evaluating Various Forms of Psychotherapy

How can we assess the effectiveness of psychotherapy? Is one technique more effective than another? For anyone considering therapy, these are important questions. According to the American Psychological Association, three factors work together to produce successful treatment. The first is the use of evidence-based treatment that is deemed appropriate for your particular issue. The second important factor is the clinical expertise of the psychologist or therapist. The third factor is your own characteristics, values, preferences, and culture. Many people begin psychotherapy feeling like their problem will never be resolved; however, psychotherapy helps people see that they can do things to make their situation better. Psychotherapy can help reduce a person’s anxiety, depression, and maladaptive behaviors. Through psychotherapy, individuals can learn to engage in healthy behaviors designed to help them better express emotions, improve relationships, think more positively, and perform more effectively at work or school. In discussing therapeutic orientations, it is important to note that many clinicians incorporate techniques from multiple approaches, a practice known as integrative or eclectic psychotherapy.

Consider the following advantages and disadvantages of some of the major forms of psychotherapy:

• Psychoanalysis: Psychoanalysis was once the only type of psychotherapy available, but presently the number of therapists practicing this approach is decreasing around the world. Psychoanalysis is not appropriate for some types of patients, including those with severe psychopathology or mental retardation. Further, psychoanalysis is often expensive because treatment usually lasts many years. Still, some patients and therapists find the prolonged and detailed analysis very rewarding.
• Cognitive-Behavioral Therapy: CBT interventions tend to be relatively brief, making them cost-effective for the average consumer. In addition, CBT is an intuitive treatment that makes logical sense to patients. It can also be adapted to suit the needs of many different populations. One disadvantage, however, is that CBT does involve significant effort on the patient’s part, because the patient is an active participant in treatment. Therapists often assign “homework” (e.g., worksheets for recording one’s thoughts and behaviors) between sessions to maintain the cognitive and behavioral habits the patient is working on. The greatest strength of CBT is the abundance of empirical support for its effectiveness.
• Humanistic Therapy: One key advantage of person-centered therapy is that it is highly acceptable to patients. In other words, people tend to find the supportive, flexible environment of this approach very rewarding. Furthermore, some of the themes of PCT translate well to other therapeutic approaches. For example, most therapists of any orientation find that clients respond well to being treated with nonjudgmental empathy.

Many studies have explored the effectiveness of psychotherapy. For example, one large-scale study that examined 16 meta-analyses of CBT reported that it was equally effective or more effective than other therapies in treating PTSD, generalized anxiety disorder, depression, and social phobia (Butlera, Chapmanb, Formanc, & Becka, 2006). Another study found that CBT was as effective at treating depression (43% success rate) as prescription medication (50% success rate) compared to the placebo rate of 25% (DeRubeis et al., 2005). Another meta-analysis found that psychodynamic therapy was also as effective at treating these types of psychological issues as CBT (Shedler, 2010). However, no studies have found one psychotherapeutic approach more effective than another (Abbass, Kisely, & Kroenke, 2006; Chorpita et al., 2011), nor have they shown any relationship between a client’s treatment outcome and the level of the clinician’s training or experience (Wampold, 2007). Regardless of which type of psychotherapy an individual chooses, one critical factor that determines the success of treatment is the person’s relationship with the psychologist or therapist.

Watch It

Review each of the types of psychotherapy you’ve learned about in this lesson in the following CrashCourse video.

You can view the transcript for “Getting Help – Psychotherapy: Crash Course Psychology #35” here (opens in new window).

Try It

Biological Therapy

Humans have a long, and sometimes disturbing history of biomedical treatment of disorders. In ancient and medieval times, the process of trepanation – a drilling or cracking of a hole in the skull to expose the brain – was sometimes used to free evil spirits or demons from within a person’s head.

Trepanation ultimately fell out of favor as a treatment for psychological disorders. However, in the 20th century another biomedical procedure, lobotomy, gained in use. Lobotomy is a form of psychosurgery in which parts of the frontal lobe of the brain are destroyed or their connections to other parts of the brain severed. The goal of lobotomy was usually to calm symptoms in people with serious psychological disorders, such as schizophrenia. Lobotomy was widely used during the twentieth century – indeed, it was so mainstream that Antonio Moniz won a Nobel Prize in physiology for his work on one lobotomy procedure. However, lobotomy was always highly controversial, and widely criticized as a tool of behavioral control of people who were engaged in behaviors that were not clinical in nature. By the 1960s and 1970s lobotomy fell out of favor in the United States.

One of the reasons lobotomy fell out of favor was the development in the 1950s and 1960s of new medications for the treatment of psychological disorders; these are now the most widely used forms of biological treatment. While these are often used in combination with psychotherapy, they also are taken by individuals not in therapy. This is known as biomedical therapy. Medications used to treat psychological disorders are called psychotropic medications and are prescribed by medical doctors, including psychiatrists. In Louisiana and New Mexico, psychologists are able to prescribe some types of these medications (American Psychological Association, 2014).

Different types and classes of medications are prescribed for different disorders. A depressed person might be given an antidepressant, a bipolar individual might be given a mood stabilizer, and a schizophrenic individual might be given an antipsychotic. These medications treat the symptoms of a psychological disorder. They can help people feel better so that they can function on a daily basis, but they do not cure the disorder. Some people may only need to take a psychotropic medication for a short period of time. Others with severe disorders like bipolar disorder or schizophrenia may need to take psychotropic medication for a long time. Table 3 shows the types of medication and how they are used.

Try It

Another biologically based treatment that continues to be used, although infrequently, is electroconvulsive therapy (ECT) (formerly known by its unscientific name as electroshock therapy). It involves using an electrical current to induce seizures to help alleviate the effects of severe depression. The exact mechanism is unknown, although it does help alleviate symptoms for people with severe depression who have not responded to traditional drug therapy (Pagnin, de Queiroz, Pini, & Cassano, 2004). About 85% of people treated with ECT improve (Reti, n.d.). However, the memory loss associated with repeated administrations has led to it being implemented as a last resort (Donahue, 2000; Prudic, Peyser, & Sackeim, 2000). A more recent alternative is transcranial magnetic stimulation (TMS), a procedure approved by the FDA in 2008 that uses magnetic fields to stimulate nerve cells in the brain to improve depression symptoms; it is used when other treatments have not worked (Mayo Clinic, 2012).

Try It

There are several modalities, or methods, of treatment: individual therapy, group therapy, couples therapy, and family therapy are the most common. In an individual therapy session, a client works one-on-one with a trained therapist. In group therapy, usually 5–10 people meet with a trained group therapist to discuss a common issue (e.g., divorce, grief, eating disorders, substance abuse, or anger management). Couples therapy involves two people in an intimate relationship who are having difficulties and are trying to resolve them. The couple may be dating, partnered, engaged, or married. The therapist helps them resolve their problems as well as implement strategies that will lead to a healthier and happier relationship. Family therapy is a special form of group therapy. The therapy group is made up of one or more families. The goal of this approach is to enhance the growth of each individual family member and the family as a whole.

Individual Therapy

Group Therapy

In group therapy, a clinician meets together with several clients with similar problems (Figure 14). When children are placed in group therapy, it is particularly important to match clients for age and problems. One benefit of group therapy is that it can help decrease a client’s shame and isolation about a problem while offering needed support, both from the therapist and other members of the group (American Psychological Association, 2014). A nine-year-old sexual abuse victim, for example, may feel very embarrassed and ashamed. If he is placed in a group with other sexually abused boys, he will realize that he is not alone. A child struggling with poor social skills would likely benefit from a group with a specific curriculum t4 foster special skills. A woman suffering from post-partum depression could feel less guilty and more supported by being in a group with similar women.

Group therapy also has some specific limitations. Members of the group may be afraid to speak in front of other people because sharing secrets and problems with complete strangers can be stressful and overwhelming. There may be personality clashes and arguments among group members. There could also be concerns about confidentiality: Someone from the group might share what another participant said to people outside of the group.

Another benefit of group therapy is that members can confront each other about their patterns. For those with some types of problems, such as sexual abusers, group therapy is the recommended treatment. Group treatment for this population is considered to have several benefits:

Group treatment is more economical than individual, couples, or family therapy. Sexual abusers often feel more comfortable admitting and discussing their offenses in a treatment group where others are modeling openness. Clients often accept feedback about their behavior more willingly from other group members than from therapists. Finally, clients can practice social skills in group treatment settings. (McGrath, Cumming, Burchard, Zeoli, & Ellerby, 2009)

Groups that have a strong educational component are called psycho-educational groups. For example, a group for children whose parents have cancer might discuss in depth what cancer is, types of treatment for cancer, and the side effects of treatments, such as hair loss. Often, group therapy sessions with children take place in school. They are led by a school counselor, a school psychologist, or a school social worker. Groups might focus on test anxiety, social isolation, self-esteem, bullying, or school failure (Shechtman, 2002). Whether the group is held in school or in a clinician’s office, group therapy has been found to be effective with children facing numerous kinds of challenges (Shechtman, 2002).

During a group session, the entire group could reflect on an individual’s problem or difficulties, and others might disclose what they have done in that situation. When a clinician is facilitating a group, the focus is always on making sure that everyone benefits and participates in the group and that no one person is the focus of the entire session. Groups can be organized in various ways: some have an overarching theme or purpose, some are time-limited, some have open membership that allows people to come and go, and some are closed. Some groups are structured with planned activities and goals, while others are unstructured: There is no specific plan, and group members themselves decide how the group will spend its time and on what goals it will focus. This can become a complex and emotionally charged process, but it is also an opportunity for personal growth (Page & Berkow, 1994).

Couples Therapy

Couples therapy involves two people in an intimate relationship who are having difficulties and are trying to resolve them (Figure 15). The couple may be dating, partnered, engaged, or married. The primary therapeutic orientation used in couples counseling is cognitive-behavioral therapy (Rathus & Sanderson, 1999). Couples meet with a therapist to discuss conflicts and/or aspects of their relationship that they want to change. The therapist helps them see how their individual backgrounds, beliefs, and actions are affecting their relationship. Often, a therapist tries to help the couple resolve these problems, as well as implement strategies that will lead to a healthier and happier relationship, such as how to listen, how to argue, and how to express feelings. However, sometimes, after working with a therapist, a couple will realize that they are too incompatible and will decide to separate. Some couples seek therapy to work out their problems, while others attend therapy to determine whether staying together is the best solution. Counseling couples in a high-conflict and volatile relationship can be difficult. In fact, psychologists Peter Pearson and Ellyn Bader, who founded the Couples Institute in Palo Alto, California, have compared the experience of the clinician in couples’ therapy to be like “piloting a helicopter in a hurricane” (Weil, 2012, para. 7).

As our society becomes increasingly multiethnic and multiracial, mental health professionals must develop cultural competence (Figure 16), which means they must understand and address issues of race, culture, and ethnicity. They must also develop strategies to effectively address the needs of various populations for which Eurocentric therapies have limited application (Sue, 2004). For example, a counselor whose treatment focuses on individual decision making may be ineffective at helping a Chinese client with a collectivist approach to problem solving (Sue, 2004).

Multicultural counseling and therapy aims to offer both a helping role and process that uses modalities and defines goals consistent with the life experiences and cultural values of clients. It strives to recognize client identities to include individual, group, and universal dimensions, advocate the use of universal and culture-specific strategies and roles in the healing process, and balance the importance of individualism and collectivism in the assessment, diagnosis, and treatment of client and client systems (Sue, 2001).

This therapeutic perspective integrates the impact of cultural and social norms, starting at the beginning of treatment. Therapists who use this perspective work with clients to obtain and integrate information about their cultural patterns into a unique treatment approach based on their particular situation (Stewart, Simmons, & Habibpour, 2012). Sociocultural therapy can include individual, group, family, and couples treatment modalities.

In this chapter, you covered a full gamut of treatment methods, including psychotherapy in its many forms as well as biomedical therapies. Put yourself in the shoes of a mental health counselor. Which treatment method or methods would you prefer to study or utilize in your practice? Which type of counseling would you prefer to seek out as a patient? Review the common types of psychotherapy below:

• Psychodynamic Therapy: The primary focus is to reveal the unconscious content of a client’s psyche in an effort to alleviate psychic tension. Although its roots are in psychoanalysis, psychodynamic therapy tends to be briefer and less intensive than traditional psychoanalysis.
• Behavioral Therapy: These methods focus exclusively on behaviors, or on behaviors in combination with thoughts and feelings that might be causing them. Those who practice behavioral therapy tend to look more at specific, learned behaviors and how the environment has an impact on those behaviors. Two primary types include operant conditioning and classical conditioning.
• Cognitive and Cognitive Behavioral Therapy (CBT): Cognitive therapy seeks to identify maladaptive cognitions (thoughts), appraisals, beliefs, and reactions, with the aim of influencing destructive negative emotions. CBT combines cognitive therapy and behavioral therapy to address maladaptive cognitions as well as dysfunctional behaviors.
• Humanistic Therapy: This form is explicitly concerned with the human context of the development of the individual with an emphasis on subjective meaning, a rejection of determinism, and a concern for positive growth rather than pathology. It posits an inherent human capacity to maximize potential.
• Group Therapy: In this type of social therapy, one or more therapists treat a small group of clients together as a group.
• Eclectic Therapy: Recently, many practitioners have begun to take what’s known as an eclectic approach, meaning they combine aspects of multiple types of therapies. This approach can be useful in that is uses the techniques and theories that work best in a specific patient’s scenario, rather than sticking solely to the methods of one discipline.

Biomedical therapies approach psychological disorders as having biological causes and focus on eliminating or alleviating symptoms of psychological disorders. The mind and body are viewed as connected; poor physical health leads to poor mental health, and vice versa.

Biomedical therapies and psychotherapy are often used in conjunction with one another to treat the whole person. Not all individuals will require biomedical therapy; however, for some, biomedical approaches can help enhance the effectiveness of psychotherapeutic approaches. For example, an individual with schizophrenia who is bombarded with visual or auditory hallucinations may find it difficult to focus in psychotherapy; with medication, the individual’s hallucinations can be eliminated or reduced to a level that allows the individual to benefit from psychotherapy.

• Pharmacotherapy: “Pharmacotherapy” refers to the use of medications in biomedical treatment. Medications exist in four classes: antipsychotics, antidepressants, anti-cycling agents, and hypnoanxiolytics. In general, the effectiveness of medications is upwards of 80%, but some of the medications also contain serious side effects. Once the medication is discontinued, symptoms often return; however, prolonged use can lead to other problems. Different types and classes of medications are prescribed for different disorders. A depressed person might be given an antidepressant, a bipolar individual might be given a mood stabilizer, and a schizophrenic individual might be given an antipsychotic. These medications treat the symptoms of a psychological disorder; they can help people feel better so that they can function on a daily basis, but they do not cure the disorder. Some people may only need to take a psychotropic medication for a short period of time. Others, with severe disorders like bipolar disorder or schizophrenia, may need to take psychotropic medication continuously for effective symptom management.
• ECT: Another biologically based treatment that continues to be used, although infrequently, is electroconvulsive therapy (ECT; formerly known by the unscientific name “electroshock therapy”). It involves using an electrical current to induce seizures in the brain in order to help alleviate the effects of certain mental conditions, such as severe forms of depression or bipolar disorder. The exact mechanism is unknown, although it does help alleviate symptoms for people with severe depression who have not responded to traditional drug therapy (Pagnin, de Queiroz, Pini, & Cassano, 2004). About 85% of people treated with ECT improve (Reti, n.d.). However, the memory loss associated with repeated administrations has led to it typically being implemented as a last resort (Donahue, 2000; Prudic, Peyser, & Sackeim, 2000). A more recent alternative to ECT is transcranial magnetic stimulation (TMS), a procedure approved by the FDA in 2008 that uses magnetic fields to stimulate nerve cells in the brain to improve depression symptoms; like ECT, it is used when other treatments have not worked (Mayo Clinic, 2012).