PSYCHOLOGICAL TREATMENTS
Treatments that use psychological methods rather than direct changes to the body are known collectively as psychotherapy. There are many different kinds of psychotherapy. Treatment is always by a trained therapist with expertise in handling psychological disorders, and the clients enter into a professional relationship with the therapist to work on alleviating the disorder. Training in psychotherapy usually involves completion of an advanced degree and supervised treatment experience, but its exact nature depends on the disciplinary background of the therapist (who might be a psychiatrist, psychologist, social worker or psychiatric nurse), and the regulations that govern practice in their country. In many countries, people with minimal or no training may still call themselves ‘psychotherapists’, so it is essential to exercise good judgement in seeking psychotherapy. Psychotherapy may take place in outpatient or inpatient settings. Either way, the psychotherapeutic relationship is a purposeful, nurturant allia nce. The psychotherapist needs good communication and relationship-building skills, self-awareness and self-monitoring, and other specific skills associated with their particular type of therapy.
In the next sections we consider some of the major forms of psychotherapy that are currently in clinical use.
PSYCHOANALYSIS AND PSYCHODYNAMIC THERAPY
Classical psychoanalysis
Classical psychoanalysis was developed by Freud. Its goals are to help the person gain insight into the ‘true’ (usually unconscious) reasons for their maladaptive behaviour, to work through their implications and associated feelings, and to strengthen the ego’s control over the id and superego.
1 Uncovering repressed memories
In this framework, recovery of unconscious memories is facilitated by the method of free association, in which the client says whatever comes to mind without editing or censorship. This is a difficult procedure, which rarely reveals repressed memories clearly. According to the traditional view, the analyst has to piece together patterns of association while dealing with the patient’s ‘resistance’ (the tendency to avoid the task at hand by, for example, changing topic or forgetting what they were about to say). Resistance is seen as a sign that the patient is on the verge of recalling a painful memory. Freud also used dreams to uncover unconscious material by regarding the content of the dream as symbolic of something else. But he believed that recollection without emotion has little therapeutic value, so psychoanalysis is considered useful only if the patient is released from the emotional forces that had kept the insight repressed.
2 Transference and countertransference
Central to psychoanalysis is transference. This is the notion that the client projects (transfers) onto the analyst characteristics that are unconsciously associated with parents and other important interpersonal figures from the client’s past. Using the transference- charged relationship, the analyst effectively holds up a mirror, allowing the client to see how he reacts to important people in his life. Through many experiences like this, it is argued that the patient’s symptoms gradually diminish. To be able to ‘stand in’ for significant others in the patient’s early life, it is important for the analyst to remain neutral. They must not allow countertransference (i.e. their own unconscious feelings towards the patient) to distort the process. Not surprisingly, trainees must undergo psychoanalysis themselves before qualifying as a psychoanalyst.
Contemporary psychodynamic therapy
The now stereotypical analytic couch is foregone in contemporary psychodynamic therapies in favour of chairs and face-to-face interaction. Classical psychoanalysts focused on what happens during analysis, so the patient’s life outside the consultation room ideally needed to remain stable until the analysis was complete.
In contrast, contemporary psychodynamic therapists use a model of abnormal behaviour that involves not only intrapsychic conflict relating to early childhood, but also current interpersonal relationships. They therefore pay close attention to the links between what goes on during therapy and the client’s life in between sessions.
Emphasis on accountability and cost-effectiveness in health care have no doubt played a role in the recent emergence of short-term dynamic psychotherapy (Levenson & Strupp, 1999). Here the goal is pragmatic – to help the client cope with a current problem or crisis in 20 sessions or fewer. Therapists are usually more active and may refer clients to self-help groups, ask them to do homework between sessions and use other procedures not typically associated with psychoanalytically derived psychotherapies. Do these therapies work? A major limitation of psychoanalytic and psychodynamic therapies is that they seem best suited to verbal, intelligent people with relatively mild psychological problems who are motivated to spend a substantial amount of time trying to uncover unconscious conflicts. Psychoanalysis is also expensive and usually only available to those who can afford private practice. The basic principles that underlie these therapies have received very little empirical attention. In a study of free asso ciation, Erdelyi (1985) found that the method resulted in more material being reported, but it wasn’t clear whether this reflected actual memory enhancement (see chapter 11). In fact, it may not be possible to test these therapies at all because the theoretical framework underpinning them frequently seems to explain all possible outcomes equally well (see chapter 15). For example, when a patient obtains insight and changes behaviour, this is said to provide evidence of treatment efficacy. But when a patient obtains insight but shows no behaviour change, in the psychoanalytic framework this doesn’t reflect on treatment efficacy as the insight is said to be merely ‘intellectual’. The picture is brighter when it comes to some of the more recent psychodynamic therapies.
There is some evidence that interpersonal therapy (a short-term psychodynamic therapy that focuses on the client’s interpersonal relationships and current circumstances) is effective in treating depression (Weissman & Markowitz, 1994). For the most part, however, the jury is still out when it comes to research evaluations of contemporary psychodynamic therapies.
BEHAVIOUR THERAPY
Just as behaviourism was a rejection of existing systems in psychology, behaviour therapy represented a rejection of psychoanalytic and psychodynamic thinking. Behaviour therapy is concerned with what the person does that causes distress. The problematic behaviour is seen to be learned, just like any other behaviour, and is not viewed as a symptom of an underlying ‘illness’. The therapist uses techniques based on the principles of learning to change the maladaptive behaviour. Consistent with its roots in the work of Pavlov, Thorndike and Skinner, behaviour therapy is highly pragmatic and focuses on the ‘here and now’ rather than early experiences. And yet it would be a mistake to conclude that behaviour therapy is a completely mechanistic, impersonal procedure. Like other psychotherapists, behaviour therapists emphasize the need for a strong, supportive therapeutic relationship between the therapist and the client in their work.
Exposure techniques
As the name implies, exposure techniques involve exposing clients to stimuli that, through pairing with anxiety responses (classical conditioning), have come to evoke anxiety or fear. Exposure is extensively used to treat agoraphobia and the panic attacks that often precede its development. In severe cases, it is usually combined with drug treatment.
The most widely used technique is systematic desensitization, developed in laboratory studies of cats by the South African psychiatrist Joseph Wolpe. Wolpe reasoned that, ‘If a response antagonistic to anxiety can be made to occur in the presence of the anxiety-evoking stimuli so that it is accompanied by a complete or partial suppression of the anxiety responses, the bond between these stimuli and anxiety responses will be weakened’ (1958, p. 71). When this principle of reciprocal inhibition (counterconditioning) is applied to humans, muscle relaxation is usually used to inhibit anxiety. The client is first taught progressive muscle relaxation (tensing and then releasing muscle groups) until she is able to relax her muscles on cue. Then the therapist works with her to develop a hierarchy of situations that she finds increasingly anxiety-provoking. For example, suppose the target behaviour is fear of speaking up in class. The following hierarchy might be developed: At home, the night before I go to class. Driving to school before the class.
Walking to my class.
Walking inside the classroom.
Looking around at the people in the room.
Walking in and saying ‘hello’ to someone in the room.
Sitting down in the front row.
Catching the professor’s eye and smiling.
Nodding or agreeing with a comment made in class.
Asking the professor a question from the front of the room.
Asking the professor a question from the back of the room.
Answering a short question from the front of the room.
Answering a short question from the back of the room.
Answering a longer question.
Making a comment on a particular point to the class.
The client is therefore exposed to the least frightening situation while deeply relaxed. When the situation no longer evokes anxiety, the therapist moves on to the next stage in the hierarchy, progressing accordingly until the client can encounter the most anxiety-provoking situation while still remaining relaxed.
Exposure to the anxiety-provoking situation is usually achieved through imagination, but can also be achieved in real life. More recently, simulated environments created using virtual reality technology have been used effectively to treat acrophobia (fear of heights), aviophobia (fear of flying) and post traumatic stress disorder (Rothbaum et al., 1995; 2001; 2002).
An alternative to the brief/ graduated exposure used in systematic desensitization is flooding – a technique that involves prolonged exposure to highly threatening events. The client’s anxiety response diminishes through habituation and eventually disappears completely. When used to treat obsessive– compulsive disorder, exposure is accompanied by response prevention (clients are prevented from performing the rituals they normally use to reduce their anxiety). For example, suppose someone has a fear of contact with objects ‘contaminated’ by other people, such as doorknobs. If they normally reduce their anxiety in such situations with repetitive hand-washing, they would be prevented from doing so at the same time as flooding therapy is administered.
Operant techniques Operant, or instrumental, conditioning occurs when behaviour is governed by the consequences that immediately follow it. A family of therapeutic techniques has emerged from this type of conditioning, generically termed ‘contingency management’. One example is the token economy – in a controlled environment (such as a psychiatric ward or classroom), tokens are used to increase the likelihood of targeted behaviours. The tokens can be exchanged for desired items or activities (e.g. snacks, TV), much as we use money in everyday life. Token economies are widely used in hospitals that treat people with chronic, severe psychological disorders like schizophrenia, and have proved to be highly effective (Chambless et al., 1998). Contingency management is also used in individual behaviour therapy. In the context of a warm, supportive relationship with the client, a behaviour therapist uses social reinforcers (e.g. nods, smiles, approval) to help bring about behaviour change.
Time out is a form of contingency management that can reduce the frequency of an undesirable behaviour by removing the person from the situation in which the behaviour is reinforced. For example, sending a child to a quiet, boring location for a short period following misbehaviour is an effective way of changing the behaviour, especially when it is coupled with positive reinforcement of appropriate behaviour. Another punishment contingency is response cost, which involves loss of a reward following a behaviour that we seek to change (such as smoking, aggression or self-abuse). Response cost suppresses behaviour longer than other forms of punishment and is considered more acceptable than more severe forms of punishment, such as are used in aversion therapy.
Aversion therapy
Aversion therapy can draw on the principles of both classical and operant conditioning. When based on classical conditioning, a problem behaviour is paired with exposure to an aversive unconditioned stimulus in an attempt to establish an aversive response to the behaviour (e.g. fear or disgust). For example, an alcoholic is made nauseous (by the drug emetine) and is then given a glass of his favourite drink. After a few pairings the nausea becomes associated with the drink. In one study using this technique, abstinence was successfully induced for a year in 63 per cent of 685 hospitalized alcoholics, and 33 per cent were still dry after three years (Wiens & Menustik, 1983; see review by Elkins, 1991). However, a problem with this method is that exposure to the original stimulus (in this case drinking alcohol) over time tends to weaken the classically conditioned response enough to result in relapse. When based on operant conditioning, the aversive stimulus acts as a punishment and is delivered immediately aft er the problematic behaviour. The Everyday psychology box in chapter 1 gives an example of how aversion therapy was used in this way to treat ruminative vomiting and save a child’s life. Aversion therapy has been used to treat a variety of problems, including alcoholism, smoking, overeating, compulsive gambling, self-injurious behaviour and some sexual deviations such as exhibitionism. One of the drawbacks, however, is that it does not teach alternative behaviours to replace the problem activities. There are also serious ethical problems, especially when the cognitive functioning of the client prevents them giving informed consent (as in the case of young children). So aversion therapy tends to be used as a last resort after other treatments have failed, to control acute behaviours that threaten the client’s or others’ wellbeing (such as self-abuse or uncontrollable physical violence). A more acceptable and less intrusive form of aversion therapy is covert sensitization. Here the client imagines both the problem behaviour and the aversive stimulus. Perhaps surprisingly, in many patients a nauseous response to alcohol, for instance, can be induced in this way.
Modelling
Vicarious learning by observing and imitating the behaviour of others is also used in behaviour therapy. The therapist models the behaviour for the client, who is then reinforced for performing it and encouraged to try it outside the therapy session. For example, a therapist can treat phobias by encouraging the client to exhibit the modelled behaviour when in the feared situation. The client first observes the model, then makes gradual contact with the feared object. Modelling is most effective when the model is similar to the client, has high status and is reinforced (e.g. receives social approval such as praise) for his action (Bandura, 1986). The similarity between the client and the model can be increased by having the model initially display fear before successfully performing the desired behaviour (Meichenbaum, 1971).
Social skills
A lack of social skills necessary for interpersonal relationships can exacerbate or even partly account for psychological disorders. So behaviour therapists include social skills training in treatment of depression (Bellack et al., 1983), anxiety disorders (van Dam- Baggen & Kraaimat, 2000) and schizophrenia (McQuaid et al., 2000). The first step is to determine skill deficits in concrete terms (e.g. avoiding eye contact, speaking too softly) before developing more appropriate behaviour through modelling and social reinforcement.
Assertiveness training is widely used, especially when the inability to express personal needs appropriately leads someone to be depressed or aggressive. It is designed to help clients express their feelings in ways that don’t infringe upon the rights of others, rather than suffering in silence or exploding in anger. Social skills training has been expanded in recent years to promote a broader array of skills, such as making conversation and participating in interpersonal problem solving. Does it work? Critics of behaviour therapy argue that it is superficial and deals only with symptoms rather than their root causes. As a result, critics argue that new symptoms are likely to arise (a process known as symptom substitution). While it is no doubt true that many problem behaviours arise in response to past circumstances, there is no evidence for symptom substitution. A second criticism is that behaviour therapy doesn’t pay attention to thought processes that might support problem behaviour. One view of abnormal behaviour is that it results from distorted thinking. Is it therefore possible that it isn’t just stimulus– response connections or reinforcement that matter, but also the way we perceive events in our life? The internal psychological processes deemed irrelevant by strict behavioural therapists might themselves be maladaptive and need to be changed. In response to these concerns, a range of techniques have been developed to influence maladaptive ways of thinking directly.
COGNITIVE THERAPY
Cognitive therapy is a relatively short-term treatment (about 20 sessions) designed to get clients thinking about events in their life – including the symptoms of their disorder – in new ways. Sessions focus on concrete problems and help clients to challenge their beliefs about the problem. Although the cognitive therapist engages the client in behavioural tasks, cognitive therapy differs from behaviour therapy in focusing on the patient’s internal (cognitive and affective) experiences. Central to cognitive therapy is the identification of the client’s latent dysfunctional schema – or underlying rules of life. For example, if a person evaluates everything he does in terms of his competence, his thinking might be dominated by the schema, ‘Unless everything I do is perfect, I’m a failure.’ To change dysfunctional schemas such as this one, the cognitive therapist uses an active, structured and directive approach, focusing on the ‘here and now’, and not offering interpretations of the unconscious origins of problems in childhood.
Beck’s cognitive therapy
Aaron Beck developed one of the most influential cognitive therapies to treat depression. Beck maintains that the depressed person’s negative view of self, the world and the future (the ‘cognitive triad’) results from the operation of maladaptive automatic thoughts – the spontaneously generated thoughts associated with specific moods or situations (e.g. ‘Everything I do turns out wrong’). In depression, these cognitive distortions can take many forms including dichotomous thinking (‘I’m either a success or a failure’), overgeneralization (‘Whatever I say just shows how stupid I am’), arbitrary inference (‘He glanced over my shoulder while talking to me. I’m a social failure’) and magnification (‘My mistake in answering the test question just shows that I’m an idiot who shouldn’t be at university’). Whatever form the cognitive distortion takes, a primary goal in cognitive therapy is to help the client identify automatic thoughts and evaluate them. The therapist helps the client to do this by asking questions like, ‘What is the evidence for this idea?’, ‘Is there another way to look at the situation?’, ‘Are these facts, or your interpretation of the facts?’ The therapist also formulates a hypothesis regarding the automatic thought and invites the client to test the validity of the hypothesis in a systematic way – a process called collaborative empiricism. In taking this approach, ultimately more realistic, accurate interpretations should replace the automatic thoughts, distorted beliefs and assumptions.
Here’s an example of cognitive therapy in action. A depressed, attractive woman in her twenties had the following interchange with her therapist. Notice how the therapist engages her in collaborative empiricism when dealing with her automatic thoughts about being ugly and undesirable.
Therapist: Other than your subjective opinion, what evidence do you have that you are ugly?
Client: Well, my sister always said I was ugly.
Therapist: Was she always right in these matters?
Client: No. Actually, she had her own reasons for telling me this.
But the real reason I know I’m ugly is that men don’t ask me out. If I weren’t ugly, I’d be dating now.
Therapist: That is a possible reason why you are not dating. But there’s an alternative explanation. You told me that you work in an office by yourself all day and spend your nights alone at home. It doesn’t seem like you’re giving yourself opportunities to meet men.
Client: I can see what you’re saying but still, if I weren’t ugly, men would ask me out.
Therapist: I suggest we run an experiment: that is, for you to become more socially active, stop turning down invitations to parties and social events and see what happens.
Following this interchange, the client became more active and was able to relinquish the thought that she was ugly. Therapy then focused on helping her change her assumption that her worth was based on her appearance. The treatment went on to deal with her assumption that she could not be happy without love (or attention from a man).
Therapist: On what do you base this belief that you can’t be happy without a man?
Client: I was really depressed for a year and a half when I didn’t have a man.
Therapist: Is there another reason why you were depressed?
Client: As we discussed, I was looking at everything in the distorted way. But I still don’t know if I could be happy if no one was interested in me.
Therapist: I don’t know either. Is there a way we could find out?
Client: Well, as an experiment, I could not go out on dates for a while and see how I feel.
Therapist: I think that’s a good idea. Although it has its flaws, the experimental method is still the best way currently available to discover the facts. . . . If you find you can be happy without a
man, this will greatly strengthen you and also make your future relationships all the better.
(Beck et al., 1979, pp. 253–4)
Although initially formulated to treat depression, Beck’s cognitive therapy has been applied to the treatment of anxiety disorders, personality disorders, eating disorders and as a complement to antipsychotic drug therapy for schizophrenia (Wright & Beck, 1994). Numerous controlled studies show that cognitive therapy is effective for depression, producing acute symptomatic relief and lower relapse rates than drug treatment. In one study the relapse rate was just 23 per cent at two years, as opposed to 78 per cent after drug treatment (Blackburn et al., 1981). There is also evidence of effectiveness for anxiety disorders, particularly generalized anxiety disorder and panic disorder.
Rational emotive therapy
Albert Ellis developed one of the earliest forms of cognitive therapy – rational emotive therapy (RET). According to Ellis (1973), when an emotional consequence (C) follows an activating event (A), it is not A that causes C but the individual’s beliefs (B) (figure 16.8). The goal of RET is to change pervasive patterns of irrational thinking. It ‘largely consists of the use of the logico-empirical method of scientific questioning, challenging and debating’ (Ellis, 1977, p. 20). So the RET therapist is challenging and confrontational, asking questions like, ‘Where is it written that life has to be fair?’ or ‘Who says you’ll have a breakdown if your partner breaks up with you?’ A common technique used in this form of therapy is to engage in shame-attacking exercises, in which clients are encouraged to deliberately do something they find embarrassing to show that the consequences are not catastrophic. Does it work? Two criticisms of cognitive therapy are that the linear causality on which it is based (cognition → behaviour) is too simple, and that it emphasizes internal events (cognition) at the expense of contextual events. But the cognitive perspective on which cognitive therapy is based is actually closer to a diathesis–stress model, in which life events, thoughts, behaviour and emotions are inextricably linked and exert reciprocal effects on each other. Indeed, attention to behaviour is central to cognitive therapy, and so the distinction between behavioural and cognitive therapy has been blurred. Beck’s therapy is generally viewed as a cognitive– behavioural therapy, and RET is now often referred to as rational emotive behaviour therapy (Ellis, 1993; 2001). Although criticized for being too simplistic, RET itself can be useful in clinical practice. But, while there is evidence that the tendency to endorse irrational thoughts is associated with a variety of disorders (Alden & Safran, 1978), Ellis’s a priori identification of a core set of irrational beliefs has been questioned. Critics argue that the utility of beliefs needs to be taken into account when we decide on their rationality. A client’s ‘irrational’ belief can be effective and desirable in their circumstances, while a ‘rational’ belief may be maladaptive in a certain situations (Arnkoff & Glass, 1982). Finally, critics question whether the positive effects of cognitive therapy reflect something specific to cognitive therapy, or to some mechanism that it shares with other psychotherapies.
HUMANISTIC THERAPY
Humanistic therapies focus on the phenomenology (conscious experience) of the client and view psychological problems as disturbances in awareness or undue restrictions on existence. According to this framework, a client’s problems can be understood only when viewed from his or her own point of view. The aims of humanistic therapies (also called experiential or phenomenological therapies) are to help people get in touch with their feelings, experience their ‘true selves’ and develop meaning in their life. This is done through the nature of the therapeutic relationship and the client’s tendency to grow as a unique individual (a process known as self-actualization).
Gestalt therapy
Developed by Fritz Perls, Gestalt therapy reflects the view that people often control their own thoughts, behaviours and feelings too much, losing touch with their emotions and authentic selves. The Gestalt therapist aims to enhance the client’s awareness of herself, which helps the client to grow (Perls, 1969). According to this viewpoint, talking about the past or future obstructs therapy, as it is an escape from the reality of the ‘here and now’, which is of paramount importance in Gestalt therapy. Awareness in the here and now supposedly leads to change. Consistent with the Gestalt principle of holism (the whole is greater than the sum of the parts; see chapter 1), the goal is to help the client, through change, to integrate polarities (e.g. feminine and masculine sides of the personality), and achieve a whole sense of the self. The Gestalt therapist may often be quite confrontational in forcing the client to focus on the here and now and deal honestly with his feelings. Indeed, according to one commentat or, Perls ‘was often seen as inhumane in application of his technique’ (Cottonne, 1992, p. 148). Role-playing is used extensively in Gestalt therapy to explore interpersonal games, conflicts between different parts of the self, and so on. Sometimes an empty chair is placed near the client, and he is asked to imagine that the person towards whom he experiences repressed emotions is sitting in the chair. The client can then safely experience his feelings by ‘talking’ to the person. In a similar vein, two chairs might be used to allow the client to ‘seat’ two different sides of the same conflict, one in each chair. The client then plays the part of each side of the conflict, as a way of learning to allow the polarities to exist. Enactment (or putting feelings or thoughts into action) is another form of role-play used in this approach. Gestalt therapy has been aptly summarized as follows: ‘The Gestalt therapist places more value in action than in words, in experience than in thoughts, in the living process of the rapeutic interaction, and the inner change resulting thereby, than in influencing beliefs’ (Naranjo, 1970, p. 47).
[Frederick ‘Fritz’ Perls (1893–1970) was born in Germany, earned his MD degree in 1926, and then worked at the Institute for Brain Damaged Soldiers in Frankfurt. He became a psychoanalyst before developing Gestalt therapy. Perls moved to South Africa in the early 1930s, where he wrote Ego, Hunger, and Aggression: A Revision of Freud’s Theory and Method (1946). In 1946 he moved to New York City and wrote The Beginning of Gestalt Therapy (with Ralph Hefferline and Paul Goodman) in 1951. Perls and his wife organized the New York Institute of Gestalt Therapy before moving to California in 1960, where he continued to offer Gestalt therapy workshops until his death in 1970.]
Client-centred therapy
This most influential humanist therapy was developed by Carl Rogers, who believed that ‘it is the client who knows what hurts, what directions to go, what problems are crucial, what experiences have been deeply buried’ (1961, pp. 11–12). In his system, called either client-centred or person-centred therapy, the client determines what to talk about and when to do so, without direction, judgement or interpretation by the therapist. Rogers argued that a person’s natural tendency to grow as a unique individual (self-actualize) is thwarted by judgements imposed on them by other people – what he called conditions of worth. He therefore emphasized the importance of affirming the worth of the client, who typically is not interrupted or questioned by the therapist. This is achieved by the exercise of three therapeutic attitudes:
1. Unconditional positive regard is established by showing the client that she is valued, no matter what. It conveys that the therapist cares about the client, accepts her and trusts in her ability to change. It does not mean that the therapist must agree with or approve of what the client says, but it does mean that the therapist non-judgementally accepts everything the client says as a reflection of her as a person.
Given these tenets, Rogerian therapists understandably do not offer advice – to do so would imply that the client is not competent and is dependent on help.
2. Also essential to the Rogerian therapist is empathy – an emotional understanding of what the client is experiencing by seeing things from his point of view. Empathy is conveyed by active listening and the use of reflection – a paraphrasing of what the client has said, which identifies the stepfather. Without direct prompting from Rogers, the client moves from a blunt assertion of mutual hatred to one of unilateral hatred to one in which he expresses respect for his stepfather and the reasons for that respect.
Client: You see I have a stepfather.
Therapist: I see.
Client: Let’s put it this way. My stepfather and I are not on the happiest terms in the world. And so, when he states something and, of course, she goes along, and I stand up and let her know that I don’t like what he is telling me, well, she usually gives in to me.
Therapist: I see.
Client: Sometimes, and sometimes it’s just the opposite.
Therapist: But part of what really makes for difficulty is the fact that you and your stepfather, as you say, are not . . . the relationship isn’t completely rosy.
Client: Let’s just put it this way, I hate him and he hates me. It’s that way.
Therapist: But you really hate him and you feel he really hates you?
Client: Well, I don’t know if he hates me or not, but I know one thing, I don’t like him whatsoever.
Therapist: You can’t speak for sure about his feelings because only he knows exactly what those are, but as far as you are concerned . . .
Client: . . . he knows how I feel about it.
Therapist: You don’t have much use for him?
Client: None whatsoever. And that’s been for about eight years now.
Therapist: So for about eight years you’ve lived with a person whom you have no respect for and really hate?
Client: Oh, I respect him.
Therapist: Ah. Excuse me. I got that wrong.
Client: I have to respect him. I don’t have to, but I do. But I don’t love him, I hate him. I can’t stand him.
Therapist: There are certain things you respect him for, but that doesn’t alter the fact that you definitely hate him and don’t love him?
Client: That’s the truth. I respect anybody who has bravery and courage and he does . . .
Therapist: . . . You do give him credit for the fact that he is brave, he has guts or something?
Client: Yeah. He shows that he can do a lot of things that, well, a lot of men can’t.
Therapist: M-hm, m-hm.
Client: And also he has asthma, and the doctor hasn’t given him very long to live. And he, even though he knows he’s going to die, he keeps working and he works at a killing pace, so I respect him for that, too.
Therapist: M-hm. So I guess you’re saying that he really has . . .
Client: . . . what it takes.
(Raskin, 1985, pp. 167–8)
3. Finally, congruence between the therapist’s actions and feelings, sometimes called genuineness, is important in this form of therapy. A therapist who is experiencing fatigue in the therapy session would not mention it in most psychotherapy approaches, but, for Rogers, mentioning the fatigue ‘strengthens the relationship because the therapist is not trying to cover up a real feeling. It may reduce or eliminate the fatigue and restore the therapist to a fully attending and empathic state’ (Raskin & Rogers, 1989, p. 172).
Does it work? Humanistic therapy has been criticized for emphasizing ‘awareness’, which is seen as counterproductive when distressed individuals may well be already over-aware. Gestalt therapy is also sometimes said to border on game-playing, despite its positive view of human nature (Cottone, 1992). Ironically, Rogers was among the first to recognize the need to evaluate psychotherapy using scientific research, and yet there is little data available to substantiate the effectiveness of his clientcentred therapy. He was the first to record therapy sessions, but analysis of those sessions shows that out of eight different categories of client statement, Rogers consistently followed only one type of statement (i.e. those expressing progress) with a positive response, such as ‘Uh-uh. That’s nice’ or ‘Oh really. Tell me more.’ It perhaps comes as no surprise, then, that his clients increasingly expressed progress during therapy. But this observation doesn’t in itself invalidate client-centred therapy. It merely shows the power of social reinforcers in influencing behaviour. In recognition of this form of therapeutic control, Rogers changed the original description of his therapy from ‘non-directive’ (which it clearly was not) to ‘person-centered’.
[Carl Rogers (1902–87) was reared in a strict religious environment. He entered the Union Theological Seminary, New York, in 1924 and became involved in working with disturbed children. When his interests shifted to clinical psychology, he obtained a doctoral degree from Columbia University. He taught at Ohio State University, the University of Chicago and the University of Wisconsin, before settling at the Center for Studies of the Person in La Jolla, California. As the founder of nondirective (later relabelled person-centred, or client-centred) therapy, he wrote many influential books, including Counseling and Psychotherapy: Newer Concepts in Practice (1942), Client-Centered Therapy (1951), On Becoming a Person (1961) and A Way of Being (1980). He was nominated for a Nobel Peace Prize in 1987.]
FAMILY AND COUPLES THERAPY
Individual psychological disorders often reflect disturbance in family relationships – Framo said that ‘whenever you have a disturbed child you have a disturbed marriage’ (1965, p. 154). And the association between problems in couple relationships and various psychological disorders is well documented (Fincham, 2003). So it’s hardly surprising that couples and family therapies have become major psychotherapeutic approaches.
Family therapy
We can trace family therapy back to the family theories of schizophrenia in the 1950s (recall the concept of the ‘schizophrenogenic mother’ described in chapter 15). The proponents of these theories, such as Bateson and colleagues (1956) emphasized distorted communication as the cause of schizophrenia. They offered a radical new perspective on psychological disorders by focusing on the interaction taking place when the behaviour occurs and moved away from considering individual behaviour isolated from an interpersonal context. The goal of family therapy is to change dysfunctional patterns
of interaction. Structural family therapy (Minuchin, 1974), as the name suggests, focuses on the organization or structure of the family and uses direct, active interventions to disrupt dysfunctional interactions. For example, a therapist working with a family who had an anorexic daughter discovered that the father felt closer to his daughter than to his wife and forbade his children to close their bedroom doors. The therapist surmised that a breakdown in generational boundaries might underlie the girl’s refusal to eat. So the first stage of treatment was a directive from the therapist for the daughter to be allowed to close her bedroom door for two hours a day, and for the husband and wife to spend an hour together each evening in their bedroom with the door shut (Hoffman, 1981). This constituted the beginning of a successful intervention in which family boundaries were redefined.
Couples therapy
Traditionally focused on the marital dyad, couples therapy is also used with gay and lesbian couples and non-married heterosexual couples. Like family therapy, various types of couple therapy are practised in an attempt to change interactional patterns. An example of such a pattern is a husband who withdrew whenever the wife raised a topic on which they disagreed – a response pattern that was extremely distressing to the wife. This response to conflict was a pattern developed in his family of origin. The conflict between his mother and father had been so distressing that, with help, the husband was eventually able to recall climbing into his wardrobe and covering his ears when his mother and father disagreed with each other. The therapist also discovered that a prior attempt to stop the conflict between his parents had resulted in a severe beating, so avoidance of conflict had been adaptive. Decades later, this response was now unconsciously guiding his interaction with his wife. The most thoroughly evaluated couple therapy is based on the premise that ‘distress results from couples’ aversive and ineffectual response to conflict’ (Koerner & Jacobson, 1994, p. 208). Interactions of distressed couples are characterized by negative reciprocity – the tendency for one partner to respond with negative behaviour when the other partner behaves negatively, resulting in long chains of escalating negative interaction. In such cases, the goal of therapy is to help couples develop communication and problem-solving skills that will allow them to avoid such cycles, and to break out of them should they occur. This form of therapy therefore tends to focus on changing behaviour and so is really a form of behaviour therapy. Do couples and family therapies work? Because many family therapies have been developed by highly skilled, charismatic therapists, some critics argue that the attraction of these therapies may reflect little more than this charisma. This concern is reinforced by the relative lack of research on many of these ther pies. Indeed, when fifteen different approaches to family and couples therapy were cross-tabulated across ten different psychological disorders, it was found that systematic evaluations of the efficacy of these therapies had been conducted on only 35 of the 150 method-by-problem combinations (Gurman et al., 1986). This is a circumstance that has improved only slightly since this time. Nevertheless, it has been reported that bona fide treatments produce beneficial outcomes for about two-thirds of cases in 20 sessions or fewer, and these treatments are probably as effective or even more effective than many individual treatments for problems relating to family or relationship conflict (Alexander, Holtzworth- Munroe & Jameson, 1994).
ASSESSING THE EFFECTS OF PSYCHOTHERAPY
In 1994, 180,000 subscribers to Consumer Reports, a popular magazine in the USA, were asked to respond to questions about mental health, including whether they had received help for a mental health problem since 1991. Of the 2,900 respondents who had received psychotherapy, 90 per cent stated that the therapy helped at least ‘somewhat’, with 54 per cent reporting that it had ‘helped a great deal’. Martin Seligman, an eminent psychologist, has argued that these findings contribute to the ‘empirical validation of psychotherapy’ (1995, p. 895). The earlier discussion of evaluating psychotropic drugs applies equally well to the appropriate evaluation of psychotherapy. Clearly the absence of a control group in the Consumer Reports study means that we cannot attribute any individual change to treatment. Also, relying solely on client report is dubious at best, given the client’s stake (for example, his/her personal investment in terms of time and money) in believing the psychotherapy worked – a clear example of cognitive dissonance. In the end the Consumer Reports survey was dismissed as uninterpretable (Hollon, 1996; Jacobson & Christensen, 1996) for several reasons, including:
the minimal response rate – 1.9 per cent of the original sample;
the unknown nature and metric of the outcome variable – what exactly constitutes being ‘helped’ and the scale used by clients to rate this outcome are both unknown; and
the self-selected nature of the sample.
Yet, although best viewed as an informal survey of client satisfaction rather than a systematic study of psychotherapy efficacy, the controversy generated by this piece had the salutary effect of forcing both proponents and critics of psychotherapy to clarify issues regarding the its evaluation. How can we assess psychotherapies? There has been sustained attention to evaluating the effectiveness of psychotherapy since the 1950s. The continued need to clarify how best to do this attests to the difficulty of the task. The first difficulty is one of sheer magnitude. With some 400 therapies and over 150 psychological disorders (Garfield & Bergin, 1994), there are potentially 60,000 treatment/disorder combinations to evaluate. To do so systematically would require 47 million comparisons. Needless to say, only a minute fraction of this number of analyses has been conducted. Some treatments have not been investigated at all, as their proponents assert simply that they ‘work’ and that objective verification is unnece ssary.
Taking drug assessment as a model in fact raises more difficulties. For example, what constitutes an appropriate control group in evaluating psychotherapy? In drug evaluations, a placebo group is a useful starting point, and placebo effects also occur in psychotherapy. But suppose in our evaluation of psychotherapeutic efficacy we set up an ‘attention placebo control group’, in which regular meetings with another human being involve theoretically inert therapeutic content. Is this truly a placebo, when the experimental treatment is premised on the therapeutic value of a human relationship? Moreover, while it is possible to use single-blind procedures in psychotherapy research, it is virtually impossible to conduct double-blind studies. Another vexing problem in applied settings is that clients choose whether to seek psychotherapy, choose the type of psychotherapy and determine how long they will remain in therapy. This self-selection means that different types of people are likely to select and remain in diff rent type of therapies, resulting in biased samples. Added to this is the difficulty of obtaining a stable group sample (clients may change therapists or discontinue therapy completely). These are just a few examples from a long list of problems confronting psychotherapy evaluation. What do we know about psychotherapy’s effectiveness? Recognizing the evolving nature of its evaluation, what have we learned about the effectiveness of psychotherapy over the last 50 years? Hans Eysenck published a landmark paper on the topic in the early 1950s. Although he was not the first to address psychotherapy outcome, it was distinguished from its predecessors by its reliance on empirical data and by its unpopular conclusions. Eysenck (1952) concluded that approximately two thirds of neurotic patients (i.e. patients with anxiety disorders and depression) recovered spontaneously, compared to 60 percent who received psychotherapy. In other words, in these groups of patients psychotherapy had no beneficial effect! However, the studies reviewed failed to meet even the minimal methodological criteria that must now be met to qualify for systematic evaluation. Nevertheless, when Eysenck reviewed the literature again eight years later, including studies that were more adequate methodologically, he reached the same conclusion: ‘With the single exception of therapeutic methods based on learning theory, results of published research . . . suggest that the therapeutic effects of psychotherapy are small or non-existent’ (1960, p. 245).
The value of Eysenck’s work may lie in the stimulus it provided to improve the quality of psychotherapy outcome research, which has since dramatically increased. In hindsight, it is also clear that Eysenck overestimated the rate of spontaneous improvement, which, according to a subsequent review, is around 30 per cent, depending on the diagnostic composition of the group (Bergin, 1971). From this revised perspective, the 60 per cent improvement rate found for psychotherapy provides some modest evidence for its efficacy. In an analysis of 475 studies involving 25,000 patients treated by a variety of psychotherapies, substantial data were accumulated. Smith, Glass and Miller (1980) executed this monumental task using meta-analysis, a quantitative method for combining results across a number of studies. Meta-analysis involves examining effect sizes (a measure of association between two variables in a standard metric that can be applied across studies). In this case, effect sizes were the average difference in im provement in treated and untreated clients in each study. These average differences were computed from a variety of outcome variables, including client report, therapist rating of client improvement and improvement observed by friends and family. Smith, Glass and Miller averaged the effect sizes across outcome variables in each study, and then averaged them across all studies. They found that the average client who received treatment was better off than 80 per cent of the clients who went untreated. These findings were repeated when clients were studied months or years after their treatment (Nicolson & Berman, 1983).
More recent meta-analyses have reached similar conclusions (e.g. Anderson & Lambert, 1995; Shadish et al., 1997; Weisz et al., 1995). We now know that for 50 per cent of clients, beneficial effects begin to appear after about six to eight sessions of psychotherapy, and that 75 per cent of those who show improvement do so by the 26th session (Howard et al., 1996). What can we conclude? Can we therefore conclude that psychotherapy is effective? The data certainly support this conclusion, but there are still some concerns. For example, examine figure 16.12 carefully and you will see that some treated clients end up worse off than the average untreated client. So you might justifiably wonder whether psychotherapy can be harmful. It is estimated that about 5–10 per cent of clients deteriorate after psychotherapy, but the causes of such changes are poorly understood (Shapiro & Shapiro, 1982; Smith et al., 1980). In addition to a bad therapist–client relationship and therapist incompetence (Hadley & Strupp, 1976; Sm ith et al., 1980), it is also possible that for some clients psychotherapy disrupts a stable pattern of functioning without offering a clear substitute (Hadley & Strupp, 1976). Clearly much remains to be learned if we are to answer the ‘ultimate question’ about psychotherapy: ‘What treatment, by whom, is most effective for this individual with that specific problem, under what set of circumstances?’ (Paul, 1969, p. 44).
