The long history of efforts to treat psychological disorders has included a bewildering mix of methods, harsh and gentle. Well-meaning individuals have cut holes in people’s heads and restrained, bled, or “beat the devil” out of them. But they also have given warm baths and massages and placed people in sunny, serene environments. They have administered drugs. And they have talked with their patients about childhood experiences, current feelings, and maladaptive thoughts and behaviors.

Reformers Philippe Pinel (1745–1826) and Dorothea Dix (1802–1887) pushed for gentler, more humane treatments and for constructing mental hospitals. Since the 1950s, drug therapies and community-based treatment programs have replaced most of those hospitals.

15-1 How do psychotherapy and the biomedical therapies differ?

Modern Western therapies can be classified into two main categories.

The care provider’s training and expertise, as well as the disorder itself, influence the choice of treatment. Psychotherapy and medication are often combined. Kay Redfield Jamison received psychotherapy in her meetings with her psychiatrist, and she took medications to control her wild mood swings.

Let’s look first at the psychotherapy options for those treated with “talk therapies.” Each is built on one or more of psychology’s major theories: psychodynamic, humanistic, behavioral, and cognitive. Most of these techniques can be used one-on-one or in groups. Some therapists combine techniques in an integrative, eclectic approach. And like Jamison, many patients receive psychotherapy combined with medication.

15-2 What are the goals and techniques of psychoanalysis, and how have they been adapted in psychodynamic therapy?

The first major psychological therapy was Sigmund Freud’s psychoanalysis. Although few clinicians today practice therapy as Freud did, his work deserves discussion. It helped form the foundation for treating psychological disorders, and it continues to influence modern therapists working from the psychodynamic perspective.

The Goals of Psychoanalysis

Freud believed that in therapy, people could achieve healthier, less anxious living by releasing the energy they had previously devoted to id-ego-superego conflicts (see Chapter 13). Freud assumed that we do not fully know ourselves. There are threatening things that we seem not to want to know—that we disavow or deny. Psychoanalysis was Freud’s method of helping people to face such unwelcome facts.

Freud’s therapy aimed to bring patients’ repressed or disowned feelings into conscious awareness. By helping them reclaim their unconscious thoughts and feelings, and by giving them insight into the origins of their disorders, he aimed to help them reduce growth-impeding inner conflicts.

The Techniques of Psychoanalysis

Psychoanalysis is historical reconstruction. Psychoanalytic theory emphasizes the power of childhood experiences to mold the adult. Thus, it aims to unearth the past in the hope of loosening its bonds on the present. After discarding hypnosis as an unreliable excavator, Freud turned to free association.

Imagine yourself as a patient using free association. You begin by relaxing, perhaps by lying on a couch. As the psychoanalyst sits out of your line of vision, you say aloud whatever comes to mind. At one moment, you’re relating a childhood memory. At another, you’re describing a dream or recent experience. It sounds easy, but soon you may notice how often you edit your thoughts as you speak. You pause for a second before uttering an embarrassing thought. You omit what seems trivial, irrelevant, or shameful. Sometimes your mind goes blank or you clutch up, unable to remember important details. You may joke or change the subject to something less threatening.

To the analyst, these mental blocks indicate resistance. They hint that anxiety lurks and you are defending against sensitive material. The analyst will note your resistances and then provide insight into their meaning. If offered at the right moment, this interpretation—of, say, your not wanting to talk about your mother—may illuminate the underlying wishes, feelings, and conflicts you are avoiding. The analyst may also offer an explanation of how this resistance fits with other pieces of your psychological puzzle, including those based on analysis of your dream content.

Over many such sessions, your relationship patterns surface in your interactions with your therapist. You may find yourself experiencing strong positive or negative feelings for your analyst. The analyst may suggest you are transferring feelings, such as feelings of dependency or mingled love and anger, that you experienced in earlier relationships with family members or other important people. By exposing such feelings, you may gain insight into your current relationships.

Relatively few North American therapists now offer traditional psychoanalysis. Much of its underlying theory is not supported by scientific research (Chapter 13). Analysts’ interpretations do not follow the scientific method—they cannot be proven or disproven. And psychoanalysis takes considerable time and money, often years of several expensive sessions each week. Some of these problems have been addressed in the modern psychodynamic perspective that has evolved from psychoanalysis.

Psychodynamic Therapy

Although influenced by Freud’s ideas, psychodynamic therapists don’t talk much about id, ego, and superego. Instead, they try to help people understand their current symptoms by focusing on themes across important relationships, including childhood experiences and the therapist relationship. “We can have loving feelings and hateful feelings toward the same person,” notes psychodynamic therapist Jonathan Shedler (2009), and “we can desire something and also fear it.” Client-therapist meetings take place once or twice a week (rather than several times per week), and often for only a few weeks or months. Rather than lying on a couch, out of the therapist’s line of vision, patients meet with their therapist face-to-face and gain perspective by exploring defended-against thoughts and feelings.

Therapist David Shapiro (1999, p. 8) illustrates this method with the case of a young man who had told women that he loved them, when he knew that he didn’t. His explanation: They expected it, so he said it. But with his wife, who wished he would say that he loved her, he found he couldn’t do that—“I don’t know why, but I can’t.”

Therapist: Do you mean, then, that if you could, you would like to?

Patient: Well, I don’t know…. Maybe I can’t say it because I’m not sure it’s true. Maybe I don’t love her.

Further interactions revealed that he could not express real love because it would feel “mushy” and “soft” and therefore unmanly. Shapiro noted that this young man was “in conflict with himself, and he [was] cut off from the nature of that conflict.” With such patients, who are estranged from themselves, therapists using psychodynamic techniques “are in a position to introduce them to themselves. We can restore their awareness of their own wishes and feelings, and their awareness, as well, of their reactions against those wishes and feelings.”

Exploring past relationship troubles may help clients understand the origin of their current difficulties. Jonathan Shedler (2010) recalled his patient “Jeffrey’s” complaints of difficulty getting along with his colleagues and wife, who saw him as hypercritical. Jeffrey then “began responding to me as if I were an unpredictable, angry adversary.” Shedler seized this opportunity to help Jeffrey recognize the relationship pattern, and its roots in the attacks and humiliation he experienced from his alcohol-abusing father. He was then able to work through and let go of this defensive style of responding to people. Without embracing all aspects of Freud’s theory, psychodynamic therapists aim to help people gain beneficial insight into their childhood experiences and unconscious dynamics.

15-3 What are the basic themes of humanistic therapy? What are the specific goals and techniques of Rogers’ client-centered approach?

The humanistic perspective (Chapter 13) emphasizes people’s inherent potential for self-fulfillment. Not surprisingly, humanistic therapies attempt to reduce the inner conflicts that interfere with natural development and growth. To achieve this goal, humanistic therapists try to give clients new insights. Indeed, because they share this goal, the psychodynamic and humanistic therapies are often referred to as insight therapies. But humanistic therapies differ from psychodynamic therapies in many other ways:

All these themes are present in the widely used humanistic technique that Carl Rogers (1902-1987) developed and called client-centered therapy. In this nondirective therapy, the therapist listens, without judging or interpreting, and refrains from directing the client toward certain insights.

Believing that most people possess the resources for growth, Rogers (1961, 1980) encouraged therapists to foster that growth by exhibiting genuineness, acceptance, and empathy. By being genuine, therapists hope to encourage clients to likewise express their true feelings. By being accepting, therapists may help clients feel freer and more open to change. By showing empathy—by sensing and reflecting their clients’ feelings—therapists can help clients experience a deeper self-understanding and self-acceptance (Hill & Nakayama, 2000). As Rogers (1980, p. 10) explained:

Hearing has consequences. When I truly hear a person and the meanings that are important to him at that moment, hearing not simply his words, but him, and when I let him know that I have heard his own private personal meanings, many things happen. There is first of all a grateful look. He feels released. He wants to tell me more about his world. He surges forth in a new sense of freedom. He becomes more open to the process of change.

I have often noticed that the more deeply I hear the meanings of the person, the more there is that happens. Almost always, when a person realizes he has been deeply heard, his eyes moisten. I think in some real sense he is weeping for joy. It is as though he were saying, “Thank God, somebody heard me. Someone knows what it’s like to be me.”

To Rogers, “hearing” was active listening. The therapist echoes, restates, and clarifies what the client has expressed verbally or nonverbally. The therapist also acknowledges those expressed feelings. Active listening is now an accepted part of counseling practices in many schools, colleges, and clinics. Counselors listen attentively. They interrupt only to restate and confirm feelings, to accept what was said, or to check their understanding of something. In the following brief excerpt, note how Rogers tried to provide a psychological mirror that would help the client see himself more clearly:

Rogers: Feeling that now, hm? That you’re just no good to yourself, no good to anybody. Never will be any good to anybody. Just that you’re completely worthless, huh?—Those really are lousy feelings. Just feel that you’re no good at all, hm?

Client: Yeah. (Muttering in low, discouraged voice) That’s what this guy I went to town with just the other day told me.

Rogers: This guy that you went to town with really told you that you were no good? Is that what you’re saying? Did I get that right?

Client: M-hm.

Rogers: I guess the meaning of that if I get it right is that here’s somebody that meant something to you and what does he think of you? Why, he’s told you that he thinks you’re no good at all. And that just really knocks the props out from under you. (Client weeps quietly.) It just brings the tears. (Silence of 20 seconds)

Client: (Rather defiantly) I don’t care though.

Rogers: You tell yourself you don’t care at all, but somehow I guess some part of you cares because some part of you weeps over it.

(Meador & Rogers, 1984, p. 167)

Can a therapist be a perfect mirror, critics have asked, without selecting and interpreting what is reflected? Rogers conceded that no one can be totally nondirective. Nevertheless, he said, the therapist’s most important contribution is to accept and understand the client. Given a nonjudgmental, grace-filled environment that provides unconditional positive regard, people may accept even their worst traits and feel valued and whole.

How can we improve communication in our own relationships by listening more actively? Three Rogers-inspired hints may help:

15-4 How does the basic assumption of behavior therapy differ from the assumptions of psychodynamic and humanistic therapies? What techniques are used in exposure therapies and aversive conditioning?

The insight therapies assume that self-awareness and psychological well-being go hand in hand. Psychodynamic therapists expect people’s problems to diminish as they gain insight into their unresolved and unconscious tensions. Humanistic therapists expect people’s problems to diminish as they get in touch with their feelings. Behavior therapists, however, doubt the healing power of self-awareness. (You can become aware of why you are highly anxious during exams and still be anxious.) Rather than delving deeply below the surface looking for inner causes, behavior therapists assume that problem behaviors are the problems, and they view learning principles as useful tools for eliminating those behaviors. If phobias or sexual dysfunctions are learned behaviors, they reason, why not replace them with new, constructive behaviors learned through classical or operant conditioning?

Classical Conditioning Techniques

One cluster of behavior therapies derives from principles developed in Ivan Pavlov’s conditioning experiments (Chapter 7). As Pavlov and others showed, we learn various behaviors and emotions through classical conditioning. If we’re attacked by a dog, we may thereafter have a conditioned fear response when other dogs approach: Our fear generalizes and all dogs become conditioned stimuli.

Could maladaptive symptoms be examples of conditioned responses? If so, might reconditioning be a solution? Learning theorist O. H. Mowrer thought so. He developed a successful conditioning therapy for chronic bed-wetters, using a liquid-sensitive pad connected to an alarm. If the sleeping child wets the bed pad, moisture triggers the alarm, waking the child. With sufficient repetition, this association of bladder relaxation with waking stops the bed-wetting. The treatment has been effective in three out of four cases and the success provides a boost to the child’s self-image (Christophersen & Edwards, 1992; Houts et al., 1994).

Can we unlearn fear responses through new conditioning? Many people have. One example: The fear of riding in an elevator is often a learned fear response to being in a confined space. Counterconditioning pairs the trigger stimulus (in this case, the enclosed space of the elevator) with a new response (relaxation) that is incompatible with fear. Two specific counterconditioning techniques—exposure therapies and aversive conditioning—have successfully counterconditioned many people with such fears.

EXPOSURE THERAPIES Picture this scene: Behavioral psychologist Mary Cover Jones is working with 3-year-old Peter, who is petrified of rabbits and other furry objects. To rid Peter of his fear, Jones plans to associate the fear-evoking rabbit with the pleasurable, relaxed response associated with eating. As Peter begins his midafternoon snack, she introduces a caged rabbit on the other side of the huge room. Peter, eagerly munching away on his crackers and drinking his milk, hardly notices. On succeeding days, she gradually moves the rabbit closer and closer. Within two months, Peter is holding the rabbit in his lap, even stroking it while he eats. Moreover, his fear of other furry objects has also gone away, having been countered, or replaced, by a relaxed state that cannot coexist with fear (Fisher, 1984; Jones, 1924).

Unfortunately for many who might have been helped by Jones’ procedures, her story of Peter and the rabbit did not enter psychology’s lore when it was reported in 1924. It was more than 30 years before psychiatrist Joseph Wolpe (1958; Wolpe & Plaud, 1997) refined Jones’ counterconditioning technique into the exposure therapies used today. These therapies, in a variety of ways, try to change people’s reactions by repeatedly exposing them to stimuli that trigger unwanted reactions. With repeated exposure to what they normally avoid or escape, people adapt. We all experience this process in everyday life. A person moving to a new apartment may be annoyed by nearby loud traffic noise, but only for a while. With repeated exposure, the person adapts. So, too, with people who have fear reactions to specific events. Exposed repeatedly to the situation that once petrified them, they can learn to react less anxiously (Barrera et al., 2013; Foa et al., 2013).

One form of exposure therapy widely used to treat phobias is systematic desensitization. You cannot simultaneously be anxious and relaxed. Therefore, if you can repeatedly relax when facing anxiety-provoking stimuli, you can gradually eliminate your anxiety. The trick is to proceed gradually. If you fear public speaking, a behavior therapist might first ask you to make a list of anxiety-triggering speaking situations. Your list would range from situations that cause you to feel mildly anxious (perhaps speaking up in a small group of friends) to those that provoke panic (having to address a large audience).

In the next step, the therapist would train you in progressive relaxation. You would learn to relax one muscle group after another, until you achieved a comfortable, complete relaxation. The therapist might then ask you to imagine, with your eyes closed, a mildly anxiety-arousing situation: You are having coffee with a group of friends and are trying to decide whether to speak up. If you feel any anxiety while imagining the scene, you will signal by raising your finger. Seeing the signal, the therapist will instruct you to switch off the mental image and go back to deep relaxation. This imagined scene is repeatedly paired with relaxation until you feel no trace of anxiety.

The therapist will then move to the next item on your list, again using relaxation techniques to desensitize you to each imagined situation. After several sessions, you will move to actual situations and practice what you had only imagined before. You will begin with relatively easy tasks and gradually move to more anxiety-filled ones. Conquering your anxiety in an actual situation, not just in your imagination, will increase your self-confidence (Foa & Kozak, 1986; Williams, 1987). Eventually, you may even become a confident public speaker. Often people fear not just a situation (such as public speaking), but also being incapacitated by their own fear response (for example, standing in front of an audience and being unable to speak). As their fear subsides, so also does their fear of the fear.

If an anxiety-arousing situation is too expensive, difficult, or embarrassing to re-create, the therapist may recommend virtual reality exposure therapy. You would don a head-mounted display unit that projects a three-dimensional virtual world in front of your eyes. The lifelike scenes, which shift as your head turns, would be tailored to your particular fear. Experimentally treated fears include flying, heights, particular animals, and public speaking (Parsons & Rizzo, 2008). If you fear flying, you could peer out a virtual window of a simulated plane. You would feel the engine’s vibrations and hear it roar as the plane taxis down the runway and takes off. In controlled studies, people participating in virtual reality exposure therapy have experienced significant relief from real-life fear (Turner & Casey, 2014).

AVERSIVE CONDITIONING Exposure therapies enable a more relaxed, positive response to an upsetting harmless stimulus. Aversive conditioning creates a negative (aversive) response to a harmful stimulus (such as alcohol). Exposure therapies help you accept what you should do. Aversive conditioning helps you to learn what you should not do.

The aversive conditioning procedure is simple: It associates the unwanted behavior with unpleasant feelings. To treat nail biting, one can paint the fingernails with a nasty-tasting nail polish (Baskind, 1997). To treat alcohol use disorder, an aversion therapist offers the client appealing drinks laced with a drug that produces severe nausea. By linking alcohol with violent nausea (recall the taste-aversion experiments with rats and coyotes in Chapter 7), the therapist seeks to transform the person’s reaction to alcohol from positive to negative (FIGURE 15.1).

Does aversive conditioning work? In the short run it may. In one classic study, 685 hospital patients with alcohol use disorder completed an aversion therapy program (Wiens & Menustik, 1983). Over the next year, they returned for several booster treatments in which alcohol was paired with sickness. At the end of that year, 63 percent were still successfully abstaining. But after three years, only 33 percent had remained abstinent.

The problem is that in therapy (as in research), cognition influences conditioning. People know that outside the therapist’s office they can drink without fear of nausea. Their ability to discriminate between the aversive conditioning situation and all other situations can limit the treatment’s effectiveness. Thus, therapists often use aversive conditioning in combination with other treatments.

Operant Conditioning

15-5 What is the main premise of therapy based on operant conditioning principles, and what are the views of its proponents and critics?

The work of B. F. Skinner and others teaches us a basic principle of operant conditioning: Voluntary behaviors are strongly influenced by their consequences. Knowing this, some behavior therapists practice behavior modification. They reinforce behaviors they consider desirable. And they fail to reinforce—or sometimes punish—behaviors they consider undesirable.

Using operant conditioning to solve specific behavior problems has raised hopes for some seemingly hopeless cases. Children with intellectual disabilities have been taught to care for themselves. Socially withdrawn children with autism spectrum disorder (ASD) have learned to interact. People with schizophrenia have been helped to behave more rationally in their hospital ward. In such cases, therapists used positive reinforcers to shape behavior. In a step-by-step manner, they rewarded behaviors that came closer and closer to the desired behavior.

In extreme cases, treatment must be intensive. One study worked with 19 withdrawn, uncommunicative 3-year-olds with ASD. For two years, 40 hours each week, the children’s parents attempted to shape their behavior (Lovaas, 1987). They positively reinforced desired behaviors and ignored or punished aggressive and self-abusive behaviors. The combination worked wonders for some children. By first grade, 9 of the 19 were functioning successfully in school and exhibiting normal intelligence. In a group of 40 comparable children not undergoing this treatment, only one showed similar improvement. Later studies focused on positive reinforcement—the effective aspect of this “Early Intensive Behavioral Intervention” (Reichow, 2012).

The rewards used to modify behavior vary because people differ in what they find reinforcing. For some, the reinforcing power of attention or praise is enough. Others require concrete rewards, such as food. In institutional settings, therapists may create a token economy. When people display desired behavior, such as getting out of bed, washing, dressing, eating, talking meaningfully, cleaning their rooms, or playing cooperatively, they receive a token or plastic coin. Later, they can exchange a number of these tokens for rewards, such as candy, TV time, day trips, or better living quarters. Token economies have been used successfully in various settings (homes, classrooms, hospitals, institutions for juvenile offenders) and among members of various populations (including disturbed children and people with schizophrenia and other mental disabilities).

Behavior modification critics express two concerns. The first is practical: How durable are the behaviors? Will people become so dependent on extrinsic rewards that the desired behaviors will stop when the reinforcers stop? Behavior modification advocates believe the behaviors will endure if therapists wean people from the tokens by shifting them toward other, real-life rewards, such as social approval. Further, they point out that the desired behaviors themselves can be rewarding. As people become more socially competent, the intrinsic satisfactions of social interaction may help them maintain the desired behaviors.

The second concern is ethical: Is it right for one human to control another’s behavior? Those who set up token economies deprive people of something they desire and decide which behaviors to reinforce. To critics, this whole process has an authoritarian taint. Advocates reply that control already exists; people’s destructive behavior patterns are already being maintained and perpetuated by natural reinforcers and punishers in their environments. Isn’t using positive rewards to reinforce adaptive behavior more humane than institutionalizing or punishing people? Advocates also argue that the right to effective treatment and an improved life justifies temporary deprivation.

15-6 What are the goals and techniques of cognitive therapy and of cognitive-behavioral therapy?

People with specific fears and problem behaviors may respond to behavior therapy. But how would you modify the wide assortment of behaviors that accompany depressive disorders? And how would you treat generalized anxiety disorders, where unfocused anxiety doesn’t lend itself to a neat list of anxiety-triggering situations? The cognitive revolution that has influenced other areas of psychology during the last half-century has influenced therapy as well.

The cognitive therapies assume that our thinking colors our feelings (FIGURE 15.2). Between an event and our response lies the mind. Self-blaming and overgeneralized explanations of bad events feed depression. Anxiety arises from an “attention bias to threat” (MacLeod & Clarke, 2015). If depressed, we may interpret a suggestion as criticism, disagreement as dislike, praise as flattery, friendliness as pity. Dwelling on such thoughts sustains negative thinking. Cognitive therapies aim to help people change their minds with new, more constructive ways of perceiving and interpreting events (Kazdin, 2015).

Beck’s Therapy for Depression

Cognitive therapist Aaron Beck believes that changing people’s thinking can change their functioning. Depressed people, he found, often reported dreams with negative themes of loss, rejection, and abandonment. These thoughts extended into their waking thoughts, and even into therapy, as clients recalled and rehearsed their failings and worst impulses (Kelly, 2000). With cognitive therapy, Beck and his colleagues (1979) sought to reverse clients’ negativity about themselves, their situations, and their futures. With this technique, gentle questioning seeks to reveal irrational thinking, and then to persuade people to remove the dark glasses through which they view life (Beck et al., 1979, pp. 145-146):

Client: I agree with the descriptions of me but I guess I don’t agree that the way I think makes me depressed.

Beck: How do you understand it?

Client: I get depressed when things go wrong. Like when I fail a test.

Beck: How can failing a test make you depressed?

Client: Well, if I fail I’ll never get into law school.

Beck: So failing the test means a lot to you. But if failing a test could drive people into clinical depression, wouldn’t you expect everyone who failed the test to have a depression? … Did everyone who failed get depressed enough to require treatment?

Client: No, but it depends on how important the test was to the person.

Beck: Right, and who decides the importance?

Client: I do.

Beck: And so, what we have to examine is your way of viewing the test (or the way that you think about the test) and how it affects your chances of getting into law school. Do you agree?

Client: Right.

Beck: Do you agree that the way you interpret the results of the test will affect you? You might feel depressed, you might have trouble sleeping, not feel like eating, and you might even wonder if you should drop out of the course.

Client: I have been thinking that I wasn’t going to make it. Yes, I agree.

Beck: Now what did failing mean?

Client: (tearful) That I couldn’t get into law school.

Beck: And what does that mean to you?

Client: That I’m just not smart enough.

Beck: Anything else?

Client: That I can never be happy.

Beck: And how do these thoughts make you feel?

Client: Very unhappy.

Beck: So it is the meaning of failing a test that makes you very unhappy. In fact, believing that you can never be happy is a powerful factor in producing unhappiness. So, you get yourself into a trap—by definition, failure to get into law school equals “I can never be happy.”

We often think in words. Therefore, getting people to change what they say to themselves is an effective way to change their thinking. Perhaps you can identify with the anxious students who, before an exam, make matters worse with self-defeating thoughts: “This exam’s probably going to be impossible. All these other students seem so relaxed and confident. I wish I were better prepared. I’m so nervous I’ll forget everything.” Psychologists call this sort of relentless, overgeneralized, self-blaming behavior catastrophizing.

To change such negative self-talk, therapists teach people to restructure their thinking in stressful situations (Meichenbaum, 1977, 1985). Sometimes it may be enough simply to say more positive things to yourself: “Relax. The exam may be hard, but it will be hard for everyone else, too. I studied harder than most people. Besides, I don’t need a perfect score to get a good grade.” After learning to “talk back” to negative thoughts, depression-prone children, teens, and college students have shown a greatly reduced rate of future depression (Reivich et al., 2013; Seligman et al., 2009). To a large extent, it is the thought that counts. TABLE 15.1 provides a sampling of techniques commonly used in cognitive therapy.

It’s not just depressed people who can benefit from positive self-talk. We all talk to ourselves (thinking “I wish I hadn’t said that” can protect us from repeating the blunder). The findings of nearly three dozen sport psychology studies show that self-talk interventions can enhance the learning of athletic skills (Hatzigeorgiadis et?al., 2011). For example, novice basketball players may be trained to think “focus” and “follow through,” swimmers to think “high elbow,” and tennis players to think “look at the ball.”

Cognitive-Behavioral Therapy

“The trouble with most therapy,” said therapist Albert Ellis (1913–2007), “is that it helps you to feel better. But you don’t get better. You have to back it up with action, action, action.” Cognitive-behavioral therapy (CBT), today’s most widely practiced psychotherapy, aims not only to alter the way people think but also to alter the way they act. Like other cognitive therapies, this integrative therapy seeks to make people aware of their irrational negative thinking and to replace it with new ways of thinking. Like other behavior therapies, it trains people to practice the more positive approach in everyday settings.

Anxiety, depressive disorders, and bipolar disorder share a common problem: emotion regulation (Aldao & Nolen-Hoeksema, 2010). An effective CBT program for these emotional disorders trains people both to replace their catastrophizing thinking with more realistic appraisals and, as homework, to practice behaviors that are incompatible with their problem (Kazantzis et al., 2010a,b; Moses & Barlow, 2006). A person might, for example, keep a log of daily situations associated with negative and positive emotions and attempt to engage more in activities that lead to feeling good. Those who fear social situations might learn to restrain the negative thoughts surrounding their social anxiety and practice approaching people.

CBT may also be useful with obsessive-compulsive disorder. In one study, people learned to prevent their compulsive behaviors by relabeling their obsessive thoughts (Schwartz et al., 1996). Feeling the urge to wash their hands again, they would tell themselves, “I’m having a compulsive urge.” They would explain to themselves that the hand-washing urge was a result of their brain’s abnormal activity, which they had previously viewed in PET scans. Then, instead of giving in, they would spend 15 minutes in an enjoyable, alternative behavior, such as practicing an instrument, taking a walk, or gardening. This helped “unstick” the brain by shifting attention and engaging other brain areas. For two or three months, the weekly therapy sessions continued, with relabeling and refocusing practice at home. By the study’s end, most participants’ symptoms had diminished, and their PET scans revealed normalized brain activity. Many other studies confirm CBT’s effectiveness for treating anxiety, depression, and eating disorders (Covin et al., 2008; Milrod et al., 2015; Zalta, 2011).

A newer CBT variation, dialectical behavior therapy (DBT), helps change harmful and even suicidal behavior patterns (Linehan et al., 2015; Valentine et al., 2015). DBT combines cognitive tactics for tolerating distress and regulating emotions with social skills training and mindfulness meditation. Individual therapy aims to teach both acceptance and change—the dialectical, or opposing, forces from which this therapy derives its name. Patients may also participate in a training group that teaches skills, provides a social context for skills practice, and assigns further practice as homework.

15-7 What are the aims and benefits of group and family therapies?

Group Therapy

Except for traditional psychoanalysis, most therapies may also occur in small groups. Group therapy does not provide the same degree of therapist involvement with each client. However, it offers many benefits:

Family Therapy

One special type of group interaction, family therapy, assumes that no person is an island. We live and grow in relation to others, especially our families, yet we also work to find an identity outside of our family. These two opposing tendencies can create stress for both the individual and the family.

Unlike most psychotherapy, which focuses on what happens inside the person’s own skin, family therapists work with multiple family members to heal relationships and to mobilize family resources. They tend to view the family as a system in which each person’s actions trigger reactions from others, and they help family members discover their role within their family’s social system. A child’s rebellion, for example, affects and is affected by other family tensions. Therapists also attempt—usually with some success, research suggests—to open up communication within the family or to help family members discover new ways of preventing or resolving conflicts (Hazelrigg et al., 1987; Shadish et al., 1993).

Self-Help Groups

More than 100 million Americans belong to small religious, interest, or support groups that meet regularly—and 9 in 10 report that group members “support each other emotionally” (Gallup, 1994). One analysis of online support groups and more than 14,000 other self-help groups reported that most such groups focus on stigmatized or hard-to-discuss illnesses (Davison et al., 2000). AIDS patients were 250 times more likely than hypertension patients to be in support groups. People with anorexia and alcohol use disorder often join groups; those with migraines and ulcers usually do not.

The grandparent of support groups, Alcoholics Anonymous (AA), reports having 2.1 million members in 115,000 groups worldwide. Its famous 12-step program, emulated by many other self-help groups, asks members to admit their powerlessness, to seek help from a higher power and from one another, and (the twelfth step) to take the message to others in need of it. Studies of 12-step programs such as AA have found that they help reduce alcohol use disorder at rates comparable with other treatment interventions (Ferri et al., 2006; Moos & Moos, 2005). In one eight-year, $27 million investigation, AA participants reduced their drinking sharply, as did those assigned to cognitive-behavioral therapy or an alternative therapy (-Project MATCH, 1997). In one study of 2300 veterans who sought treatment for alcohol use disorder, a high level of AA involvement was followed by diminished alcohol problems (McKellar et al., 2003). The more meetings members attend, the greater their alcohol abstinence (Moos & Moos, 2006). Those whose personal stories include a “redemptive narrative”—who see something good as having come from their experience—more often sustain sobriety (Dunlop & Tracy, 2013).

In an individualist age, with more and more people living alone or feeling isolated, the popularity of support groups—for the addicted, the bereaved, the divorced, or simply those seeking fellowship and growth—may reflect a longing for community and connectedness.

* * *

For a synopsis of these modern psychotherapies, see TABLE 15.2.

Many Americans have great confidence in psychotherapy’s effectiveness. “Seek counseling” or “Ask your mate to find a therapist,” advice columnists often advise. Before 1950, psychiatrists were the primary providers of mental health care. Today’s providers include clinical and counseling psychologists; clinical social workers; pastoral, marital, abuse, and school counselors; and psychiatric nurses. With such an enormous outlay of time as well as money and effort, it is important to ask: Are the millions of people worldwide justified in placing their hopes in psychotherapy?

Is Psychotherapy Effective?

15-8 Does psychotherapy work? How can we know?

Asking whether psychotherapy has worked is not as simple as asking whether antibiotics have worked to treat an infection. So how can we assess psychotherapy’s effectiveness? By how we feel about our progress? By how our therapist feels about it? By how our friends and family feel about it? By how our behavior has changed?

CLIENTS’ PERCEPTIONS If clients’ testimonials were the only measuring stick, we could strongly assert psychotherapy’s effectiveness. Consider the 2900 Consumer Reports readers who reported on their experiences with mental health professionals (1995; Kotkin et al., 1996; Seligman, 1995). How many were at least “fairly well satisfied”? Almost 90 percent (as was Kay Redfield Jamison, as we saw at this chapter’s beginning). Among those who recalled feeling fair or very poor when beginning therapy, 9 in 10 now were feeling very good, good, or at least so-so. We have their word for it—and who should know better?

But client testimonials don’t persuade everyone. Critics note reasons for skepticism:

CLINICIANS’ PERCEPTIONS If clinicians’ perceptions were proof of therapy’s effectiveness, we would have even more reason to celebrate. Case studies of successful treatment abound. Furthermore, therapists are like the rest of us. They treasure compliments from clients saying good-bye or later expressing their gratitude. The problem is that clients justify entering psychotherapy by emphasizing their unhappiness. They justify leaving by emphasizing their well-being. And they stay in touch only if they are satisfied. Thus, therapists are most aware of the failures of other therapists—those whose clients, having experienced only temporary relief, are now seeking a new therapist for their recurring problems. The same person, with the same recurring anxieties, depression, or marital difficulty, may be a “success” story in several therapists’ files. Moreover, therapists, like the rest of us, are vulnerable to cognitive errors, such as confirmation bias and illusory correlation (Lilienfeld et al., 2014).

OUTCOME RESEARCH How, then, can we objectively assess psychotherapy’s effectiveness? What outcomes can we expect—what types of people and problems are helped, and by what type of psychotherapy?

In search of answers, psychologists have turned to controlled research. This is a well-traveled path. In the 1800s, skeptical medical doctors began to realize that many patients got better on their own and that many fashionable treatments (bleeding, purging) might be doing no good. Sorting fact from superstition required following patients and recording outcomes with and without a particular treatment. Typhoid fever patients, for example, often improved after being bled, convincing most physicians that the treatment worked. Then came the shock. A control group was given mere bed rest, and after five weeks of fever, 70 percent improved, showing that the bleeding was worthless (Thomas, 1992).

In the twentieth century, psychology, with its many different therapy options, faced a similar challenge. British psychologist Hans Eysenck (1952) launched a spirited debate when he summarized 24 studies of psychotherapy outcomes. He found that two-thirds of those receiving psychotherapy for disorders not involving hallucinations or delusions improved markedly. To this day, no one disputes that optimistic estimate.

Why, then, are we still debating psychotherapy’s effectiveness? Because Eysenck also reported similar improvement among untreated persons, such as those who were on waiting lists for treatment. With or without psychotherapy, he said, roughly two-thirds improved noticeably. Time was a great healer.

An avalanche of criticism greeted Eysenck’s conclusions. Some pointed out errors in his analyses. Others noted that he based his ideas on only 24 studies. Now, more than a half-century later, there are hundreds of studies. The best of these are randomized clinical trials: Researchers randomly assign people on a waiting list to therapy or to no therapy. Later, they evaluate everyone and compare the outcomes, with assessments by others who don’t know whether therapy was given. Statistical digests of the results of many studies, or meta-analyses, give us the bottom-line result.

Therapists welcomed the first meta-analysis of some 475 psychotherapy outcome studies (Smith et al., 1980). It showed that the average therapy client ends up better off than 80 percent of the untreated individuals on waiting lists (FIGURE 15.3). The claim is modest—by definition, about 50 percent of untreated people also are better off than the average untreated person.

Dozens of subsequent summaries have now examined psychotherapy’s effectiveness. Their verdict echoes the results of the earlier outcome studies: Those not undergoing therapy often improve, but those undergoing therapy are more likely to improve, and to improve more quickly and with less risk of relapse. Moreover, between the treatment sessions for depression and anxiety, many people experience sudden symptom reductions. Those “sudden gains” bode well for long-term improvement (Aderka et al., 2012).

Is psychotherapy also cost-effective? Again, the answer is Yes. Studies show that when people seek psychological treatment, their search for other medical treatment drops—by 16 percent in one digest of 91 studies (Chiles et al., 1999). Given the staggering annual cost of psychological disorders and substance abuse—including crime, accidents, lost work, and treatment—psychotherapy is a good investment, much like money spent on prenatal and well-baby care. Both reduce long-term costs. Boosting employees’ psychological well-being can lower medical costs, improve work efficiency, and diminish absenteeism.

But note that the claim—that psychotherapy, on average, is somewhat effective—refers to no one therapy in particular. It is like reassuring lung-cancer patients that medical treatment of health problems is, “on average,” somewhat effective. What people want to know is whether a particular treatment is effective for their specific problem.

Which Psychotherapies Work Best?

15-9 Are some psychotherapies more effective than others for specific disorders?

The early statistical summaries and surveys did not find that any one type of psychotherapy is generally better than others (Smith et al., 1977, 1980). Later studies have similarly found little connection between clients’ outcomes and their clinicians’ experience, training, supervision, and licensing (Luborsky et al., 2002; Wampold, 2007). A Consumer Reports survey illustrated this point by asking: Were clients treated by a psychiatrist, psychologist, or social worker? Were they seen in a group or individual context? Did the therapist have extensive or relatively limited training and experience? It didn’t matter. Clients seemed equally satisfied (Seligman, 1995).

So, was the dodo bird in Alice in Wonderland right: “Everyone has won and all must have prizes”? Not quite. Some forms of therapy get prizes for effectively treating particular problems. Behavioral conditioning therapies have had especially good results with specific behavior problems, such as bed-wetting, phobias, compulsions, marital problems, and sexual dysfunctions (Baker et al., 2008; Hunsley & DiGiulio, 2002; Shadish & Baldwin, 2005). Psychodynamic therapy has helped treat depression and anxiety (Driessen et al., 2010; Leichsenring & Rabung, 2008; Shedler, 2010). With mild to moderate depression, nondirective (client-centered) counseling often helps (Cuijpers et al., 2013). And many studies confirm cognitive and cognitive-behavioral therapy’s effectiveness (some say superiority) in coping with anxiety, posttraumatic stress disorder, and depression (Baker et al., 2008; De Los Reyes & Kazdin, 2009; Stewart & Chambliss, 2009; Tolin, 2010).

Moreover, we can say that therapy is most effective when the problem is clear-cut (Singer, 1981; Westen & Morrison, 2001). Those who experience phobias or panic, who are unassertive, or who are frustrated by sexual performance problems can hope for improvement. Those with less-focused problems, such as depression and anxiety, usually benefit in the short term but often relapse later. The more specific the problem, the greater the hope.

But no prizes—and little or no scientific support—go to certain other therapies (Arkowitz & Lilienfeld, 2006). We would all therefore be wise to avoid energy therapies that propose to manipulate people’s invisible energy fields, recovered-memory therapies that aim to unearth “repressed memories” of early child abuse (Chapter 8), and rebirthing therapies that engage people in reenacting the supposed trauma of their birth.

As with some medical treatments, it’s possible for psychological treatments to be not only ineffective but also harmful—by making people worse or preventing their getting better (Barlow, 2010; Castonguay et al., 2010; Dimidjian & Hollon, 2010). The National Science and Technology Council cites the Scared Straight program (seeking to deter children and youth from crime) as an example of well-intentioned programs that have proved ineffective or even harmful.

The evaluation question—which therapies get prizes and which do not?—lies at the heart of what some call psychology’s civil war. To what extent should science guide both clinical practice and the willingness of health care providers and insurers to pay for psychotherapy? On one side are research psychologists using scientific methods to extend the list of well-defined and validated therapies for various disorders. They decry clinicians who “give more weight to their personal experiences” (Baker et al., 2008). On the other side are nonscientist therapists who view their practice as more art than science, something that cannot be described in a manual or tested in an experiment. People are too complex and psychotherapy is too intuitive for such an approach, many therapists say.

Between these two factions stand the science-oriented clinicians calling for evidence-based practice, which has been endorsed by the American Psychological Association and others (2006; Lilienfeld et al., 2013). Therapists using this approach integrate the best available research with clinical expertise and with patient preferences and characteristics (FIGURE 15.4). After rigorous evaluation, clinicians apply therapies suited to their own skills and their patients’ unique situations. Increasingly, insurer and government support for mental health services requires evidence-based practice.

Evaluating Alternative Therapies

15-10 How do alternative therapies fare under scientific scrutiny?

The tendency of many abnormal states of mind to return to normal, combined with the placebo effect (the healing power of mere belief in a treatment), creates fertile soil for pseudotherapies. Bolstered by anecdotes, boosted by the media, and broadcast on the Internet, alternative therapies—newer, nontraditional therapies, which often claim healing powers for various ailments—can spread like wildfire. In one national survey, 57 percent of those with a history of anxiety attacks and 54 percent of those with a history of depression had used alternative treatments, such as herbal medicine, massage, and spiritual healing (Kessler et al., 2001).

Proponents of alternative therapies often feel that their personal testimonials are evidence enough. But how well do these therapies stand up to scientific scrutiny? There is little evidence for or against most of them. Some, however, have been the subject of controlled research. Let’s consider two. As we do, remember that sifting sense from nonsense requires the scientific attitude: being skeptical but not cynical, open to surprises but not gullible.

EYE MOVEMENT DESENSITIZATION AND REPROCESSING DR EMDR (eye movement desensitization and reprocessing) is a therapy adored by thousands and dismissed by thousands more as a sham—“an excellent vehicle for illustrating the differences between scientific and pseudoscientific therapy techniques,” suggested James Herbert and six others (2000).

Psychologist Francine Shapiro (1989, 2007, 2012) developed EMDR while walking in a park and observing that anxious thoughts vanished as her eyes spontaneously darted about. Back in the clinic, she had people imagine traumatic scenes while she triggered eye movements by waving her finger in front of their eyes, supposedly enabling them to unlock and reprocess previously frozen memories. Tens of thousands of mental health professionals from more than 75 countries have since undergone training (EMDR, 2011). No new therapy has attracted so many devotees so quickly since Franz Anton Mesmer introduced hypnosis (then called animal magnetism) more than two centuries ago (also after feeling inspired by an outdoor experience).

Does EMDR work? Shapiro believes it does, and she cites four studies in which it worked for 84 to 100 percent of single-trauma victims (Shapiro, 1999, 2002). Moreover, the treatment need take no more than three 90-minute sessions. The Society of Clinical Psychology task force on empirically validated treatments has acknowledged that EMDR is “probably efficacious” for the treatment of nonmilitary posttraumatic stress disorder (Chambless et al., 1997; see also Bisson & Andrew, 2007; Rodenburg et al., 2009; Seidler & Wagner, 2006).

Why, wonder the skeptics, would rapidly moving one’s eyes while recalling traumas be therapeutic? Some argue that the eye movements relax or distract patients, thus allowing memory-associated emotions to extinguish (Gunter & Bodner, 2008). Others believe the eye movements in themselves are not the therapeutic ingredient (nor is watching high-speed Ping-Pong therapeutic). Trials in which people imagined traumatic scenes and tapped a finger, or just stared straight ahead while the therapist’s finger wagged, have also produced therapeutic results (Devilly, 2003). EMDR does work better than doing nothing, acknowledge the skeptics (Lilienfeld & Arkowitz, 2006/2007). But skeptics suspect that what is therapeutic is the combination of exposure therapy—repeatedly calling up traumatic memories and reconsolidating them in a safe and reassuring context—and perhaps some placebo effect. Had Mesmer’s pseudotherapy been compared with no treatment at all, it, too (thanks to the healing power of positive belief), might have been found “probably efficacious,” observed Richard McNally (1999).

LIGHT EXPOSURE THERAPY Have you ever found yourself oversleeping, gaining weight, and feeling lethargic during the dark mornings and overcast days of winter? Slowing down and conserving energy during the cold, barren winters likely gave our distant ancestors a survival advantage. For people today, however—especially for women and those living far from the equator—the wintertime blahs may constitute a seasonal pattern for major depressive disorder. To counteract these dark feelings, National Institute of Mental Health researchers in the early 1980s had an idea: Give people a timed daily dose of intense light. Sure enough, people reported feeling better.

Was light exposure a bright idea, or another dim-witted example of the placebo effect? Research illuminates the issue. One study exposed some people with a seasonal pattern in their depression symptoms to 90 minutes of bright light and others to a sham placebo treatment—a hissing “negative ion generator” about which the staff expressed similar enthusiasm (but which was generating nothing). After four weeks, 61 percent of those exposed to morning light had greatly improved, as had 50 percent of those exposed to evening light and 32 percent of those exposed to the placebo (Eastman et al., 1998). Other studies have found that 30 minutes of exposure to 10,000-lux white fluorescent light produced relief for more than half the people receiving morning light therapy (Flory et al., 2010; Terman et al., 1998, 2001). From 20 carefully controlled trials we have a verdict (Golden et al., 2005; Wirz-Justice, 2009): Morning bright light does dim depression symptoms for many of those suffering in a seasonal pattern. Moreover, it does so as effectively as taking antidepressant drugs or undergoing cognitive-behavioral therapy (Lam et al., 2006; Rohan et al., 2007). The effects are clear in brain scans; light therapy sparks activity in a brain region that influences the body’s arousal and hormones (Ishida et al., 2005).

How Do Psychotherapies Help People?

15-11 What three elements are shared by all forms of psychotherapy?

How can it be that therapists’ training and experience do not seem to influence clients’ outcomes? The answer seems to be that all psychotherapies offer three basic benefits (Frank, 1982; Goldfried & Padawer, 1982; Strupp, 1986; Wampold 2001, 2007).

HOPE FOR DEMORALIZED PEOPLE People seeking therapy typically feel anxious, depressed, self-disapproving, and incapable of turning things around. What any psychotherapy offers is the expectation that, with commitment from the therapy seeker, things can and will get better. This belief, apart from any therapy technique, may improve morale, create feelings of self-efficacy, and reduce symptoms (Corrigan, 2014; Prioleau et al., 1983).

A NEW PERSPECTIVE LEADING TO NEW BEHAVIORS Every psychotherapy offers people an explanation of their symptoms. Therapy is a new experience that can help people change their behaviors and their views of themselves. Armed with a believable fresh perspective, they may approach life with new energy.

AN EMPATHIC, TRUSTING, CARING RELATIONSHIP No matter what technique they use, effective psychotherapists are empathic. They seek to understand people’s experience. They communicate care and concern. And they earn trust through respectful listening, reassurance, and guidance. These qualities were clear in recorded therapy sessions from 36 recognized master therapists (Goldfried et al., 1998). Some took a cognitive-behavioral approach. Others used psychodynamic principles. Regardless, they were strikingly similar during the most significant parts of their sessions. At key moments, the empathic therapists of both types would help clients evaluate themselves, link one aspect of their life with another, and gain insight into their interactions with others. The emotional bond between psychotherapist and client—the therapeutic alliance—helps explain why some therapists are more effective than others (Klein et al., 2003; Wampold, 2001). One U.S. National Institute of Mental Health depression-treatment study confirmed that the most effective therapists were those who were perceived as most empathic and caring and who established the closest therapeutic bonds with their clients (Blatt et al., 1996).

That all psychotherapies offer hope through a fresh perspective provided by a caring person is what also enables paraprofessionals (briefly trained caregivers) to assist so many troubled people so effectively (Christensen & Jacobson, 1994). These three common elements are also part of what the growing numbers of self-help support groups offer their members. And they are part of what traditional healers have offered (Jackson, 1992). Healers everywhere—special people to whom others disclose their suffering, whether psychiatrists, witch doctors, or shamans—have listened in order to understand and to empathize, reassure, advise, console, interpret, or explain (Torrey, 1986). Such qualities may explain why people who feel supported by close relationships—who enjoy the fellowship and friendship of caring people—have been less likely to need or seek therapy (Frank, 1982; O’Connor & Brown, 1984).

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To recap, people who seek help usually improve. So do many of those who do not undergo psychotherapy, and that is a tribute to our human resourcefulness and our capacity to care for one another. Nevertheless, though the therapist’s orientation and experience appear not to matter much, people who receive some psychotherapy usually improve more than those who do not. People with clear-cut, specific problems tend to improve the most.

Culture and Values in Psychotherapy

15-12 How do culture and values influence the therapist-client relationship?

All psychotherapies offer hope. Nearly all psychotherapists attempt to enhance their clients’ sensitivity, openness, personal responsibility, and sense of purpose (Jensen & Bergin, 1988). But therapists also differ from one another and may differ from their clients (Delaney et al., 2007; Kelly, 1990).

These differences can create a mismatch when a therapist from one culture interacts with a client from another. In North America, Europe, and Australia, for example, many therapists reflect the majority culture’s individualism, which often gives priority to personal desires and identity. Clients with a collectivist perspective, as with many from Asian cultures, may assume people will be more mindful of others’ expectations. These clients may have trouble relating to therapies that require them to think only of their own well-being.

Such differences help explain minority populations’ reluctance to use mental health services, and their tendency to prematurely terminate therapy (Chen et al., 2009; Sue, 2006). In one experiment, Asian-American clients matched with counselors who shared their cultural values (rather than mismatched with those who did not) perceived more counselor empathy and felt a stronger alliance with the counselor (Kim et al., 2005). Recognizing that therapists and clients may differ in their values, communication styles, and language, all American Psychological Association–accredited therapy-training programs provide training in cultural sensitivity and welcome members of underrepresented cultural groups.

Therapist and client may also have differing religious perspectives. Highly religious people may prefer and benefit from religiously similar therapists (Masters, 2010; Smith et al., 2007; Wade et al., 2006). They may have trouble establishing an emotional bond with a therapist who does not share their values. People living in “cultures of honor”—which prize being strong and tough—tend to be more reluctant to seek mental health care, as it may be viewed as an admission of weakness (Brown et al., 2014).

Finding a Mental Health Professional

15-13 What should a person look for when selecting a therapist?

Life for everyone is marked by a mix of serenity and stress, blessing and bereavement, good moods and bad. So, when should we seek a mental health professional’s help? The American Psychological Association offers these common trouble signals:

In looking for a therapist, you may want to have a preliminary consultation with two or three. College health centers are generally good starting points, and may offer some free services. You can describe your problem and learn each therapist’s treatment approach. You can ask questions about the therapist’s values, credentials (TABLE 15.3), and fees. And you can assess your own feelings about each of them. The emotional bond between therapist and client is perhaps the most important factor in effective therapy.

Learning Objectives

Test Yourself by taking a moment to answer each of these Learning Objective Questions (repeated here from within the chapter). Research suggests that trying to answer these questions on your own will improve your long-term memory of the concepts (McDaniel et al., 2009).

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Terms and Concepts to Remember

Test yourself on these terms.

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Experience the Testing Effect

Test yourself repeatedly throughout your studies. This will not only help you figure out what you know and don’t know; the testing itself will help you learn and remember the information more effectively thanks to the testing effect.

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Use to create your personalized study plan, which will direct you to the resources that will help you most in .