Among the dozens of psychotherapies, we will focus on the most influential. 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. Psychotherapists often combine multiple methods. Indeed, many psychotherapists describe their approach as eclectic, using a blend of therapies.

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 (Chapter 12). Freud assumed that we do not fully know ourselves. He believed that there are threatening things we repress—things we do not want to know, so we disown or deny them.

Freud’s therapy aimed to bring patients’ repressed feelings into conscious awareness. By helping them reclaim their unconscious thoughts and feelings, the therapist (analyst) would also help them gain insight into the origins of their disorders. This insight could in turn inspire them to take responsibility for their own growth.

The Techniques of Psychoanalysis

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Psychoanalytic theory emphasizes the power of childhood experiences to mold us. Thus, its main method is historical reconstruction. It aims to unearth the past in the hope of loosening its bonds on the present. After trying and discarding hypnosis as a possible excavating tool, Freud turned to free association.

Imagine yourself as a patient using free association. You begin by relaxing, perhaps by lying on a couch. The psychoanalyst, who sits out of your line of vision, asks you to 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 notice how often you edit your thoughts as you speak. You pause for a second before describing an embarrassing thought. You skip things that seem trivial, off point, or shameful. Sometimes your mind goes blank, unable to remember important details. You may joke or change the subject to something less threatening.

To an analyst, these mental blips are blocks that indicate resistance. They hint that anxiety lurks and you are defending against sensitive material. The analyst will note your resistance and then provide insight into its meaning. If offered at the right moment, this interpretation—of, say, your not wanting to talk about your mother or call, text, or message her—may reveal 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 an analysis of your dream content.

Multiply that one session by dozens and your relationship patterns will surface in your interactions with your analyst. You may find you have strong positive or negative feelings for your analyst. The analyst may suggest you are transferring feelings, such as 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 U.S. therapists now offer traditional psychoanalysis. Much of its underlying theory is not supported by scientific research (Chapter 12). 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-client relationship. “We can have loving feelings and hateful feelings toward the same person,” noted one psychodynamic therapist, and “we can desire something and also fear it” (Shedler, 2009). Client-therapist meetings take place once or twice a week (rather than several times weekly) and often for only a few weeks or months. Rather than lying on a couch, out of the therapist’s line of vision, clients meet with their therapist face to face.

In these meetings, clients explore and gain perspective on defended-against thoughts and feelings. One therapist illustrated this with the case of a young man who previously had told women that he loved them, when he knew that he didn’t (Shapiro, 1999, p. 8). But now 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.”

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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 the client could not express real love because it would feel “mushy” and “soft” and therefore unmanly. The therapist noted that this young man was “in conflict with himself, and . . . 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” (Shapiro, 1999, p. 8).

Exploring past relationship troubles may help clients understand the origin of their current difficulties. Another therapist (Shedler, 2010a) recalled a client’s complaints of difficulty getting along with his colleagues and wife, who saw him as overly critical. The client, “Jeffrey,” then “began responding to me as if I were an unpredictable, angry adversary.” Seizing the opportunity to help Jeffrey recognize the relationship pattern, the therapist helped him explore the pattern’s roots in the attacks and humiliation he had experienced from his father. Jeffrey 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 insight into their childhood experiences and unconscious dynamics.

The humanistic perspective (Chapter 12) emphasizes people’s innate 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, humanistic and psychodynamic 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 a widely used humanistic technique developed by Carl Rogers (1902–1987). Person-centered therapy focuses on the person’s conscious self-perceptions. It is nondirective—the therapist listens, without judging or interpreting, and refrains from directing the client toward certain insights.

Rogers (1961, 1980) believed that most people already possess the resources for growth. He encouraged therapists to foster 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 expresses (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.

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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 granted 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 Rogerian hints may help:

The insight therapies assume that self-awareness and psychological well-being go hand in hand.

Behavior therapies, however, take a different approach. Rather than searching beneath the surface for inner causes, they assume that problem behaviors are the problems. (You can become aware of why you are highly anxious during exams and still be anxious.) By harnessing the power of learning principles, behavior therapists offer clients useful tools for getting rid of unwanted behaviors. They view phobias, for example, as learned behaviors. So why not use conditioning techniques to replace them with new behaviors?

Classical Conditioning Techniques

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One cluster of behavior therapies draws on principles developed in Ivan Pavlov’s conditioning experiments (Chapter 6). 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 other unwanted responses also be explained by conditioning? 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. After a number of trials, the child associates bladder relaxation with waking. In three out of four cases, the treatment has stopped the bed-wetting, and the success has boosted the child’s self-image (Christophersen & Edwards, 1992; Houts et al., 1994).

Let’s broaden the discussion. What triggers your worst fear responses? Public speaking? Flying? Tight spaces? Circus clowns? Whatever the trigger, do you think you could unlearn your fear responses? With new conditioning, many people have. An example: The fear of riding in an elevator is often a learned response to the stimulus of being confined in a tight space. Therapists have successfully counterconditioned people with a fear of confined spaces. They pair the trigger stimulus (the enclosed space of the elevator) with a new response (relaxation) that cannot coexist with fear.

To replace unwanted responses with new responses, therapists may use exposure therapies and aversive conditioning.

EXPOSURE THERAPIES Picture the animal you fear the most. Maybe it’s a snake, a spider, or even a cat or a dog. For 3-year-old Peter, it was a rabbit. To rid Peter of his fear of rabbits and other furry objects, psychologist Mary Cover Jones had a plan: Associate the fear-evoking rabbit with the pleasurable, relaxed response associated with eating.

As Peter began his midafternoon snack, she introduced a caged rabbit on the other side of the huge room. Peter, eagerly munching on his crackers and slurping his milk, hardly noticed the furry animal. Day by day, Jones moved the rabbit closer and closer. Within two months, Peter was holding the rabbit in his lap, even stroking it while he ate. His fear of rabbits and other furry objects had disappeared. It had been countered, or replaced, by a relaxed state that could not 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. More than 30 years later, 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 responses. We all experience this process in everyday life. Someone who has moved to a new apartment may be annoyed by loud traffic sounds nearby—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 terrified 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 be anxious and relaxed at the same time. Therefore, if you can repeatedly relax when facing anxiety-provoking stimuli, you can gradually eliminate your anxiety. The trick is to proceed gradually. Imagine you fear public speaking. A behavior therapist first asks you to list all situations that trigger your public speaking anxiety. Your list ranges from situations that cause you to feel mildly anxious (perhaps speaking up in a small group of friends) to those that provoke feelings of panic (having to address a large audience).

The therapist then trains you in progressive relaxation. You learn to release tension in one muscle group after another, until you feel comfortable and relaxed. The therapist then asks you to imagine, with your eyes closed, a mildly anxiety-arousing situation—perhaps a mental image of having coffee with a group of friends and trying to decide whether to speak up. You are told to signal, by raising your finger, if you feel any anxiety while imagining this scene. Seeing the signal, the therapist instructs 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 then moves to the next item on your list, again using relaxation techniques to desensitize you to each imagined situation. After several sessions, you move to actual situations and practice what you had only imagined before. You 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, raises your self-confidence (Foa & Kozak, 1986; Williams, 1987). Eventually, you may even become a confident public speaker.

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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, public speaking, particular animals, and heights (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 treated with virtual reality exposure therapy have experienced significant relief from real-life fear (Turner & Casey, 2014).

AVERSIVE CONDITIONING Exposure therapies help you learn what you should do. They enable a more relaxed, positive response to an upsetting harmless stimulus.

Aversive conditioning helps you to learn what you should not do. It creates a negative (aversive) response to a harmful stimulus.

The aversive conditioning procedure is simple. It associates the unwanted behavior with unpleasant feelings. Is nail biting the problem? The therapist might suggest painting the fingernails with a yucky-tasting nail polish (Baskind, 1997). Is alcohol use disorder the problem? The therapist may offer the client appealing drinks laced with a drug that produces severe nausea. If that therapy links alcohol with violent nausea, the person’s reaction to alcohol may change from positive to negative (FIGURE 14.1).

Does aversive conditioning work? In the short run it may. In one classic study, 685 patients with alcohol use disorder completed an aversion therapy program (Wiens & Menustik, 1983). Over the next year, they returned for several booster treatments that paired alcohol with sickness. At the end of that year, 63 percent were not drinking alcohol. But after three years, only 33 percent were alcohol free.

Aversive conditioning has a built-in problem: Our thoughts can override conditioning processes (Chapter 6). People know that the alcohol-nausea link exists only in certain situations. This knowledge limits the treatment’s effectiveness. Thus, therapists often combine aversive conditioning with other treatments.

Operant Conditioning Techniques

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If you swim, you know fear. Through trial, error, and instruction, you learned how to put your head underwater without suffocating, how to pull your body through the water, and perhaps even how to dive safely. Operant conditioning shaped your swimming. You were reinforced for safe, effective behaviors. And you were naturally punished, as when you swallowed water, for improper swimming behaviors.

Remember a basic operant conditioning concept: Consequences drive our voluntary behaviors (Chapter 6). Knowing this, therapists can practice behavior modification. They reinforce behaviors they consider desirable. And they do not reinforce, or they sometimes punish, undesirable behavior. 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 learned how to behave more rationally. In each case, therapists used positive reinforcers to shape behavior. In a step-by-step manner, they rewarded behaviors that came closer and closer to the desired behaviors.

In extreme cases, treatment must be intensive. One study worked with 19 withdrawn, uncommunicative three-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 control group (not receiving this treatment), only one child showed similar improvement. Later studies focused on positive reinforcement—the effective part of this early intensive behavioral intervention (Reichow, 2012).

Not everyone finds the same things rewarding. Hence, the rewards used to modify behavior vary. Some people may respond well to attention or praise. Others require concrete rewards, such as food. Even then, certain foods won’t work as reinforcements for everyone. One of us [ND] finds chocolate neither tasty nor rewarding. Pizza is both, so a nice slice would better shape his behaviors. (What might best shape your behaviors?)

To modify behavior, therapists may create a token economy. People receive a token or plastic coin when they display a desired behavior—getting out of bed, washing, dressing, eating, talking meaningfully, cleaning their room, or playing cooperatively. Later, they can exchange a number of these tokens for candy, TV time, a day trip, better living quarters, or some other reward. Token economies have worked well in various settings (homes, classrooms, hospitals, institutions for delinquent youth), and among people with various disabilities (Matson & Boisjoli, 2009).

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 disorder, where unfocused anxiety doesn’t lend itself to a neat list of anxiety-triggering situations? The same cognitive revolution that 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 14.2). Between an event and our response lies the mind. Self-blaming and overgeneralized explanations of bad events feed depression (Chapter 13). If depressed, we may interpret a suggestion as criticism, disagreement as dislike, praise as flattery, friendliness as pity. Dwelling on such thoughts can sustain our bad mood. Cognitive therapies aim to help people break out of depression’s vicious cycle by adopting new ways of perceiving and interpreting events (Kazdin, 2015).

Beck’s Therapy for Depression

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Depressed people don’t see the world through rose-colored glasses. They perceive the world as full of loss, rejection, and abandonment. In daily life, they may be overly attentive to potential threats, and this ongoing focus gives rise to anxiety (MacLeod & Clarke, 2015). In therapy, they often recall and rehearse their own failings and worst impulses (Kelly, 2000).

Cognitive therapist Aaron Beck developed cognitive therapy to show depressed clients the irrational nature of their thinking, and to reverse their negative views of 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. Have you ever studied hard for an exam but felt extremely anxious before taking it? Many well-prepared students make matters worse with self-defeating thoughts: “This exam is going to be impossible. Everyone else seems so relaxed and confident. I wish I were better prepared. I’m so nervous I’ll forget everything.” Psychologists call this relentless, overgeneralized, self-blaming behavior catastrophizing.

To change such negative self-talk, therapists teach people to alter 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. (For a sampling of commonly used cognitive therapy techniques, see TABLE 14.1.)

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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) takes a combined approach to depression and other disorders. This widely practiced integrative therapy aims to alter not only the way clients think but also the way they act. Like other cognitive therapies, CBT seeks to make people aware of their irrational negative thinking and to replace it with new ways of thinking. And like other behavior therapies, it trains people to practice a more positive approach in everyday settings.

Anxiety, depressive disorders, and bipolar disorder share a common problem: emotion regulation (Aldao & Nolen-Hoeksema, 2010). In cognitive-behavioral therapy, people learn to make more realistic appraisals and, as homework, to practice behaviors that are incompatible with their problem (Kazantzis & Dattilio, 2010; Kazantzis et al., 2010; Moses & Barlow, 2006). A person might 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 shut down negative thoughts that trigger social anxiety and practice approaching people.

CBT effectively treats people with obsessive-compulsive disorder (Öst et al., 2015). In one classic study, people with obsessive-compulsive disorder 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 some enjoyable alternative behavior—practicing an instrument, taking a walk, 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 (Cristea et al., 2015; Milrod et al., 2015; Turner et al., 2016).

A newer CBT variation, dialectical behavior therapy (DBT), helps change harmful and even suicidal behavior patterns (Linehan et al., 2015; Valentine et al., 2015). Dialectical means “opposing,” and this therapy attempts to make peace between two opposing forces—acceptance and change. DBT combines cognitive tactics (for tolerating distress and regulating emotions) with social skills training and mindfulness meditation (see Chapter 10). Group training sessions offer additional opportunities to practice new skills in a social context, with further practice as homework.

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So far, we have focused mainly on therapies in which one therapist treats one client. Most therapies (though not traditional psychoanalysis) can also occur in small groups.

Group therapy does not provide the same degree of therapist involvement with each client. However, it offers other benefits:

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 family, yet we also work to find an identity outside of our family. These two opposing tendencies can create stress for the individual and the family. This helps explain why therapists tend to view families as systems, in which each person’s actions trigger reactions from others. To change negative interactions, the therapist often attempts to guide family members toward positive relationships and improved communication.