16.2 Psychological Treatments: Healing the Mind through Interaction

Psychological therapy, or psychotherapy, is an interaction between a socially sanctioned clinician and someone suffering from a psychological problem, with the goal of providing support or relief from the problem. Currently over 500 different forms of psychotherapy exist. Although there are similarities among all the psychotherapies, each approach is unique in its goals, aims, and methods. A survey of 1,000 psychotherapists asked them to describe their main theoretical orientation (Norcross, Hedges, & Castle, 2002; see FIGURE 16.1). Over a third reported using eclectic psychotherapy, a form of psychotherapy that involves drawing on techniques from different forms of therapy, depending on the client and the problem. This allows therapists to apply an appropriate theoretical perspective suited to the problem at hand, rather than adhering to a single theoretical perspective for all clients and all types of problems. Nevertheless, as Figure 16.1 shows, the majority of psychotherapists use a single approach, such as psychodynamic therapy, humanistic and existential therapies, behavioral and cognitive therapies, or group therapy. We’ll examine each of those four major branches of psychotherapy in turn.

Figure 16.1: Approaches to Psychotherapy in the 21st Century This chart shows the percentage of psychologists (from among 1,000 members of the American Psychological Association’s Division of Psychotherapy) who have various primary psychotherapy orientations (adapted from Norcross et al., 2002).

Psychodynamic Therapy

Psychodynamic psychotherapy has its roots in Freud’s psychoanalytically oriented theory of personality. Psychodynamic psychotherapies explore childhood events and encourage individuals to use this understanding to develop insight into their psychological problems. Psychoanalysis was the first psychodynamic therapy to develop, but it has largely been replaced by modern psychodynamic therapies, such as interpersonal psychotherapy.

Psychoanalysis

In traditional psychoanalysis, the client lies on a couch, with the therapist sitting behind, out of the client’s view.

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As you saw in the Personality chapter, psychoanalysis assumes that people are born with aggressive and sexual urges that are repressed during childhood development through the use of defense mechanisms. Psychoanalysts encourage their clients to bring these repressed conflicts into consciousness so that the clients can understand them and reduce their unwanted influences. Psychoanalysts focus a great deal on early childhood events because they believe that urges and conflicts were likely to be repressed during this time.

Traditional psychoanalysis involves four or five sessions per week over an average of 3 to 6 years (Ursano & Silberman, 2003). During a session, the client reclines on a couch, facing away from the analyst, and is asked to express whatever thoughts and feelings come to mind. Occasionally, the therapist may comment on some of the information presented by the client, but does not express his or her values and judgments. The stereotypic image you might have of psychological therapy—a person lying on a couch talking to a person sitting in a chair—springs from this approach.

What Happens in Psychoanalysis

The goal of psychoanalysis is for the client to understand the unconscious in a process Freud called developing insight. A psychoanalyst can use several key techniques to help the client develop insight, including the following.

Free Association. In free association, the client reports every thought that enters the mind, without censorship or filtering. This strategy allows the stream of consciousness to flow unimpeded. If the client stops, the therapist prompts further associations (“And what does that make you think of?”). The therapist may then look for themes that recur during therapy sessions.

Dream Analysis. Psychoanalysis may treat dreams as metaphors that symbolize unconscious conflicts or wishes and that contain disguised clues that the therapist can help the client understand. A psychoanalytic therapy session might begin with an invitation for the client to recount a dream, after which the client might be asked to participate in the interpretation by freely associating to the dream.

Interpretation. This is the process by which the therapist deciphers the meaning (e.g., unconscious impulses or fantasies) underlying what the client says and does. Interpretation is used throughout therapy, during free association and dream analysis, as well as in other aspects of the treatment. During the process of interpretation, the therapist suggests possible meanings to the client, looking for signs that the correct meaning has been discovered.

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Analysis of Resistance. In the process of “trying on” different interpretations of the client’s thoughts and actions, the therapist may suggest an interpretation that the client finds particularly unacceptable. Resistance is a reluctance to cooperate with treatment for fear of confronting unpleasant unconscious material. For example, the therapist might suggest that the client’s problem with obsessive health worries could be traced to a childhood rivalry with her mother for her father’s love and attention. The client could find the suggestion insulting and resist the interpretation. The therapist might interpret this resistance as a signal not that the interpretation is wrong but instead that the interpretation is on the right track. If a client always shifts the topic of discussion away from a particular idea, it might signal to the therapist that this is indeed an issue the client could be directed to confront in order to develop insight.

Through the course of meeting so frequently over such a long period of time, the client and psychoanalyst often develop a close relationship. Freud noticed this relationship developing in his analyses and was at first troubled by it: Clients would develop an unusually strong attachment to him, almost as though they were viewing him as a parent or a lover, and he worried that this could interfere with achieving the goal of insight. Over time, however, he came to believe that the development and resolution of this relationship was a key process of psychoanalysis. Transference occurs when the analyst begins to assume a major significance in the client’s life and the client reacts to the analyst based on unconscious childhood fantasies. Successful psychoanalysis involves analyzing the transference so that the client understands this reaction and why it occurs.

Beyond Psychoanalysis

Although Freud’s insights and techniques are fundamental, modern psychodynamic treatments differ from classic psychoanalysis in both their content and procedures. One of the most widely used psychodynamic treatments is interpersonal psychotherapy (IPT), a form of psychotherapy that focuses on helping clients improve current relationships (Weissman, Markowitz, & Klerman, 2000). In terms of content, rather than using free association, therapists using IPT talk to clients about their interpersonal behaviors and feelings. They pay particular attention to the client’s grief (an exaggerated reaction to the loss of a loved one), role disputes (conflicts with a significant other), role transitions (changes in life status, such as starting a new job, getting married, or retiring), or interpersonal deficits (lack of the necessary skills to start or maintain a relationship). The treatment focuses on interpersonal functioning with the assumption that, as interpersonal relations improve, symptoms will subside.

In the movie Good Will Hunting, the lead character, played by actor Matt Damon, forms a strong bond with his therapist, played by Robin Williams. As in psychodynamic therapy, the therapist uses their relationship to help break down the patient’s defense mechanisms and resolve an inner conflict. The amazing bond that was formed between therapist and patient, and the life-changing treatment delivered is the stuff of therapists’ dreams (and Hollywood scripts).

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Modern psychodynamic psychotherapies such as IPT also differ from classical psychoanalysis in the procedures used. For starters, in modern psychodynamic therapy the therapist and client typically sit face-to-face. In addition, therapy is less intensive, with meetings often occurring only once a week and therapy lasting months rather than years. In contrast to classical psychoanalysis, modern psychodynamic therapists are more likely to see relief from symptoms as a reasonable goal for therapy (in addition to the goal of facilitating insight), and they are more likely to offer support or advice in addition to interpretation (Barber et al., 2013). Therapists are also now less likely to interpret a client’s statements as a sign of unconscious sexual or aggressive impulses. However, other concepts, such as transference and fostering insight into unconscious processes, remain features of most psychodynamic therapies. Freud’s couch cast a long shadow.

Although psychodynamic therapy has been around for a long time and continues to be widely practiced, there is relatively little evidence for its effectiveness. Comparisons to other forms of treatment such as cognitive behavior therapy (described later) suggest that psychodynamic therapy is somewhat less effective (Watzke et al., 2012). Moreover, there is some evidence that some of the aspects of psychodynamic therapy long believed to be effective may actually be harmful. For instance, research suggests that the more a therapist makes interpretations about perceived transference in the client, the worse the therapeutic alliance and the worse the clinical outcome (Henry et al., 1994). Despite findings like these, there is some evidence that long-term psychodynamic psychotherapy (lasting at least a year) is more effective than short-term psychotherapy (Leichsenring & Rabung, 2008). Psychodynamic therapy is not as widely used as it once was, but many psychologists still use it in practice, and many people say that they find it helpful.

Humanistic and Existential Therapies

Humanistic and existential therapies emerged in the middle of the 20th century, in part as a reaction to the negative views that psychoanalysis holds about human nature. Humanistic and existential therapies assume that human nature is generally positive, and they emphasize the natural tendency of each individual to strive for personal improvement. Humanistic and existential therapies share the assumption that psychological problems stem from feelings of alienation and loneliness, and that those feelings can be traced to failures to reach one’s potential (in the humanistic approach) or from failures to find meaning in life (in the existential approach). Although interest in these approaches peaked in the 1960s and 1970s, some therapists continue to use these approaches today. Two well-known types are person-centered therapy (a humanistic approach) and gestalt therapy (an existential approach).

Person-Centered Therapy

Person-centered therapy (or client-centered therapy) assumes that all individuals have a tendency toward growth and that this growth can be facilitated by acceptance and genuine reactions from the therapist. Psychologist Carl Rogers (1902–1987) developed person-centered therapy in the 1940s and 1950s (Rogers, 1951). Person-centered therapy assumes that each person is qualified to determine his or her own goals for therapy, such as feeling more confident or making a career decision, and even the frequency and length of therapy. In this type of nondirective treatment, the therapist tends not to provide advice or suggestions about what the client should be doing, but instead paraphrases the client’s words, mirroring the client’s thoughts and sentiments (e.g., “I think I hear you saying…”). Person-centered therapists believe that with adequate support, the client will recognize the right things to do.

Rogers encouraged person-centered therapists to demonstrate three basic qualities: congruence, empathy, and unconditional positive regard. Congruence refers to openness and honesty in the therapeutic relationship and ensuring that the therapist communicates the same message at all levels. For example, the same message must be communicated in the therapist’s words, the therapist’s facial expression, and the therapist’s body language. Saying “I think your concerns are valid” while smirking would simply not do. Empathy refers to the continuous process of trying to understand the client by getting inside his or her way of thinking, feeling, and understanding the world. Interestingly, research has shown that the more empathic a client says their clinician is being, the more similarity there is between the client’s and therapist’s level of physiological arousal in that moment (Marci et al., 2007). This suggests that therapists who are being empathic may really be feeling some of what their clients are feeling. Seeing the world from the client’s perspective enables the therapist to better appreciate the client’s apprehensions, worries, or fears. Finally, the therapist must treat the client with unconditional positive regard by providing a nonjudgmental, warm, and accepting environment in which the client can feel safe expressing his or her thoughts and feelings.

The goal is not to uncover repressed conflicts, as in psychodynamic therapy, but instead to try to understand the client’s experience and reflect that experience back to the client in a supportive way, encouraging the client’s natural tendency toward growth. This style of therapy is reminiscent of psychoanalysis in its way of encouraging the client toward the free expression of thoughts and feelings.

Gestalt Therapy

As part of gestalt therapy, clients may be encouraged to imagine that another person is sitting across from them in a chair. The client then moves from chair to chair, role-playing what he or she would say to the imagined person and what that person would answer.

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Gestalt therapy was founded by Frederick “Fritz” Perls (1893–1970) and colleagues in the 1940s and 1950s (Perls, Hefferkine, & Goodman, 1951). Gestalt therapy has the goal of helping the client become aware of his or her thoughts, behaviors, experiences, and feelings and to “own” or take responsibility for them. Gestalt therapists are encouraged to be enthusiastic and warm toward their clients, an approach they share with person-centered therapists. To help facilitate the client’s awareness, gestalt therapists also reflect back to the client their impressions of the client.

Gestalt therapy emphasizes the experiences and behaviors that are occurring at that particular moment in the therapy session. For example, if a client is talking about something stressful that occurred during the previous week, the therapist might shift the attention to the client’s current experience by asking, “How do you feel as you describe what happened to you?” This technique is known as focusing. Clients are also encouraged to put their feelings into action. One way to do this is the empty chair technique, in which the client imagines that another person (e.g., a spouse, a parent, a coworker) is in an empty chair, sitting directly across from the client. The client then moves from chair to chair, alternating from role-playing what he or she would say to the other person and how he or she imagines the other person would respond. Gestalt techniques originated as a form of psychotherapy but are now often used in counseling or “life coaching” to help people prepare for new job or family situations (Grant, 2008).

Behavioral and Cognitive Therapies

Unlike the talk therapies described before, behavioral and cognitive treatments emphasize actively changing a person’s current thoughts and behaviors as a way to decrease or eliminate their psychopathology. In the evolution of psychological treatments, clients started out lying down in psychoanalysis, then sitting in psychodynamic and related approaches, but are often standing and engaging in behavior-change homework assignments in their everyday life in behavioral and cognitive therapies.

Behavior Therapy

Whereas Freud developed psychoanalysis as an offshoot of hypnosis and other techniques used by other clinicians before him, behavior therapy was developed based on laboratory findings from earlier behavioral psychologists. As you read in the Psychology: Evolution of a Science chapter, behaviorists rejected theories that were based on “invisible” mental properties that were difficult to test and impossible to observe directly. Behaviorists found psychoanalytic ideas particularly hard to test: How do you know whether a person has an unconscious conflict or whether insight has occurred? Behavioral principles, in contrast, focused solely on behaviors that could be observed (e.g., avoidance of a feared object, such as refusing to get on an airplane). Behavior therapy assumes that disordered behavior is learned and that symptom relief is achieved through changing overt maladaptive behaviors into more constructive behaviors. A variety of behavior therapy techniques have been developed for many disorders, based on the learning principles you encountered in the Learning chapter, including operant conditioning procedures (which focus on reinforcement and punishment) and classical conditioning procedures (which focus on extinction). Here are three examples of behavior therapy techniques in action:

A behavioral psychologist might treat a temper tantrum using time-out from reinforcement, which is based on the behavioral principle of operant conditioning and ensures that a child will not be rewarded for her undesired behavior.

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Eliminating Unwanted Behaviors. How would you change a 3-year-old boy’s habit of throwing tantrums at the grocery store? A behavior therapist might investigate what happens immediately before and after the tantrum: Did the child get candy to “shut him up?” The study of operant conditioning shows that behavior can be influenced by its consequences (the reinforcing or punishing events that follow). Adjusting these might help change the behavior. Making the consequences less reinforcing (no candy!) and more punishing (a period of time-out facing the wall in the grocery store while the parent watches from nearby rather than providing a rush of attention) could eliminate the problem behavior.

Promoting Desired Behaviors. Candy and time-out can have a strong influence on child behavior, but they work less well with adults. How might you get an individual with schizophrenia to engage in activities of daily living? How would you get a cocaine addict to stop using drugs? A behavior therapy technique that has proven to be quite effective in such cases is the token economy, which involves giving clients “tokens” for desired behaviors, which they can later trade for rewards. For instance, in the case of cocaine dependence, the desired behavior is not using cocaine. Programs that reward non-use (verified by urine samples) with vouchers that can be exchanged for rewards such as money, bus passes, clothes, and so on, have shown an ability to significantly reduce cocaine use and associated psychological problems (Petry, Alessi, & Rash, 2013). Similar systems are used to promote desired behaviors in classrooms, the workplace, and commercial advertising (e.g., airline and credit card rewards programs).

Reducing Unwanted Emotional Responses. One of the most powerful ways to reduce fear is by gradual exposure to the feared object or situation. Exposure therapy involves confronting an emotion-arousing stimulus directly and repeatedly, ultimately leading to a decrease in the emotional response. This technique depends on the processes of habituation and response extinction. For example, in Christine’s case her clinician gradually exposed her to the content of her obsessions (dirt and germs), which became less and less distressing with repeated exposure. Similarly, for clients who are afraid of social interaction and unable to function at school or work, a behavioral treatment might involve exposure first to imagined situations in which they talk briefly with one person, then a bit longer talk to a medium-sized group, and finally, giving a speech to a large group. It’s now known that in vivo (live) exposure is more effective than imaginary exposure (Choy, Fyer, & Lipsitz, 2007). In other words, if a person fears social situations, it is better for that person to practice social interaction than merely to imagine it. Behavioral therapists use an exposure hierarchy to expose the client gradually to the feared object or situation. Easier situations are practiced first, and as fear decreases, the client progresses to more difficult or frightening situations (see TABLE 16.1).

An exposure therapy client with obsessive-compulsive disorder who fears contamination in public restrooms might be given “homework” to visit three such restrooms in a week, touch the toilets, and then not wash up.

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Exposure therapy can also help people overcome unwanted emotional and behavioral responses through exposure and response prevention. Persons with OCD, for example, might have recurrent thoughts that their hands are dirty and need washing. Washing stops the uncomfortable feelings of contamination only briefly, though, and they wash again and again in search of relief. In exposure with response prevention, they might be asked in therapy to get their hands dirty on purpose (first by touching a coin picked up from the ground, then by touching a public toilet, and later by touching a dead mouse) and leave them dirty for hours. They may need to do this only a few times to break the cycle and be freed from the obsessive ritual (Foa et al., 2007).

Cognitive Therapy

Whereas behavior therapy focuses primarily on changing a person’s behavior, cognitive therapy, as the name suggests, focuses on helping a client identify and correct any distorted thinking about self, others, or the world (Beck, 2005). For example, behaviorists might explain a phobia as the outcome of a classical conditioning experience such as being bitten by a dog, where the dog bite leads to the development of a dog phobia through the association of the dog with the experience of pain. Cognitive theorists might instead emphasize the interpretation of the event. It might not be the event itself that caused the fear, but rather the individual’s beliefs and assumptions about the event and the feared stimulus. In the case of a dog bite, cognitive theorists might focus on a person’s new or strengthened belief that dogs are dangerous to explain the fear.

Cognitive therapist Aaron Beck’s approach to psychotherapy helps people change maladaptive thinking patterns using a direct and rational approach.

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Cognitive therapies use a principal technique called cognitive restructuring, which involves teaching clients to question the automatic beliefs, assumptions, and predictions that often lead to negative emotions and to replace negative thinking with more realistic and positive beliefs. Specifically, clients are taught to examine the evidence for and against a particular belief or to be more accepting of outcomes that may be undesirable yet still manageable. For example, a depressed client may believe that she is stupid and will never pass her college courses—all on the basis of one poor grade. In this situation, the therapist would work with the client to examine the validity of this belief. The therapist would consider relevant evidence such as grades on previous exams, performance on other coursework, and examples of intelligence outside school. It may be that the client has never failed a course before and has achieved good grades in this particular course in the past. In this case, the therapist would encourage the client to consider all this information in determining whether she is truly “stupid.” TABLE 16.2 shows a variety of potentially irrational ideas that serve to unleash unwanted emotions such as anger, depression, or anxiety. Any of these irrational beliefs might bedevil a person with serious emotional problems if left unchallenged and are potential targets for cognitive restructuring. In therapy sessions, the cognitive therapist will help the client to identify evidence that supports, and fails to support, each negative thought in order to help the client generate more balanced thoughts that accurately reflect the true state of affairs. In other words, the clinician tries to remove the dark lens through which the client views the world, not with the goal of replacing it with rose-colored glasses, but instead with clear glass. Here is a brief sample transcript of what part of a cognitive therapy session might sound like.

In addition to cognitive restructuring techniques, which try to change a person’s thoughts to be more balanced or accurate, some forms of cognitive therapy also include techniques for coping with unwanted thoughts and feelings, techniques that resemble meditation (see the Consciousness chapter). Clients may be encouraged to attend to their troubling thoughts or emotions or be given meditative techniques that allow them to gain a new focus (Hofmann & Asmundson, 2008). One such technique, called mindfulness meditation, teaches an individual to be fully present in each moment; to be aware of his or her thoughts, feelings, and sensations; and to detect symptoms before they become a problem. Researchers have found mindfulness meditation to be helpful for preventing relapse in depression. In one study, people recovering from depression were about half as likely to relapse during a 60-week assessment period if they received mindfulness meditation-based cognitive therapy than if they received treatment as usual (Teasdale, Segal, & Williams, 2000).

Cognitive Behavioral Therapy

How might the use of behavior change homework improve the effectiveness of behavior therapy?

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Historically, cognitive and behavioral therapies were considered distinct systems of therapy, and some people continue to follow this distinction, using solely behavioral or cognitive techniques. Today, the extent to which therapists use cognitive versus behavioral techniques depends on the individual therapist as well as the type of problem being treated. Most therapists working with anxiety and depression use a blend of cognitive and behavioral therapeutic strategies, often referred to as cognitive behavioral therapy (CBT). In a way, this technique acknowledges that there may be behaviors that people cannot control through rational thought, but also that there are ways of helping people think more rationally when thought does play a role. In contrast to traditional behavior therapy and cognitive therapy, CBT is problem focused, meaning that it is undertaken for specific problems (e.g., reducing the frequency of panic attacks or returning to work after a bout of depression), and action oriented, meaning that the therapist tries to assist the client in selecting specific strategies to help address those problems. The client is expected to do things, such as engage in exposure exercises, practice behavior change skills or use a diary to monitor relevant symptoms (e.g., the severity of depressed mood, panic attack symptoms). This is in contrast to psychodynamic or other therapies where goals may not be explicitly discussed or agreed on and the client’s only necessary action is to attend the therapy session.

CBT also contrasts with psychodynamic approaches in its assumptions about what the client can know. CBT is transparent in that nothing is withheld from the client. By the end of the course of therapy, most clients have a very good understanding of the treatment they have received as well as the specific techniques that are used to make the desired changes. For example, clients with OCD who fear contamination would feel confident in knowing how to confront feared situations such as public washrooms and why confronting this situation is helpful.

Cognitive behavioral therapies have been found to be effective for a number of disorders (Butler et al., 2006; see the Hot Science box). Substantial effects of CBT have been found for unipolar depression, generalized anxiety disorder, panic disorder, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders. CBT has moderate but less substantial effects for marital distress, anger, somatic disorders, and chronic pain.

HOT SCIENCE: “Rebooting” Psychological Treatment

Modern psychotherapy has advanced far beyond the days of Freud and his free-associating patients. We now have more sophisticated treatments that have been developed based on recent advances in psychological science and supported in experimental studies showing that they actually do decrease peoples’ psychological suffering. However, psychological treatment is still pretty primitive in many ways. It usually involves a patient meeting once per week with a clinician who attempts to talk them out of their psychological disorder – just as it did in the earliest days of psychological treatment. In a recent paper, Alan Kazdin (and his student Stacey Blase) called for a “rebooting” of psychotherapy research and practice (Kazdin & Blase, 2011). What is needed, they argue, is a portfolio of treatment delivery approaches that take advantage of recent advances in technology.

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Although most psychologists providing treatment to those with psychological disorders still use traditional psychotherapy, researchers are developing and testing new methods of assessing and treating disorders that make creative use of new technologies. One of the most exciting recent advances in psychological treatment involves computerized training programs. For example, research suggests that biases in the ways that people process information cause psychological disorders. Cognitive bias modification (CBM) is a computerized intervention that focuses on eliminating these biases (MacLeod & Mathews, 2012). Specifically, people with social anxiety show selective attention for threatening information (e.g., when shown several faces they have an automatic tendency to look at the angrier one). In one form of CBM for social anxiety, the patient completes a computerized training program in which he or she is repeatedly shown pairs of faces, one angry and one neutral, that flash on the screen very quickly (for 500 milliseconds) after which the letter “E” or “F” appears behind one of them and the patient’s task is to indicate whether the letter is an “E” or “F.” In CBM, the “E” or “F” always, or nearly always, appears behind the neutral face, which over time teaches the person to ignore the angry face and attend to the neutral face, thus reducing their tendency to attend to threatening faces. The training is intended to generalize beyond faces to reduce attention to threatening stimuli in general. In a recent placebo-controlled trial, Eldar and colleagues (2012) recently found that four sessions of CBM led to significant reductions in symptoms of various anxiety disorders in a sample of anxious children. CBM has been tested for the treatment of a range of different psychological disorders (Beard, Sawyer & Hofmann, 2012) and represents an exciting new direction in treatment development. However, it is important to note that in CBM, as with many novel treatments, several non-replications followed the initial successful trials (e.g., Enock & McNally, 2013), suggesting that the jury is still out regarding the effectiveness of this new type of treatment.

In addition to new forms of treatment that can be administered in clinics, advances in technology are allowing psychologists to bring the clinic into people’s everyday life. Psychologists are now using computers, cellular phones, and wearable bio-sensors to measure patients’ experiences in the real world in real-time, and also to administer interventions well beyond the clinic walls (e.g., using text messages to remind patients not to smoke or to practice the skills they learned during their last therapy session). The development of ‘mobile health’ or ‘mHealth’ interventions has been extremely exciting; however, one recent review found that more than half of interventions that used mobile technologies fail to show any benefit (Kaplan & Stone, 2013). So although the development of portable technological devices has opened up lots of new opportunities for intervention, it is important that psychologists carefully evaluate which can help improve health outcomes, and which are simply fancier ways of providing ineffective treatment.

Group Treatments: Healing Multiple Minds at the Same Time

It is natural to think of psychopathology as an illness that affects only the individual. A particular person “is depressed,” for example, or “has anxiety.” Yet each person lives in a world of other people, and interactions with others may intensify and even create disorders. A depressed person may be lonely after moving away from friends and loved ones, or an anxious person could be worried about pressures from parents. These ideas suggest that people might be able to recover from disorders in the same way they got into them—not just as an individual effort, but through social processes.

Couples and Family Therapy

What do you do when your relationship is in trouble? One option is couples therapy. In the romantic comedy, Couples Retreat, four couples take a weeklong resort vacation that includes daily couples therapy. Hilarity ensues.

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When a couple is “having problems,” neither individual may be suffering from any psychopathology. Rather, it may be the relationship itself that is disordered. Couples therapy is when a married, cohabitating, or dating couple is seen together in therapy to work on problems usually arising within the relationship. A traditional use of couples therapy might involve a couple seeking help because they are unhappy with their relationship. In this scenario, both members of the couple are expected to attend therapy sessions and the problem is seen as arising from their interaction rather than from the problems of one half of the couple. Treatment strategies would target changes in both parties, focusing on ways to break their repetitive dysfunctional pattern.

There are cases when therapy with even larger groups is warranted. An individual may be having a problem—say, an adolescent is abusing alcohol—but the source of the problem is the individual’s relationships with family members; perhaps the mother is herself an alcoholic who subtly encourages the adolescent to drink and the father travels and neglects the family. In this case, it could be useful for the therapist to work with the whole group at once in family therapy—psychotherapy involving members of a family. Family therapy can be particularly effective when adolescent children are having problems (Masten, 2004).

Families enter therapy for many reasons, sometimes to help particular members and other times because there are problems in one or more of the relationships in the family.

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In family therapy, the “client” is the entire family. Family therapists believe that problem behaviors exhibited by a particular family member are the result of a dysfunctional family. For example, an adolescent girl suffering from bulimia might be treated in therapy with her mother, father, and older brother. The therapist would work to understand how the family members relate to one another, how the family is organized, and how it changes over time. In discussions with the family, the therapist might discover that the parents’ excessive enthusiasm about her brother’s athletic career led the girl to try to gain their approval by controlling her weight to become “beautiful.” Both couples and family therapy involve more than one person attending therapy together, and the problems and solutions are seen as arising from the interaction of these individuals rather than simply from any one individual.

Group Therapy

Taking these ideas one step further, if individuals (or families) can benefit from talking with a psychotherapist, perhaps they can also benefit from talking with other clients who are talking with the therapist. This is group therapy, a technique in which multiple participants (who often do not know one another at the outset) work on their individual problems in a group atmosphere. The therapist in group therapy serves more as a discussion leader than as a personal therapist, conducting the sessions both by talking with individuals and by encouraging them to talk with one another. Group therapy is often used for people who have a common problem, such as substance abuse, but it can also be used for those with differing problems.

Why do people choose group therapy? One advantage is that attending a group with others who have similar problems shows clients that they are not alone in their suffering. In addition, group members model appropriate behaviors for one another and share their insights about how to deal with their problems. Group therapy is often just as effective as individual therapy (e.g., Jonsson & Hougaard, 2008). So, from a societal perspective, group therapy is much more efficient.

Group therapy also has disadvantages. It may be difficult to assemble a group of individuals who have similar needs. This is particularly an issue with CBT, which tends to focus on specific problems such as depression or panic disorder. Group therapy may become a problem if one or more members undermine the treatment of other group members. This can occur if some group members dominate the discussions, threaten other group members, or make others in the group uncomfortable (e.g., attempting to date other members). Finally, clients in group therapy get less attention than they might in individual psychotherapy.

Self-Help and Support Groups

Self-help groups are a cost-effective, time-effective, and treatment-effective solution for dealing with some types of psychological problems. Many people like self-help groups, but are they effective? How could you test this?”

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An important offshoot of group therapy is the concept of self-help groups and support groups, which are discussion groups that focus on a particular disorder or difficult life experience and are often run by peers who have themselves struggled with the same issues. The most famous self-help and support groups are Alcoholics Anonymous (AA), Gamblers Anonymous, and Al-Anon (a program for the family and friends of those with alcohol problems). Other self-help groups offer support to cancer survivors or to parents of children with autism or to people with mood disorders, eating disorders, and substance abuse problems. In fact, self-help and support groups exist for just about every psychological disorder. In addition to being cost-effective, self-help and support groups allow people to realize that they are not the only ones with a particular problem and give them the opportunity to offer guidance and support to each other based on personal experiences of success.

In some cases, though, self-help and support groups can do more harm than good. Some members may be disruptive or aggressive or encourage one another to engage in behaviors that are countertherapeutic (e.g., avoiding feared situations or using alcohol to cope). People with moderate problems may be exposed to others with severe problems and may become oversensitized to symptoms they might not otherwise have found disturbing. Because self-help and support groups are usually not led by trained therapists, mechanisms to evaluate these groups or to ensure their quality are rarely in place.

AA has more than 2 million members in the United States, with 185,000 group meetings that occur around the world (Mack, Franklin, & Frances, 2003). Members are encouraged to follow “12 steps” to reach the goal of lifelong abstinence from all drinking, and the steps include believing in a higher power, practicing prayer and meditation, and making amends for harm to others. Most members attend group meetings several times per week, and between meetings they receive additional support from their “sponsor.” A few studies examining the effectiveness of AA have been conducted, and it appears that individuals who participate tend to overcome problem drinking with greater success than those who do not participate in AA (Fiorentine, 1999; Morgenstern et al., 1997). However, several tenets of the AA philosophy are not supported by the research. We know that the general AA program is useful, but questions about which parts of this program are most helpful have yet to be studied.

Considered together, the many social approaches to psychotherapy reveal how important interpersonal relationships are for each of us. It may not always be clear how psychotherapy works, whether one approach is better than another, or what particular theory should be used to understand how problems have developed. What is clear, however, is that social interactions between people—both in individual therapy and in all the different forms of therapy in groups—can be useful in treating psychological disorders.