The Big Picture: Chapter Overview

The case of Steve, at the beginning of the chapter, illustrates how various types of therapy can simultaneously contribute to the management of a psychological disorder. There are several mental health professionals who vary in degree, education, and nature of training. Psychiatrists, who are medical doctors, can administer drugs as part of therapy. The theories of personality serve as the foundation for many forms of psychotherapy. This chapter is organized as previous chapters and explores biological therapy, psychotherapy, and sociocultural therapy. Psychotherapy is the process used by mental health professionals to help individuals recognize, define, and overcome their psychological and interpersonal difficulties and improve their adjustment.

Biological therapies are designed to alter the way an individual's body functions in order to reduce or eliminate the symptoms of psychological disorders. The most common type of biomedical therapy is drug therapy. Drug therapy is mainly used for anxiety disorders, mood disorders, and schizophrenia. Antianxiety drugs are also knows as tranquilizers (e.g., Xanax, Valium, Librium). Antidepressant drugs regulate mood (e.g., Elavil, MAO inhibitors, Prozac, Paxil, lithium). A new antidepressant drug is being developed that targets an amino acid, substance P., and is expected help in the treatment of depression with fewer side effects. Antipsychotic drugs are used for schizophrenia and reduce tension, hallucinations, and improve sleep and social behavior (e.g., neuroleptics, which block the activity of dopamine). Tardive dyskinesia is a major side effect of neurolpetic drugs and involves grotesque, involuntary movements of facial muscles and mouth. Another neuroleptic drug, Clozaril, has toxic effects on white blood cells in some patients. Electroconvulsive therapy (ECT) and psychosurgery are two extreme techniques that are used as last resorts. ECT is mainly used to treat severe depression and involves causing a seizure. Adverse side effects include memory loss or other cognitive impairments. Psychosurgery involves the removal or destruction of brain tissue to improve psychological adjustment.

Psychotherapies can be classified into four perspectives: psychodynamic, humanistic, behavioral, and cognitive. Insight therapy is used by psychodynamic and humanistic psychologists with the goal of encouraging insight and self-awareness. The psychodynamic therapies stress the importance of the unconscious mind, the role of infancy and childhood experiences, and extensive interpretation by a therapist. Psychoanalysis is a well-known psychodynamic therapy. In psychoanalysis, the individual's unconscious thoughts are analyzed. Freud believed that mental disturbances are caused by unresolved unconscious conflicts, often involving sexuality, that originate in early childhood. The therapist may use free association, which is encouraging the patient to say out loud whatever comes to mind no matter how trivial or embarrassing; this would allow for emotional feelings to be released through catharsis. The therapist would also interpret free association, dreams, statements, and behaviors to search for the underlying symbolic meaning. In dream analysis, the therapist analyzes the dream's manifest content to determine its latent content. Transference refers to the person's relating to the therapist in ways that reproduce or relive important relationships. Resistance is a term used to describe unconscious defense strategies that prevent the analyst from understanding the person's problems. An important theme in contemporary psychodynamic theories is the development of the self in social contexts such as early relationships with attachment figures. Few contemporary psychodynamic therapists rigorously follow Freud's guidelines.

In the humanistic therapies, clients are encouraged to understand themselves and to grow personally. The humanistic perspective focuses on conscious thoughts, the present, personal growth, and self-fulfillment. Client-centered therapy was developed by Carl Rogers and creates a warm, supportive atmosphere to improve the client's self-concept and to encourage the client to gain insight about problems. Unconditional positive regard, genuineness, and active listening are critical in creating this type of atmosphere. Perls developed Gestalt therapy to help clients become more aware of their feelings and to face their problems. Role playing and confrontation are often used in Gestalt therapy to help clients. Both the humanistic therapies encourage clients to take responsibility for their feelings and actions and to understand themselves.

Behavior therapies are based on the principles of learning to reduce or eliminate maladaptive behavior. Behavior therapists assume that overt maladaptive symptoms are the problem and not unconscious conflicts or inaccurate perceptions. Behavior therapy is based on the learning principles of classical, operant, and social cognitive theories. Systematic desensitization, a technique that uses the principles of classical conditioning, has been used to treat phobias; anxiety is treated by getting the person to associate deep relaxation with increasingly intense anxiety-producing situations. Aversive conditioning is used to teach people to avoid such behaviors as smoking, overeating, and drinking. Aversive conditioning consists of repeated pairings of the undesirable behavior with aversive stimuli to decrease the behavior's rewards. Using operant conditioning is based on the idea that maladaptive behavior patterns are learned and, therefore, can be unlearned. Behavior modification is a therapy technique that uses operant conditioning. It is believed that many problem behaviors are caused by inadequate response consequences. In a token economy, behaviors are reinforced with tokens that can be exchanged for desired rewards.

Cognitive therapists emphasize that an individual's cognitions, or thoughts, are the main sources of abnormal behavior. Cognitive therapies focus on changing the individual's thoughts or cognitions to change behaviors. Rational-emotive therapy is an example of cognitive therapy. In this type of therapy, the therapist disputes the individual's self-defeating beliefs and encourages the client to change his or her belief system. Beck's cognitive therapy tries to change the illogical thinking of depressed individuals. Beck's approach helps clients to make connections between logical errors and emotional responses. Cognitive behavior therapy consists of a combination of cognitive therapy to change self-defeating thoughts and behavior therapy to change behaviors. This approach considers self-efficacy the key to successful therapy. Self-instructional methods encourage individuals to change their own behavior. Cognitive therapy in conjunction with drug therapy has been effectively used to treat anxiety disorders. Studies have also shown that cognitive therapy is just as effective as drug therapy in the treatment of depression. Cognitive therapy is increasingly being used in the treatment of schizophrenia.

Sociocultural therapies take into consideration that the individual is part of a social system and seek to treat the person within the context of those groups that he/she belongs to. Sociocultural therapies include group therapy, family/couple therapy, and self-help support groups. Other issues in this approach are community mental health and cultural perspectives in therapy. Group therapies stress that social relationships are important in successful therapy; therefore, group interaction may be more beneficial than individual therapy. Family therapy is group therapy with family members. Family therapy techniques include validation, reframing, structural change, and detriangulation. Self-help support groups are voluntary organizations of individuals who get together to discuss topics of common interest. Weight Watchers is an example of a self-help support group. Community psychology focuses on both prevention and treatment of mental disorders. Prevention takes one of three courses: primary (e.g., targeting high risk populations), secondary (e.g., screening for early detection), and tertiary (e.g., halfway houses). From the cultural perspective, variables such as ethnicity and gender should be taken in consideration in the development of therapies.

Much research has been conducted to determine whether or not psychotherapy is effective and if one approach is superior to another. Hans Eysenck concluded that psychotherapy is ineffective and found that neurotic individuals on a waiting list showed marked improvement even though they did not receive psychotherapy. Using meta-analysis, which statistically combines the results of many different studies, researchers found that psychotherapy is effective in general. When comparing different approaches, research has found that behavior therapy and insight therapies were superior to no treatment, but did not differ from each other in effectiveness. Some therapies have been found to be more effective in treating some disorders than others. Behavior therapies have been most successful in treating phobias and sexual dysfunctions, while cognitive therapies are effective in treating depression and anxiety. Relaxation training is effective in treating anxiety disorders. The most effective psychotherapies have the common elements of expectations, mastery, and emotional arousal as well as a supportive therapeutic relationship. In the last two decades, psychologists have turned their attention to gender and ethnic concerns in psychotherapy.

Most therapists take an eclectic or integrative approach to therapy. In this approach, the therapist is open to using various therapeutic techniques. An example of this is the use of psychotherapy in combination with drug therapy.

Psychotherapy is expensive, which may contribute to the criticism that psychotherapists are more likely to offer their services to young, attractive, verbal, intelligent, and successful clients than to quiet, ugly, old, institutionalized, and different clients. Managed care has changed the mental health care delivery to control health care costs and has been met with much criticism.

Psychotherapy is practiced by clinical psychologists, psychiatrists, counselors, and other mental health professionals. Society controls individuals who practice psychotherapy through licensing and certification.

A person seeking professional help for a psychological disorder should identify the professional credential of the mental health professional, give the therapy some time before judging how useful it is, and be a careful consumer of the services.