Treatment of Abnormal Behavior

Unit XIII Treatment of Abnormal Behavior

PD Unit Overview Psychologists work hard to identify the causes and symptoms of psycho- • Evaluate the pros and cons of using operant conditioning logical disorders. But the goal of that hard work is not just identification. principles in therapy. Psychologists hope that such identification of causes and symptoms will • Distinguish the goals and techniques of cognitive therapy and lead to the development of treatments for disorders. The treatments dis- cognitive-behavioral therapy. cussed in this unit cover the gamut of perspectives described throughout • Analyze the goals and benefi ts of group and family therapy. this book. From psychoanalysis to biological therapies, these treatments • Analyze the eff ectiveness of psychotherapy from the perspective highlight the underlying theories of what causes some people to struggle of the client, the clinician, and the outcome. with psychological illness. Some disorders are treated more effectively with certain treatments and not others. Knowledge of all these treatments could • Evaluate which psychotherapies are most eff ective for specifi c help you or someone you care for get the kind of help needed to address disorders. a potential struggle with mental illness. Receiving the right treatment can • Analyze alternative therapies using scientifi c inquiry. make a positive difference in someone’s life. After reading this unit, stu- • Determine the 3 elements shared by all forms of psychotherapy. dents will be able to: • Analyze how culture, gender, and values infl uence the therapist– • Diff erentiate among psychotherapy, biomedical therapy, and an client relationship. eclectic approach to therapy. • Identify some guidelines for selecting a therapist. • Explain the goals and techniques of psychoanalysis and how • Explain the rationale of preventive mental health programs. they’ve been adapted to psychodynamic therapy. • Describe the various drug therapies. • Describe the basic themes of humanistic therapy, specifi cally the • Explain how double-blind studies work to evaluate the goals and techniques of Rogers’ client-centered approach. eff ectiveness of drug therapies. • Contrast behavior therapy with psychodynamic and humanistic • Describe how psychosurgery and brain stimulation techniques therapies. treat disorders. • Describe how exposure therapies and aversive conditioning work. • Analyze how a healthy lifestyle’s eff ect on depression refl ects the • Explain how operant conditioning principles can inform biopsychosocial systems. therapeutic techniques.

Alignment to AP® Course Description Topic 13: Treatment of Abnormal Behavior (7–9% of AP® Examination)

Module Topic Essential Questions

Module 70 Introduction to Therapy • What does it mean to be mentally well?

Psychoanalysis and • Can mental illnesses be treated by exploring our unconscious? Psychodynamic Therapy

Humanistic Therapies • How important are listening and support to effective therapy?

Treatment of Abnormal Behavior Unit XIII 707a

MyersPsyAP_TE_2e_U13.indd 1 3/3/14 8:44 AM Module Topic Essential Questions

Module 71 Behavior Therapies • How can we unlearn maladaptive behaviors?

Cognitive Therapies • How can changing our thoughts change our maladaptive behavior?

Group and Family Therapies • How important are family members and other people to effective therapy?

Module 72 Evaluating Psychotherapies • How do we know a therapy is effective?

Preventing Psychological Disorders • How do we prevent mental illness?

Module 73 Drug Therapies • Are drug therapies effective?

Brain Stimulation • How does altering the brain’s electrochemistry affect mental health?

Psychosurgery • How important to our mental health are different parts of the brain?

Therapeutic Lifestyle Change • How important is it to change our lifestyles to promote mental health?

Unit Resources Module 70 Module 72

STUDENT ACTIVITIES STUDENT ACTIVITY • Attitudes Toward Seeking Professional Psychological Help • Fact or Falsehood? • Fact or Falsehood? FLIP IT VIDEOS • The Self-Concealment Scale • Evidence-Based Practice: Applying Science to Therapy • Role-Playing to Demonstrate Client-Centered Therapy Module 73 Module 71 MyersAP_SE_2e_Mod70_B.indd 707 1/21/14 9:36 AM STUDENT ACTIVITY STUDENT ACTIVITIES • Fact or Falsehood? • Fact or Falsehood? FLIP IT VIDEO • Practicing Systematic Desensitization • How Drug Therapy Works • Modifying a Phobia • Positive and Negative Symptoms • Frequency of Self-Reinforcement Questionnaire TEACHER DEMONSTRATION • Using Systematic Desensitization to Treat Eraser Phobia FLIP IT VIDEO • Counterconditioning: How It Works

707b Unit XIII Treatment of Abnormal Behavior

MyersPsyAP_TE_2e_U13.indd 2 3/3/14 8:44 AM TEACH Unit XIII TRMTRM Common Pitfalls Some of your students may currently be seeing a psychotherapist, coun- Treatment of Abnormal selor, psychiatrist, or clinical psychologist for any number of personal or family issues. Be sensitive to this pos- Behavior sibility as you teach this module. Use Student Activity: Attitudes Modules Toward Seeking Professional Psy- chological Help from the TRM to 70 Introduction to Therapy, and Psychodynamic and assess student attitudes toward Humanistic Therapies psychotherapy. 71 Behavior, Cognitive, and Group Therapies 72 Evaluating Psychotherapies and Prevention Strategies 73 The Biomedical Therapies

ay Redfi eld Jamison, an award-winning clinical psychologist and world ex- pert on the emotional extremes of bipolar disorder, knows her subject fi rst- K An Unquiet Mind, hand. “For as long as I can remember,” she recalled in “I was frighteningly, although often wonderfully, beholden to moods. Intensely emotional as a child, mercurial as a young girl, fi rst severely depressed as an adolescent, and then unrelentingly caught up in the cycles of manic-depressive illness [now known as bipolar disorder] by the time I began my professional life, I became, both by necessity and intellectual inclination, a student of moods” (1995, pp. 4–5). Her life was blessed with times of intense sensitivity and passionate energy. But like her father’s, it was also at times plagued by reckless spending, racing conversation, and sleeplessness, alternating with swings into “the blackest caves of the mind.” Then, “in the midst of utter confusion,” she made a sane and profoundly helpful decision. Risking professional embarrassment she made an appointment with a therapist, a psychiatrist she would visit weekly for years to come.

He kept me alive a thousand times over. He saw me through madness, despair, won- derful and terrible love affairs, disillusionments and triumphs, recurrences of illness, an almost fatal suicide attempt, the death of a man I greatly loved, and the enormous pleasures and aggravations of my professional life. . . . He was very tough, as well

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Module Topic Standard Schedule Days Block Schedule Days Module 70 Introduction to Therapy Psychoanalysis and Psychodynamic Therapy 1 Humanistic Therapies 1 Module 71 Behavior Therapies Cognitive Therapies 1 Group and Family Therapies Module 72 Evaluating Psychotherapies Preventing Psychological Disorders

Module 73 Drug Therapies 1 1/2 Brain Stimulation Psychosurgery Therapeutic Lifestyle Change Treatment of Abnormal Behavior Unit XIII 707

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as very kind, and even though he understood more than anyone how much I felt I was losing—in energy, vivacity, and originality—by taking medication, he never was seduced into losing sight of the overall perspective of how costly, damaging, and life threatening my illness was. . . . Although I went to him to be treated for an illness, he taught me . . . the total beholdenness of brain to mind and mind to brain (pp. 87–88).

“Psychotherapy heals,” Jamison reports. “It makes some sense of the confusion, reins in the terrifying thoughts and feelings, returns some control and hope and possibility from it all.”

TEACH TRMTRM Discussion Starter Module 70 Use the Module 70 Fact or Falsehood? activity from the TRM to introduce the Introduction to Therapy, and concepts from this module. Psychodynamic and Humanistic Therapies ENGAGE Enrichment Module Learning Objectives Image Source RF/Sydney Bourne/Getty Images As noted in Unit XII, Dorothea Dix psychotherapy, biomedical therapy, eclectic 70-1 Discuss how and an began her crusade for the humane approach to therapy differ. treatment of mentally ill patients when she started to tutor inmates at 70-270-2 Discuss the goals and techniques of psychoanalysis, and describe how they have been adapted in psychodynamic therapy. a women’s prison. Men and women who were mentally ill or disabled were 70-370-3 Identify the basic themes of humanistic therapy, and describe the being housed there with hardened specifi c goals and techniques of Rogers’ client-centered approach. female criminals. Dix advocated for reforms in all existing U.S. states and throughout Europe. he long history of efforts to treat psychological disorders has included a bewildering T mix of harsh and gentle methods. 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 electric shocks. And they have talked with their patients about childhood experiences, current feelings, and maladaptive thoughts and behaviors. Reformers Philippe Pinel and Dorothea Dix pushed for gentler, more humane treatments and for constructing mental hospitals. Since the 1950s, the introduction of effective drug therapies and community -based treatment programs have emptied most of those hospitals.

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708 Unit XIII Treatment of Abnormal Behavior

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Introduction to Therapy ENGAGE psychotherapy, biomedical therapy, eclectic approach 70-170-1 How do and an to therapy differ? Critical Questions Today’s therapies can be classifi ed into two main categories. In psychotherapy, a trained AP® Exam Tip Insurance coverage for mental health therapist uses psychological techniques to assist someone seeking to overcome diffi cul- limits the amount of time a person ties or achieve personal growth. Biomedical therapy offers medication or other biological Most of the treatments discussed in this unit come from the can spend in therapy. Have students treatments. perspectives you’ve been learning Many therapists combine techniques. Jamison received psychotherapy in her meetings about since Unit I. As you reach fi nd out what mental health coverage with her psychiatrist, and she took medications to control her wild mood swings. Many each major section—like the psychotherapists describe themselves as taking an eclectic approach, using a blend of upcoming one on psychoanalytic they have through their parents or and psychodynamic therapy—try psychotherapies. Like Jamison, many patients also can receive psychotherapy combined to anticipate how someone from legal guardians, or what coverage is with medication. that perspective would approach generally provided to employees in Let’s look fi rst at the psychotherapeutic “talk therapies.” Among the dozens of types of therapy (for example, “What would Freud do?”). This should the professions they’re considering psychotherapy, we will look at the most infl uential. Each is built on one or more of psychol- help you organize and retain the ogy’s major theories: psychodynamic, humanistic, behavioral, and cognitive. Most of these information as you read. after graduation. techniques can be used one-on-one or in groups. We’ll explore psychodynamic and humanistic therapies in this module, and behavior, cognitive, and group therapies in Module 71. How much time in outpatient therapy can a person spend in a The history of treatment Visitors calendar year? to eighteenth-century mental hospitals paid to gawk at patients, as though How much time in inpatient they were viewing zoo animals. William Hogarth’s (1697–1764) therapy can a person spend in a painting captured one of these visits to London’s St. Mary of Bethlehem calendar year? hospital (commonly called Bedlam). Do insurance companies specify

The Granger Collection, NYC. All rights reserved. what types of mental health therapy they will cover? What kind of coverage does the state offer through Medicaid? psychotherapy treatment involving psychological techniques; consists of interactions between a trained TEACH therapist and someone seeking to overcome psychological diffi culties or Psychoanalysis and Psychodynamic Therapy achieve personal growth. Concept Connections biomedical therapy prescribed Before Freud, psychology was a 70-270-2 What are the goals and techniques of psychoanalysis, and how have medications or procedures that act they been adapted in psychodynamic therapy? directly on the person’s physiology. new science concerned more with eclectic approach Sigmund Freud’s psychoanalysis was the fi rst of the psychological therapies. Few clini- an approach describing the human experience to psychotherapy that, depending on cians today practice therapy as Freud did, but his work deserves discussion as part of the the client’s problems, uses techniques than developing eff ective therapeutic foundation for treating psychological disorders. from various forms of therapy. techniques. Goals psychoanalysis Sigmund Freud’s therapeutic technique. Structuralism, the school founded Psychoanalytic theory presumes that healthier, less anxious living becomes possible when Freud believed the patient’s by Wilhelm Wundt in 1879, sought people release the energy they had previously devoted to id - ego - superego confl icts (see free associations, resistances, Module 55). Freud assumed that we do not fully know ourselves. There are threatening dreams, and transferences—and to describe what consciousness the therapist’s interpretations things that we seem to want not to know—that we disavow or deny. “We can have loving of them—released previously was, positing that people shared feelings and hateful feelings toward the same person,” notes Jonathan Shedler (2009), and repressed feelings, allowing the common experiences and “we can desire something and also fear it.” patient to gain self - insight. perceptions about the world. Functionalism, a school favored by G. Stanley Hall in the United States, stated that describing sensations MyersAP_SE_2e_Mod70_B.indd 708 1/21/14 9:36 AM MyersAP_SE_2e_Mod70_B.indd TEACH 709 1/21/14 9:36 AM was not as important as knowing how the mind worked. Concept Connections Review the stages of development in Freud’s The phallic stage continues until school theory (from Unit X): starts. Young children face such Freudian The oral stage lasts from birth to about 18 issues as the Oedipus complex, penis envy, months. Infants are gratified by activities and castration anxiety. like sucking and biting. Early weaning may The latency stage, occurring during the lead to bad habits such as overeating or elementary school years, occurs when smoking. children learn gender roles by associating The anal stage spans the potty-training with same-sex friends. years. Children have to balance societal The genital stage starts at puberty. Freud demands with their own desires. If a child is believed that if people do not have sexual trained too early, he or she may develop an experiences, they will develop problems anal-retentive personality. later in life.

Introduction to Therapy, and Psychodynamic and Humanistic Therapies Module 70 709

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Freud’s therapy aimed to bring patients’ repressed or disowned feelings into conscious ENGAGE awareness. By helping them reclaim their unconscious thoughts and feelings and giving them insight into the origins of their disorders, he aimed to help them reduce growth- Enrichment impeding inner confl icts. Traditional Freudian analysis calls for Techniques the therapist to be out of the physical Psychoanalysis is historical reconstruction. Psychoanalytic theory empha- view of the patient. Freud believed sizes the formative power of childhood experiences and their ability to that resistance would develop if a mold the adult. Thus, it aims to unearth one’s past in hope of unmasking patient could see the therapist. And the present. After discarding hypnosis as an unreliable excavator, Freud turned to free association. if a patient hesitates during free © The New Yorker Collection, 2009, cartoonbank.com. from Noth Paul All Rights Reserved. Imagine yourself as a patient using free association. First, you re- “I’m more interested in hearing about the eggs lax, perhaps by lying on a couch. As the psychoanalyst sits out of your association or doesn’t share his or her you’re hiding from yourself.” line of vision, you say aloud whatever comes to mind. At one moment, innermost thoughts, then the analyst you’re relating a childhood memory. At another, you’re describing a dream or recent AP® Exam Tip will perceive that patient as resisting experience. It sounds easy, but soon you notice how often you edit your thoughts as treatment, which is also viewed as Psychoanalytic treatment is the you speak. You pause for a second before uttering an embarrassing thought. You omit public image of psychology. If you what seems trivial, irrelevant, or shameful. Sometimes your mind goes blank or you fi nd refl ecting a deep-seated psychologi- were to ask people to sketch a psychologist at work, you would yourself unable to remember important details. You may joke or change the subject to cal problem. see lots of sketches of therapists something less threatening. taking notes while they were seated To the analyst, these mental blocks indicate resistance. They hint that anxiety behind patients on couches. Keep in mind that most modern therapy lurks and you are defending against sensitive material. The analyst will note your resis- ENGAGE is very different from this image, tances and then provide insight into their meaning. If offered at the right moment, this and psychology careers stretch well interpretation—of, say, your not wanting to talk about your mother—may illuminate Critical Questions beyond therapy. the underlying wishes, feelings, and confl icts you are avoiding. The analyst may also Freudian analysis remains contro- offer an explanation of how this resistance fi ts with other pieces of your psychological puzzle, including those based on analysis of your dream content. versial because the therapist tries “I haven’t seen my analyst in 200 Over many such sessions, your relationship patterns surface in your interaction with years. He was a strict Freudian. to probe the unconscious, which is If I’d been going all this time, your therapist. You may fi nd yourself experiencing strong positive or negative feelings for I’d probably almost be cured your analyst. The analyst may suggest you are transferring feelings, such as dependency or supposedly full of locked, painful OODY LLEN AFTER by now.” -W A , mingled love and anger, that you experienced in earlier relationships with family members AWAKENING FROM SUSPENDED ANIMATION childhood memories. Critics contend IN THE MOVIE SLEEPER or other important people. By exposing such feelings, you may gain insight into your current that therapists can actually create relationships. Relatively few U.S. therapists now offer traditional psychoanalysis. Much of its under- such memories in clients, leading such lying theory is not supported by scientifi c research (Module 56). Analysts’ interpretations clients to believe they have experi- resistance in psychoanalysis, cannot be proven or disproven. And psychoanalysis takes considerable time and money, the blocking from consciousness of enced repressed childhood trauma. often years of several sessions per week. Some of these problems have been addressed in anxiety- laden material. the modern psychodynamic perspective that has evolved from psychoanalysis. How has the research of Elizabeth interpretation in psychoanalysis, the analyst’s noting supposed Psychodynamic Therapy Loftus raised doubts about the dream meanings, resistances, and existence of repressed memories? other signifi cant behaviors and Therapists who use psychodynamic therapy techniques don’t talk much about id, ego, events in order to promote insight. and superego. Instead they try to help people understand their current symptoms. They (See Unit VII.) transference in psychoanalysis, focus on themes across important relationships, including childhood experiences and the How might modern psychoanalysts the patient’s transfer to the analyst therapist relationship. Rather than lying on a couch, out of the therapist’s line of vision, of emotions linked with other patients meet with their therapist face to face. These meetings take place once or twice relationships (such as love or hatred work to avoid creating memories a week (rather than several times per week), and often for only a few weeks or months for a parent). (rather than several years). in their clients? psychodynamic therapy therapy In these meetings, patients explore and gain perspective into defended-against thoughts deriving from the psychoanalytic tradition that views individuals as and feelings. Therapist David Shapiro (1999, p. 8) illustrates with the case of a young man responding to unconscious forces who had told women that he loved them, when knowing well that he didn’t. They expected and childhood experiences, and that it, so he said it. But later with his wife, who wishes he would say that he loves her, he fi nds seeks to enhance self-insight. he “cannot” do that—“I don’t know why, but I can’t.”

ENGAGEMyersAP_SE_2e_Mod70_B.indd 710 TEACH 1/21/14 9:36 AM MyersAP_SE_2e_Mod70_B.indd 711 1/21/14 9:36 AM Active Learning Concept Connections Have students collect cartoons, advertise- Students may wonder why never losing an argu- ments, and movie or TV references to Freudian ment is not good for establishing the credibility of ideas and bring them to class. Students can psychoanalysis. Remind students that confi r- work in groups to identify the concepts in play, mation bias (Unit VII) poses a danger to critical analyzing whether each depiction is posi- thinking. People tend to look for evidence that tive or negative. Students can also determine confi rms their preconceptions rather than search- whether the depiction is presented in a factual ing for evidence that disputes their ideas, mean- or farcical way. ing that they will often miss even glaring evidence that refutes strongly held beliefs. With Freudian analysis, no alternative explanations for behavior are accepted since all resistance to treatment is simply confi rmation of a repressed problem.

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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. ENGAGE Maybe I don’t love her. Enrichment Further interactions reveal that he can’t express real love because it would feel “mushy” and “soft” and therefore unmanly. He is “in confl ict with himself, and he is cut off from Interpersonal psychotherapy (IPT) is the nature of that confl ict.” Shapiro noted that with such patients, who are estranged from a short-term therapy that has been themselves, therapists using psychodynamic techniques “are in a position to introduce shown to be eff ective for treating 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.” depression. Depression isn’t caused by Psychodynamic therapies may also help reveal past relationship troubles as the origin Véronique Burger/Science Source Véronique interpersonal events alone, but it usu- of current diffi culties. Jonathan Shedler (2010a) recalls his patient Jeffrey’s complaints of diffi culty getting along with his colleagues and wife, who saw him as hypercritical. Jeffrey then ally has an interpersonal component, “began responding to me as if I were an unpredictable, angry adversary.” Shedler seized this aff ecting relationships. The types of opportunity to help Jeffrey recognize the relationship pattern, and its roots in the attacks interpersonal events that IPT focuses and humiliation he experienced from his alcohol-abusing father—and to work through and let go of this defensive responding to people. on include the following: Interpersonal psychotherapy, a brief (12- to 16-session) variation of psychodynamic therapy, has effectively treated depression (Cuijpers, 2011). Although interpersonal psychother- Interpersonal disputes and apy aims to help people gain insight into the roots of their diffi culties, its goal is symptom conflicts relief in the here and now. Rather than focusing mostly on undoing past hurts and offering Role transitions (such as becoming interpretations, the therapist concentrates primarily on current relationships and on helping people improve their relationship skills. a parent or losing a parent) The case of Anna, a 34-year - old married professional, illustrates these goals. Five months Grief that goes beyond the normal after receiving a promotion, with accompanying increased responsibilities and longer hours, Face -to -face therapy Anna experienced tensions with her husband over his wish for a second child. She began In contemporary psychodynamic bereavement period therapy, the couch has disappeared. feeling depressed, had trouble sleeping, became irritable, and was gaining weight. A thera- But the influence of psychoanalytic Deficits that patients have pist using psychodynamic techniques might have helped Anna gain insight into her angry theory continues in some areas, as impulses and her defenses against anger. A therapist applying interpersonal techniques the therapist seeks information from in initiating and maintaining the patient’s childhood and helps the would concur but would also engage her thinking on more immediate issues—how she person bring unconscious feelings into relationships could balance work and home, resolve the dispute with her husband, and express her emo- conscious awareness. tions more effectively (Markowitz et al., 1998). TEACH Humanistic Therapies Concept Connections 70-370-3 What are the basic themes of humanistic therapy? What are the specifi c goals and techniques of Rogers’ client-centered approach? Link humanistic therapy to Abraham The humanistic perspective (Module 57) has emphasized people’s inherent potential for Maslow’s hierarchy of needs self - fulfi llment. Like psychodynamic therapies, humanistic therapies have attempted to re- (Unit VIII). Instead of explaining behav- insight therapies duce growth-impeding inner confl icts by providing clients with new insights. Indeed, the a variety of insight therapies. therapies that aim to improve ior in terms of buried unconscious psychodynamic and humanistic therapies are often referred to as But psychological functioning by humanistic therapy differs from psychoanalytic therapy in many other ways: increasing a person’s awareness of feelings and desires, Maslow believed • Humanistic therapy aims to boost people’s self-fulfi llment by helping them grow in self- underlying motives and defenses. that full human potential could be awareness and self-acceptance. achieved if certain basic needs were • Promoting this growth, not curing illness, is the focus of therapy. Thus, those in therapy met. He theorized that people could became “clients” or just “persons” rather than “patients” (a change many other therapists have adopted). not appreciate beauty if they were • The path to growth is taking immediate responsibility for one’s feelings and actions, rather worried about where their next meal than uncovering hidden determinants. was coming from or if they did not • Conscious thoughts are more important than the unconscious. have a loving relationship with others. • The present and future are more important than the past. The goal is to explore feelings as they occur, rather than achieve insights into the childhood origins of the feelings.

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Carl Rogers (1902–1987) developed the widely used humanistic technique he called TEACH client - centered therapy, which focuses on the person’s conscious self - perceptions. In TRMTRM this nondirective therapy, the therapist listens, without judging or interpreting, and seeks to Common Pitfalls refrain from directing the client toward certain insights. Believing that most people possess the resources for growth, Rogers (1961, 1980) As noted in Unit XII, not much analysis AP® Exam Tip encouraged therapists to exhibit acceptance, genuineness, and empathy. When therapists occurred in person-centered therapy. A You can remember cceptance, enable their clients to feel unconditionally accepted, when they drop their façades and Genuineness, and Empathy as To facilitate unconditional positive “AGE.” genuinely express their true feelings, and when they empathically sense and refl ect their regard, genuineness, and empathy, clients’ feelings, the clients may deepen their self- understanding and self-acceptance (Hill & Nakayama, 2000). As Rogers (1980, p. 10) explained, Carl Rogers would answer questions Hearing has consequences. When I truly hear a person and the meanings that are with questions— “How does that important to him at that moment, hearing not simply his words, but him, and when make you feel?” was the most com- I let him know that I have heard his own private personal meanings, many things happen. There is fi rst of all a grateful look. He feels released. He wants to tell me mon. Rogers believed that if people more about his world. He surges forth in a new sense of freedom. He becomes received the attention and acceptance more open to the process of change. I have often noticed that the more deeply I hear the meanings of the person, they needed, they could cure them- the more there is that happens. Almost always, when a person realizes he has been selves. The therapist merely existed to 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 provide that support. what it’s like to be me.” Use Student Activity: The Self- “We have two ears and one “Hearing” refers to Rogers’ technique of active listening—echoing, restating, and Concealment Scale from the TRM to mouth that we may listen the seeking clarifi cation of what the person expresses (verbally or nonverbally) and acknowl- more and talk the less.” -ZENO, edging the expressed feelings. Active listening is now an accepted part of therapeutic coun- help students become more open 335–263 B.C.E., DIOGENES LAERTIUS seling practices in many high schools, colleges, and clinics. The counselor listens attentively about therapy. and interrupts only to restate and confi rm feelings, to accept what is being expressed, or to seek clarifi cation. The following brief excerpt between Rogers and a male client illustrates ENGAGE how he sought to provide a psychological mirror that would help clients see themselves more clearly. Critical Questions Rogers: Feeling that now, hm? That you’re just no good to yourself, no good to any- Have students consider the eff ect of body. 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? referring to people as patients rather Client: Yeah. (Muttering in low, discouraged voice) That’s what this guy I went to town than as clients. with just the other day told me. Rogers: How does the use of each term client - centered therapy 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? affect the whole therapeutic a humanistic therapy, developed by Carl Rogers, in which the Client: M-hm. relationship? therapist uses techniques such as Rogers: I guess the meaning of that if I get it right is that here’s somebody that—meant active listening within a genuine, In what other situations have accepting, empathic environment to something to you and what does he think of you? Why, he’s told you that he thinks semantics (the meaning of facilitate clients’ growth. (Also called you’re no good at all. And that just really knocks the props out from under you. (Client person - centered therapy.) weeps quietly.) It just brings the tears. (Silence of 20 seconds) different words) affected how active listening empathic Client: (Rather defi antly) I don’t care though. different jobs, issues, and roles listening in which the listener Rogers: You tell yourself you don’t care at all, but somehow I guess some part of you echoes, restates, and clarifi es. A cares because some part of you weeps over it. in society are viewed? (To get feature of Rogers’ client- centered the conversation rolling, suggest therapy. (Meador & Rogers, 1984, p. 167) that garbage collectors be called unconditional positive regard Can a therapist be a perfect mirror, without selecting and interpreting what is refl ected? a caring, accepting, nonjudgmental Rogers conceded that one cannot be totally nondirective. Nevertheless, he believed that attitude, which Carl Rogers believed sanitation engineers or that the therapist’s most important contribution is to accept and understand the client. Given a would help clients to develop self- unconditional positive regard, overthrowing a political leader awareness and self-acceptance. nonjudgmental, grace - fi lled environment that provides be called regime change. Refer to people may accept even their worst traits and feel valued and whole. one comedienne who calls herself a “domestic goddess” rather than a housewife.) ENGAGEMyersAP_SE_2e_Mod70_B.indd 712 1/21/14 9:36 AM MyersAP_SE_2e_Mod70_B.indd 713 1/21/14 9:36 AM TRMTRM Active Learning Have students create their own scripts that utilize the principles of active listening. They can present their “conversations” to the class, discussing whether their interpretations of Rogerian technique would be helpful. Use Student Activity: Role-Playing to Dem- onstrate Client-Centered Therapy from the TRM to help students develop their own active listening skills.

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Active listening Carl Rogers (right) empathized with a client during this ENGAGE group therapy session. Enrichment Virginia Axline, a student of Rogers, has extended the client-centered approach to the treatment of children

Magazine, © Time Warner, Inc. Warner, Life Magazine, © Time Michael Rougier, in play therapy. She has written Dibs: In Search of Self. This book can be assigned in preparation for class discussion of the humanistic therapies and, in particular, Rogers’ nondirective If you want to listen more actively in your own relationships, three Rogerian hints may help: approach. The more general humanis- 1. Paraphrase. Rather than saying “I know how you feel,” check your understanding by tic themes of becoming aware of one’s summarizing the person’s words in your own words. feelings as they occur, of emphasizing 2. Invite clarifi cation. “What might be an example of that?” may encourage the person conscious rather than unconscious to say more. 3. Refl ect feelings. “It sounds frustrating” might mirror what you’re sensing from the material, of encouraging responsibil- person’s body language and intensity. ity for one’s actions, and of promoting Before You Move On growth and fulﬁ llment are also clearly evident in the book. c ASK YOURSELF Ask your students to write a paper Think of your closest friends. Do they tend to express more empathy than those you don’t feel as close to? How have your own active listening skills changed as you’ve gotten older? identifying the important elements of client-centered therapy (for example, c TEST YOURSELF In psychoanalysis, what does it mean when we refer to transference, resistance, and active listening, genuineness, accep- interpretation? tance, empathy) in Dibs. Answers to the Test Yourself questions can be found in Appendix E at the end of the book. ENGAGE Critical Questions Could too much unconditional positive regard be a bad thing? Have students consider the following questions: How might unconditional positive regard lead to unwarranted self- esteem? Why would people in therapy benefit most from unconditional positive regard?

MyersAP_SE_2e_Mod70_B.indd 712 1/21/14 9:36 AM MyersAP_SE_2e_Mod70_B.inddENGAGE 713 1/21/14 9:36 AM Active Learning Present case studies from various abnormal psychology textbooks and have students explain the person’s behavior from a particular perspective. You may assign a particular perspective for study and have students come up with a case study reﬂ ecting common disorders that therapists from that perspective would likely treat. Then ask students to describe what type of treatment that type of therapist would recommend to this new “patient.”

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CLOSE & ASSESS Module 70 Review How do psychotherapy, biomedical therapy, Exit Assessment 70-1 70-370-3 What are the basic themes of humanistic and an eclectic approach to therapy differ? therapy, and what are the specifi c goals Provide students with a list of terms and techniques of Rogers’ client-centered from this module—psychodynamic, • Psychotherapy is treatment involving psychological approach? techniques; it consists of interactions between a trained resistance, interpretation, transferring, therapist and someone seeking to overcome psychological • Both psychoanalytic and humanistic therapies are insight client-centered therapy, unconditional diffi culties or achieve personal growth. therapies—they attempt to improve functioning by increasing clients’ awareness of motives and defenses. positive regard, active listening—and • The major psychotherapies derive from psychology’s have them match the term with either psychodynamic, humanistic, behavioral, and cognitive • Humanistic therapy’s goals have included helping clients perspectives. grow in self-awareness and self-acceptance; promoting Freud or Rogers. This activity will help personal growth rather than curing illness; helping clients Biomedical therapy treats psychological disorders with • take responsibility for their own growth; focusing on ensure they know which terms cor- medications or procedures that act directly on a patient’s conscious thoughts rather than unconscious motivations; physiology. respond to which founder. and seeing the present and future as more important than • An eclectic approach combines techniques from various the past. forms of psychotherapy. • Carl Rogers’ client-centered therapy proposed that therapists’ most important contributions are to function 70-270-2 What are the goals and techniques of psychoanalysis, and how have they been as a psychological mirror through active listening and to adapted in psychodynamic therapy? provide a growth-fostering environment of unconditional positive regard, characterized by genuineness, acceptance, • Through psychoanalysis, Sigmund Freud tried to give and empathy. people self-insight and relief from their disorders by bringing anxiety-laden feelings and thoughts into conscious awareness. • Techniques included using free association and interpretation of instances of resistance and transference. • Contemporary psychodynamic therapy has been infl uenced by traditional psychoanalysis but is briefer, less expensive, and more focused on helping the client fi nd relief from current symptoms. • Therapists help clients understand themes that run through past and current relationships. • Interpersonal therapy is a brief 12- to 16-session form of psychodynamic therapy that has been effective in treating depression.

Answers to Multiple-Choice Multiple-Choice Questions Questions 1. Many clinical psychologists incorporate a variety of 2. What do psychodynamic therapists call the blocking of approaches into their therapy. They are said to take a(n) anxiety-laden material from the conscious? 1. d ______approach. a. Resistance 2. a a. transference b. Interpretation b. biomedical c. Transference c. psychoanalytic d. Face-to-face therapy d. eclectic e. Interpersonal psychotherapy e. psychodynamic

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3. Which of the following is one of the ways humanistic 4. Which of the following is a feature of client-centered 3. e therapies differ from psychoanalytic therapies? therapy? a. Humanist therapies believe the past is more a. Free association 4. b important than the present and future. b. Active listening b. Humanist therapies boost self-fulﬁ llment by c. Resistance decreasing self-acceptance. d. Freudian interpretation c. Humanist therapies believe the path to growth is e. Medical/biological treatment found by uncovering hidden determinants. d. Humanist therapies believe that unconscious thoughts are more important than conscious thoughts. e. Humanist therapies focus on promoting growth, not curing illness.

Practice FRQs Answer to Practice FRQ 2 1. Explain what psychoanalysis is, and then discuss the 2. Explain what client-centered therapy is, then describe 1 point: Client-centered therapy is relationship of transference and resistance to the therapy. the two major techniques of the therapy. (3 points) a humanistic therapy developed by Answer Carl Rogers that uses an accepting 1 point: Psychoanalysis is a Freudian therapy that seeks to environment to facilitate growth. get patients to release repressed feelings to gain self-insight. 1 point: Transference is the patient’s transfer of emotion to 1 point: Active listening is empathic the analyst. listening that restates and clariﬁ es 1 point: Resistance is the blocking of consciousness (by the what a patient says. patient) of anxiety-laden material. 1 point: Unconditional positive regard is a caring, nonjudgmental attitude that promotes self-awareness in clients.

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TEACH TRMTRM Discussion Starter Module 71 Use the Module 71 Discussion Starter: Fact or Falsehood? activity from the Behavior, Cognitive, and Group Therapies TRM to introduce the concepts from this module. Module Learning Objectives ENGAGE 71-171-1 Explain how the basic assumption of behavior therapy differs Richard T. Nowitz/CORBIS Active Learning from those of psychodynamic and humanistic therapies, and describe the techniques used in exposure therapies and aversive conditioning. Classical and operant conditioning techniques can be used for many 71-271-2 State the main premise of therapy based on operant conditioning principles, and describe the views of its proponents and critics. diﬀ erent disorders and issues, from addictions to laziness. Have students 71-371-3 Discuss the goals and techniques of cognitive therapy and of research how classical conditioning is cognitive-behavioral therapy. used in popular treatment programs 71-471-4 Discuss the aims and benefi ts of group and family therapy. for various life problems, including the following: Self-injurious behavior in autistic Behavior Therapies children behavior therapy therapy that applies learning principles to the How does the basic assumption of behavior therapy differ from those elimination of unwanted behaviors. 71-171-1 Addictions of psychodynamic and humanistic therapies? What techniques are Children who have become so- used in exposure therapies and aversive conditioning? called “couch potatoes” The insight therapies assume that many psychological problems diminish as self- awareness grows. Psychodynamic therapies expect problems to subside as people gain insight into their unresolved and unconscious tensions. Humanistic therapies ENGAGE expect problems to diminish as people get in touch with their feelings. Proponents of behavior therapy, however, doubt the healing power of self- awareness. (You can be- Critical Questions come aware of why you are highly anxious during tests and still be anxious.) are Traditional behaviorists were not They assume that problem behaviors the problems, and the application of learning principles can eliminate them. Rather than delving deeply below the concerned with the thoughts and surface looking for inner causes, therapies using behavioral techniques view feelings of those with established maladaptive symptoms—such as phobias or sexual dysfunctions—as learned behaviors that can be replaced by constructive behaviors. fears. They believed that all behavior ScienceCartoonsPlus.com resulted from a stimulus–response Classical Conditioning Techniques relationship and that concepts such as AP® Exam Tip One cluster of behavior therapies derives from principles developed in Ivan Pavlov’s early twentieth- century conditioning experiments (Module 26). As Pavlov and others showed, we the unconscious mind were irrelevant Before you read the next several pages of this module, you may learn various behaviors and emotions through classical conditioning. Could maladaptive to people’s current situations. want to quickly review the symptoms be examples of conditioned responses? If so, might reconditioning be a solu- material on classical and operant tion? Learning theorist O. H. Mowrer thought so and developed a successful conditioning Why would scientists find the conditioning in Unit VI. therapy for chronic bed - wetters. The child sleeps on a liquid - sensitive pad connected to an behaviorist perspective more alarm. Moisture on the pad triggers the alarm, waking the child. With sufﬁ cient repetition, appealing than Freudian views? this association of bladder relaxation with waking up stops the bed -wetting. In three out Does the underlying cause of a behavior really matter if therapy is successful in eliminating it? Why or why not? MyersAP_SE_2e_Mod71_B.indd 716 1/21/14 9:36 AM MyersAP_SE_2e_Mod71_B.indd 717 1/21/14 9:36 AM Should people focus on experiences from the past or current circumstances? Why or why not?

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of four cases the treatment is effective, and the success provides a boost to the child’s self - image (Christophersen & Edwards, 1992; Houts et al., 1994). Another example: If a claustrophobic fear of elevators is a learned aversion to the stimulus of being in a conﬁ ned space, then might one unlearn that association by undergoing counterconditioning another round of conditioning to replace the fear response? Counterconditioning pairs behavior the trigger stimulus (in this case, the enclosed space of the elevator) with a new response therapy procedures that use classical conditioning to evoke (relaxation) that is incompatible with fear. Indeed, behavior therapists have successfully new responses to stimuli that are counterconditioned people with such fears. Two speciﬁ c counterconditioning techniques— triggering unwanted behaviors; exposure therapy and aversive conditioning—replace unwanted responses. include exposure therapies and aversive conditioning.

EXPOSURE THERAPIES exposure therapies behavioral TEACH Picture this scene reported in 1924 by psychologist Mary Cover Jones: Three - year - old Peter techniques, such as systematic desensitization virtual reality is petrifi ed of rabbits and other furry objects. Jones plans to replace Peter’s fear of rabbits and Concept Connections exposure therapy, with a conditioned response incompatible with fear. Her strategy is to associate the fear- that treat anxieties by exposing people (in imagination Remind students that Mary Cover evoking rabbit with the pleasurable, relaxed response associated with eating. or actual situations) to the things As Peter begins his midafternoon snack, Jones introduces a caged rabbit on the other they fear and avoid. Jones was a student of John Watson. side of the huge room. Peter, eagerly munching away on his crackers and drinking his milk, systematic desensitization With his infamous Little Albert study hardly notices. On succeeding days, she gradually moves the rabbit closer and closer. Within a type of exposure therapy that in 1929, Watson had demonstrated two months, Peter is tolerating the rabbit in his lap, even stroking it while he eats. Moreover, associates a pleasant, relaxed state his fear of other furry objects subsides as well, having been countered, or replaced, by a re- with gradually increasing anxiety - that fear could be learned through laxed state that cannot coexist with fear (Fisher, 1984; Jones, 1924). triggering stimuli. Commonly used to treat phobias. classical conditioning. Jones later Unfortunately for those who might have been helped by her counterconditioning procedures, Jones’ story of Peter and the rabbit did not immediately become part of psychol- showed that people could unlearn ogy’s lore. It was more than 30 years later that psychiatrist Joseph Wolpe (1958; Wolpe & fear by associating that same object Plaud, 1997) refi ned Jones’ technique into what are now the most widely used types of be- with positive stimuli, work that havior therapies: exposure therapies, which expose people to what they normally avoid or escape (behaviors that get reinforced by reduced anxiety). Exposure therapies have them undergirds the premise of systematic face their fear, and thus overcome their fear of the fear response itself. As people can ha- desensitization. bituate to the sound of a train passing their new apartment, so, with repeated exposure, can they become less anxiously responsive to things that once petrifi ed them (Rosa-Alcázar et al., 2008; Wolitzky-Taylor et al., 2008). ENGAGE One widely used exposure therapy is systematic desensitization. Wolpe assumed, as did Jones, that you cannot be simultaneously anxious and relaxed. Therefore, if you can TRMTRM Enrichment repeatedly relax when facing anxiety - provoking stimuli, you can gradually eliminate your An extreme and controversial form anxiety. The trick is to proceed gradually. Let’s see how this might work with social anxiety disorder. Imagine yourself afraid of public speaking. A therapist might fi rst ask for your help of systematic desensitization is in constructing a hierarchy of anxiety-triggering speaking situations. Yours might range from called “fl ooding.” In fl ooding, a patient mildly anxiety- provoking situations, perhaps speaking up in a small group of friends, to panic - provoking situations, such as having to address a large audience. is immersed in the feared object or Next, using progressive relaxation, the therapist would train you to relax one muscle group situation. Imagine being thrown into after another, until you achieve a blissful state of complete relaxation and comfort. Then the a swimming pool if you fear the water therapist would 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 or having roaches crawl all over you up. If imagining the scene causes you to feel any anxiety, you would signal your tension by if you fear them. The idea behind this raising your fi nger, and the therapist would instruct you to switch off the mental image and type of therapy is to show a patient go back to deep relaxation. This imagined scene is repeatedly paired with relaxation until you feel no trace of anxiety. that he or she has no reason to be The therapist would progress up the constructed anxiety hierarchy, using the relaxed afraid of the item that triggers the state to desensitize you to each imagined situation. After several sessions, you move to actual situations and practice what you had only imagined before, beginning with relatively fear, and experiencing it in this way easy tasks and gradually moving to more anxiety- fi lled ones. Conquering your anxiety in will lead to less fear. an actual situation, not just in your imagination, raises your self- confi dence (Foa & Kozak, Use Teacher Demonstration: Using 1986; Williams, 1987). Eventually, you may even become a confi dent public speaker. Systematic Desensitization to Treat Eraser Phobia and Student Activity: Practicing Systematic Desensitization from the TRM to show students how MyersAP_SE_2e_Mod71_B.indd 716 1/21/14 9:36 AM MyersAP_SE_2e_Mod71_B.inddENGAGE 717 TEACH 1/21/14 9:36 AM this type of treatment works. Active Learning Flip It Challenge students to complete some system- Students can get additional help understand- atic desensitization exercises. ing counterconditioning by watching the Flip It Have them imagine a situation in which Video: Counterconditioning: How It Works. they feel anxious. They should concentrate on their feelings about it. Ask them if they experience those emotions intensely or not. Have them now think of a situation in which they are relaxed and feeling good. They should also concentrate on their emotions in this situation. Are these emotions as intense as those associated with the anxiety- producing situation? Why or why not?

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When an anxiety - arousing situa- ENGAGE tion is too expensive, diffi cult, or embarrassing to re-create, virtual reality Enrichment exposure therapy offers an effi cient Students may fi nd it amusing that middle ground. Wearing a head- Bob Mahoney/The Image Works Bob Mahoney/The Image Works mounted display unit that projects a even The Simpsons has delved into three- dimensional virtual world, you aversive conditioning. In an episode would view a lifelike series of scenes entitled “There’s No Disgrace Like that would be tailored to your particular fear and shift as your head turned. Home,” Homer Simpson, the fam- Experiments led by several research ily patriarch, decides that his family teams have treated many different people with many different fears—fl y- Virtual reality exposure needs therapy after a disastrous expe- ing, heights, particular animals, and public speaking (Parsons & Rizzo, 2008). People who therapy Virtual reality technology rience at his company’s picnic. At the exposes people to vivid simulations fear fl ying, for example, can peer out a virtual window of a simulated plane, feel vibrations, end of the episode, each family mem- of feared stimuli, such as a plane’s and hear the engine roar as the plane taxis down the runway and takes off. In studies takeoff. comparing control groups with people experiencing virtual reality exposure therapy, the ber is hooked up to an electroshock therapy has provided greater relief from real-life fear (Hoffman, 2004; Krijn et al., 2004). therapy machine and gets to adminis- Developments in virtual reality therapy suggest the likelihood of increasingly sophisti- ter a shock to another family member cated simulated worlds in which people, using avatars (computer representations of them- virtual reality exposure selves), try out new behaviors in virtual environments (Gorini, 2007). For example, someone whenever he or she unleashes an therapy an anxiety treatment with social anxiety disorder might visit virtual parties or group discussions, which others unwelcome comment or action. that progressively exposes people join over time. to electronic simulations of their greatest fears, such as airplane AVERSIVE CONDITIONING TEACH fl ying, spiders, or public speaking. In systematic desensitization, the goal is substituting a positive (relaxed) response for a aversive conditioning a type of negative (fearful) response to a harmless stimulus. In aversive conditioning, the goal is counterconditioning that associates substituting a negative (aversive) response for a positive response to a harmful stimulus Concept Connections an unpleasant state (such as (such as alcohol). Thus, aversive conditioning is the reverse of systematic desensitization—it Remind students about the discus- nausea) with an unwanted behavior (such as drinking alcohol). seeks to condition an aversion to something the person should avoid. sion of taste aversion in Unit VI. When The procedure is simple: It associates the unwanted behavior with unpleasant feelings. speaking to his students, Martin To treat nail biting, one can paint the fi ngernails with a nasty - tasting nail polish (Baskind, 1997). To treat alcohol use disorder, an aversion therapist offers the client appealing drinks Bolt told them all about his aversion laced with a drug that produces severe nausea. By linking alcohol with violent nausea (recall to commercially produced frozen the taste -aversion experiments with rats and coyotes in Module 29), the therapist seeks to FIGURE 71.1 chicken dinners. Once he had stored transform the person’s reaction to alcohol from positive to negative ( ). such a dinner in the freezer of his Figure 71.1 department’s refrigerator, and when Aversion therapy for alcohol use US UR he went to retrieve it, he encountered disorder After repeatedly imbibing (drug) (nausea) an alcoholic drink mixed with a drug a frozen laboratory rat. A student that produces severe nausea, some people with a history of alcohol use assistant, not knowing how to dispose disorder develop at least a temporary conditioned aversion to alcohol. of the deceased animal, had carefully (Remember: US is unconditioned wrapped it in plastic and temporarily stimulus, UR is unconditioned NS US UR response, NS is neutral stimulus, CS (alcohol) + (drug) (nausea) placed it in the freezer close to the is conditioned stimulus, and CR is conditioned response.) chicken dinner. Bolt always found

frozen chicken dinners repulsive after CS CR this experience. (alcohol) (nausea)

ENGAGE Enrichment Alzheimer’s patients have diffi - susceptibilityMyersAP_SE_2e_Mod71_B.indd to aversive 718 conditioning. People 1/21/14 9:36 AM MyersAP_SE_2e_Mod71_B.indd 719 1/21/14 9:36 AM culty being conditioned to blink in TEACH with autism can be conditioned more quickly response to a tone that previously than those without autism. Those with autism Common Pitfalls signaled an impending air puff . seem to overattend to neutral stimuli, which Use Figure 71. 1 to review the procedures The opposite is true in people with facilitates the conditioning process and results of classical conditioning. These procedures obsessive-compulsive disorder (OCD). in mistimed learned responses. are often confusing for students, so use this Under certain conditions, people with opportunity to help reinforce the underlying Azar, B. (1999, March). Classical conditioning could OCD can be conditioned 3 times faster concepts. than people without OCD. This fi nding link disorders and brain dysfunction, researchers suggest. APA Monitor, p. 17. is consistent with the idea that victims of anxiety disorders experience a

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Does aversive conditioning work? In the short run it may. Arthur Wiens and Carol Menustik (1983) studied 685 patients with alcohol use disorder who completed an aversion therapy program at a Portland, Oregon, hospital. One year later, after returning for several booster treatments of alcohol- sickness pairings, 63 percent were still successfully abstain- ing. But after three years, only 33 percent had remained abstinent. The problem is that cognition inﬂ uences conditioning. People know that outside the therapist’s ofﬁ ce 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

71-271-2 What is the main premise of therapy based on operant conditioning principles, and what are the views of its proponents and critics? Pioneering researcher B. F. Skinner helped us understand the basic concept in operant conditioning (Modules 27 and 28) that voluntary behaviors are strongly infl uenced by their consequences. Knowing this, today’s therapists can practice behavior modifi cation—reinforcing desired behaviors, and withholding reinforcement for undesired behaviors. Using operant conditioning to solve specifi c behavior problems has raised hopes for some otherwise 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 use positive reinforcers to shape behavior in a step - by - step manner, rewarding closer and closer approximations of the desired behavior. In extreme cases, treatment must be intensive. One study worked with 19 withdrawn, uncommunicative 3-year - olds with ASD. Each participated in a 2-year program in which their parents spent 40 hours a week attempting to shape their behavior (Lovaas, 1987). The combination of positively reinforcing desired behaviors, and ignoring or punishing aggressive and self- abusive behaviors, worked wonders for some. By fi rst grade, 9 of the 19 children were functioning successfully in school and exhibiting normal intelligence. In a group of 40 comparable children not undergoing this effortful treatment, only one showed similar improvement. (Ensuing studies suggested that positive reinforcement without punishment was most effective.) Rewards used to modify behavior vary. For some people, the reinforcing power of atten- TEACH tion or praise is suffi cient. Others require concrete rewards, such as food. In institutional settings, therapists may create a token economy. When people display appropriate behavior, token economy an operant TRMTRM Teaching Tip such as getting out of bed, washing, dressing, eating, talking coherently, cleaning up their conditioning procedure in which people earn a token of some sort Ask students whether they have ever rooms, or playing cooperatively, they receive a token or plastic coin as a positive reinforcer. for exhibiting a desired behavior Later, they can exchange their accumulated tokens for various rewards, such as candy, TV and can later exchange the tokens participated in a token economy. If time, trips to town, or better living quarters. Token economies have been successfully ap- for various privileges or treats. plied in various settings (homes, classrooms, hospitals, institutions for juvenile offenders) they say yes, have them list diff erent and among members of various populations (including disturbed children and people with situations in which a token economy schizophrenia and other mental disabilities). is used. If they say no, ask them if Critics of behavior modifi cation express two concerns. The fi rst is practical: How durable are the behaviors? Will people become so dependent on extrinsic rewards that the appropri- they have ever received report cards ate behaviors will stop when the reinforcers stop? Proponents of behavior modifi cation be- or “conduct grades.” Students are lieve the behaviors will endure if therapists wean patients from the tokens by shifting them not paid to go to school and behave toward other, real-life rewards, such as social approval. They also point out that the appropriate behaviors themselves can be intrinsically rewarding. For example, as a withdrawn themselves while there, but teachers person becomes more socially competent, the intrinsic satisfactions of social interaction do give grades that are designed to may help the person maintain the behavior. evaluate the performance of students both academically and behaviorally. In addition, many elementary school classrooms use token economies. Children who behave get to pick a MyersAP_SE_2e_Mod71_B.indd 718 1/21/14 9:36 AM MyersAP_SE_2e_Mod71_B.indd 719 1/21/14 9:36 AM prize out of a “treasure box” or cash in “good behavior dollars” for goodies or privileges. Use Student Activity: Modifying a Phobia from the TRM to help students apply therapeutic techniques to their own lives.

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The second concern is ethical: Is it right for one human to control another’s behavior? Those ENGAGE 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 Critical Questions that some patients request the therapy. Moreover, control already exists; rewards and pun- B. F. Skinner believed that living a ishers are already maintaining destructive behavior patterns. So why not reinforce adaptive behavior instead? Treatment with positive rewards is more humane than being institution- life based on operant conditioning alized or punished, advocates argue, and the right to effective treatment and an improved principles would actually make people life justifi es temporary deprivation. more free; they would be in control of their environments. Communist and Cognitive Therapies totalitarian governments, however, 71-3 What are the goals and techniques of cognitive therapy and of use classical and operant conditioning cognitive-behavioral therapy? principles to keep people’s behavior AP® Exam Tip We have seen how behavior therapies treat specifi c fears and problem behaviors. But how do they deal with major depression? Or with generalized anxiety disorder, in which anxiety in check. Have students explore how Behavior therapies focus on what we do. Cognitive therapies focus has no focus and developing a hierarchy of anxiety- triggering situations is diffi cult? Thera- totalitarian governments use condi- on what we think. That’s a very pists treating these less clearly defi ned psychological problems have had help from the same basic distinction, but it is critically cognitive revolution that has profoundly changed other areas of psychology during the last tioning to limit people’s freedom: important for your understanding. half-century. How do such governments use Cognitive therapy for variable reinforcement schedules eating disorders aided by journaling Cognitive therapists guide to produce fear and superstitions? Lara Jo Regan people toward new ways of explaining How is brainwashing accomplished their good and bad experiences. By recording positive events and how with conditioning procedures? she has enabled them, this woman may become more mindful of her self- control and more optimistic. TEACH TRMTRM Concept Connections cognitive therapy therapy that Link cognitive therapy and Figure 71.2 teaches people new, more adaptive ways of thinking; based on the to optimistic thinking. Optimistic assumption that thoughts intervene between events and our emotional thinking has 3 important qualities; reactions. it is: The cognitive therapies assume that our thinking colors our feelings (FIGURE 71.2). Temporary, not permanent. Between the event and our response lies the mind. Self - blaming and overgeneralized ex- “Life does not consist mainly, planations of bad events are often an integral part of the vicious cycle of depression (see Pessimists believe that bad events or even largely, of facts and Module 67). The depressed person interprets a suggestion as criticism, disagreement as dis- will become a permanent fixture happenings. It consists mainly like, praise as fl attery, friendliness as pity. Ruminating on such thoughts sustains the nega- of the storm of thoughts that are tive thinking. If such thinking patterns can be learned, then surely they can be replaced. in their lives, whereas optimists forever blowing through one’s mind.” -MARK TWAIN, 1835–1910 Cognitive therapists therefore try in various ways to teach people new, more constructive believe that bad events are ways of thinking. If people are miserable, they can be helped to change their minds. temporary. Figure 71.2 Circumstantial, not personal. A cognitive perspective on Lost job Internal beliefs: Depression Pessimists believe that bad events psychological disorders The I’m worthless. It’s hopeless.. person’s emotional reactions are are a result of some personal flaw produced not directly by the event that cannot be changed, while but by the person’s thoughts in Internal beliefs: response to the event. Lost job My boss is a jerk. No depression optimists believe that bad events I deserve something better. are the result of circumstances that can be controlled. Localized, not pervasive. Pessimists

believe that a bad experience MyersAP_SE_2e_Mod71_B.indd 720 1/21/14 9:36 AM MyersAP_SE_2e_Mod71_B.indd 721 1/21/14 9:36 AM in one area of life will influence other areas, causing continuous havoc. Optimists believe that bad events will remain isolated in time, not affecting later decisions or opportunities. Use Student Activity: Frequency of Self-Reinforcement Questionnaire from the TRM to help students assess their thinking styles.

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Rational-Emotive Behavior Therapy rational-emotive behavior rational-emotive behavior ENGAGE According to Albert Ellis (1962, 1987, 1993), the creator of therapy (REBT) a confrontational therapy (REBT), many problems arise from irrational thinking. For example, he described cognitive therapy, developed Enrichment a disturbed woman and suggested how therapy might challenge her illogical, self-defeating by Albert Ellis, that vigorously assumptions (Ellis, 2011, pp. 198–199): challenges people’s illogical, Most cognitive-behavioral therapies self-defeating attitudes and [She] does not merely believe it is undesirable if her lover rejects her. She tends to assumptions. use the ABC model, where A stands believe, also, that (a) it is awful; (b) she cannot stand it; (c) she should not, must for “activating events” that lead not be rejected; (d) she will never be accepted by any desirable partner; (e) she is a worthless person because one lover has rejected her; and (f) she deserves to to “irrational beliefs” (the B in the be rejected for being so worthless. Such common covert hypotheses are illogical, model). Emotional disturbances lead unrealistic, and destructive. . . . They can be easily elicited and demolished by any scientist worth his or her salt; and the rational-emotive therapist is exactly that: an to the C of the model, which are “con- exposing and nonsense-annihilating scientist. sequences.” Rational-emotive behav- Change people’s thinking by revealing the “absurdity” of their self-defeating ideas, the ioral therapy adds 2 other letters to sharp-tongued Ellis believed, and you will change their self-defeating feelings and enable healthier behaviors. the model: D and E. The D stands for “disputing” irrational beliefs and Aaron Beck’s Therapy for Depression the E for ﬁ nding more “eﬀ ective” ways Cognitive therapist Aaron Beck also believes that changing people’s thinking can change of thinking and behaving. their functioning, though he has a gentler approach. Originally trained in Freudian techniques, Beck analyzed the dreams of depressed people. He found recurring negative themes Rational-emotive behavior therapy. In of loss, rejection, and abandonment that extended into their waking thoughts. Such nega- Psychology encyclopedia. http://psychology. tivity even extends into therapy, as clients recall and rehearse their failings and worst im- jrank.org/pages/532/Rational-Emotive- pulses (Kelly, 2000). With cognitive therapy, Beck and his colleagues (1979) have sought to reverse clients’ catastrophizing beliefs about themselves, their situations, and their futures. Behavior-Therapy.html 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 ENGAGE makes me depressed. Enrichment Beck: How do you understand it? Client: I get depressed when things go wrong. Like when I fail a test. Here are some of the ways in which Beck: How can failing a test make you depressed? rational-emotive behavioral therapy Client: Well, if I fail I’ll never get into law school. helps people with irrational thinking: Beck: So failing the test means a lot to you. But if failing a test could drive people into clini- Thought stopping. When the cal 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 hears an irrational thought, Client: No, but it depends on how important the test was to the person. the therapist yells, “Stop!” Beck: Right, and who decides the importance? Reframing. The therapist guides Client: I do. the client, leading him or her to Beck: And so, what we have to examine is your way of viewing the test (or the way look at the situation from a more that you think about the test) and how it affects your chances of getting into law school. Do you agree? positive angle. Client: Right. Disputing. The therapist shows Beck: Do you agree that the way you interpret the results of the test will affect you? You the client that his or her beliefs are 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. irrational by offering evidence or Client: I have been thinking that I wasn’t going to make it. Yes, I agree. reasoning against them. Beck: Now what did failing mean? Rational-emotive behavior therapy. In Psychology encyclopedia. http://psychology. jrank.org/pages/532/Rational-Emotive- Behavior-Therapy.html

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Client: (tearful) That I couldn’t get into law school. ENGAGE Beck: And what does that mean to you? Critical Questions Client: That I’m just not smart enough. Beck: Anything else? Combination therapies tend to be Client: That I can never be happy. more eff ective than single therapeutic Beck: And how do these thoughts make you feel? approaches. Have students ponder Client: Very unhappy. why this might be so: Beck: So it is the meaning of failing a test that makes you very unhappy. In fact, believ- How do combination therapies ing that you can never be happy is a powerful factor in producing unhappiness. So, you get yourself into a trap—by defi nition, failure to get into law school equals “I can address the different explanations never be happy.” for human behavior? PEANUTS We often think in words. Therefore, getting people to change what For what other disorders are they say to themselves is an effective way to change their thinking. Per- haps you can identify with the anxious students who, before a test, make combination therapies effective? matters worse with self - defeating thoughts: “This test’s probably going to be impossible. All these other students seem so relaxed and confi dent. ENGAGE I wish I were better prepared. Anyhow, I’m so nervous I’ll forget everything.” To change such negative self- talk, Donald Meichenbaum (1977, Active Learning 1985) offered stress inoculation training: teaching people to restructure their thinking in stressful situations. Sometimes it may be enough simply Have students identify a personal to say more positive things to oneself: “Relax. The test may be hard, but it belief they think might be irrational will be hard for everyone else, too. I studied harder than most people. Be- sides, I don’t need a perfect score to get a good grade in this class.” After or unproductive. Using Table 71.1, ask being trained to dispute their negative thoughts, depression-prone chil- your students to apply the techniques dren, teens, and college students exhibit a greatly reduced rate of future depression (Seligman, 2002; Seligman et al., 2009). To a large extent, it is listed to their own thoughts. They Drawing by Charles Schulz; ©1956. Reprinted by permission of United Features Syndicate. the thought that counts. TABLE 71.1 provides a sampling of techniques should write out the ways in which commonly used in cognitive therapy. they revealed, tested, and hope to change their beliefs. Debrief with the Table 71.1 Selected Cognitive Therapy Techniques students: not by having them share Aim of Technique Technique Therapists’ Directives their irrational beliefs or the ways in Reveal beliefs Question your interpretations Explore your beliefs, revealing faulty assumptions such as “I must be liked which they hope to change them, but by everyone.” rather by asking them to share their Rank thoughts and emotions Gain perspective by ranking your thoughts and emotions from mildly to extremely upsetting. thoughts on the processes for trans- forming beliefs: Test beliefs Examine consequences Explore diffi cult situations, assessing possible consequences and challenging faulty reasoning. Was it easy or difficult to use these Decatastrophize thinking Work through the actual worst-case consequences of the situation you techniques? Why? face (it is often not as bad as imagined). Then determine how to cope with the real situation you face. Which technique was most Change beliefs Take appropriate responsibility Challenge total self-blame and negative thinking, noting aspects for difficult? which you may be truly responsible, as well as aspects that aren’t your Could these techniques help you responsibility. change your irrational beliefs? Why Resist extremes Develop new ways of thinking and feeling to replace maladaptive habits. or why not? For example, change from thinking “I am a total failure” to “I got a failing grade on that paper, and I can make these changes to succeed next time.”

MyersAP_SE_2e_Mod71_B.inddTEACH 722 1/22/14 8:09 AM MyersAP_SE_2e_Mod71_B.indd 723 1/21/14 9:36 AM Teaching Tip For a fun informal assessment, have students identify ﬁ ctional characters who seem to be experiencing some type of mental disorder. What type of treatment would they recommend for that disorder? This activity will help you learn if students know the symptoms of major mental illnesses and the appropriate treatments for the associated disorders.

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Cognitive-Behavioral Therapy ENGAGE Cognitive - behavioral therapy (CBT), a widely practiced integrative therapy, aims not only to alter the way people think (cognitive therapy), but also to alter the way they act Active Learning (behavior therapy). It seeks to make people aware of their irrational negative thinking, to replace it with new ways of thinking, and to practice the more positive approach in everyday “The trouble with most therapy Have students research how many is that it helps you to feel better. settings. Behavioral change is typically addressed fi rst, followed by sessions on cognitive But you don’t get better. You have nonpsychiatric therapy services are change; the therapy concludes with a focus on maintaining both and preventing relapses. to back it up with action, action, Anxiety and mood disorders share a common problem: emotion regulation (Aldao & action.” -THERAPIST ALBERT ELLIS available in your city or area. They (1913–2007) Nolen-Hoeksema, 2010). An effective CBT program for these emotional disorders trains can use the local Yellow Pages to fi nd people both to replace their catastrophizing thinking with more realistic appraisals, and, listings for clinical psychologists in 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 situ- private practice, community mental ations associated with negative and positive emotions, and engage more in activities that health centers, halfway houses, crisis lead them to feeling good. Or those who fear social situations might be assigned to practice hotlines, and similar services that do approaching people. CBT may also be useful with obsessive-compulsive disorder. In one study, people learned not rely on psychiatrists to deliver to prevent their compulsive behaviors by relabeling their obsessive thoughts (Schwartz et psychotherapy. al., 1996). Feeling the urge to wash their hands again, they would tell themselves, “I’m having a compulsive urge,” and attribute it to their brain’s abnormal activity, as previously cognitive-behavioral therapy viewed in their PET scans. Instead of giving in to the urge, they would then spend 15 min- (CBT) a popular integrative utes in an enjoyable, alternative behavior, such as practicing an instrument, taking a walk, therapy that combines cognitive or gardening. This helped “unstick” the brain by shifting attention and engaging other brain therapy (changing self-defeating areas. For two or three months, the weekly therapy sessions continued, with relabeling and thinking) with behavior therapy refocusing practice at home. By the study’s end, most participants’ symptoms had dimin- (changing behavior). ished and their PET scans revealed normalized brain activity. Many other studies confi rm group therapy therapy conducted CBT’s effectiveness for those with anxiety, depression, or anorexia nervosa (Covin et al., with groups rather than individuals, 2008; Mitte, 2005; Norton & Price, 2007). Studies have also found that cognitive-behavioral permitting therapeutic benefi ts from group interaction. skills can be effectively taught and therapy conducted over the Internet (Barak et al., 2008; Kessler et al., 2009; Marks & Cavanaugh, 2009; Stross, 2011).

Group and Family Therapies ENGAGE Group Therapy ABC Family’s 71-471-4 What are the aims and benefi ts of group and family therapy? and Seventeen Magazine’s 2011 film Cyberbully realistically portrayed main Active Learning characters attending group therapy, Group Therapy where they found they were not alone Have students contact an organiza- in their troublesome feelings. tion that off ers support groups. Ask Except for traditional psychoanalysis, most therapies may also occur in small groups. Group therapy does not pro- the group’s leader the following vide the same degree of therapist involvement with each questions: client. However, it offers benefi ts: How many people generally attend • It saves therapists’ time and clients’ money, often with no less effectiveness than individual therapy a meeting? (Fuhriman & Burlingame, 1994). Who is in charge of the session? • It offers a social laboratory for exploring social behaviors and developing social skills. Therapists frequently Typically, is that person a therapist suggest group therapy for people experiencing or a group member? Photograph Courtesy of Muse Entertainment Enterprises Inc. frequent confl icts or whose behavior distresses others. What qualifications does the group For up to 90 minutes weekly, the therapist guides people’s interactions as they discuss issues and try out leader have? new behaviors. Are specific lessons or objectives planned for the meeting or is the session open to free discussion? Why is this particular method used? MyersAP_SE_2e_Mod71_B.indd 722 1/22/14 8:09 AM MyersAP_SE_2e_Mod71_B.indd 723 1/21/14 9:36 AM

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• It enables people to see that others share their problems. It can be a relief to discover that ENGAGE you are not alone—to learn that others, despite their composure, experience some of the same troublesome feelings and behaviors. Active Learning • It provides feedback as clients try out new ways of behaving. Hearing that you look poised, Many support groups utilize thera- even though you feel anxious and self-conscious, can be very reassuring. peutic techniques as they provide Family Therapy a network of people who depend One special type of group interaction, family therapy, assumes that no person is an island: on each other for support and aid. We live and grow in relation to others, especially our families. We struggle to differentiate Contact local support group organiza- ourselves from our families, but we also need to connect with them emotionally. Some of our problem behaviors arise from the tension between these two tendencies, which can tions to ask what type of therapeutic create family stress. techniques they use in their sessions: Unlike most psychotherapy, which focuses on what happens inside the person’s own skin, family therapists work with multiple family members to heal relationships Are sessions led by a qualified or and to mobilize family resources. They tend to view the family as a system in which each certified therapist? Why or why person’s actions trigger reactions from others, and they help family members discover not? 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 What rules does the group follow success, research suggests—to open up communication within the family or to help during discussions? family members discover new ways of preventing or resolving confl icts (Hazelrigg et al., 1987; Shadish et al., 1993). How much contact do group Self-Help Groups members have outside of the support group meetings? Many people also participate in self - help and support groups (Yalom, 1985). One analysis of online support groups and more than 14,000 self - help groups reported that most sup- What types of planned activities port groups focus on stigmatized or hard - to - discuss illnesses (Davison et al., 2000). AIDS does the group provide? patients, for example, are 250 times more likely than hypertension patients to be in support groups. Those struggling with anorexia and alcohol use disorder often join groups; those with migraines and ulcers usually do not. People with hearing loss have national organiza- ENGAGE tions with local chapters; people with vision loss more often cope on their own. The grandparent of support groups, Alcoholics Anonymous (AA), reports having Critical Questions more than 2 million members in 114,000 groups worldwide. Its famous 12-step program, emulated by many other self- help groups, asks members to admit their power- Have your students discuss the advan- lessness, to seek help from a higher power and from one another, and (the twelfth step) tages and disadvantages of family FYI to take the message to others in need of it. In one eight- year, $27 million investiga- tion, AA participants reduced their drinking sharply, although so did those assigned to therapy. Some questions they may With more than 2 million members worldwide, AA is said to be “the cognitive-behavioral therapy or to “motivational therapy” (Project Match, 1997). Other consider include: largest organization on Earth that studies have similarly found that 12-step programs such as AA have helped reduce nobody wanted to join” (Finlay, alcohol use disorder comparably with other treatment interventions (Ferri et al., 2006; If a patient has a dysfunctional 2000). Moos & Moos, 2005). The more meetings members attend, the greater their alcohol family life, how might individual abstinence (Moos & Moos, 2006). In one study of 2300 veterans who sought treatment therapy be only partially effective? for alcohol use disorder, a high level of AA involvement was followed by diminished alcohol problems (McKellar et al., 2003). Would a person be less willing to In an individualistic age, with more and more people living alone or feeling isolated, open up about personal issues if the popularity of support groups—for the addicted, the bereaved, the divorced, or simply those seeking fellowship and growth—seems to refl ect a longing for community and con- the rest of the family knew about nectedness. More than 100 million Americans belong to small religious, interest, or self- help family therapy therapy that these feelings? Why or why not? treats the family as a system. Views groups that meet regularly—and 9 in 10 report that group members “support each other an individual’s unwanted behaviors emotionally” (Gallup, 1994). as infl uenced by, or directed at, * * * other family members. For a synopsis of the modern forms of psychotherapy we’ve been discussing, see TABLE 71.2.

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Table 71.2 Comparing Modern Psychotherapies CLOSE & ASSESS Therapy Presumed Problem Therapy Aim Therapy Technique Exit Assessment Psychodynamic Unconscious confl icts from Reduce anxiety through self-insight. Interpret patients’ memories and childhood experiences feelings. Use Table 71.2 to review the tech- Client-centered Barriers to self-understanding Enable growth via unconditional positive Listen actively and refl ect clients’ niques discussed in this module. You and self-acceptance regard, genuineness, and empathy. feelings. may want to provide a copy of this Behavior Dysfunctional behaviors Relearn adaptive behaviors; extinguish Use classical conditioning (via chart with some of the cells left blank problem ones. exposure or aversion therapy) or operant conditioning (as in token for students to fi ll in. economies).

Cognitive Negative, self-defeating Promote healthier thinking and self-talk. Train people to dispute negative thinking thoughts and attributions.

Cognitive- Self-harmful thoughts and Promote healthier thinking and adaptive Train people to counter self-harmful behavioral behaviors behaviors. thoughts and to act out their new ways of thinking.

Group and Stressful relationships Heal relationships. Develop an understanding of family family and other social systems, explore roles, and improve communication.

Before You Move On c ASK YOURSELF Critics say that behavior modiﬁ cation techniques, such as those used in token economies, are inhumane. Do you agree or disagree? Why? c TEST YOURSELF What is the major distinction between the underlying assumptions in insight therapies and in behavior therapies? Answers to the Test Yourself questions can be found in Appendix E at the end of the book.

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Module 71 Review How does the basic assumption of behavior 71-171-1 71-3 What are the goals and techniques therapy differ from those of psychodynamic of cognitive therapy and of cognitive- and humanistic therapies? What techniques behavioral therapy? are used in exposure therapies and aversive conditioning? • The cognitive therapies, such as Aaron Beck’s cognitive therapy for depression, assume that our thinking • Behavior therapies are not insight therapies. Their goal is to infl uences our feelings, and that the therapist’s role is to apply learning principles to modify problem behaviors. change clients’ self-defeating thinking by training them to view themselves in more positive ways. • Classical conditioning techniques, including exposure therapies (such as systematic desensitization or virtual reality • Rational-emotive behavior therapy (REBT) is a exposure therapy) and aversive conditioning, attempt to confrontational cognitive therapy that actively challenges change behaviors through counterconditioning—evoking irrational beliefs. new responses to old stimuli that trigger unwanted The widely researched and practiced cognitive-behavioral behaviors. • therapy (CBT) combines cognitive therapy and behavior therapy by helping clients regularly act out their new ways 71-2 What is the main premise of therapy based on operant conditioning principles, and of thinking and talking in their everyday life. what are the views of its proponents and What are the aims and benefi ts of group critics? 71-471-4 and family therapy? Therapy based on operant conditioning principles uses • Group therapy sessions can help more people and costs behavior modifi cation techniques to change unwanted • less per person than individual therapy would. Clients behaviors through positively reinforcing desired behaviors may benefi t from exploring feelings and developing social and ignoring or punishing undesirable behaviors. skills in a group situation, from learning that others have • Critics maintain that (1) techniques such as those used similar problems, and from getting feedback on new ways in token economies may produce behavior changes that of behaving. disappear when rewards end, and (2) deciding which Family therapy views a family as an interactive system and behaviors should change is authoritarian and unethical. • attempts to help members discover the roles they play and • Proponents argue that treatment with positive rewards is to learn to communicate more openly and directly. more humane than punishing people or institutionalizing them for undesired behaviors.

Answers to Multiple-Choice Multiple-Choice Questions

Questions 1. Dr. Welle tries to help her clients by teaching them 2. Mary Cover Jones helped a little boy named Peter to modify the things they do when under stress or overcome his fear of rabbits by gradually moving a rabbit 1. a experiencing symptoms. This means that Dr. Welle closer to him each day while he was eating his snack. 2. d engages in therapy. This was one of the ﬁ rst applications of a. behavior a. group therapy. b. cognitive b. virtual reality exposure therapy. c. group c. aversive therapy. d. rational-emotive behavior d. exposure therapy. e. client-centered e. cognitive therapy.

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3. On which of the following are token economies based? 4. Which of the following is considered a beneﬁ t of group 3. b a. Classical conditioning therapy? b. Operant conditioning a. It is the most effective therapy for children. 4. e c. Group therapy b. It is particularly effective in the treatment of d. Cognitive therapy antisocial personality disorder. e. Cognitive-behavioral therapy c. It is particularly effective in the treatment of schizophrenia. d. It is the only setting proven effective for virtual reality exposure therapy. e. It saves time and money when compared with other forms of therapy.

Practice FRQs Answer to Practice FRQ 2 1. 2. Name and describe two speciﬁ c types of group therapy. Explain what systematic desensitization is, then describe 1 point: Systematic desensitization the two major components of the therapy. Answer (3 points) is a form of behavior therapy (also 1 point: Family therapy is a means of treating an entire acceptable: classical conditioning and family as an interdependent system. exposure therapy). 1 point: Self-help groups, such as Alcoholics Anonymous (AA), are groups of individuals who share a similar problem 1 point: Systematic desensitization is working together to overcome that problem. a gradual, step-by-step therapy. 1 point: Systematic desensitization pairs the feared stimulus with relaxation (because you can’t be frightened and relaxed at the same time).

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TEACH TRMTRM Discussion Starter Module 72 Use the Module 72 Fact or Falsehood? activity from the TRM to introduce the Evaluating Psychotherapies and Prevention concepts from this module. Strategies ENGAGE Active Learning Module Learning Objectives Have students come up with an 72-1 Discuss whether psychotherapy works as interpreted by clients, experiment that tests the effi cacy of clinicians, and outcome research. a therapeutic intervention. The inter- 72-272-2 Describe which psychotherapies are most effective for specifi c vention does not have to be specifi c, disorders. but the experimental methodology 72-372-3 Discuss how alternative therapies fare under scientifi c scrutiny. should include a control group and an RubberBall/SuperStock experimental group, blind or double- 72-472-4 Describe the three elements shared by all forms of psychotherapy.y. blind procedures, and randomiza- Discuss how culture, gender, and values infl uence the therapist-client tion techniques. Have students also 72-572-5 relationship. discuss the ethical considerations involved in conducting an effi cacy 72-672-6 Identify some guidelines for selecting a therapist.

experiment. 72-7 Explain the rationale of preventive mental health programs.

Evaluating Psychotherapies

Advice columnists frequently urge their troubled letter writers to get professional help: “Don’t give up. Find a therapist who can help you. Make an appointment.” Many Americans share this conﬁ dence in psychotherapy’s effectiveness. Before 1950, psychiatrists were the primary providers of mental health care. Today’s providers include clinical and counseling psychologists; clinical social workers; clergy; marital and school counselors; and psychiatric nurses. With such an enormous outlay of time as well as money, effort, and hope, it is important to ask: Are the millions of people worldwide justiﬁ ed in placing their hopes in psychotherapy? Is Psychotherapy Effective?

72-1 Does psychotherapy work? Who decides?

The question, though simply put, is not simple to answer. Measuring therapy’s effectiveness is not like taking your body’s temperature to see if your fever has gone away. If you and I were to undergo psychotherapy, how would we assess its 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?

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CLIENTS’ PERCEPTIONS TEACH If clients’ testimonials were the only measuring stick, we could strongly affi rm the effectiveness of psychotherapy. When 2900 Consumer Reports readers (1995; Kotkin et al., 1996; Concept Connections Seligman, 1995) related their experiences with mental health professionals, 89 percent said they were at least “fairly well satisfi ed.” Among those who recalled feeling fair or very poor Remind students that in Unit II Myers when beginning therapy, 9 in 10 now were feeling very good, good, or at least so - so. We discussed the benefi ts and drawbacks have their word for it—and who should know better? We should not dismiss these testimonials lightly. But for several reasons, client of case study research. The benefi ts testimonials do not persuade psychotherapy’s skeptics: include a detailed understanding • People often enter therapy in crisis. When, with the normal ebb and fl ow of of a case and the ability to conduct events, the crisis passes, people may attribute their improvement to the therapy. research that would be unethical in • Clients may need to believe the therapy was worth the effort. To admit investing time and money in something ineffective is like admitting to experimental situations. The draw- having one’s car serviced repeatedly by a mechanic who never fi xes it. Self - backs include the lack of generaliz- justifi cation is a powerful human motive. ability and of control over confound- • Clients generally speak kindly of their therapists. Even if the problems remain, say the critics, clients “work hard to fi nd something positive to say. The therapist Feng Li/Getty Images ing variables. had been very understanding, the client had gained a new perspective, he learned Trauma These women were to communicate better, his mind was eased, anything at all so as not to have to say mourning the tragic loss of lives and homes in the 2010 earthquake in treatment was a failure” (Zilbergeld, 1983, p. 117). China. Those who suffer through such As earlier units document, we are prone to selective and biased recall and to making judg- trauma may benefit from counseling, though many people recover on their ments that confi rm our beliefs. Consider the testimonials gathered in a massive experiment with own, or with the help of supportive over 500 Massachusetts boys, aged 5 to 13 years, many of whom seemed bound for delinquency. relationships with family and friends. By the toss of a coin, half the boys were assigned to a 5- year treatment program. The treated boys “Life itself still remains a very effective therapist,” noted psychodynamic were visited by counselors twice a month. They participated in community programs, and they therapist Karen Horney (Our Inner received academic tutoring, medical attention, and family assistance as needed. Some 30 years Conflicts, 1945). later, Joan McCord (1978, 1979) located 485 participants, sent them questionnaires, and checked public records from courts, mental hospitals, and other sources. Was the treatment successful? Client testimonials yielded encouraging results, even glowing reports. Some men noted that, had it not been for their counselors, “I would probably be in jail,” “My life would have gone the other way,” or “I think I would have ended up in a life of crime.” Court records offered apparent support: Even among the “diffi cult” boys in the treatment group, 66 percent had no offi cial juvenile crime record. But recall psychology’s most powerful tool for sorting reality from wishful thinking: the control group. For every boy in the treatment group, there was a similar boy in a control group, receiving no counseling. Of these untreated men, 70 percent had no juvenile record. On several other measures, such as a record of having committed a second crime, alcohol use disorder, death rate, and job satisfaction, the untreated men exhibited slightly fewer problems. The glowing testimonials of those treated had been unintentionally deceiving.

CLINICIANS’ PERCEPTIONS Do clinicians’ perceptions give us any more reason to celebrate? Case studies of successful treatment abound. The problem is that clients justify entering psychotherapy by emphasizing their unhappiness and justify leaving by emphasizing their well- being. Therapists treasure compliments from clients as they say good- bye or later express their gratitude, but they hear little from clients who experience only temporary relief and seek out new therapists for their recurring problems. Thus, the same person—with the same recurring anxieties, depression, or marital difﬁ culty—may be a “success” story in several therapists’ ﬁ les. Because people enter therapy when they are extremely unhappy, and usually leave when they are less extremely unhappy, most therapists, like most clients, testify to therapy’s success—regardless of the treatment (see Thinking Critically About: “Regressing” From Unusual to Usual on the next page).

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TEACH Thinking Critically About Common Pitfalls “Regressing” From Unusual to Usual Regression toward the mean is a Clients’ and therapists’ perceptions of therapy’s effectiveness • Students who score much lower or higher on a test than are vulnerable to infl ation from two phenomena. One is the pla- they usually do are likely, when retested, to return toward statistical term students may not be cebo effect—the power of belief in a treatment. If you think a their average. familiar with. Have students recall treatment is going to be effective, it just may be (thanks to the • Unusual ESP subjects who defy chance when fi rst tested healing power of your positive expectations). nearly always lose their “psychic powers” when retested their study of the normal curve The second phenomenon is regression toward the (a phenomenon parapsychologists have called the decline (Units II and XI). In a normal curve, mean—the tendency for unusual events (or emotions) to “re- effect). the mean identifi es where the center gress” (return) to their average state. Thus, extraordinary hap- • Coaches often yell at their players after an unusually bad penings (feeling low) tend to be followed by more ordinary ones fi rst half. They may then feel rewarded for having done so of the data lies. If students were to (a return to our more usual state). Indeed, when things hit bot- when the team’s performance improves (returns to normal) chart their test scores in your class, tom, whatever we try—going to a psychotherapist, starting during the second half. they would arrive at an average. While yoga, doing aerobic exercise—is more likely to be followed by In each case, the cause - effect link may be genuine. Each improvement than by further descent. may, however, be an instance of the natural tendency for be- individual tests may show signifi cant havior to regress from the unusual to the more usual. And this

deviation from the mean, only mul- “Once you become sensitized to it, you see regression defi nes the task for therapy-effi cacy research: Does the client’s tiple, consistently diff erent test scores everywhere.” improvement following a particular therapy exceed what could Psychologist Daniel Kahneman (1985) be expected from the placebo and regression effects alone, over time would shift the mean in shown by comparison with control groups? either direction on the graph. So, one The point may seem obvious, yet we regularly miss it: We regression toward the mean sometimes attribute what may be a normal regression (the ex- the tendency for extreme or unusual performance (or behavior, or unusual scores to fall back (regress) toward their average. pected return to normal) to something we have done. Consider: thought, or experience) is just that— unusual—and our behavior is bound to return to our “normal.” OUTCOME RESEARCH How, then, can we objectively measure the effectiveness of psychotherapy if neither clients nor clinicians can tell us? How can we determine which people and problems are best helped, and by what type of psychotherapy? In search of answers, psychologists have turned to controlled research studies. Similar research in the 1800s transformed the fi eld of medicine. Physicians, skeptical of many of the fashionable treatments (bleeding, purging, infusions of plant and metal substances), began to realize that many patients got better on their own, without these treatments, and that others died despite them. Sorting fact from superstition required observing patients with and without a particular treatment. Typhoid fever patients, for example, often improved after being bled, convincing most physicians that the treatment worked. Not until a control group was given mere bed rest—and 70 percent were observed to improve after fi ve weeks of fever—did physicians learn, to their shock, that the bleeding was worthless (Thomas, 1992). In psychology, the opening challenge to the effectiveness of psychotherapy was issued by British psychologist Hans Eysenck (1952). Launching a spirited debate, he summarized studies showing that two - thirds of those receiving psychotherapy for nonpsychotic disorders improved markedly. To this day, no one disputes that optimistic estimate. Why, then, are we still debating psychotherapy’s effectiveness? Because Eysenck also re- TEACH ported similar improvement among untreated persons, such as those who were on waiting lists. With or without psychotherapy, he said, roughly two- thirds improved noticeably. Time Teaching Tip was a great healer. Although the phrase randomized Later research revealed shortcomings in Eysenck’s analyses; his sample was small (only clinical trials is not a bolded key term, 24 studies of psychotherapy outcomes in 1952). Today, hundreds of studies are available. The best are randomized clinical trials, in which researchers randomly assign people on a waiting it is an important phrase for students list to therapy or to no therapy, and later evaluate everyone, using tests and assessments to know. This type of experimental procedure is considered the “gold standard” for outcome research.

As students become consumers of MyersAP_SE_2e_Mod72_B.indd 730 1/21/14 9:36 AM MyersAP_SE_2e_Mod72_B.indd 731 1/21/14 9:36 AM psychological and medical therapy, they should ﬁ nd out from their providers if the treatments used have been subjected to this type of procedure.

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by others who don’t know whether therapy was given. The results of many such studies AP® Exam Tip are then digested by means of meta - analysis, a statistical procedure that combines the ENGAGE You will need to understand what conclusions of a large number of different studies. Simply said, meta - analyses give us the basic statistical concepts are, but bottom-line results of lots of studies. you will not need to do any actual Enrichment Psychotherapists welcomed the fi rst meta - analysis of some 475 psychotherapy out- calculations on the AP® exam. A classic meta-analysis was conducted come 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 72.1). The claim by Mary Lee Smith and her colleagues is modest—by defi nition, about 50 percent of untreated people also are better off than the to determine whether psychotherapy average untreated person. Nevertheless, Mary Lee Smith and her colleagues exulted that was eff ective. These researchers found “psychotherapy benefi ts people of all ages as reliably as schooling educates them, medicine cures them, or business turns a profi t” (p. 183). that overall, most psychotherapies were eff ective, and all demonstrated about the same levels of eff ectiveness. Figure 72.1 Interestingly, the researchers found Number of Treatment versus no Average Average treatment persons untreated psychotherapy These two normal that around 35–40 percent of people person client distribution curves based on a meta- analysis (combining data from 475 got better simply by deciding they studies) show the improvement of untreated people and psychotherapy needed to seek psychological treat- clients. The outcome for the average therapy client surpassed that for ment. It seems that admitting you 80 percent of the untreated people. have a problem is a signifi cant fi rst (Adapted from Smith et al., 1980.) step toward healing.

Poor Good outcome outcome TEACH 80% of untreated people have poorer outcomes than Common Pitfalls the average treated person. The graph in Figure 72.1 is an important one for students to understand. Dozens of subsequent summaries have now examined this question. Their verdict meta-analysis a procedure for echoes the results of the earlier outcome studies: Those not undergoing therapy often improve, statistically combining the results of Not only does it demonstrate the but those undergoing therapy are more likely to improve more quickly, and with less risk of relapse. many different research studies. Is psychotherapy also cost- effective? Again, the answer is Yes. Studies show that when importance of people seeking psycho- people seek psychological treatment, their search for other medical treatment drops—by 16 logical therapy when they experience percent in one digest of 91 studies (Chiles et al., 1999). Given the staggering annual cost of mental illness, the graph also dem- psychological disorders and substance abuse—including crime, accidents, lost work, and treatment—psychotherapy is a good investment, much like money spent on prenatal and onstrates concepts in statistics, such well- baby care. Both reduce long- term costs. Boosting employees’ psychological well- being, as signifi cant diff erences and normal for example, can lower medical costs, improve work effi ciency, and diminish absenteeism. distributions. Review these concepts 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 “on average,” with students using this graph. medical treatment of health problems is effective. What people want to know is the effectiveness of a particular treatment for their specifi c problems. The Relative Effectiveness of Different Psychotherapies

72-272-2 Are some psychotherapies more effective than others for specifi c disorders? So what can we tell people considering psychotherapy, and those paying for it, about which psychotherapy will be most effective for their problem? The statistical summaries and sur- veys fail to pinpoint any one type of therapy as generally superior (Smith et al., 1977, 1980). Clients seemed equally satisﬁ ed, Consumer Reports concluded, whether treated by a psychiatrist,

MyersAP_SE_2e_Mod72_B.indd 730 1/21/14 9:36 AM MyersAP_SE_2e_Mod72_B.inddENGAGE 731 1/21/14 9:36 AM Critical Questions Unfortunately, many people who have psychological disorders do not receive a clear- cut diagnosis, making it diﬃ cult to conduct clean outcome research free of confounding variables. Have students brainstorm about why clear-cut diagnoses are diﬃ cult to make: How does a patient’s level of candor or openness contribute to the ability of the therapist to diagnose the problem? How can substance abuse interfere with an accurate diagnosis?

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psychologist, or social worker; whether seen in a group or individual context; whether the ENGAGE therapist had extensive or relatively limited training and experience (Seligman, 1995). Other “Whatever differences in treatment studies concur. There is little if any connection between clinicians’ experience, training, super- Active Learning effi cacy exist, they appear to be vision, and licensing and their clients’ outcomes (Luborsky et al., 2002; Wampold, 2007). extremely small, at best.” -BRUCE So, was the dodo bird in Alice in Wonderland right: “Everyone has won and all must have Ask students to research the unsub- WAMPOLD ET AL., 1997 prizes”? Not quite. Some forms of therapy get prizes for particular problems, though there is stantiated therapeutic practices Myers often an overlapping—or comorbidity—of disorders. Behavioral conditioning therapies, for lists here. Have students both gener- example, have achieved especially favorable results with specifi c behavior problems, such ate a list of maladies these practices as bed-wetting, phobias, compulsions, marital problems, and sexual dysfunctions (Baker et al., 2008; Hunsley & DiGiulio, 2002; Shadish & Baldwin, 2005). Psychodynamic therapy has aim to treat and explain how scientifi c helped treat depression and anxiety (Driessen et al., 2010; Leichsenring & Rabung, 2008; research has debunked their use. Be Shedler, 2010b). And new studies confi rm cognitive and cognitive-behavioral therapy’s effectiveness in coping with anxiety, posttraumatic stress disorder, and depression (Baker et mindful that some students or their “Different sores have different salves.” -ENGLISH PROVERB al., 2008; De Los Reyes & Kazdin, 2009; Stewart & Chambliss, 2009; Tolin, 2010). families may have participated in Moreover, we can say that therapy is most effective when the problem is clear- cut these practices in the past. Help your (Singer, 1981; Westen & Morrison, 2001). Those who experience phobias or panic and those who are unassertive can hope for improvement. Those with less- focused problems, such as students see that although they may depression and anxiety, usually benefi t in the short term but often relapse later. And those have previously believed such prac- with the negative symptoms of chronic schizophrenia or a desire to change their entire tices to be eff ective, research does not personality are unlikely to benefi t from therapy alone (Pfammatter et al., 2006; Zilbergeld, 1983). The more specifi c the problem, the greater the hope. support the notion of their general But no prizes—and little or no scientifi c support—go to certain other therapies (Arkow- eff ectiveness. itz & Lilienfeld, 2006). We would all therefore be wise to avoid energy therapies that propose to manipulate people’s invisible energy fi elds, recovered-memory therapies that aim to un- evidence-based practice earth “repressed memories” of early child abuse (Module 33), and rebirthing therapies that ENGAGE clinical decision making that engage people in reenacting the supposed trauma of their birth. integrates the best available As with some medical treatments, it’s possible for psychological treatments not only to be Online Activities research with clinical expertise ineffective but harmful—by making people worse or preventing their getting better (Barlow, and patient characteristics and 2010; Castonguay et al., 2010; Dimidjian & Hollon, 2010). The National Science and Technolo- Another therapy that has been preferences. gy Council cites the Scared Straight program (seeking to deter children and youth from crime) debunked is therapeutic touch as an example of well-intentioned programs that have proved ineffective or even harmful. The therapy, in which a practitioner will 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 attempt to manipulate the “auras” the willingness of health care providers and insurers to pay for therapy? and “energy fi elds” around a person’s On the one side are research psychologists using scientifi c methods to extend the body to promote healing. Therapeu- list of well - defi ned and validated therapies for various disorders. They decry clinicians who “give more weight to their personal experiences” (Baker et al., 2008). On the other tic touch therapy (which does not, Clinical decision making side are nonscientist therapists who view their practice as more art than science, saying ironically, involve any actual touching) that people are too complex and therapy too intuitive to describe in a manual or test in an experiment. Between these two factions stand the science-oriented clinicians, who should not be confused with touch aim to base practice on evidence and make mental health professionals accountable for therapy. Touch therapy involves actual effectiveness. To encourage evidence-based practice in psychology, the American Psychological massage therapy to treat diff erent Patient’s values, Best characteristics, available Association and others (2006; Baker et al., 2008; Levant & Hasan, 2008) have followed the illnesses. Touch therapy can increase preferences, research Institute of Medicine’s lead, advocating that clinicians integrate the best available research circumstances evidence with clinical expertise and with patient preferences and characteristics. Available therapies weight in premature babies, alleviate Clinical depression, reduce stress hormone expertise “should be rigorously evaluated” and then applied by clinicians who are mindful of their Figure 72.2 skills and of each patient’s unique situation (FIGURE 72.2). Increasingly, insurer and gov- levels, and improve immune response. Evidence-based clinical ernment support for mental health services requires evidence-based practice. In 2007, for For more information on touch decision making The ideal clinical example, Britain’s National Health Service announced that it would pour the equivalent of decision making is a three-legged $600 million into training new mental health workers in evidence-based practices (such therapy, refer to the Touch Research stool, upheld by research evidence, clinical expertise, and knowledge of as cognitive-behavioral therapy) and to disseminating information about such treatments Institute web page at www.miami. the patient. (DeAngelis, 2008). edu/touch-research/.

MyersAP_SE_2e_Mod72_B.inddTEACH 732 1/21/14 9:36 AM MyersAP_SE_2e_Mod72_B.indd 733 1/23/14 11:17 AM Flip It Students can get additional help understanding evidence-based practice by watching the Flip It Video: Evidence-Based Practice: Apply- ing Science to Therapy.

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Evaluating Alternative Therapies TEACH 72-372-3 How do alternative therapies fare under scientifi c scrutiny? Concept Connections The tendency of many abnormal states of mind to regress to normal, combined with the Remind students of the placebo placebo effect, creates fertile soil for pseudotherapies. Bolstered by anecdotes, heralded by eff ect. This eff ect, in which people’s the media, and broadcast on the Internet, alternative therapies can spread like wildfi re. In one national survey, 57 percent of those with a history of anxiety attacks and 54 percent of belief in a therapy can lead to their those with a history of depression had used alternative treatments, such as herbal medicine, actually feeling better, helps explain massage, and spiritual healing (Kessler et al., 2001). Testimonials aside, what does the evidence say? This is a tough question, because there why 29 percent of patients generally is no evidence for or against most of them, though their proponents often feel personal ex- do improve while on a placebo. But perience is evidence enough. Some, however, have been the subject of controlled research. this still does not compare to the Let’s consider two of them. As we do, remember that sifting sense from nonsense requires the scientifi c attitude: being skeptical but not cynical, open to surprises but not gullible. 50 percent success rate of real treatment programs. EYE MOVEMENT DESENSITIZATION AND REPROCESSING (EMDR) 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 differenc- ENGAGE es between scientifi c and pseudoscientifi c therapy techniques,” suggested James Herbert and seven others (2000). Francine Shapiro (1989, 2007) developed EMDR while walking in a Online Activities park and observing that anxious thoughts vanished as her eyes spontaneously darted about. Have students explore the pseudo- Offering her novel anxiety treatment to others, she had people imagine traumatic scenes while she triggered eye movements by waving her fi nger in front of their eyes, supposedly science debunking eff orts of James enabling them to unlock and reprocess previously frozen memories. Tens of thousands of Randi on the web at www.randi.org. mental health professionals from more than 75 countries have since undergone training (EMDR, 2011). Not since the similarly charismatic Franz Anton Mesmer introduced animal Students can read articles about his magnetism (hypnosis) more than two centuries ago (also after feeling inspired by an outdoor latest debunking eff orts and get experience) has a new therapy attracted so many devotees so quickly. updates on his ongoing challenge Does it work? For 84 to 100 percent of single- trauma victims participating in four studies, the answer is Yes, reports Shapiro (1999, 2002). Moreover, the treatment need take no with psychic Sylvia Browne. more than three 90-minute sessions. The Society of Clinical Psychology task force on em- pirically validated treatments acknowledges that EMDR is “probably effi cacious” for the ENGAGE treatment of nonmilitary post traumatic stress disorder (Chambless et al., 1997; see also Bis- son & Andrew, 2007; Rodenburg et al., 2009; Seidler & Wagner, 2006). Active Learning Why, wonder the skeptics, would rapidly moving one’s eyes while recalling traumas be therapeutic? Some argue that eye movements serve to relax or distract patients, thus allowing Have students comb through “Studies indicate that EMDR is the memory-associated emotions to extinguish (Gunter & Bodner, 2008). Others believe that just as effective with fi xed eyes. magazines and newspapers to see eye movements in themselves are not the therapeutic ingredient. Trials in which people imag- If that conclusion is right, what’s ined traumatic scenes and tapped a fi nger, or just stared straight ahead while the therapist’s useful in the therapy (chiefl y what types of alternative therapy are behavioral desensitization) is fi nger wagged, have produced therapeutic results (Devilly, 2003). EMDR does work better not new, and what’s new is advertised. than doing nothing, acknowledge the skeptics (Lilienfeld & Arkowitz, 2007b), but many sus- superfl uous.” -HARVARD MENTAL pect that what is therapeutic is the combination of exposure therapy—repeatedly associating HEALTH LETTER, 2002 What claims of effectiveness do with traumatic memories a safe and reassuring context that provides some emotional distance these ads make? from the experience—and a robust placebo effect. Had Mesmer’s pseudotherapy been compared with no treatment at all, it, too (thanks to the healing power of positive belief), might What type of credentials do the have been found “probably effi cacious,” observed Richard McNally (1999). practitioners possess?

LIGHT EXPOSURE THERAPY What type of disorders do these Have you ever found yourself oversleeping, gaining weight, and feeling lethargic during the therapies claim to treat? dark mornings and overcast days of winter? There likely was a survival advantage to your dis- tant ancestors’ slowing down and conserving energy during the dark days of winter. For some people, however, especially women and those living far from the equator, the wintertime

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blahs constitute a seasonal pattern for major de- ENGAGE pressive disorder. To counteract these dark spirits, National Institute of Mental Health researchers Enrichment i n the early 1980s had an idea: Give people a timed Seasonal aﬀ ective disorder (SAD) is daily dose of intense light. Sure enough, people reported they felt better. not listed as a separate disorder in Was this a bright idea, or another dim- DSM-5. Rather, it is included as a quali- witted example of the placebo effect? Research ﬁ er for mood disorders in general. The sheds some light. One study exposed some people with a seasonal pattern in their depres- criterion with seasonal pattern is an sion symptoms to 90 minutes of bright light and option for diagnosing someone with a others to a sham placebo treatment—a hissing

© Katheryn LeMieux, distributed by King Features Syndicate “negative ion generator” about which the staff mood disorder. expressed similar enthusiasm (but which was not even turned on). After four weeks, 61 percent of those exposed to morning light had ENGAGE 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 min- Enrichment BSIP SA/Alamy utes of exposure to 10,000-lux white ﬂ uorescent light produced relief for more than half the people receiving morning light therapy (Flory et al., 2010; Terman et al., 1998, 2001). C. R. Snyder developed a theory of From 20 carefully controlled trials we have a verdict (Golden et al., 2005; Wirz-Justice, 2009): hope that shows why hope may be Morning bright light does indeed dim depression symptoms for many of those suffering in a seasonal pattern. Moreover, it does so as effectively as taking antidepressant drugs or un- important for demoralized people. dergoing cognitive-behavioral therapy (Lam et al., 2006; Rohan et al., 2007). The effects are Snyder proposed that hope has 3 clear in brain scans; light therapy sparks activity in a brain region that inﬂ uences the body’s components: arousal and hormones (Ishida et al., 2005). Goals: People with clear, concrete, Commonalities Among Psychotherapies

and challenging yet attainable 72-472-4 What three elements are shared by all forms of psychotherapy? goals were more likely to make Light therapy To counteract winter plans for the future and believe in depression, some people spend time Why have studies found little correlation between therapists’ training and experience and each morning exposed to intense light clients’ outcomes? In search of some answers, Jerome Frank (1982), Marvin Goldfried (Gold- themselves. that mimics natural outdoor light. Light boxes with the appropriate intensity fried & Padawer, 1982), Hans Strupp (1986), and Bruce Wampold (2001, 2007) have studied Agency: People with high are available from health supply and the common ingredients of various therapies. They suggest that all therapies offer at least lighting stores. three beneﬁ ts: agency—beliefs about their • Hope for demoralized people People seeking therapy typically feel anxious, abilities and capabilities for depressed, devoid of self - esteem, and incapable of turning things around. What any action—tend to be more willing therapy offers is the expectation that, with commitment from the therapy seeker, to pursue goals and accomplish things can and will get better. This belief, apart from any therapeutic technique, may function as a placebo, improving morale, creating feelings of self - efﬁ cacy, and them. diminishing symptoms (Prioleau et al., 1983). Pathways: People who develop • A new perspective Every therapy also offers people a plausible explanation of their symptoms and an alternative way of looking at themselves or responding to their multiple pathways for achieving world. Armed with a believable fresh perspective, they may approach life with a new goals have a higher degree of hope attitude, open to making changes in their behaviors and their views of themselves. and are more likely to thrive, even • An empathic, trusting, caring relationship To say that therapy outcome is unrelated therapists after failure. to training and experience is not to say all are equally effective. No matter what therapeutic technique they use, effective therapists are empathic people who seek to understand another’s experience; who communicate their care and concern to the client; and who earn the client’s trust through respectful listening, reassurance, and advice. Marvin Goldfried and his associates (1998) found these qualities in recorded therapy sessions from 36 recognized master therapists. Some took a

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cognitive -behavioral approach, others emphasized psychodynamic teachings. Regardless, the striking fi nding was how similar they were. At key moments, the TEACH empathic therapists of both persuasions would help clients evaluate themselves, link one aspect of their life with another, and gain insight into their interactions with others. Concept Connections therapeutic alliance Remind students that Carl Rogers was The emotional bond between therapist and client—the —is a key ngton/Getty Images David Buffi aspect of effective therapy (Klein et al., 2003; Wampold, 2001). One U.S. National Institute of the leading advocate of the impor- Mental Health depression- treatment study confi rmed that the most effective therapists were tance of the client–therapist relation- 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 therapies offer hope through a fresh ship. He developed his client-centered perspective offered by a caring person is what also enables paraprofessionals (briefl y trained therapy in response to the very caregivers) to assist so many troubled people so effectively (Christensen & Jacobson, 1994). therapist-heavy approach of Freud These three common elements are also part of what the growing numbers of self-help and support groups offer their members. And they are part of what traditional healers have and his students. In Freudian therapy, offered (Jackson, 1992). Healers everywhere—special people to whom others disclose their the therapist is in control and tells suffering, whether psychiatrists, witch doctors, or shamans—have listened in order to understand and to empathize, reassure, advise, console, interpret, or explain (Torrey, 1986). clients what they are thinking, feeling,

Such qualities may explain why people who feel supported by close relationships—who A caring relationship Effective and remembering. In client-centered enjoy the fellowship and friendship of caring people—are less likely to need or seek therapy therapists form a bond of trust with therapy, the client is the person in (Frank, 1982; O’Connor & Brown, 1984). their clients. control, receiving active listening and * * * To recap, people who seek help usually improve. So do many of those who do not undergo unconditional positive regard from psychotherapy, and that is a tribute to our human resourcefulness and our capacity to care the therapist. for one another. Nevertheless, though the therapist’s orientation and experience appear not therapeutic alliance a bond of to matter much, people who receive some psychotherapy usually improve more than those trust and mutual understanding who do not. People with clear - cut, speciﬁ c problems tend to improve the most. between a therapist and client, who work together constructively to Culture, Gender, and Values in Psychotherapy overcome the client’s problem.

72-5 How do culture, gender, and values infl uence the therapist-client relationship? All therapies offer hope, and nearly all therapists attempt to enhance their clients’ sensitivity, openness, personal responsibility, and sense of purpose (Jensen & Bergin, 1988). But in matters of diversity, therapists differ from one another and may differ from their clients (Delaney et al., 2007; Kelly, 1990). These differences can become signifi cant when a therapist from one culture or gender meets a client from another. In North America, Europe, and Australia, for example, most therapists refl ect their culture’s individualism, which often gives priority to personal desires and identity, particularly for men. Clients who are immigrants from Asian countries, where people are mindful of others’ expectations, may have trouble relating to therapies that require them to think only of their own well-being. And women seeking therapy who are from a collectivist culture might be doubly discomfi ted. Such differences help explain minority populations’ reluc- tance 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, American Psychological Association–accredited therapy training programs now provide training in cultural sensitivity and recruit members of underrepresented cultural groups. Another area of potential confl ict related to values is religion. Highly religious people may prefer and benefi t 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.

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Albert Ellis, who advocated the aggressive rational-emotive behavior therapy (REBT), ENGAGE and Allen Bergin, co- editor of the Handbook of Psychotherapy and Behavior Change, illustrated how sharply therapists can differ, and how those differences can affect their view of a healthy Active Learning person. Ellis (1980) assumed that “no one and nothing is supreme,” that “self - gratifi cation” Have students contact your state’s should be encouraged, and that “unequivocal love, commitment, service, and . . . fi delity to any interpersonal commitment, especially marriage, leads to harmful consequences.” Bergin licensing board to fi nd out what (1980) assumed the opposite—that “because God is supreme, humility and the acceptance of types of training one must complete divine authority are virtues,” that “self- control and committed love and self- sacrifi ce are to be in order to practice psychotherapy encouraged,” and that “infi delity to any interpersonal commitment, especially marriage, leads to harmful consequences.” legally. Bergin and Ellis disagreed more radically than most therapists on what values are What is the minimum amount of healthiest. In so doing, however, they agreed on a more general point: Psychotherapists’ personal beliefs infl uence their practice. Because clients tend to adopt their therapists’ values training a psychotherapist must (Worthington et al., 1996), some psychologists believe therapists should divulge those val- receive in order to obtain a license? ues more openly. (For those thinking about seeking therapy, Close-up: A Consumer’s Guide to Psychotherapists offers some tips on when to seek help and how to start searching for a How many licensed practitioners therapist who shares your perspective and goals.) are in your state? Your area? Close-up Do psychotherapists have to pass A Consumer’s Guide to Psychotherapists an exam to obtain a license? Which What should a person look for when • Sudden mood shifts one(s)? Do they get an opportunity 72-672-6 selecting a therapist? • Thoughts of suicide to take it again if they fail the first Life for everyone is marked by a mix of serenity and stress, bless- • Compulsive rituals, such as hand washing time? How many times can an ing and bereavement, good moods and bad. So, when should we • Hearing voices or seeing things that others don’t experience seek a mental health professional’s help? The American Psycho- unlicensed psychotherapist take logical Association offers these common trouble signals: In looking for a therapist, you may want to have a preliminary such a test? • Feelings of hopelessness consultation with two or three. High school counseling offi ces are generally good starting points, and may offer some free services. • Deep and lasting depression What should a potential client You can describe your problem and learn each therapist’s treatment • Self - destructive behavior, such as substance use disorder look for to ensure that his or her approach. You can ask questions about the therapist’s values, cre- • Disruptive fears therapist is state-licensed? dentials (TABLE 72.1), and fees. And you can assess your own feelings about each of them. The emotional bond between therapist TABLE 72.1 and client is perhaps the most important factor in effective therapy. TEACH Therapists and Their Training

Common Pitfalls Type Description

Remind students of the diﬀ er- Clinical Most are psychologists with a Ph.D. (includes research training) or Psy.D. (focuses on therapy) ence between psychologists and psychologists supplemented by a supervised internship and, often, post doctoral training. About half work in agencies and institutions, half in private practice. psychiatrists: Psychiatrists Psychiatrists are physicians who specialize in the treatment of psychological disorders. Not all psychiatrists Psychologists are trained in Ph.D. have had extensive training in psychotherapy, but as M.D.s or D.O.s they can prescribe medications. Thus, programs that emphasize the they tend to see those with the most serious problems. Many have their own private practice. psychological bases for mental Clinical or psychiatric A two-year master of social work graduate program plus postgraduate supervision prepares some social workers illness and provide clinical training. social workers to offer psychotherapy, mostly to people with everyday personal and family problems. About half have earned the National Association of Social Workers’ designation of clinical social worker. Except in 2 states and the military, Counselors Marriage and family counselors specialize in problems arising from family relations. Clergy provide counseling clinical psychologists cannot to countless people. Abuse counselors work with substance abusers and with spouse and child abusers and prescribe medication. their victims. Mental health and other counselors may be required to have a two-year master’s degree. Psychiatrists are trained in medical schools as doctors first, followed by a residency or fellowship specializing in psychiatry. The

emphasis of most psychiatrists is MyersAP_SE_2e_Mod72_B.indd 736 1/21/14 9:36 AM MyersAP_SE_2e_Mod72_B.indd 737 1/21/14 9:36 AM more medical than psychological. All psychiatrists who are properly licensed can prescribe medication.

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Preventing Psychological Disorders TEACH 72-7 What is the rationale for preventive mental health programs? Concept Connections

We have seen that lifestyle change can help reverse some of the symptoms of psychological Link the discussion on preventing disorders. Might such change also prevent some disorders by building individuals’ resilience— resilience the personal strength psychological disorders with social an ability to cope with stress and recover from adversity? Faced with unforeseen trauma, most that helps most people cope with adults exhibit resilience. This was true of New Yorkers in the aftermath of the September 11 stress and recover from adversity psychology, as discussed in Unit XIV. terrorist attacks, especially those who enjoyed supportive close relationships and who had not and even trauma. The social context is an important recently experienced other stressful events (Bonanno et al., 2007). More than 9 in 10 New York- factor in both diagnosing and treating ers, although stunned and grief- stricken by 9/11, did not have a dysfunctional stress reaction. By the following January, the stress symptoms of those who did were mostly gone (Person et mental illness. Psychologists need to al., 2006). Even in groups of combat - stressed veterans and political rebels who have survived pay attention to that social context in dozens of episodes of torture, most do not later exhibit posttraumatic stress disorder (Mineka & order to help their patients get better Zinbarg, 1996). Psychotherapies and biomedical therapies tend to locate the cause of psychological and deal with situations as they arise. disorders within the person with the disorder. We infer that people who act cruelly must be cruel and that people who act “crazy” must be “sick.” We attach labels to such people, thereby distinguishing them from “normal” folks. It follows, then, that we try to treat “ab- ENGAGE normal” people by giving them insight into their problems, by changing their thinking, by helping them gain control with drugs. Critical Questions There is an alternative viewpoint: We could interpret many psychological disorders as Resilience is an emerging topic of understandable responses to a disturbing and stressful society. According to this view, it is not just the person who needs treatment, but also the person’s social context. Better to pre- study. Some researchers explore vent a problem by reforming a sick situation and by developing people’s coping competen- factors that lead to resilience, such as cies than to wait for a problem to arise and then treat it. grit or mindset. Others explore how A story about the rescue of a drowning person from a rushing river illustrates this viewpoint: Having successfully administered fi rst aid to the fi rst victim, the rescuer spots another interpreting social context can lead “It is better to prevent than to struggling person and pulls her out, too. After a half - dozen repetitions, the rescuer suddenly cure.” -PERUVIAN FOLK WISDOM to resilience. Have students consider turns and starts running away while the river sweeps yet another fl oundering person into these questions: view. “Aren’t you going to rescue that fellow?” asks a bystander. “Heck no,” the rescuer replies. “I’m going upstream to fi nd out what’s pushing all these people in.” Is adversity necessary to develop Preventive mental health is upstream work. It seeks to prevent psychological casualties by resilience? identifying and alleviating the conditions that cause them. As George Albee (1986) pointed out, “Mental disorders arise from there is abundant evidence that poverty, meaningless work, constant criticism, unemployment, physical ones, and likewise Might thinking differently about racism, sexism, and heterosexism undermine people’s sense of competence, personal control, physical disorders arise from stressful or traumatic situations and self- esteem. Such stresses increase their risk of depression, alcohol use disorder, and suicide. mental ones.” -THE MAHABHARATA, 200 B.C.E. We who care about preventing psychological casualties should, Albee contended, support help someone cope better with the programs that alleviate these demoralizing situations. We eliminated smallpox not by treat- outcomes of those situations? ing the affl icted but by inoculating the unaffl icted. We conquered yellow fever by controlling mosquitoes. Preventing psychological problems means empowering those who feel helpless, In what ways can someone think changing environments that breed loneliness, renewing the disintegrating family, promoting about stress or difficulty that communication training for couples, and bolstering parents’ and teachers’ skills. “Everything would lead to resilience? aimed at improving the human condition, at making life more fulfi lling and meaningful, may be considered part of primary prevention of mental or emotional disturbance” (Kessler & Albee, 1975, p. 557). That includes the cognitive training that promotes positive thinking in children at risk for depression (Brunwasser et al., 2009; Gillham et al., 2006; Stice et al., 2009). A 2009 National Research Council and Institute of Medicine report—Preventing Mental, Emo- tional, and Behavioral Disorders Among Young People—offers encouragement. It documents that intervention efforts often based on cognitive-behavioral therapy principles signifi cantly boost child and adolescent fl ourishing. Through such preventive efforts and healthy lifestyles, fewer of us will fall into the rushing river of psychological disorders.

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Evaluating Psychotherapies and Prevention Strategies Module 72 737

MyersPsyAP_TE_2e_U13.indd 737 3/3/14 8:46 AM 738 Unit XIII Treatment of Abnormal Behavior

CLOSE & ASSESS Before You Move On Exit Assessment c ASK YOURSELF Can you think of a specifi c way that improving the environment in your own community Have students design an experi- might prevent some psychological disorders among its residents? ment testing whether a therapeutic c TEST YOURSELF technique is eff ective. Make sure What is the difference between preventive mental health and psychological or biomedical students include a placebo in their therapy? Answers to the Test Yourself questions can be found in Appendix E at the end of the book. design. Have them explain why using an experiment to test eff ectiveness is likely better than using case study research. Module 72 Review

72-1 Does psychotherapy work? Who decides? 72-372-3 How do alternative therapies fare under scientifi c scrutiny?

• Clients’ and therapists’ positive testimonials cannot prove • Controlled research has found some benefi ts of eye that therapy is actually effective, and the placebo effect movement desensitization and reprocessing (EMDR) and regression toward the mean (the tendency for extreme therapy for PTSD, though possibly for reasons unrelated or unusual scores to fall back toward their average) to eye movements. make it diffi cult to judge whether improvement occurred Light exposure therapy does seem to relieve depression because of the treatment. • symptoms for those with a seasonal pattern of major • Using meta-analyses to statistically combine the results depressive disorder by activating a brain region that of hundreds of randomized psychotherapy outcome infl uences arousal and hormones. studies, researchers have found that those not undergoing treatment often improve, but those undergoing 72-472-4 What three elements are shared by all forms psychotherapy are more likely to improve more quickly, of psychotherapy? and with less chance of relapse. • All psychotherapies offer new hope for demoralized people; a fresh perspective; and (if the therapist is 72-2 Are some psychotherapies more effective than others for specifi c disorders? effective) an empathic, trusting, and caring relationship. The emotional bond of trust and understanding between No one type of psychotherapy is generally superior to all • • therapist and client—the therapeutic alliance—is an others. Therapy is most effective for those with clear-cut, important element in effective therapy. specifi c problems.

• Some therapies—such as behavior conditioning for 72-572-5 How do culture, gender, and values treating phobias and compulsions—are more effective for infl uence the therapist-client relationship? speciﬁ c disorders. • Therapists differ in the values that inﬂ uence their goals • Psychodynamic therapy helped treat depression and in therapy and their views of progress. These differences anxiety, and cognitive and cognitive-behavioral therapies may create problems if therapists and clients differ in their have been effective in coping with anxiety, obsessive- cultural, gender, or religious perspectives. compulsive disorder, posttraumatic stress disorder, and depression. • Evidence-based practice integrates the best available research with clinicians’ expertise and patients’ characteristics, preferences, and circumstances.

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738 Unit XIII Treatment of Abnormal Behavior

MyersPsyAP_TE_2e_U13.indd 738 3/3/14 8:46 AM Evaluating Psychotherapies and Prevention Strategies Module 72 739

What should a person look for when 72-672-6 72-772-7 What is the rationale for preventive mental selecting a therapist? health programs?

• A person seeking therapy may want to ask about the • Preventive mental health programs are based on the idea therapist’s treatment approach, values, credentials, and that many psychological disorders could be prevented by fees. changing oppressive, esteem-destroying environments • An important consideration is whether the therapy seeker into more benevolent, nurturing environments that foster feels comfortable and able to establish a bond with the growth, self-conﬁ dence, and resilience. therapist.

Multiple-Choice Questions Answers to Multiple-Choice 1. Which of the following does the text’s author call 3. Which of the following is the best phrase for a bond of Questions psychology’s most powerful tool for sorting reality from trust and mutual understanding between a therapist wishful thinking? and client who are working to overcome the client’s 1. d 3. a a. ESP or “psychic powers” problem? 2. e b. Regression toward the mean a. Therapeutic alliance c. Client perception b. EMDR d. Control group c. Evidence-based practice e. Placebo effect d. Meta-analysis e. Outcome research 2. Which of the following best describes meta-analysis? a. Evidenced-based practice b. A treatment versus no treatment group c. A tendency for smaller scores to move toward the average d. Regressing from unusual to usual e. A way to combine the results of lots of studies

Practice FRQs Answer to Practice FRQ 2 1. 2. Explain the three sides of evidence-based clinical Psychotherapies have many common ingredients. 1 point: Hope for demoralized people. decision making. Identify three commonly agreed-upon beneﬁ ts of psychotherapies. Answer 1 point: A plausible explanation of (3 points) 1 point: Using the best available research evidence. their symptoms. 1 point: Clinical expertise. 1 point: An empathic, trusting, caring 1 point: Using a patient’s values, preferences, and relationship. circumstances.

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Evaluating Psychotherapies and Prevention Strategies Module 72 739

MyersPsyAP_TE_2e_U13.indd 739 3/3/14 8:46 AM 740 Unit XIII Treatment of Abnormal Behavior

TEACH TRMTRM Discussion Starter Module 73 Use the Module 73 Fact or Falsehood? activity from the TRM to introduce the The Biomedical Therapies concepts from this module.

TEACH Module Learning Objectives

Teaching Tip 73-173-1 Identify and describe the drug therapies, and explain how double- TANNEN MAURY/Landov Be sure to emphasize to students that blind studies help researchers evaluate a drug’s effectiveness. taking these medications without a 73-2 Describe the use of brain stimulation techniques and psychosurgery prescription is dangerous. The balance in treating specifi c disorders. of neurotransmitters in the nervous 73-3 Describe how, by taking care of themselves with a healthy lifestyle, system is delicate. The drugs used to people might fi nd some relief from depression, and explain how this treat mental illness are designed to refl ects our being biopsychosocial systems. alter that balance in favor of better mental health. These medications should only be taken under the sychotherapy is one way to treat psychological disorders. The other, often used with direction of a certifi ed professional; P serious disorders, is biomedical therapy—physically changing the brain’s functioning by altering its chemistry with drugs, or affecting its circuitry with electroconvulsive shock, otherwise, the result could be serious magnetic impulses, or psychosurgery. Primary care providers prescribe most drugs for anxiety psychopharmacology the study and depression, followed by psychiatrists and, in some states, psychologists. mental damage, not mental health. of the effects of drugs on mind and behavior. TEACH Drug Therapies What are the drug therapies? How do double-blind studies help Drug or placebo effect? For many 73-1 Common Pitfalls people, depression lifts while taking researchers evaluate a drug’s effectiveness? an antidepressant drug. But people Distinguish a drug’s main eff ects from given a placebo may experience the By far the most widely used biomedical treatments today are the drug therapies. Since the 1950s, its side eff ects: same effect. Double-blind clinical trials discoveries in psychopharmacology (the study of drug effects on mind and behavior) have suggest that, especially for those with revolutionized the treatment of people with severe disorders, liberating hundreds of thousands severe depression, antidepressant Main effects are the effects the drugs do have at least a modest from hospital confi nement. Thanks to drug therapy—and to efforts to minimize involuntary drugs are supposed to create clinical effect. hospitalization and to support people through community mental health programs—the resi- in patients. Antianxiety and dent population of mental hospitals is a small fraction of what it was a half- century ago. For some unable to care for themselves, however, release from hospitals has antidepressant drugs are intended meant homelessness, not liberation. to alleviate anxiety and depression Almost any new treatment, including drug therapy, is greeted by an initial wave of enthusiasm as many people apparently improve. But that in the patients who take them. enthusiasm often diminishes after researchers subtract the rates of (1) nor- Side effects are the unintended mal recovery among untreated persons and (2) recovery due to the placebo effect, which arises from the positive expectations of patients and mental consequences of taking certain health workers alike. So, to evaluate the effectiveness of any new drug, drugs. Patients may experience researchers give half the patients the drug, and the other half a similar - nausea, headaches, sexual side appearing placebo. Because neither the staff nor the patients know who

© The New Yorker Collection, 2007, Edward Koren from cartoonbank.com. All Rights Reserved. gets which, this is called a double - blind procedure. The good news: In double- effects, and exacerbation of other “Our psychopharmacologist is a genius.” blind studies, some drugs have proven useful. medical conditions. Side effects can vary from person to person.

MyersAP_SE_2e_Mod73_B.inddTEACH 740 1/21/14 9:36 AM MyersAP_SE_2e_Mod73_B.indd 741 1/21/14 9:36 AM Flip It Students can get additional help understanding drug treatments by watching the Flip It Video: How Drug Therapy Works.

740 Unit XIII Treatment of Abnormal Behavior

MyersPsyAP_TE_2e_U13.indd 740 3/3/14 8:46 AM The Biomedical Therapies Module 73 741

Antipsychotic Drugs ® AP Exam Tip ENGAGE The revolution in drug therapy for psychological disorders began with the accidental discov- The discussion of drug therapies ery that certain drugs, used for other medical purposes, calmed patients with psychoses (dis- is a great opportunity for you Active Learning orders in which hallucinations or delusions indicate some loss of contact with reality). These to review information about antipsychotic drugs, neurotransmitters and brain such as chlorpromazine (sold as Thorazine), dampened responsive- function. See Unit III if you need Have students research the diff erent ness to irrelevant stimuli. Thus, they provided the most help to patients experiencing posi- to brush up on these topics. types of drugs used to treat psychosis. tive symptoms of schizophrenia, such as auditory hallucinations and paranoia (Lehman et al., 1998; Lenzenweger et al., 1989). How are Clozaril and Risperdal The molecules of most conventional antipsychotic drugs are antagonists; they are simi- FYI different from Thorazine? lar enough to molecules of the neurotransmitter dopamine to occupy its receptor sites and Perhaps you can guess an block its activity. This fi nding reinforces the idea that an overactive dopamine system con- occasional side effect of L-dopa, Do all these drugs bind exclusively tributes to schizophrenia. a drug that raises dopamine levels for Parkinson’s patients: to dopamine receptors? If not, to Antipsychotics also have powerful side effects. Some produce sluggishness, tremors, hallucinations. and twitches similar to those of Parkinson’s disease (Kaplan & Saddock, 1989). Long-term what receptors do they bind? use of antipsychotics can produce tardive dyskinesia, with involuntary movements of the Does health care insurance offer facial muscles (such as grimacing), tongue, and limbs. Although not more effective in controlling schizophrenia symptoms, many of the newer-generation antipsychotics, such as coverage for the long-term use of risperidone (Risperdal) and olanzapine (Zyprexa), have fewer of these effects. These drugs these drugs? Why or why not? may, however, increase the risk of obesity and diabetes (Buchanan et al., 2010; Tiihonen et al., 2009). Antipsychotics, combined with life-skills programs and family support, have given new TEACH hope to many people with schizophrenia (Guo, 2010). Hundreds of thousands of patients have left the wards of mental hospitals and returned to work and to near-normal lives Teaching Tip (Leucht et al., 2003). Be sure students know the term Antianxiety Drugs tardive dyskinesia for the AP® Like alcohol, antianxiety drugs, such as Xanax or Ativan, depress central nervous system antipsychotic drugs drugs used exam. This is a common side eff ect activity (and so should not be used in combination with alcohol). Antianxiety drugs are of- to treat schizophrenia and other of antipsychotic drugs, and students ten used in combination with psychological therapy. One antianxiety drug, the antibiotic D- forms of severe thought disorder. cycloserine, acts upon a receptor that, in combination with behavioral treatments, facilitates antianxiety drugs drugs used to may be asked about this term on the the extinction of learned fears. Experiments indicate that the drug enhances the benefi ts control anxiety and agitation. exam. Tardive dyskinesia is a disorder of exposure therapy and helps relieve the symptoms of posttraumatic stress disorder and antidepressant drugs drugs that involves involuntary movements, obsessive-compulsive disorder (Davis, 2005; Kushner et al., 2007). used to treat depression, anxiety A criticism sometimes made of the behavior therapies—that they reduce symptoms disorders, obsessive-compulsive particularly in the lower face. without resolving underlying problems—is also made of drug therapies. Unlike the behav- disorder, and posttraumatic stress disorder. (Several widely used ior therapies, however, these substances may be used as an ongoing treatment. “Popping antidepressant drugs are selective ENGAGE a Xanax” at the fi rst sign of tension can create a learned response; the immediate relief serotonin reuptake inhibitors—SSRIs.) reinforces a person’s tendency to take drugs when anxious. Antianxiety drugs can also be Critical Questions addicting. After heavy use, people who stop taking them may experience increased anxiety, insomnia, and other withdrawal symptoms. In 2002, a reality-TV show followed the Over the dozen years at the end of the twentieth century, the rate of outpatient treat- late model and actress Anna Nicole ment for anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder nearly doubled. The proportion of psychiatric patients receiving medication during Smith as she tried to cope with life’s that time increased from 52 to 70 percent (Olfson et al., 2004). And the new standard drug daily struggles. In one episode, she treatment for anxiety disorders? Antidepressants. confessed that her dog was on Prozac. Antidepressant Drugs The cameras showed a dog that The antidepressants were named for their ability to lift people up from a state of depres- seemed highly sedated and “spaced sion, and this was their main use until recently. The label is a bit of a misnomer now that these out.” This sparked discussion about drugs are increasingly being used to successfully treat anxiety disorders, obsessive- compulsive disorder, and posttraumatic stress disorder. These drugs are agonists; they work by increas- whether pets should be given medica- ing the availability of certain neurotransmitters, such as norepinephrine or serotonin, which tion to control their unruly, odd, or eccentric behaviors. Have students consider whether pets should be treated for psychological disorders: MyersAP_SE_2e_Mod73_B.indd 740 1/21/14 9:36 AM MyersAP_SE_2e_Mod73_B.indd 741TEACH 1/21/14 9:36 AM Do the drug companies that Concept Connections manufacture such drugs recommend their use with pets? Link the discussion on relieving tension to medications to relieve feelings of anxiety and Why or why not? negative reinforcement (Unit VI). Reinforce- tension because the drugs do eliminate those What type of credentials does ment is designed to encourage a behavior by unpleasant feelings. While this protocol is one need to be called a “pet either giving a reward or taking away some- eff ective in the short term, the power of nega- psychiatrist” ? thing unpleasant. Negative reinforcement does tive reinforcement may encourage people to the latter, removing something that a person take drugs any time they feel anxious—even What do veterinary medical wants to avoid. In cases of anxiety, people are in situations they could handle without using associations say about the use of going to be more likely to take their prescribed drugs. human drugs on animals?

The Biomedical Therapies Module 73 741

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elevate arousal and mood and appear scarce when a person experiences feelings of depres- TEACH sion or anxiety. Fluoxetine, which tens of millions of users worldwide have known as Prozac, falls into this category of drugs. The most commonly prescribed drugs in this group, includ- Flip It ing Prozac and its cousins Zoloft and Paxil, work by blocking the reabsorption and removal Students can get additional help © John Greim/Age fotostock of serotonin from synapses (FIGURE 73.1). Given their use in treating disorders other than understanding schizophrenia and depression—from anxiety to strokes—this group of drugs is most often called SSRIs (selective serotonin reuptake inhibitors) rather than antidepressants (Kramer, 2011). Some of the older its symptoms by watching the Flip antidepressant drugs work by blocking the reabsorption or breakdown of both norepineph- It Video: Positive and Negative rine and serotonin. Though effective, these dual- action drugs have more potential side effects, such as dry mouth, weight gain, hypertension, or dizzy spells (Anderson, 2000; Mulrow, 1999). Symptoms. Administering them by means of a patch, bypassing the intestines and liver, helps reduce such side effects (Bodkin & Amsterdam, 2002). ENGAGE After the introduction of SSRI drugs, the percentage of patients receiving medication for depression jumped dramatically, from 70 percent in 1987, the year before SSRIs were Enrichment introduced, to 89 percent in 2001 (Olfson et al., 2003; Stafford et al., 2001). From 1996 to 2005, the number of Americans prescribed antidepressant drugs doubled, from 13 to 27 mil- Depression is a cyclic disorder, so lion (Olfson & Marcus, 2009). Between 2002 and 2007 in Australia, antidepressant drug use many patients suff er relapses, which increased 41 percent (Hollingworth et al., 2010). Be advised: Patients with depression who begin taking antidepressants do not wake up the longer drug therapy may prevent. next day singing “It’s a beautiful day”! Although the drugs begin to infl uence neurotransmission A February 2003 study published in within hours, their full psychological effect often requires four weeks. One possible reason for the medical journal The Lancet shows the delay is that increased serotonin promotes neurogenesis—the birth of new brain cells, perhaps reversing stress - induced loss of neurons (Becker & Wojtowicz, 2007; Jacobs, 2004). that long-term use of antidepres- Antidepressant drugs are not the only way to give the body a lift. Aerobic exercise, which sants reduces the number of relapses calms people who feel anxious and energizes those who feel depressed, does about as much good for some people with mild to moderate depression, and has additional positive side ef- patients experience. Researchers in fects (more on this topic later in this module). Cognitive therapy, by helping people reverse England, along with other research- their habitual negative thinking style, can boost the drug- aided relief from depression and ers in Britain, Japan, and the United reduce the post -treatment risk of relapse (Hollon et al., 2002; Keller et al., 2000; Vittengl et al., 2007). Better yet, some studies suggest, is to attack depression (and anxiety) from both below States, reviewed data from 33 trials Figure 73.1 and above (Cuijpers et al., 2010; Walkup et al., 2008). Use antidepressant drugs (which work, involving over 4000 depressed Biology of antidepressants bottom- up, on the emotion- forming limbic system) in conjunction with cognitive-behavioral Shown here is the action of Prozac, therapy (which works top - down, starting with changed frontal lobe activity). patients. In these trials, patients had which partially blocks the reuptake of fi nished the standard course of treat- serotonin. ment (4–6 months) and were off ered Message is sent across synaptic gap. Message is received; excess serotonin Prozac partially blocks normal reuptake of the molecules are reabsorbed by sending neuron. neurotransmitter serotonin; excess serotonin an opportunity to continue treat- in synapse enhances its mood-lifting effect. ment. One group of patients received Sending a placebo, while the other one took neuron Action antidepressants. potential

Reuptake Synaptic gap

Receiving neuron

Serotonin Serotonin Prozac molecule Receptors (a) (b) (c)

MyersAP_SE_2e_Mod73_B.inddTEACH 742 1/21/14 9:36 AM MyersAP_SE_2e_Mod73_B.indd 743 1/21/14 9:36 AM Teaching Tip Remind students that even biomedical therapies need to be subjected to randomized controlled clinical trials. The eﬀ ectiveness of medical therapies is just as important to understand as the eﬀ ectiveness of psychological therapies.

742 Unit XIII Treatment of Abnormal Behavior

MyersPsyAP_TE_2e_U13.indd 742 3/3/14 8:46 AM The Biomedical Therapies Module 73 743

Researchers generally agree that people with depression often improve after a month on antidepressants. But after allowing for natural recovery and the pla- ENGAGE cebo effect, how big is the drug effect? Not big, report Irving Kirsch and his colleagues (1998, 2002, 2010). Their analyses of double - blind clinical trials indicate Active Learning that the placebo effect accounted for about 75 percent of the active drug’s effect. Have students research the diﬀ erent In a follow-up review that included unpublished clinical trials, the antidepressant drug effect was again modest (Kirsch et al., 2008). The placebo effect was drugs mentioned in this module: less for those with severe depression, which made the added beneﬁ t of the drug What type of receptors do drugs somewhat greater for them. “Given these results, there seems little reason to prescribe antidepressant medication to any but the most severely depressed pa- like Valium, Librium, and Xanax

tients, unless alternative treatments have failed,” Kirsch concluded (BBC, 2008). © The New Yorker Collection, 2000, C. Vey from P. cartoonbank.com. All Rights Reserved. bind with? A newer analysis confi rms that the antidepressant benefi t compared with pla- “If this doesn’t help you don’t worry, it’s a placebo.” cebos is “minimal or nonexistent, on average, in patients with mild or moderate What are the side effects of taking symptoms.” For those folks, aerobic exercise or psychotherapy is often effective. But among these drugs? patients with “very severe” depression, the medication advantage becomes “substantial” “No twisted thought without a twisted molecule.” -ATTRIBUTED TO (Fournier et al., 2010). Are they addicting? If so, how are PSYCHOLOGIST RALPH GERARD patients monitored to prevent Mood - Stabilizing Medications addiction? In addition to antipsychotic, antianxiety, and antidepressant drugs, psychiatrists have mood - stabilizing drugs in their arsenal. For those suffering the emotional highs and lows of bipolar How are selective serotonin disorder, the simple salt lithium can be an effective mood stabilizer. Australian physician reuptake inhibitors (SSRIs) different John Cade discovered this in the 1940s when he administered lithium to a patient with se- from monamine oxidase inhibitors vere mania and the patient became perfectly well in less than a week (Snyder, 1986). After suffering mood swings for years, about 7 in 10 people with bipolar disorder benefi t from a (MAOIs)? (MAOIs are older types of long - term daily dose of this cheap salt, which helps prevent or ease manic episodes and, drugs that are more dangerous than to a lesser extent, lifts depression (Solomon et al., 1995). It also protects neural health, thus reducing bipolar patients’ vulnerability to signifi cant cognitive decline (Kessing et al., 2010). “Lithium prevents my seductive SSRIs when taken in overdose.) but disastrous highs, diminishes Lithium also reduces bipolar patients’ risk of suicide—to about one-sixth of bipolar pa- my depressions, clears out the What type of side effects do SSRIs tients not taking lithium (Tondo et al., 1997). Lithium amounts in drinking water have also wool and webbing from my correlated with lower suicide rates (across 18 Japanese cities and towns) and lower crime disordered thinking, slows me have? down, gentles me out, keeps rates (across 27 Texas counties) (Ohgami et al., 2009; Schrauzer & Shrestha, 1990, 2010; me from ruining my career and How effective are these different Terao et al., 2010). Although we do not fully understand why, lithium works. And so does relationships, keeps me out of Depakote, a drug originally used to treat epilepsy and more recently found effective in the a hospital, alive, and makes types of drugs? control of manic episodes associated with bipolar disorder. psychotherapy possible.” -KAY REDFIELD JAMISON, AN UNQUIET MIND, 1995 Brain Stimulation

73-273-2 How are brain stimulation and psychosurgery used in treating specifi c electroconvulsive therapy (ECT) disorders? a biomedical therapy for severely depressed patients in which a brief Electroconvulsive Therapy electric current is sent through the brain of an anesthetized patient. A more controversial brain manipulation occurs through shock treatment, or electroconvulsive therapy (ECT). When ECT was ﬁ rst introduced in 1938, the wide- awake patient was strapped to a table and jolted with roughly 100 volts of electricity to the brain, producing racking convulsions and brief unconsciousness. ECT therefore gained a barbaric image, one FYI that lingers. Today, however, the patient receives a general anesthetic and a muscle relaxant The medical use of electricity is (to prevent injury from seizures) before a psychiatrist delivers 30 to 60 seconds of electri- an ancient practice. Physicians cal current (FIGURE 73.2 on the next page). Within 30 minutes, the patient awakens and treated the Roman Emperor remembers nothing of the treatment or of the preceding hours. After three such sessions Claudius (10 B.C.E.–54 C.E.) for headaches by pressing electric each week for two to four weeks, 80 percent or more of people receiving ECT improve mark- eels to his temples. edly, showing some memory loss for the treatment period but no discernible brain damage.

MyersAP_SE_2e_Mod73_B.indd 742 1/21/14 9:36 AM MyersAP_SE_2e_Mod73_B.inddENGAGE 743 1/21/14 9:36 AM Enrichment The aim of electroconvulsive therapy (ECT) is deﬂ ected by the skull. Since muscle relaxants to produce a seizure in the brain, similar to that may interfere with breathing, an anesthesiolo- which occurs spontaneously in some types of gist administers oxygen. The muscle relaxants epilepsy. In fact, research suggests that without often block all outward signs of a seizure, so a seizure, ECT is ineﬀ ective. A small electric the patient’s brain waves must be monitored. current passes through 2 electrodes placed The entire procedure takes about 5 minutes, on the patient’s head. Only a portion of this and complications are rare. current reaches the brain because most of it is

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Figure 73.2 Stimulating TEACH Recording EEG Electroconvulsive therapy electrodes Although controversial, ECT is often Common Pitfalls ECT device an effective treatment for depression ECT has gotten a bad rap in such mov- that does not respond to drug therapy. “Electroconvulsive” is no ies as One Flew Over the Cuckoo’s Nest, longer accurate because patients are now given a drug that prevents Ground a ﬁ lm from the late 1970s starring injurious seizures. ECG Recording (heart rate) a young Jack Nicholson and Louise Blood pressure cuff Fletcher (both of whom won Oscars Intravenous line (sedative, muscle for their portrayals). In that movie, relaxant)

Nicholson’s character is subjected to Oximeter (blood-oxygen ECT as a way to control him rather monitor) than treat him. Today, ECT is only used on patients whose depres- Blood pressure sion is so deep they do not respond cuff positively to other treatments. The electrical stimulation seems to jump- EMG start neural communication, leading (records electrical activity from the muscles) to improved mood.

Study after study conﬁ rms that ECT is an effective treatment for severe depression in ENGAGE “treatment-resistant” patients who have not responded to drug therapy (Bailine et al., 2010; Fink, 2009; UK ECT Review Group, 2003). An editorial in the Journal of the Ameri-

Active Learning Rick Friedman/Corbis can Medical Association concluded that “the results of ECT in treating severe depression Since patients sleep through ECT, are among the most positive treatment effects in all of medicine” (Glass, 2001). How does ECT alleviate severe depression? After more than 70 years, no one it should come as no surprise that knows for sure. One recipient likened ECT to the smallpox vaccine, which was sav- in one study, 82 percent rated the ing lives before we knew how it worked. Others think of it as rebooting their cerebral computer. But what makes it therapeutic? Perhaps the shock - induced seizures calm therapy as equally upsetting as or cer- neural centers where overactivity produces depression. ECT, like antidepressant tainly no more upsetting than going drugs and exercise, also appears to boost the production of new brain cells (Bolwig to the dentist. Have students explore & Madsen, 2007). ECT proponent In her book, Shock: Skeptics have raised one other possible explanation for how ECT works: as a placebo how ECT has changed over the years The Healing Power of Electroconvulsive effect. Most ECT studies have failed to contain a control condition in which people are Therapy (2006), Kitty Dukakis writes, to become an eﬀ ective, humane treat- “I used to . . . be unable to shake the randomly assigned to receive the same general anesthesia and simulated ECT without the ment for major depression: dread even when I was feeling good, shock. When given this placebo treatment, note John Read and Richard Bentall (2010), because I knew the bad feelings would the positive expectation is therapeutic, though a Food and Drug Administration (2011) return. ECT has wiped away that What techniques were used in the foreboding. It has given me a sense of research review concludes that ECT is more effective than a placebo, especially in the past to administer ECT? control, of hope.” short run. ECT is now administered with briefer pulses, sometimes only to the brain’s right side What procedures are now utilized and with less memory disruption (HMHL, 2007). Yet no matter how impressive the results, that make the treatment less the idea of electrically shocking people still strikes many as barbaric, especially given our ignorance about why ECT works. Moreover, about 4 in 10 ECT-treated patients relapse into unpleasant? depression within six months (Kellner et al., 2006). Nevertheless, in the minds of many psychiatrists and patients, ECT is a lesser evil than severe depression’s misery, anguish, and risk of suicide. As research psychologist Norman Endler (1982) reported after ECT alleviated his deep depression, “A miracle had happened in two weeks.”

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Alternative Neurostimulation Therapies Two other neural stimulation techniques—magnetic stimulation and deep-brain stimulation— are raising hopes for gentler alternatives that jump - start neural circuits in the depressed brain. repetitive transcranial magnetic MAGNETIC STIMULATION stimulation (rTMS) the application of repeated pulses of magnetic Depressed moods seem to improve when repeated pulses surge through a magnetic coil energy to the brain; used to stimulate held close to a person’s skull (FIGURE 73.3). The painless procedure—called repetitive or suppress brain activity. transcranial magnetic stimulation (rTMS)—is performed on wide- awake patients over several weeks. Unlike ECT, the rTMS procedure produces no seizures, memory loss, or other serious side effects. (Headaches can result.) Initial studies have found “modest” positive beneﬁ ts of rTMS (Daskalakis et al., 2008; FYI George et al., 2010; López-Ibor et al., 2008). How it works is unclear. One possible explanation is that the stimulation energizes the brain’s left frontal lobe, which is relatively inactive A meta-analysis of 17 clinical experiments found that one during depression (Helmuth, 2001). Repeated stimulation may cause nerve cells to form other stimulation procedure new functioning circuits through the process of long-term potentiation. (See Module 32 for alleviates depression: massage more details on long-term potentiation.) therapy (Hou et al., 2010).

Wire coil Maximum Figure 73.3 TEACH field depth Magnets for the mind Repetitive transcranial magnetic stimulation Common Pitfalls (rTMS) sends a painless magnetic field Pulsed through the skull to the surface of the magnetic It may seem to students that repeti- field cortex. Pulses can be used to stimulate or dampen activity in various cortical tive transcranial magnetic stimulation areas. (From George, 2003.) (rTMS) is one of those “debunked” therapies mentioned earlier in the Positioning Activated frame neurons Magnetic text. Little research shows that mag- field nets improve health in other areas. However, rTMS and ECT appear to work in a similar fashion: They both stimulate electrical activity in the

Resting brain. Since all neural communication neurons is electrical, it is logical to assume that the forces aﬀ ecting electrical currents,

jaroon/iStockphoto such as magnets, could also work on the brain. DEEP-BRAIN STIMULATION Other patients whose depression has resisted both drugs that ﬂ ood the body and ECT that jolts at least half the brain have beneﬁ ted from an experimental treatment pinpointed at a depression center in the brain. Neuroscientist Helen Mayberg and her colleagues (2005, 2006, 2007, 2009) have been focusing on a neural hub that bridges the thinking frontal lobes to the limbic system. This area, which is overactive in the brain of a depressed or temporarily sad person, calms when treated by ECT or antidepressants. To experimentally excite neurons that inhibit this negative emotion-feeding activity, Mayberg drew upon the deep-brain stimulation technology sometimes used to treat Parkinson’s tremors. Among an initial 20 patients receiving implanted electrodes and a pacemaker stimulator, 12 experienced relief, which was sustained over three to six years of follow-up (Kennedy et al., 2011).

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A depression switch? ENGAGE By comparing the brains of patients with and without depression,

researcher Helen Mayberg identified © Erik S. Lesser Enrichment a brain area that appears active in people who are depressed or sad, Lobotomies would have died out and whose activity may be calmed much more quickly as a therapeutic by deep-brain stimulation. treatment had it not been for Walter psychosurgery surgery that Freeman, an American physician. removes or destroys brain tissue in Freeman and James Watts developed an effort to change behavior. lobotomy a psychosurgical the Freeman–Watts Standard Proce- procedure once used to calm dure that established the guidelines uncontrollably emotional or violent patients. The procedure cut the for the surgery. Freeman grew weary nerves connecting the frontal lobes Some felt suddenly more aware and became more talkative and engaged; others improved to the emotion - controlling centers only slightly if at all. Future research will explore whether Mayberg has discovered a switch of the length and messiness of the of the inner brain. that can lift depression. Other researchers are following up on reports that deep-brain stim- Moniz-style operation, so he devel- ulation can offer relief to people with obsessive-compulsive disorder (Rabins et al., 2009). oped the “ice pick lobotomy.” In this gruesome procedure, Freeman would Psychosurgery

insert a traditional ice pick into the Because its effects are irreversible, psychosurgery—surgery that removes or destroys eye sockets of anesthetized patients brain tissue—is the most drastic and the least- used biomedical intervention for chang- and, with a small mallet, tap the pick ing behavior. In the 1930s, Portuguese physician Egas Moniz developed what became the best - known psychosurgical operation: the lobotomy. Moniz found that cutting the New York Times Co./Getty Images Times New York through the bone into the prefrontal nerves connecting the frontal lobes with the emotion - controlling centers of the inner cortex. He would then swipe the pick brain calmed uncontrollably emotional and violent patients. In what would later be- back and forth to sever the connec- come a crude but easy and inexpensive procedure that took only about 10 minutes, a neurosurgeon would shock the patient into a coma, hammer an icepick-like instrument tions to the prefrontal cortex. Freeman through each eye socket into the brain, and then wiggle it to sever connections running would have his interns time him as up to the frontal lobes. Between 1936 and 1954, tens of thousands of severely disturbed people were “lobotomized” (Valenstein, 1986). he performed operations. Other neu- Although the intention was simply to disconnect emotion from thought, a loboto- rosurgeons watching the procedure my’s effect was often more drastic: It usually decreased the person’s misery or tension, would faint at the sight. Even Watts but also produced a permanently lethargic, immature, uncreative person. During the 1950s, after some 35,000 people had been lobotomized in the United States alone, broke his ties with Freeman over this calming drugs became available and psychosurgery was largely abandoned. Today, lo- procedure. botomies are history. But more precise, microscale psychosurgery is sometimes used in Failed lobotomy This 1940 photo extreme cases. For example, if a patient suffers uncontrollable seizures, surgeons can deacti- shows Rosemary Kennedy (center) vate the specifi c nerve clusters that cause or transmit the convulsions. MRI-guided precision ENGAGE at age 22 with brother (and future surgery is also occasionally done to cut the circuits involved in severe obsessive - compulsive U.S. president) John and sister Jean. A year later her father, on medical disorder (Carey, 2009, 2011; Sachdev & Sachdev, 1997). Because these procedures are irre- Enrichment advice, approved a lobotomy that was versible, they are controversial and neurosurgeons perform them only as a last resort. promised to control her reportedly Today, psychosurgery is much more violent mood swings. The procedure left her confined to a hospital with an Therapeutic Lifestyle Change precise and targeted than the loboto- infantile mentality until her death in 2005 at age 86. mies of old. Our greater understand- 73-373-3 How, by taking care of themselves with a healthy lifestyle, might ing of brain anatomy and function people fi nd some relief from depression, and how does this refl ect our being biopsychosocial systems? allows surgeons to pinpoint areas of The effectiveness of the biomedical therapies reminds us of a fundamental lesson: We fi nd trouble rather than remove or damage it convenient to talk of separate psychological and biological infl uences, but everything psy- whole sections of the brain. Patients chological is also biological (FIGURE 73.4). Every thought and feeling depends on the are typically awake during brain surgery so doctors can stimulate the areas in and around the trouble site to

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functioning brain. Every creative idea, every moment of joy or anger, every period of depres- TEACH sion emerges from the electrochemical activity of the living brain. The inﬂ uence is two - way: Mind When psychotherapy relieves obsessive- compulsive behavior, PET scans reveal a calmer brain (Schwartz et al., 1996). Concept Connections Anxiety disorders, obsessive-compulsive disorder, posttraumatic stress disorder, Remind students how the lifestyle major depression, bipolar disorder, and schizophrenia are all biological events. As we Body changes suggested here are discussed have seen over and again, a human being is an integrated biopsychosocial system. For years, we have considered the health of our bodies and minds separately. That neat separation in other units: Figure 73.4 no longer seems valid. Stress affects body chemistry and health. And chemical imbal- Aerobic exercise is discussed as ances, whatever their cause, can produce schizophrenia, depression, and other mental Mind -body interaction The disorders. biomedical therapies assume that producing health benefits in mind and body are a unit: Affect one That lesson is being applied by Stephen Ilardi (2009) in training seminars promoting and you will affect the other. Unit VIII. therapeutic lifestyle change. Human brains and bodies were designed for physical activity and social engagement, they note. Our ancestors hunted, gathered, and built in groups, with Adequate sleep is mentioned little evidence of disabling depression. Indeed, those whose way of life entails strenuous several times as important to good physical activity, strong community ties, sunlight exposure, and plenty of sleep (think of foraging bands in Papua New Guinea, or Amish farming communities in North America) health, cognition, and behavior; it rarely experience depression. For both children and adults, is discussed in detail in Unit V. outdoor activity in natural environments—perhaps a walk in the woods—reduces stress and promotes health (NEEF, Light exposure is discussed earlier

2011; Phillips, 2011). “Simply put: humans were never sturti/Getty Images in this unit. designed for the sedentary, disengaged, socially isolated, poorly nourished, sleep-deprived pace of twenty-fi rst- Social connection is discussed century American life.” extensively in Unit VIII (the need to The Ilardi team was also impressed by research show- belong) and Unit XIV. ing that regular aerobic exercise and a complete night’s sleep boost mood and energy. So they invited small groups of people with depression to undergo a 12-week training TEACH program with the following goals: • Aerobic exercise, 30 minutes a day, at least 3 times Concept Connections weekly (increasing fi tness and vitality, stimulating A focus on mental health rather than endorphins) mental illness is a hallmark of positive • Adequate sleep, with a goal of 7 to 8 hours a night (increasing energy and alertness, Healthier lifestyles Researchers boosting immunity) suggest that therapeutic lifestyle psychology, a movement to study change can be an effective antidote for • Light exposure, at least 30 minutes each morning with a light box (amplifying arousal, people with depression.The changes optimal functioning and bring a bal- infl uencing hormones) include managing sleep time, spending more time outdoors (or with a light anced perspective to psychology. • Social connection, with less alone time and at least two meaningful social engagements box), getting more exercise, and weekly (satisfying the human need to belong) developing more social connections. • Antirumination, by identifying and redirecting negative thoughts (enhancing positive thinking) • Nutritional supplements, including a daily fi sh oil supplement with omega-3 fatty acids (supporting healthy brain functioning) In one study of 74 people, 77 percent of those who completed the program experienced relief from depressive symptoms, compared with 19 percent in those assigned to a treatment-as-usual control condition. Future research will seek to replicate this striking result of lifestyle change, and also to identify which of the treatment components (additively or in some combination) produce the therapeutic effect. In the meantime, there seems little reason to doubt the truth of the Latin adage, Mens sana in corpore sano: “A healthy mind in a healthy body.” TABLE 73.1 on the next page summarizes some aspects of the biomedical therapies we’ve discussed.

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CLOSE & ASSESS Table 73.1 Comparing Biomedical Therapies Therapy Presumed Problem Therapy Aim Therapy Technique Exit Assessment Drug therapies Neurotransmitter malfunction Control symptoms of Alter brain chemistry through drugs. Have students write the deﬁ nition of psychological disorders. the treatments in this module. Be sure Brain Severe, “treatment-resistant” Alleviate depression that is Stimulate brain through to have them include the disorders for stimulation depression unresponsive to drug therapy. electroconvulsive shock, magnetic impulses, or deep-brain stimulation. which each medication or treatment is Psychosurgery Brain malfunction Relieve severe disorders. Remove or destroy brain tissue. commonly prescribed. Therapeutic Stress and unhealthy lifestyle Restore healthy biological state. Alter lifestyle through adequate lifestyle change exercise, sleep, and other changes.

Before You Move On c ASK YOURSELF If a troubled friend asked, how would you summarize the available biomedical therapies? c TEST YOURSELF How do researchers evaluate the effectiveness of particular drug therapies? Answers to the Test Yourself questions can be found in Appendix E at the end of the book.

Module 73 Review

73-173-1 What are the drug therapies? How do double-blind studies help researchers evaluate a drug’s effectiveness?

• Psychopharmacology, the study of drug effects on mind and • Antidepressant drugs, which increase the availability of behavior, has helped make drug therapy the most widely serotonin and norepinephrine, are used for depression, used biomedical therapy. with modest effectiveness beyond that of placebo drugs. The antidepressants known as selective serotonin Antipsychotic drugs, used in treating schizophrenia, block • reuptake inhibitors (SSRIs) are now used to treat other dopamine activity. Side effects may include tardive disorders, including strokes, anxiety disorders, obsessive- dyskinesia (with involuntary movements of facial muscles, compulsive disorder, and posttraumatic stress disorder. tongue, and limbs) or increased risk of obesity and diabetes. • Lithium and Depakote are mood stabilizers prescribed for those with bipolar disorder. • Antianxiety drugs, which depress central nervous system activity, are used to treat anxiety disorders, obsessive- • Studies may use a double-blind procedure to avoid the compulsive disorder, and posttraumatic stress disorder. placebo effect and researchers’ bias. These drugs can be physically and psychologically addictive.

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How are brain stimulation and 73-273-2 73-373-3 How, by taking care of themselves with a psychosurgery used in treating specifi c healthy lifestyle, might people fi nd some disorders? relief from depression, and how does this refl ect our being biopsychosocial systems? • Electroconvulsive therapy (ECT), in which a brief electric current is sent through the brain of an anesthetized patient, • Depressed people who undergo a program of aerobic is an effective treatment for severely depressed people who exercise, adequate sleep, light exposure, social have not responded to other therapy. engagement, negative-thought reduction, and better nutrition often gain some relief. • Newer alternative treatments for depression include repetitive transcranial magnetic stimulation (rTMS) and, in • In our integrated biopsychosocial system, stress affects preliminary clinical experiments, deep-brain stimulation our body chemistry and health; chemical imbalances can that calms an overactive brain region linked with negative produce depression; and social support and other lifestyle emotions. changes can lead to relief of symptoms. • Psychosurgery removes or destroys brain tissue in hopes of modifying behavior. • Radical psychosurgical procedures such as the lobotomy were once popular, but neurosurgeons now rarely perform brain surgery to change behavior or moods. • Brain surgery is a last-resort treatment because its effects are irreversible. Multiple-Choice Questions Answers to Multiple-Choice 1. Which neurotransmitter is affected by antipsychotic 3. Which of the following was the purpose of lobotomies? Questions medications? a. To alleviate depression a. Epinephrine d. Acetylcholine b. To minimize delusions and hallucinations 1. b 3. e b. Dopamine e. Serotonin c. To “erase” troubling memories 2. d c. Norepinephrine d. To recover repressed memories e. To separate the reasoning centers of the brain from 2. Which of the following is most effectively treated with the emotional centers electroconvulsive therapy (ECT)? a. Psychosis d. Depression b. Schizophrenia e. Generalized anxiety c. Obsessive-compulsive disorder disorder

Practice FRQs Answer to Practice FRQ 2

1. Identify the category of drugs used to treat schizophrenia 2. Brieﬂ y describe four therapeutic lifestyle changes 1 point each (up to 4) for any of the and the category of drugs used to treat obsessive- advocated by Stephen Ilardi, and describe their beneﬁ ts. following: compulsive disorder. Then explain what each of these (4 points) two categories of drugs does inside the brain. Aerobic exercise: 30 minutes a day, 3 times weekly (increasing fitness, Answer stimulating endorphins). 2 points: Antipsychotic medications are the preferred drug treatment for schizophrenia. They work by blocking Adequate sleep: 7–8 hours a night dopamine receptors. (increasing energy and alertness, 2 points: Antidepressant medications are the preferred drug boosting immunity). treatment for obsessive-compulsive disorder. They work by blocking the reuptake of serotonin. Light exposure: at least 30 minutes each morning (amplifying arousal, influencing hormones). Social connection: at least 2 meaningful social engagements MyersAP_SE_2e_Mod73_B.indd 748 1/21/14 9:36 AM MyersAP_SE_2e_Mod73_B.indd 749 1/21/14 9:36 AM weekly (satisfying the need to belong). Anti-rumination: identifying and redirecting negative thoughts (enhancing positive thinking). Nutritional supplements: including omega-3 fatty acids (supporting healthy brain functioning).

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Key Terms and Concepts to Remember psychotherapy, p. 709 counterconditioning, p. 717 meta-analysis, p. 731 biomedical therapy, p. 709 exposure therapies, p. 717 evidence-based practice, p. 732 eclectic approach, p. 709 systematic desensitization, p. 717 therapeutic alliance, p. 735 psychoanalysis, p. 709 virtual reality exposure therapy, p. 718 resilience, p. 737 resistance, p. 710 aversive conditioning, p. 718 psychopharmacology, p. 740 interpretation, p. 710 token economy, p. 719 antipsychotic drugs, p. 741 transference, p. 710 cognitive therapy, p. 720 antianxiety drugs, p. 741 psychodynamic therapy, p. 710 rational-emotive behavior therapy antidepressant drugs, p. 741 insight therapies, p. 711 (REBT), p. 721 electroconvulsive therapy (ECT), p. 743 client - centered therapy, p. 712 cognitive - behavioral therapy (CBT), repetitive transcranial magnetic p. 723 active listening, p. 712 stimulation (rTMS), p. 745 group therapy, p. 723 unconditional positive regard, p. 712 psychosurgery, p. 746 family therapy, p. 724 behavior therapy, p. 716 lobotomy, p. 746 regression toward the mean, p. 730

Key Contributors to Remember Sigmund Freud, p. 709 Joseph Wolpe, p. 717 Albert Ellis, p. 721 Carl Rogers, p. 712 B. F. Skinner, p. 719 Aaron Beck, p. 721 Mary Cover Jones, p. 717

AP® Exam Practice Questions

Answers to Multiple-Choice Multiple-Choice Questions

Questions 1. In an effort to help a child overcome a fear of dogs, a 2. Which of the following is a similarity between therapist pairs a trigger stimulus (something associated humanistic and psychoanalytic therapies? 1. b with dogs) with a new stimulus that causes a response a. Both approaches focus on the present more than the 2. e that is incompatible with fear (for example, an appealing past. snack or toy). Which clinical orientation is this therapist b. Both approaches are more concerned with conscious using? than unconscious feelings. a. Psychodynamic c. Both approaches focus on taking immediate b. Behavioral responsibility for one’s feelings. c. Biomedical d. Both approaches focus on growth instead of curing d. Client-centered illness. e. Humanistic e. Both approaches are generally considered insight therapies.

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750 Unit XIII Treatment of Abnormal Behavior

MyersPsyAP_TE_2e_U13.indd 750 3/3/14 8:46 AM Review Unit XIII 751

3. A psychotherapist who uses a blend of therapies is 9. In which kind of therapy would the therapist be most 3. a 7. a 11. c practicing what kind of approach? likely to note the following during a session: “Blocks in a. Eclectic the fl ow of free associations indicate resistance”? 4. d 8. c 12. c b. Psychodynamic a. Cognitive therapy 5. a 9. b 13. d c. Cognitive b. Psychoanalysis d. Cognitive-behavioral c. Client-centered therapy 6. c 10. e 14. a e. Humanistic d. Behavioral therapy 4. Some patients whose depression resists drugs have e. Person-centered therapy benefi ted from which experimental treatment? 10. Which kind of therapy below is most closely associated a. Transference with the goal of altering thoughts and actions? b. Meta-analysis a. Aversive conditioning c. Antipsychotic drugs b. Psychodynamic d. Deep-brain stimulation c. Client-centered e. Resistance d. Family 5. Which kind of drug is most closely associated with e. Cognitive-behavioral increasing the availability of norepinephrine or 11. Allowing people to discover, in a social context, that serotonin? others have problems similar to their own is a unique a. Antidepressant benefi t of what kind of therapy? b. Antipsychotic a. Psychodynamic c. Antianxiety b. Psychopharmacological d. Mood-stabilizing c. Group e. Muscle relaxant d. Cognitive 6. Which of the following is seen as an effective treatment e. Humanistic for severe depression that does not respond to drug 12. Which of the following therapeutic approaches is therapy? scientifi cally supported? a. Lobotomy a. Recovered-memory therapies b. Token economy b. Rebirthing therapies c. ECT c. Cognitive therapy d. Crisis debriefi ng d. Energy therapies e. EMDR therapy e. Crisis debriefi ng 7. Echoing, restating, and seeking clarifi cation of what a 13. Most antipsychotic drugs mimic a certain person expresses (verbally or nonverbally) in a therapy neurotransmitter by blocking its activity at the receptor session is called sites. These drugs affect which one of the following a. active listening. neurotransmitters? b. virtual reality exposure therapy. a. Adrenaline c. systematic desensitization. b. Epinephrine d. family therapy. c. Serotonin e. classical conditioning. d. Dopamine 8. In the context of psychoanalytic theory, experiencing e. Acetylcholine strong positive or negative feelings for your analyst is a 14. Which of the following is not recommended by therapists sign of what? as a way to help prevent or get over depression? a. Counterconditioning a. Recovered-memory therapies b. Meta-analysis b. Aerobic exercise Rubric for Free-Response c. Transference c. Light exposure d. Tardive dyskinesia d. Increased social connections Question 2 e. Aversive conditioning e. Antirumination strategies 1 point: The biomedical approach involves treating psychological disorders by prescribing medications or using procedures that act directly on the person’s physiology. p. 709 Mood-stabilizing drugs such as lithium can be used to treat bipolar MyersAP_SE_2e_Mod73_B.indd 750 1/21/14 9:36 AM MyersAP_SE_2e_Mod73_B.indd1 751point: Systematic desensitization involves The rationale for using systematic desensitiza-1/21/14 9:36 AM training the client in the process of progres- tion with phobias is that it is not possible for disorder, in order to prevent or reduce sive relaxation, and creating a hierarchy of individuals to be simultaneously anxious and manic episodes, protect neural health anxiety-triggering situations related to the relaxed. The act of repeatedly and purposefully by reducing vulnerability to cognitive fear that they are trying to eliminate. The client relaxing while being presented with anxiety- decline, and decrease suicide risk. works progressively through the situations on provoking stimuli can gradually help individuals p. 743 the hierarchy, starting with the situations that overcome the anxiety they experience when OR cause the least amount of anxiety and gradu- confronted with their phobia. p. 717 ally working up to the most threatening situa- The biomedical approach is the (Rubric continued on page 752.) tion, while simultaneously utilizing progressive most eff ective treatment for bipolar relaxation techniques. p. 717 disorder because the symptoms of this disorder are a result of problems created by neurotransmitter imbalances, which may be corrected with medications. pp. 741–743

Review Module XIII 751

MyersPsyAP_TE_2e_U13.indd 751 3/3/14 8:46 AM 752 Unit XIII Treatment of Abnormal Behavior

15. d 15. A psychotherapist states, “Getting people to change what they say to themselves is an effective way to 1 point: Group therapy involves treating change their thinking.” This statement best exemplifi es individuals by meeting with them at the which kind of therapeutic approach? same time as several other individuals a. Behavioral b. Psychodynamic who are also in treatment for the same c. Biomedical condition. pp. 723–724 d. Cognitive e. Active listening The rationale for using the group therapy approach to treat individuals who Free-Response Questions have addictions is that it can reduce 1. Your friend Lawrence recently confi ded in you that 2. For each of the following pairs, fi rst defi ne the particular the cost of therapy, allow participants he has been diagnosed with major depression. He type of treatment referenced, then explain the rationale to benefi t from interactions with oth- heard about several different kinds of treatments: for using this therapy to treat an individual with the psychodynamic therapy, exposure therapy, REBT, SSRIs, particular disorder with which it is paired. ers, off er an opportunity to practice and rTMS. Explain what you would tell Lawrence about • Bipolar disorder and the biomedical approach new behaviors, and provide patients how each type of therapy works and whether research • Phobias and systematic desensitization with feedback from both the therapist indicates that it might be an effective treatment for major depression. • Dissociative identity disorder and psychoanalysis and others who are going through the • Addiction and group therapy Rubric for Free-Response Question 1 same experiences. p. 723 • Depression and rational-emotive behavior therapy 1 point: Psychodynamic therapy involves a therapist and (REBT) 1 point: Rational-emotive behavior client attempting to gain perspective and insight into a cli- (5 points) ent’s unconscious confl icts and anxieties. Outcome research therapy (REBT) is a confrontational type 3. indicates that psychodynamic therapy has had success with Different therapies rely on different underlying of cognitive-behavioral therapy created depression symptoms. Pages 710–711 psychological perspectives about causes and explanations of thinking and behavior. List at least by Albert Ellis, which involves having 1 point: Exposure therapy exposes people to the things that one specifi c therapeutic technique for each of the they fear and avoid in order to reduce the fear or anxiety. This the therapist challenge the illogical, psychological approaches below and explain how that type of therapy is specifi cally focused on reducing specifi c technique uses that psychological approach. self-defeating, or irrational attitudes and anxiety symptoms and is not designed to treat depression. thoughts that are causing mental illness Pages 717–718 • Biological and replace them with cognitions that 1 point: Albert Ellis’ rational-emotive behavior therapy • Cognitive (REBT), a type of cognitive therapy, attempts to stop irratio- • Behavioral are rational and adaptive. p. 721 nal thinking by challenging a person’s illogical, self-defeating (3 points) assumptions. Since many of the symptoms of major depres- The rationale for using rational- sion involve negative, pessimistic thinking, this treatment is emotive behavior therapy to treat worth exploring as a treatment for depression. Page 721 individuals with depression is that 1 point: SSRIs, such as Zoloft, Paxil, and Prozac, work by partially blocking the reabsorption and removal of serotonin individuals experience depression from synapses. The fact that more serotonin remains in the because of their irrational thought synapses serves to reduce the symptoms of depression. processes. As a result, if the therapist Pages 741–743 1 point: can help patients realize how absurd Repetitive transcranial magnetic stimulation (rTMS) sends repeated pulses of magnetic energy into the brain, and self-defeating their cognitions usually into the left frontal lobe. This approach has proven actually are, they may be able to effective in the treatment of depression. Page 745

change these thoughts to ones that Multiple-choice self-tests and more may be found at are rational and allow for healthier www.worthpublishers.com/MyersAP2e behaviors and choices. p. 721

Rubric for Free-Response Question 3 1MyersAP_SE_2e_Mod73_B.indd point: For the cognitive 752 perspective, students 1 point: For the behavioral perspective, stu- 1/21/14 9:36 AM 1 point: For the biological perspective, can list any of the following therapies: rational- dents can list any of the following therapies: students can list any of the biomedi- emotive behavior therapy (REBT), Aaron Beck’s counterconditioning, exposure therapies, cal therapies: psychopharmacology depression therapy, cognitive-behavioral aversive conditioning, systematic desen- (drug therapies involving antidepres- therapy (CBT), group therapy, family therapy, sitization, virtual reality exposure therapy, sant, antianxiety, or antipsychotic or self-help groups. These therapies rely on behavior modiﬁ cation, or token economy. drugs), electroconvulsive therapy exploring how clients interpret and remember These therapies rely on clients modifying their (ECT), repetitive transcranial magnetic information and interactions, and modify- behavior through either pairings of stimuli and stimulation (rTMS), deep-brain stimu- ing any that are harmful (self-destructive, responses (classical conditioning) or reinforce- lation, psychosurgery (lobotomy), or self-defeating, and so on), which will result in ments/punishments (operant conditioning). therapeutic lifestyle change. These behavior changes. pp. 721–725 pp. 717–720 treatments all rely on changing brain chemistry as a way to inﬂ uence the behaviors associated with psychological disorders. pp. 740–748

752 Unit XIII Treatment of Abnormal Behavior

MyersPsyAP_TE_2e_U13.indd 752 3/3/14 8:46 AM