PSYCHOLOGICAL

TREATMENT
16.1 Describe who seeks psychological
treatment and what the most common
goals are

Explain how the success of

16.2
psychological treatment is measured.

16.3 Describe some of the factors that must be

considered to provide optimal treatment.

16.4 List the psychological approaches most

often used to treat abnormal behavior.

16.5 Explain the roles that social values and

culture play in psychological treatment.

16.5 Describe three biological approaches used

to treat abnormal behavior.
Introduction

Psychological treatment is designed to

promote new understandings, behaviors, or
both on the client's part. The fact that these
interventions are deliberately planned and
systematically guided by certain theoretical
preconceptions is what distinguishes
professional psychological treatment from
more informal helping relationships.
The belief that people with psychological problems Overview
can change—can learn more adaptive ways of
perceiving, evaluating, and behaving—is the conviction
underlying all psychotherapy or psychological
treatment.

Achieving these changes is by no means easy. Nevertheless,

it holds promise even for the most severe mental disorders.

Psychotherapeutic interventions have been applied to a wide

variety of chronic problems. Even severely disturbed clients
with psychosis may profit from a therapeutic relationship
that takes into account their level of functioning and
maintains therapeutic sub goals that are within their
capabilities.
 Overview
Moreover, contrary to common opinion, psychotherapy can
be less expensive in the long run than alternative modes of
intervention.

Numerous therapeutic approaches have been tried

throughout history (some of them cruel and unusual in
hindsight), and many exist today.

However, the era of managed care has prompted new and

increasingly stringent demands that the efficacy of
treatments be empirically demonstrated.
 PSYCHOLOGICAL DISORDERS
AND STRESSFUL LIFE
CIRCUMSTANCES

Perhaps the most obvious candidates for

psychological treatment are people
experiencing one of the psychological
disorders described in this book.

However, most people who receive treatment

do not meet the full criteria for a
psychological disorder (WHO World Mental
Health Survey Consortium, 2004).

WHY DO PEOPLE SEEK Many people seek therapy due to sudden and
THERAPY? highly stressful situations such as a divorce or
unemployment— situations that can lead

people to feel so overwhelmed by a crisis that

People who seek therapy vary widely in their problems and in their
they cannot manage on their own.
motivations to solve them. Below we explore a few such motivations.
 1
Some people enter therapy by an indirect route.
Motivation to enter treatment differs widely among
psychotherapy clients.In general, males are more

RELUCTANT reluctant to seek help when they are experiencing

problems than females.

CLIENTS

2
In the case of depression, far more men than
women say that they would never consider seeing
a therapist; when men are depressed they are even
reluctant to seek informal help from their friends.
 3
In addition, men who subscribe to masculine
stereotypes emphasizing self-reliance and lack of
emotionality also tend to experience more gender-

RELUCTANT role conflict when they consider traditional

counseling, with its focus on emotions and

CLIENTS
emotional disclosure.

4
For a man who prides himself on being
emotionally stoic, seeking help for a problem like
depression may present a major threat to his self-
esteem.
 WHO PROVIDES
PSYCHOTHERAPEUTIC
SERVICES?

PHYSICIANS

Members of many different professions

have traditionally provided advice and
counsel to individuals in emotional
distress. Physicians, in addition to caring
for their patients’ physical problems.
Many physicians are trained to recognize
psychological problems that are beyond
their expertise and to refer patients to
psychological specialists or psychiatrists.
 CLERGY

Another professional group that deals

extensively with emotional problems is the
clergy. A minister, priest, or rabbi is
frequently the first professional to
encounter a person experiencing an
emotional crisis. Like general-practice
physicians, they are trained to recognize
problems that require professional
management and to refer seriously
disturbed people to mental health
specialists.
 PSYCHOLOGISTS

Psychologists, psychologists, and social

workers are the three types of mental
health professionals who most commonly
administer psychological treatment in
mental health settings.
 THERAPEUTIC Effective psychotherapy
RELATIONSHIP includes:

Assess the client’s situation more objectively

A sense of working Besides helping provide a new perspective

1 collaboratively on the problem

Offer a client a safe setting in which he or she is

Agreement between patient and encouraged to practice new ways of feeling and acting
2 therapist about the goals and tasks of

therapy
The therapist must be flexible enough to use
An effective bond between a variety of interactive styles
3 patient and therapist

 Psychologists and, of course,

consumers of psychological
treatment have a strong interest in

Measuring
measuring whether treatment is
successful or not. Unfortunately,

Success In
evaluating treatment success is not
always as easy as it might seem.

Psychotherapy
Objectifying & A client’s reports of change in their symptoms
or functioning

Quantifying
Change
A clinician’s ratings of changes that have
occurred

Reports from the client’s family or friends

Comparison of pretreatment and posttreatment

scores on instruments designed to measure
relevant facets of psychological functioning

Measures of change in selected overt behaviors.

Each of these sources has strengths, but also
some important limitations.
 CLIENT
Strongly Disagree Strongly Agree
20% 20%

RATINGS
Disagree Agree
20% 20%

Neutral
20%

Psychologists are increasingly using self-report

measures to measure the effectiveness of therapy,
there is an emphasis on using client ratings on
quantitative measures to determine how much
change has occurred. For example, the Beck
Depression Inventory (BDI) - but a person's self-
reports are not always a reliable source.
Unfortunately, a client is not necessarily a reliable
source of information on therapeutic outcomes. Not
only do clients want to believe for various personal
reasons that they are getting better, but they may
also want to please their therapists by reporting that
they have made progress.
 CLINICIAN
Strongly Disagree Strongly Agree
20% 20%

RATINGS
Disagree Agree
20% 20%

Neutral
20%

The effectiveness of therapy also is

often evaluated by the treating clinician.
For instance, The Hamilton Rating Scale
for Depression is a rating scale used by
clinicians to measure the severity of a
patient's depression.
Although the clinician may be more objective
than the patient, clinicians also may not be the
best judge of clients' progress because they
may be biased in favor of seeing themselves as
competent and successful. Clinicians can inflate
improvement averages by deliberately or subtly
encouraging difficult clients to discontinue
therapy.
 THIRD-PARTY
Strongly Disagree Strongly Agree
20% 20%

RATINGS
Disagree Agree
20% 20%

Client change also can be evaluated by Neutral

third-party raters, meaning people not 20%

involved in the treatment. This may

include family members or trained
independent evaluators. The latter are
people trained to conduct clinical
interviews and to rate the amount of
clinical change that has occurred in a
patient.
Relatives of the client may be inclined to "see"
the improvement they had hoped for, although
they often seem to be more realistic than either
the therapist or the client. Independent
evaluators who are blind to the condition are
used frequently in rigorous accommodations of
treatment effectiveness.

OBJECTIVE
MEASURES
Another widely used objective measure of client change
is performed on various psychological tests. A client
evaluated in this way takes a battery of tests before
and after therapy, and the differences in scores are
assumed to reflect progress, lack of progress, or
occasionally even deterioration.
In research settings, functional magnetic
resonance imaging (fMRI) can be used to
examine brain activity before and after
treatment. Some of the changes that
such tests show may be artefactual, as
with regression to the mean. Without
follow-up assessment, they provide little
information on how enduring any change
is likely to be.
For example, Nakao and colleagues
(2005) studied 10 outpatients with
obsessive-compulsive disorder (OCD).
Patients have treated for 12 weeks with
the SSRI (selective serotonin reuptake
inhibitor) fluvoxamine (Luvox) or with
behavior therapy. The results showed
that, after 12 weeks of behavior therapy,
patients with OCD again show changes
in several brain regions that are
implicated in this condition.

OVERT
BEHAVIORS

Perhaps the most direct way to know if someone has

improved in treatment is to observe their behavior directly.
For instance, if someone is being treated for a bug phobia,
the clinician can observe the client’s ability to approach and
hold bugs of different sizes before, during, and after
treatment to see if the individual’s behavior has changed. The
advantage of behavioral observation is that it is objective,
difficult to “fake,” and often reflective of precisely the change
that is intended in treatment. The downside is that it may be
less appropriate for problems that are less easily observed
(e.g., suicidal thoughts).
Would Change Occur
Anyway?
What happens to disturbed people who do not
obtain formal treatment? In view of the many
ways in which people can help each other, it is
not surprising that improvement often occurs
without professional intervention. Moreover,
some forms of psychopathology, such as
depressive episodes or brief psychotic disorders,
sometimes run a fairly short course with or
without treatment. In other instances, disturbed
people improve over time for reasons that are
not apparent.

Research suggests that about 50 percent of

patients show clinically significant change after
21 therapy sessions. After 40 sessions, about 75
percent of patients have improved.
Can Therapy Be Harmful?
The outcomes of psychotherapy are not
invariably either neutral (no effect) or
positive. Some clients are harmed by their
encounters with psychotherapists. It has
been estimated that between 5 and 10
percent of clients deteriorate during
treatment. Unfortunately, clinicians are often
quite bad at recognizing when their clients
are not doing well.
A special case of therapeutic harm concerns what
are called boundary violations. This is when the
therapist behaves in ways that exploit the trust of
the patient or engages in behavior that is highly
inappropriate (e.g., taking the patient to dinner, or
giving the patient gifts). E.g. one case involved a
patient who had been treated by a psychiatrist for
10 years. During this time the patient gave the
therapist gifts of a refrigerator and a dining table
and six chairs. The psychiatrist also sold the
patient two of his boats, without her even having
seen them.
A sexual relationship between a patient and the
therapist is a serious boundary violation. This is
highly unethical conduct. When exploitive and
unprofessional behavior occurs, it results in great
harm to patients. Anyone seeking therapy needs
to be sufficiently aware that the therapist she or
he chooses is committed to high ethical and
professional standards.
WHAT
THERAPEUTIC
APPROACHES
MUST BE
USED?
Evidence-Based Treatment:
When a pharmaceutical company develops a new drug, it must obtain
approval of the drug from the U.S. Food and Drug Administration (FDA)
before that drug can be marketed.

These tests, using voluntary and informed patients as subjects, are

called randomized clinical trials (RCTs) or, more simply, efficacy
trials.

If subjects on the active drug have improved in health significantly

more than subjects on the placebo, the investigator has evidence of
the drug's efficacy.

Obviously, the same design could be modified to compare the

efficacy of two or more active drugs, with the option of adding a
placebo condition.
Evidence-Based Treatment:
Thousands of such studies are in progress daily across the country.

They usually take place in academic medical settings, and many are
financially supported by the pharmaceutical industry.

Most such research has thus adopted the strategy of either

comparing two or more purportedly "active" therapies or using a no-
treatment ("wait for list") control of the same duration as the active-
drug treatment.

Another problem is that therapists, even those with the same

theoretical orientations, often differ markedly in the manner in
which they deliver therapy.
Evidence-Based Treatment:

Efforts to "manualize" therapy represent one way that researchers

have tried to minimize the variability in patients' clinical outcomes
that might result from characteristics of the therapist themselves
(such as personal charisma).

Efficacy, or RCT, studies of psychosocial treatments are

increasingly common.

These time-limited studies typically focus on patients who have a single

DSM diagnosis (patients with comorbid diagnoses are sometimes
excluded) and involve two or more treatment or control (e.g., wait list)
conditions, where at least one of the treatment conditions is psychosocial
(another could be some biological therapy, such as a particular drug).
Advances in psychopharmacology—the use
of medications to treat mental disorders—

Medication or
have allowed many people who would
otherwise need hospitalization to remain
with their families and function in the
community.
Psychotherapy?
These advances have also reduced the
time patients need to spend in the
hospital and have made restraints and
locked wards largely relics of the past.

In short, medication has led to a much

more favorable hospital climate for
patients and staff alike.
Nevertheless, certain issues arise in the
use of psychotropic drugs. Aside from

Medication or
possible unwanted side effects, there is the
complexity of matching drugs and dosage

Psychotherapy?
to the needs of each specific patient.

It is also sometimes necessary for patients

to change medication during the course of
treatment.

The use of medications in isolation from

other treatment methods may not be ideal
for some disorders because drugs
themselves generally do not cure
disorders.
 There is now a national trend toward greater

Medication or
use of psychiatric medications at the
expense of psychotherapy.

Psychotherapy?
This may be problematic because, as many
investigators have pointed out, drugs tend to
alleviate symptoms by inducing biochemical
changes, not by helping the individual understand
and change the personal or situational factors
that may be creating or reinforcing maladaptive
behaviors.

Moreover, when drugs are discontinued, patients

may be at risk of relapsing. For many disorders, a
variety of evidence-based forms of psychotherapy
may produce more long-lasting benefits than
medications alone unless the medications are
continued indefinitely.
 01

Combined
The integration of medication and
psychotherapy remains common in clinical
practice, particularly for disorders such as

Treatments
schizophrenia and bipolar disorder.

02
Such integrated approaches are also
appreciated and regarded as essential by the
patients themselves.

03
The integrative approach is a good example
of the biopsychosocial perspective that best
describes current thinking about mental
disorders and that is reflected throughout
this book.
 41
Medications can be combined with a

Combined
broad range of psychological
approaches.

Treatments 05
In some cases, they can help patients
benefit more fully from
psychotherapy.

06
Typically, psychosocial interventions
are combined with psychiatric
medications.
 07
This may be especially beneficial for

Combined
patients with severe disorders.

08
Treatments In the psychotherapy-alone condition, 52 percent
of patients responded to treatment. However,
patients for whom the two treatments were
combined did even better, with an overall positive
response rate of 85 percent.

09
Quite possibly, combined treatment is
effective because medications and
psychotherapy may target different
symptoms and work at different rates.
PSYCHOSOCIAL
APPROACHES TO
TREATMENT
 BEHAVIOR THERAPY
Exposure Therapy
·During exposure therapy, the
patient or client is confronted
with the fear-producing stimulus
in a therapeutic manner.
·a behavior therapy technique
that is widely used in the
treatment of anxiety disorders is
exposure. If anxiety is learned,
then, from the behavior therapy
perspective, it can be unlearned.
·Exposure therapy embodies the
'face your fears' maxim and
involves encouraging clients to
repeatedly face an object or
situation which causes them
anxiety.
Aversion Therapy
·It involves modifying undesirable
behavior with the old-fashioned
method of punishment.
·For example, drugs that have
noxious effects, such as
Antabuse, induce nausea and
vomiting when a person who has
taken it ingests alcohol.
·aversive conditioning has been
used to treat a wide range of
maladaptive behaviors including
smoking, drinking, overeating,
drug dependence, gambling,
sexual deviance, and bizarre
psychotic behavior.

 BEHAVIOR THERAPY
Modeling
·This technique involves learning
through observation and
modeling the behavior of others.
·It allows individuals to learn new
skills or acceptable behaviors by
watching someone else perform
those desired skills.
Systematic-Reinforcement
(Contingency management)
This approach uses a formal written
contract between a client and a
therapist that outlines behavior-
change goals, reinforcements,
rewards, and penalties.
Token Economies
·Based on the principle of operant
conditioning.
·This strategy relies on reinforcement
to modify behavior.
·This technique was used for patients
experiencing long-term stays in
psychiatric hospitals. When they
behaved appropriately in the hospital
ward, patients earned tokens that they
could later use to receive rewards or
privileges.
 Cognitive and Cognitive
Behavior Therapy

Rational Emotive Beck’s Cognitive

Behavior Therapy Therapy

·REBT attempts to change a client’s ·This focuses on the distortions and

maladaptive thought processes, on thought processes that can lead to
which maladaptive emotional negative behaviors.
responses and, thus, behavior are ·Beck's cognitive theory considers
presumed to depend.
the subjective symptoms such as a
·The task of REBT is to restructure an
negative view of self, world, and
individual’s belief system and self-
future defining features of
evaluation that are preventing the
individual from having a more
depression.
positive sense of self-worth and an
emotionally satisfying, fulfilling life.
 HUMANISTIC–EXPERIENTIAL
THERAPY
Client-Centered Motivational
Therapy Interviewing

It focuses on the natural power

It is a method that helps people
of the organism to heal itself.
resolve ambivalent feelings and
The main goal of Person-
insecurities to find the internal
Centered Therapy is to increase
motivation they need to change
self-acceptance and self-
their behavior.
esteem. Personal growth and
it employs a more direct
self-expression. Minimize
approach that explores the
negative feelings (such as
client’s own reasons for wanting
defensiveness, regret, guilt, and
to change.
insecurity) and better
Motivational interviewing is
understanding and trust in
most often used in the areas of
oneself.
substance abuse and addiction.
 HUMANISTIC–EXPERIENTIAL
THERAPY

Gestalt Therapy

It is centered on increasing
a person's awareness,
freedom, and self-direction.
It focuses on a person's
present life rather than
delving into their past
experiences.
PSYCHODYNAMIC
THERAPY

·Psychodynamic therapy is a broad treatment approach that

focuses on individual personality dynamics, usually from a
psychoanalytic or some psychoanalytically derived
perspective.
·Psychoanalytic therapy is the oldest form of psychological
therapy and began with Sigmund Freud.
 PSYCHODYNAMIC
THERAPY
The therapy is mainly practiced in two basic forms:
Ø classical psychoanalysis
Ø psychodynamically oriented psychotherapy
classical psychoanalysis is an intensive (at least three
sessions per week), long-term procedure for uncovering
repressed memories, thoughts, fears, and conflicts
presumably stemming from problems in early psychosexual
development—and helping individuals come to terms with
them in light of the realities of adult life.
 FREUDIAN
PSYCHOANALYSIS

I.free association
II.analysis of dreams,
III.analysis of resistance,
IV.analysis of transference.

COUPLE AND
FAMILY
THERAPY
 Traditional behavioral couple therapy
(TBCT)

COUPLES
TBCT is based on a social-learning model and views
marital satisfaction and marital distress in terms of
reinforcement.

THERAPY
The goal of TBCT is to increase caring behaviors in
the relationship and to teach partners to resolve
their conflicts in a more constructive way through
training in communication skills and adaptive
problem-solving.
Couples therapy is a form of psychotherapy
that can help you and your partner improve
your relationship.
Integrative behavioral couple therapy
(IBCT)

IBCT focuses on acceptance and includes strategies

that help each member of the couple come to terms
with and accept some of the limitations of his or her
partner.
FAMILY
THERAPY
Family therapy is a type of psychotherapy that
can help family members improve
communication and resolve conflicts.

structural family therapy

Type of family therapy that looks at the structure
of a family unit and improves the interactions
between family members.
The goal of structural family therapy is changing
the organization of the family in such a way that
the family members will behave more supportively
and less pathogenically toward each other
 “Integrative” usually means that the therapy combines
different approaches and fuses them together.
ECLECTICISM AND Therapists are considered “eclectic” when they selectively

INTEGRATION apply techniques from a variety of approaches to best fit

your needs

There are many forms of psychotherapy that look pretty

similar today to how they looked decades ago.
REBOOTING there have been some exciting changes in recent years
regarding how psychological treatment is studied and
PSYCHOTHERAPY practiced.
Kazdin and Blaise have referred to these (and future) changes
as a “rebooting” of psychotherapy research and practice.
Social values And
Psychotherapy
·In a broader perspective, there is the complex and controversial
issue of the role of values in science.
· Psychotherapy is not, or at least should not be, a system of
ethics; it is a set of tools to be used at the discretion of a therapist
in pursuit of a client's welfare.
 Social values And
Psychotherapy

·Many psychologists and other

scientists try to sidestep this issue
by insisting that science is value free
—that it is concerned only with
gathering facts, not with how the
facts are applied. Or does the
therapist have a larger responsibility
values of the therapist, the
to look beyond individual pathology
and con- front the abnormality of the
marital relationship?
There are strong pressures
Therapy takes place in a
on a therapist—from
context that involves the
parents, schools, courts, and
other social institutions—to
client, and the society in
help people adjust to the
which they live.
world as it is.

PSYCHOTHERAPY
AND
CULTURAL DIVERSITY

The establishment and maintenance of an effective

psychotherapeutic "working alliance" between
client and therapist is generally regarded as a
crucial and indispensable element in determining
the success of the outcome

there is little or no solid evidence that psycho-therapeutic outcomes are diminished when the client and therapist
differ in race or ethnicity. However, members of minority groups are seriously underrepresented in treatment
research studies, and this makes it difficult to fully assess their needs and out-comes ·However, the factors that are
behind these disparities are complex and not well understood in general, minority patients tend to prefer ethnically
similar therapists over European American therapists.
PSYCHOTHERAPY
AND
CULTURAL DIVERSITY
·The lack of trained therapists familiar with the issues important
to different ethnic groups is a serious drawback, given the
unique problems often associated with certain groups.
When specialized, culturally adapted interventions are made
available in community settings, ethnic minority clients are less
likely to drop out of treatment and often do well
·However, such programs are still lacking in many communities.
· Also lacking are research investigations designed to
understand how culture and ethnicity affect a person's ability to
access and receive psychiatric and psychological treatments.
Biological
Approaches to
Treatment
Medications are important in the treatment of many
disorders. It is now common in clinical practice to
combine medication and psychological treatments.
 Antipsychotic Drugs
The most used antipsychotic medications are
the atypical neuroleptics. These improve both
positive and negative symptoms and have
fewer extrapyramidal symptoms (unwanted
side effect involving movement) than
conventional (first-generation) antipsychotics.
Anti-Anxiety Drugs
Antianxiety drugs are used for conditions in which tension
and anxiety are significant components. They do not
provide a cure. Antianxiety medications have little place in
the treatment of psychosis. However, they are often used
as supplementary treatments in certain neurological
disorders to control such symptoms as convulsive seizures.
Anxiolytic (antianxiety) medications work via their effect
on the GABA system. They are widely prescribed.
Lithium
Lithium is an important medication in the
treatment of mania. However, some of the
newer mood-stabilizing drugs (which are also
used to treat epilepsy) are now more frequently
prescribed.
Anti-Depressants Drugs
Some of the earlier antidepressant medications (e.g.,
tricyclics and MAOIs) have now been replaced by SSRIs and
SNRIs. Although more widely used, there is no compelling
evidence that these newer medications are more effective
than older antidepressants. In general, antidepressants
work through their influence on the serotonin and
norepinephrine neurotransmitter systems
 ELECTROCONVULSIVE THERAPY

although not frequently used, ECT is a safe and

effective treatment for depression and other
disorders. It causes some short-term cognitive side
effects, especially when administered bilaterally

NON-MEDICINAL TRANSCRANIAL MAGNETIC STIMULATION:

A newer, more targeted approach that uses electricity

BIOLOGICAL to change brain functioning is transcranial magnetic

stimulation (TMS). TMS is a treatment in which the
clinician positions a pulsed magnet over a carefully
selected area of the patient’s scalp and uses it to create

TREATMENT an electrical field that increases or decreases neuronal

activity in the brain

NEUROSURGERY
it is ironic that this procedure—which results in
permanent structural changes in the brain of the
patient and has been highly criticized by many within
the profession. Neurosurgery is used as a treatment
of last resort. Even when patients improve clinically,
they may have permanent, adverse side effects.
 our team
Maheen Noor Laiba Tariq Rimsha Aslam
Topic: 16.6 and made all slides Topic: 16.3 Topic: 16.4
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Aimen Mukhtar Fatma Gondal

Topic: 16.2 Topic: 16.5
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