Gateway THEME Psychotherapies are based on a common core of therapeutic principles. Medical therapies treat the physical causes of psychological disorders. In many cases, these approaches are complementary.

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Joe stared at some ducks through the blinds in his psychology professor’s office. They were quacking as they explored the campus pond. As psychologists, we meet many students with personal problems. Still, Joe’s teacher was surprised to see him at her office door. His excellent work in class and his healthy, casual appearance left her unprepared for his first words. “I feel like I’m losing my mind,” he said. “Can I talk to you?”

Over the next hour, Joe described his own personal hell. In a sense, he was like the ducks outside, appearing peaceful on the surface, but madly paddling underneath. He was working hard to hide a world of crippling fear, anxiety, and depression. At work, he was deathly afraid of talking to coworkers and cus- tomers. His social phobia led to frequent absenteeism and embarrassing behavior. At school, Joe felt “dif- ferent” and was sure that other students could tell he was “weird.” Several disastrous romances had left him terrified of women. Lately, he had been so depressed that he thought of suicide.

Joe’s request for help was a turning point. At a time when he was becoming his own worst enemy, Joe realized he needed help. In Joe’s case, that person was a talented clinical psychologist to whom his teacher referred him. With psychotherapy (and some temporary help from an antidepression medication), the psy- chologist was able to help Joe come to grips with his emotions and regain his balance.

This chapter discusses methods used to alleviate problems like Joe’s. We will begin with a look at the origins of modern therapy before describing therapies that emphasize the value of viewing personal prob- lems with insight and changing thought patterns. Then, we will focus on behavior therapies, which directly change troublesome actions. After that, we will explore medical therapies, which are based on psychiatric drugs and other physical treatments. We conclude with a look at some contemporary issues in therapy.

Gateway QUESTIONS 15.1 How did psychotherapy originate? 15.2 Is Freudian psychoanalysis still used? 15.3 How do psychotherapies differ? 15.4 What are the major humanistic therapies? 15.5 How does cognitive therapy change thoughts

and emotions? 15.6 What is behavior therapy? 15.7 What role do operant principles play in

behavior therapy?

15.8 How do psychiatrists treat psychological disorders?

15.9 Are various psychotherapies effective, and what do they have in common?

15.10 What will therapy be like in the future? 15.11 How are behavioral principles applied to

everyday problems and how could a person find professional help?



9781285519517, Introduction to Psychology: Gateways to Mind and Behavior with Concept Maps and Reviews, Thirteenth Edition, Coon/Mitterer – © Cengage Learning. All rights reserved. No distribution allowed without express authorization.

Chapter 15512

Origins of Therapy— Bored Out of Your Skull

Gateway Question 15.1: How did psychotherapy originate? Fortunately, the odds are that you will not experience problems as serious as those of Joe, the student we just met. But if you did, what help is available? In most cases, it would be some form of psycho- therapy, a psychological technique that can bring about positive changes in personality, behavior, or personal adjustment. It might, as with Joe, also include a medical therapy. Let’s begin with a brief history of mental health care, including a discussion of psychoanaly- sis, the first fully developed psychotherapy.

Early treatments for mental problems give good reasons to appreciate modern therapies (Sharf, 2012). Archaeological find- ings dating to the Stone Age suggest that most primitive approaches were marked by fear and superstitious belief in demons, witchcraft, and magic. If Joe were unlucky enough to have been born several thousand years ago, his “treatment” might have left him feeling “bored.” You see, one of the more dramatic “cures” practiced by primitive “therapists” was a process called trepanning (treh-PAN- ing), also sometimes spelled trephining (Terry, 2006). In modern usage, trepanning is any surgical procedure in which a hole is bored in the skull. In the hands of primitive therapists, it meant boring, chipping, or bashing holes in a patient’s head. Presumably, this was done to relieve pressure or release evil spirits (• Figure 15.1).

Joe would not have been much better off during the Middle Ages. Then, treatments for mental illness in Europe focused on demonology, the study of demons and persons plagued by spirits. Medieval “therapists” commonly blamed abnormal behavior on supernatural forces, such as possession by the devil, or on curses from witches and wizards. As a cure, they used exorcism to “cast out evil spirits.” For the fortunate, exorcism was a religious ritual. More often, physical torture was used to make the body an inhospitable place for the devil to reside.

One reason for the rise of demonology may lie in ergot- ism (AIR-got-ism), a psychotic-like condition caused by ergot poisoning. In the Middle Ages, rye (grain) fields were often infested with ergot fungus. Ergot, we now know, is a natural source of LSD and other mind-altering chemicals. Eating tainted bread could have caused symptoms that were easily mistaken for bewitchment or madness. Pinch- ing sensations, muscle twitches, facial spasms, delirium, and hallucinations are all signs of ergot poisoning (Matossian, 1982). Modern analyses of “demonic possession” suggest that many victims may have been suffering from epilepsy, schizophrenia (Mirsky & Duncan, 2005), dissociative dis- orders (van der Hart, Lierens, & Goodwin, 1996), and depression (Thase, 2006). Thus, many people “treated” by demonologists may have been doubly victimized.

Then, in 1793, a French doctor named Philippe Pinel changed the Bicêtre Asylum in Paris from a squalid “mad- house” into a mental hospital by unchaining the inmates (Harris, 2003). Finally, the emotionally disturbed were

regarded as “mentally ill” and given compassionate treatment. Although it has been more than 200 years since Pinel began more humane treatment, the process of improving care continues today.

When was psychotherapy developed? The first true psychother- apy was created by Sigmund Freud little more than 100 years ago ( Jacobs, 2003). As a physician in Vienna, Freud was intrigued by cases of hysteria. People suffering from hysteria have physical symptoms (such as paralysis or numbness) for which no physical causes can be found.

Such problems are now called somatoform disorders, as discussed in Chapter 14, pages 499–501.


• Figure 15.1 Primitive “treatment” for mental disorders sometimes took the form of boring a hole in the skull. This example shows signs of healing, which means the “patient” actually survived the treatment. Many didn’t.

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(left) Many early asylums were no more than prisons with inmates held in chains. (right) One late 19th-century “treatment” was based on swinging the patient in a harness—presumably to calm the patient’s nerves.

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Therapies 513

Psychotherapy Any psychological technique used to facilitate positive changes in a person’s personality, behavior, or adjustment.

Demonology In medieval Europe, the study of demons and the treatment of persons “possessed” by demons.

Hysteria (now called somatoform disorders) An outdated term describing people with physical symptoms (such as paralysis or numbness) for which no physical causes can be found.

Psychoanalysis A Freudian therapy that emphasizes the use of free association, dream interpretation, resistances, and transference to uncover unconscious conflicts.

Free association In psychoanalysis, the technique of having a client say anything that comes to mind, regardless of how embarrassing or unimportant it may seem.

Resistance A blockage in the flow of free association; topics the client resists thinking or talking about.

Slowly, Freud became convinced that hysteria was related to deeply hidden unconscious conflicts and developed psychoanalysis in order to help patients gain insight into those conflicts (Knafo, 2009). Because it is the “granddaddy” of more modern therapies, let’s examine psychoanalysis in some detail.

Psychoanalysis—Expedition into the Unconscious

Gateway Question 15.2: Is Freudian psychoanalysis still used? Isn’t psychoanalysis the therapy for which the patient lies on a couch? Freud’s patients usually reclined on a couch during therapy, while Freud sat out of sight taking notes and offering interpretations. This procedure was supposed to encourage a free flow of thoughts and images from the unconscious. However, it is the least impor- tant element of psychoanalysis, and many modern analysts have abandoned it.

How did Freud treat emotional problems? Freud’s theory stressed that “neurosis” and “hysteria” are caused by repressed memories, motives, and conflicts—particularly those stemming from instinctual drives for sex and aggression. Although they are hidden, these forces remain active in the personality and cause some people to develop rigid ego defenses and compulsive, self- defeating behavior. Thus, the main goal of psychoanalysis is to reduce internal conflicts that lead to emotional suffering (Fayek, 2010).

Freud developed four basic techniques to uncover the uncon- scious roots of neurosis (Freud, 1949). These are free association, dream analysis, analysis of resistance, and analysis of transference.

Free Association The basis for free association is saying whatever comes to mind without worrying whether ideas are painful, embarrassing, or illogical. Thoughts are simply allowed to move freely from one idea to the next, without self-censorship. The purpose of free associa- tion is to lower defenses so that unconscious thoughts and feelings can emerge (Hoffer & Youngren, 2004).

Dream Analysis Freud believed that dreams disguise consciously unacceptable feel- ings and forbidden desires in dream form (Rock, 2004). The psy- choanalyst can use this “royal road to the unconscious” to help the patient work past the obvious, visible meaning of the dream (its manifest content) to uncover the hidden, symbolic meaning (its latent content). This is achieved by analyzing dream symbols (images that have personal or emotional meanings).

Suppose that a young man dreams of pulling a pistol from his waistband and aiming at a target as his wife watches. The pistol repeatedly fails to discharge, and the man’s wife laughs at him. Freud might have seen this as an indication of repressed feelings of sexual impotence, with the gun serving as a disguised image of the penis.

See Chapter 5, pages 178–179 and 198–199, for more information of Freudian dream theory.


Analysis of Resistance When free associating or describing dreams, patients may resist talking about or thinking about certain topics. Such resistances (blockages in the flow of ideas) reveal particularly important unconscious conflicts. As analysts become aware of resistances, they bring them to the patient’s awareness so the patient can deal with them realistically. Rather than being roadblocks in therapy, resistances can be clues and challenges (Engle & Arkowitz, 2006).

Pioneering psychotherapist Sigmund Freud’s famous couch.

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Chapter 15514

Analysis of Transference Transference is the tendency to “transfer” feelings to a therapist similar to those the patient had for important persons in his or her past. At times, the patient may act as if the analyst is a rejecting father, an unloving or overprotective mother, or a former lover, for example. As the patient re-experiences repressed emotions, the therapist can help the patient recognize and understand them. Troubled persons often provoke anger, rejection, boredom, criti- cism, and other negative reactions from others. Effective therapists learn to avoid reacting as others do and playing the patient’s habit- ual resistance and transference “games.” This, too, contributes to therapeutic change (Fayek, 2010).

Psychoanalysis Today What is the status of psychoanalysis today? Traditional psychoanalysis was open-ended, calling for three to five therapy sessions a week, often for many years. Today, most patients are seen only once or twice per week, but treatment may still go on for years (Friedman et al., 1998). Because of the huge amounts of time and money this requires, psychoanalysts have become relatively rare. Nevertheless, psycho- analysis made a major contribution to modern therapies by highlight- ing the importance of unconscious conflicts (Friedman, 2006).

Many therapists have switched to doing time-limited brief psy- chodynamic therapy, which uses direct questioning to reveal unconscious conflicts (Binder, 2004). Modern therapists also actively provoke emotional reactions that will lower defenses and provide insights. Interestingly, brief therapy appears to accelerate recovery. Patients seem to realize that they need to get to the heart of their problems quickly (Messer & Kaplan, 2004).

Interpersonal Psychotherapy One example of a brief dynamic therapy is interpersonal psycho- therapy (IPT), which was first developed to help depressed people improve their relationships with others (Teyber & McClure, 2011). Research has confirmed that IPT is effective for depressive disorders, as well as eating disorders, substance abuse, social pho- bias, and personality disorders (Fiore et al., 2008; Hoffart, 2005; Prochaska & Norcross, 2010; Talbot & Gamble, 2008).

Liona’s therapy is a good example of IPT (Brown & Barlow, 2011). Liona was suffering from depression that a therapist helped her trace to a conflict with her parents. When her father was absent, Liona adopted the role of her mother’s protector and friend. How- ever, when her father was home, she was expected to resume her role as a daughter. She was angry with her father for frequently abandon- ing her mother and upset about having to switch roles so often. Liona’s IPT sessions (which sometimes included her mother) focused on clarifying Liona’s family roles. Her mood improved a lot after her mother urged her to “stick to being herself.”

Is Traditional Psychoanalysis Effective? The development of newer, more streamlined dynamic therapies is in part due to questions about whether traditional psychoanalysis “works.” In a classic criticism, Hans Eysenck (1994) suggested that

psychoanalysis simply takes so long that patients experience a spontaneous remission of symptoms (improvement due to the mere passage of time).

How seriously should the possibility of spontaneous remission be taken? It’s true that problems ranging from hyperactivity to anxiety do improve with the passage of time. Regardless, researchers have confirmed that psychoanalysis does, in fact, produce improvement in a majority of patients (Doidge, 1997).

The real value of Eysenck’s critique is that it encouraged psy- chologists to try new ideas and techniques. Researchers began to ask, “When psychoanalysis works, why does it work? Which parts of it are essential and which are unnecessary?” Modern therapists have given surprisingly varied answers to these questions. Let’s move on to survey some of the ways modern therapies differ. Later, we will acquaint you with some of the therapies currently in use.

Dimensions of Therapy— Let Me Count the Ways

Gateway Question 15.3: How do psychotherapies differ? In contrast to medical therapies, which are physical in nature, psychotherapy refers to any psychological technique that can bring about positive changes in personality, behavior, or personal adjustment. Psychotherapy is usually based on a dialogue between therapists and their clients, although some therapists also use learning principles to directly alter troublesome behaviors (Corsini & Wedding, 2011).

Therapists have many approaches to choose from: psycho- analysis, which we just discussed, as well as client-centered ther- apy, Gestalt therapy, cognitive therapy, and behavior therapy—to name but a few. As we will see throughout the chapter, each therapy emphasizes different concepts and methods. For this reason, the best approach for a particular person or problem may vary (Prochaska & Norcross, 2010).

Dimensions of Psychotherapy The terms in the list that follows describe some basic aspects of various psychotherapies (Prochaska & Norcross, 2010; Sharf, 2012). Notice that more than one term may apply to a particular therapy. For example, it is possible to have a directive, action- oriented, open-ended group therapy or a nondirective, individual, insight-oriented, time-limited therapy:

• Insight vs. action therapy: Does the therapy aim to bring clients to a deeper understanding of their thoughts, emotions, and behavior? Or is it designed to bring about direct changes in troublesome thoughts, habits, feelings, or behavior, without seeking insight into their origins or meanings?

• Directive vs. nondirective therapy: Does the therapist provide strong guidance and advice? Or does the therapist merely assist clients, who are responsible for solving their own problems?

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Therapies 515

Transference The tendency of patients to transfer feelings to a therapist that correspond to those the patient had for important persons in his or her past.

Brief psychodynamic therapy A modern therapy based on psychoanalytic theory but designed to produce insights more quickly.

Interpersonal psychotherapy (IPT) A brief dynamic psychotherapy designed to help people by improving their relationships with other people.

Spontaneous remission Improvement of symptoms due to the mere passage of time.

• Individual vs. group therapy: Does the therapy involve one therapist with one client? Or do several clients participate at the same time?

• Open-ended vs. time-limited therapy: Is the therapy open- ended? Or is it begun with the expectation that it will last only a limited number of sessions?

Myths Psychotherapy has often been depicted as a complete personal transformation—a sort of “major overhaul” of the psyche. But therapy is not equally effective for all problems. Chances of improvement are fairly good for phobias, low self-esteem, some sexual problems, and marital conflicts. More complex problems can be difficult to solve and may, as in Joe’s case, require medical treatment as well. The most extreme cases may not respond to psychotherapy at all, leaving a medical therapy as the only viable treatment option.

In short, it is often unrealistic to expect psychotherapy to undo a person’s entire past. For many people, the major benefit of psy- chotherapy is that it provides comfort, support, and a way to make constructive changes (Bloch, 2006; Burns, 2010). Yet, even when problems are severe, therapy may help a person gain a new perspec- tive or learn behaviors to better cope with life. Psychotherapy can be hard work for both clients and therapists, but when it succeeds, few activities are more worthwhile.

It’s also a mistake to think that psychotherapy is used only to solve problems or end a crisis. Even if a person is already doing well, therapy can be a way to promote personal growth (Bloch, 2006). Therapists in the positive psychology movement are developing ways to help people make use of their personal strengths. Rather than trying to fix what is “wrong” with a person, they seek to nur- ture positive traits and actively solve problems (Compton, 2005). ■ Table 15.1 lists some of the elements of positive mental health that therapists seek to restore or promote. Before we dig deeper into some of the different types of psychotherapy, let’s enhance your positive academic health with a short review.

Elements of Positive Mental Health

• Personal autonomy and independence

• A sense of identity

• Feelings of personal worth

• Skilled interpersonal communication

• Sensitivity, nurturance, and trust

• Genuineness and honesty with self and other

• Self-control and personal responsibility

• Committed and loving personal relationships

• Capacity to forgive others and oneself

• Personal values and a purpose in life

• Self-awareness and motivation for personal growth

• Adaptive coping strategies for managing stresses and crises

• Fulfillment and satisfaction in work

• Good habits of physical health

■ TABLE 15.1

Adapted from Bergin, 1991; Bloch, 2006.

Knowledge Builder Treating Psychological Distress

RECITE 1. One modern scientific explanation of medieval “possessions” by

“demons” is related to the effects of a. ergot poisoning b. trepanning c. exorcism

d. unconscious transference 2. Pinel is famous for his use of exorcism. T or F? 3. In psychoanalysis, an emotional attachment to the therapist is

called: a. free association b. manifest association c. resistance

d. transference Match:

4. _____ Directive therapies A. Change behavior 5. _____ Action therapies B. Place responsibility on the client 6. _____ Insight therapies C. The client is guided strongly 7. _____ Nondirective therapies D. Seek understanding

8. An approach that is incompatible with insight therapy is a. individual therapy b. action therapy c. nondirective

therapy d. time-limited psychotherapy

REFLECT Think Critically

9. According to Freud’s concept of transference, patients “transfer” their feelings onto the psychoanalyst. In light of this idea, to what might the term countertransference refer?


The use of trepanning, demonology, and exorcism all implied that the mentally ill are “cursed.” To what extent are the mentally ill rejected and stigmatized today?

Try to free associate (aloud) for 10 minutes. How difficult was it? Did anything interesting surface?

Can you explain, in your own words, the role of dream analysis, resistances, and transference in psychoanalysis?

Make a list describing what you think it means to be mentally healthy. How well does your list match the items in ■ Table 15.1?

Answers: 1. a 2. F 3. d 4. C 5. A 6. D 7. B 8. d 9. Psychoanalysts (and therapists in general) are also human. They may transfer their own unresolved, unconscious feelings onto their patients. This sometimes hampers the effectiveness of therapy (Kim & Gray, 2009).

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Chapter 15516

Humanistic Therapies— Restoring Human Potential

Gateway Question 15.4: What are the major humanistic therapies? When most people picture psychotherapists at work, they imagine them talking with their clients. Let’s sample a variety of talk- oriented approaches. Humanistic therapies tend to be insight thera- pies intended to help clients gain deeper insight into their thoughts, emotions, and behavior. In contrast, cognitive therapies tend to be action therapies less concerned with insight than with helping peo- ple change harmful thinking patterns. Let’s start with some insight.

Better self-knowledge was the goal of traditional psychoanaly- sis. However, Freud claimed that his patients could expect only to change their “hysterical misery into common unhappiness”! Humanistic therapists are more optimistic, believing that humans have a natural urge to seek health and self-growth. Most assume that it is possible for people to use their potentials fully and live rich, rewarding lives. In this section, we’ll discuss three of the most common humanistic therapies: client-centered therapy, existential therapy, and Gestalt therapy.

Client-Centered Therapy What is client-centered therapy? How is it different from psychoanaly- sis? Whereas psychoanalysis is directive and based on insights from the unconscious, client-centered therapy (also called person- centered therapy) is nondirective and based on insights from con- scious thoughts and feelings (Brodley, 2006; Wampold, 2007). The psychoanalyst tends to take a position of authority, stating what dreams, thoughts, or memories “mean.” In contrast, Carl Rogers (1902–1987), who originated client-centered therapy, believed that what is right or valuable for the therapist may be wrong for the cli- ent. (Rogers preferred the term “client” to “patient” because “patient” implies that a person is “sick” and needs to be “cured.”) Conse- quently, in client-centered therapy, the client determines what will be discussed during each session.

If the client runs things, what does the therapist do? The therapist cannot “fix” the client. Instead, the client must actively seek to solve his or her problems (Whitton, 2003). The therapist’s job is to create a safe “atmosphere of growth” by providing opportunities for change.

How do therapists create such an atmosphere? Rogers believed that effective therapists maintain four basic conditions. First, the therapist offers the client unconditional positive regard (unshak- able personal acceptance). The therapist refuses to react with shock, dismay, or disapproval to anything the client says or feels. Total acceptance by the therapist is the first step to self-acceptance by the client.

Second, the therapist attempts to achieve genuine empathy by trying to see the world through the client’s eyes and feeling some part of what the client is feeling.

As a third essential condition, the therapist strives to be authen- tic (genuine and honest). The therapist must not hide behind a professional role. Rogers believed that phony fronts destroy the growth atmosphere sought in client-centered therapy.

Fourth, the therapist does not make interpretations, propose solutions, or offer advice. Instead, the therapist reflects (rephrases, summarizes, or repeats) the client’s thoughts and feelings. This enables the therapist to act as a psychological “mirror” so clients can see themselves more clearly. Rogers theorized that a person armed with a realistic self-image and greater self-acceptance will gradually discover solutions to life’s problems.

Existential Therapy According to the existentialists, “being in the world” (existence) creates deep anxiety. Each of us must deal with the realities of death. We must face the fact that we create our private world by making choices. We must overcome isolation on a vast and indif- ferent planet. Most of all, we must confront feelings of meaning- lessness (Schneider, Galvin, & Serlin, 2009).

What do these concerns have to do with psychotherapy? Existen- tial therapy focuses on the problems of existence, such as meaning, choice, and responsibility. Like client-centered therapy, it pro- motes self-knowledge. However, there are important differences. Client-centered therapy seeks to uncover a “true self ” hidden behind a screen of defenses. In contrast, existential therapy empha- sizes free will, the human ability to make choices. Accordingly, existential therapists believe you can choose to become the person you want to be.

Existential therapists try to give clients the courage to make rewarding and socially constructive choices. Typically, therapy focuses on death, freedom, isolation, and meaninglessness, the “ulti- mate concerns” of existence (van Deurzen & Kenward, 2005). These universal human challenges include an awareness of one’s mortality, the responsibility that comes with freedom to choose, being alone in your own private world, and the need to create meaning in your life.

One example of existential therapy is Victor Frankl’s logother- apy, which emphasizes the need to find and maintain meaning in

Psychotherapist Carl Rogers, who originated client- centered therapy.

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