Treatment of Psychological Disorders

Treatment of Psychological Disorders

Dorothea Dix (1802–1887) “I … call your attention to the state of the Insane Persons confined within this Commonwealth, in cages.” Culver Pictures

Today we comprehend deep outer space and can state with certainty the chemical composition of Jupiter’s atmosphere. But in understanding and treating the disturbances of deep inner space—the psychological disorders described in Unit 12—we are only beginning to make real progress. In the 2200 years since Eratosthenes correctly estimated the Earth’s circumference, we have charted the heavens, cracked the genetic code, and eliminated or found cures for all sorts of diseases. Meanwhile, we have treated psychological disorders with a bewildering array of harsh and gentle methods: by cutting holes in the head and by giving warm baths and massages; by restraining, bleeding, or “beating the devil” out of people and by placing them in sunny, serene environments; by administering drugs and electric shocks and by talking—talking about childhood experiences, about current feelings, about maladaptive thoughts and behaviors.

The transition from brutal to gentler treatments occurred thanks to the efforts of reformers such as Philippe Pinel in France and Dorothea Dix in the United States, Canada, and Scotland. Both advocated constructing mental hospitals to offer more humane methods of treatment. But times have once again changed, and the introduction of therapeutic drugs and community-based treatment programs has largely emptied mental health hospitals since the mid-1950s.

Today’s mental health therapies can be classified into two main categories, and the favored treatment depends on both the disorder and the therapist’s viewpoint. Learning-related disorders, such as phobias, are likely candidates for psychotherapy, in which a trained therapist uses psychological techniques to assist someone seeking to overcome difficulties or achieve personal growth. Biologically influenced disorders, such as schizophrenia, will often be treated with biomedical therapy—a prescribed medication or medical procedure that acts directly on the patient’s nervous system.

Depending on the client and the problem, some therapists—particularly the many using a biopsychosocial approach—draw from a variety of techniques. Many patients receive drug therapy in combination with psychotherapy. Half of all psychotherapists describe themselves as taking an eclectic approach, using a blend of therapies (Beitman et al., 1989; Castonguay & Goldfried, 1994). Psychotherapy integration attempts to combine a selection of assorted techniques into a single, coherent system.

The history of treatment As William Hogarth’s (1697–1764) painting of London’s St. Mary of Bethlehem hospital (commonly called Bedlam) depicts, visitors to eighteenth-century mental hospitals paid to gawk at patients, as though they were viewing zoo animals. Benjamin Rush (1746–1813), a founder of the movement for more humane treatment of the mentally ill, designed the chair on the far right “for the benefit of maniacal patients.” He believed the restraints would help them regain their sensibilities. The Granger Collection

The Psychological Therapies

AMONG THE DOZENS OF TYPES of psychotherapy, we will look at only the most influential. Each is built on one or more of psychology’s major theories: psychoanalytic, humanistic, behavioral, and cognitive. Most of these techniques can be used one-on-one or in groups.

Psychoanalysis

What are the aims and methods of psychoanalysis, and how have they been adapted in psychodynamic therapy?

Sigmund Freud’s psychoanalysis was the first of the psychological therapies, and its terminology has crept into our modern vocabulary. Few clinicians today practice therapy as Freud did, but some of his techniques and assumptions survive, especially in the psychodynamic therapies.

Aims

Because Freud assumed that many psychological problems are fueled by childhood’s residue of repressed impulses and conflicts (see Unit 10), he and his students sought to bring these repressed feelings into patients’ conscious awareness. By gaining insight into the origins of the disorder—by excavating their childhood past and fulfilling the ancient imperative to “know thyself” in a deep way—patients then work through the buried feelings and take responsibility for their own growth. Psychoanalytic theory presumes that healthier, less anxious living becomes possible when people release the energy they had previously devoted to idego-superego conflicts.

Freud’s consulting room Freud’s office was rich with antiquities from around the world, including artwork related to his ideas about unconscious motives. His famous couch, piled high with pillows, placed patients in a comfortable reclining position facing away from him to help them focus inward. Edmund Engelman

Methods

Psychoanalysis is historical reconstruction. Psychoanalytic theory emphasizes the formative power of childhood experiences, and thus aims to unearth the past in hope of unmasking the present. But how?

After trying hypnosis and discarding it as unreliable, Freud turned to free association. Imagine yourself as a patient using free association. First, you relax, perhaps by lying on a couch. To help you focus on your own thoughts and feelings, the psychoanalyst may sit out of your line of vision. You say aloud whatever comes to your mind, at one moment an early childhood memory, at another a dream or recent experience. It sounds easy, but soon you notice how often you edit your thoughts as you speak, omitting what seems trivial, irrelevant, or shameful. Even in the safe presence of the analyst, you may pause momentarily before uttering an embarrassing thought. You may joke or change the subject to something less threatening. Sometimes your mind goes blank or you find yourself unable to remember important details.

“You say, ‘Off with her head’ but what I’m hearing is, ‘I feel neglected.’”

To the psychoanalyst, these blocks in the flow of your free associations indicate resistance. They hint that anxiety lurks and you are defending against sensitive material. The analyst will note your resistances and then interpret their meaning, providing insight into your underlying wishes, feelings, and conflicts. If offered at the right moment, this interpretation—of, say, your not wanting to talk about your mother—may illuminate what you are avoiding and demonstrate how this resistance fits with other pieces of your psychological puzzle.

Freud believed that another clue to unconscious conflicts is your dreams’ latent content—their underlying but censored meaning. Thus, after inviting you to report a dream, the analyst may offer a dream analysis, suggesting its meaning.

During many such sessions you will probably disclose to your analyst more of yourself than you have ever revealed to anyone else, much of it pertaining to your earliest memories. You may find yourself experiencing strong positive or negative feelings for your analyst, who may suggest you are transferring to your analyst feelings you experienced in earlier relationships with family members or other important people. By exposing feelings you have previously defended against, such as dependency or mingled love and anger, transference will give you a belated chance to work through them, with your analyst’s help. Examining your feelings may also give you insight into your current relationships, not just those of early childhood.

“I haven’t seen my analyst in 200 years. He was a strict Freudian. If I’d been going all this time, I’d probably almost be cured by now.”

Woody Allen, after awakening from suspended animation in the movie Sleeper

Psychoanalysts acknowledge the criticism that their interpretations cannot be proven or disproven. But they insist that interpretations often are a great help to patients. Psychoanalysis, they say, is therapy, not science.

Traditional psychoanalysis takes time, up to several years of several sessions a week, and it is expensive. (Three times a week for just two years at more than $100 per hour comes to at least $30,000.) Outside of France, Germany, Quebec, and New York City, relatively few therapists offer it (Goode, 2003). In the United States, at least, this is not surprising, given that U.S. managed health care limits the types and length of insured mental health services.

Psychodynamic Therapy

Influenced by Freud, psychodynamic therapists try to understand a patient’s current symptoms by focusing on themes across important relationships, including childhood experiences and the therapist relationship. They also help the person explore and gain perspective on defended-against thoughts and feelings. But these therapists may talk to the patient face to face (rather than out of the patient’s line of vision), once a week (rather than several times weekly), and for only a few weeks or months (rather than several years).

No brief excerpt can exemplify the way psychodynamic therapy interprets a patient’s conflict. But the following interaction between therapist David Malan (1978, pp. 133–134) and a depressed patient illustrates the goal of enabling insight by looking for common, recurring themes, especially in relationships.

Malan: I get the feeling that you’re the sort of person who needs to keep active. If you don’t keep active, then something goes wrong. Is that true?

Patient: Yes.

Malan: I get a second feeling about you and that is that you must, underneath all this, have an awful lot of very strong and upsetting feelings. Somehow they’re there but you aren’t really quite in touch with them. Isn’t this right? I feel you’ve been like that as long as you can remember.

Patient: For quite a few years, whenever I really sat down and thought about it I got depressed, so I tried not to think about it.

Malan: You see, you’ve established a pattern, haven’t you? You’re even like that here with me, because in spite of the fact that you’re in some trouble and you feel that the bottom is falling out of your world, the way you’re telling me this is just as if there wasn’t anything wrong.

“Look, making you happy is out of the question, but I can give you a compelling narrative for your misery.”© The New Yorker Collection, 2007, Robert Mankoff from cartoonbank.com. All rights reserved.

Notice how Malan interpreted the woman’s earlier remarks (when she did most of the talking) and suggested that her relationship with him reveals a characteristic pattern of behavior? He was suggesting insights into her problems.

Interpersonal psychotherapy, a brief (12- to 16-session) variation of psychodynamic therapy, has been effective in treating depression (Weissman, 1999). Interpersonal psychotherapy aims to help people gain insight into the roots of their difficulties, but its goal is symptom relief in the here and now, not overall personality change. Rather than focusing mostly on undoing past hurts and offering interpretations, the therapist focuses primarily on current relationships and on helping people improve their relationship skills.

The case of Anna (not her real name), a 34-year-old married professional, illustrates these goals. Five months after receiving a promotion, with accompanying increased responsibilities and longer hours, Anna experienced increased tensions with her husband over his wish for a second child. She began feeling depressed, had trouble sleeping, became irritable, and was gaining weight. A typical psychodynamic therapist might have helped Anna gain insight into her angry impulses and her defenses against anger. An interpersonal therapist similarly wanted Anna to gain these insights, but also engaged her thinking on more immediate issues—how she could balance work and home, resolve the dispute with her husband, and express her emotions more effectively (Markowitz et al., 1998).

Face-to-face therapy In this type of therapy session, the couch has disappeared. But the influence of psychoanalytic theory may not have, especially if the therapist probes for the origin of the patient’s symptoms by seeking information from the patient’s childhood. Photofusion Picture Library/Alamy

Humanistic Therapies

What are the basic themes of humanistic therapy, such as Rogers’ client-centered approach?

The humanistic perspective (Unit 10) has emphasized people’s inherent potential for self-fulfillment. Not surprisingly, humanistic therapists aim to boost self-fulfillment by helping people grow in self-awareness and self-acceptance. Like psychoanalytic therapies, humanistic therapies have attempted to reduce the inner conflicts that are impeding natural developmental growth by providing clients with new insights. Indeed, the psychoanalytic and humanistic therapies are often referred to as insight therapies. But humanistic therapists differ from psychoanalysts in focusing on

the present and future more than the past. They explore feelings as they occur, rather than achieving insights into the childhood origins of the feelings.
conscious rather than unconscious thoughts.
taking immediate responsibility for one’s feelings and actions, rather than uncovering hidden determinants.
promoting growth instead of curing illness. Thus, those in therapy became “clients” rather than “patients” (a change many therapists have since adopted).

Carl Rogers (1902–1987) developed the widely used humanistic technique he called client-centered therapy, which focuses on the person’s conscious self-perceptions. In this nondirective therapy, the therapist listens, without judging or interpreting, and seeks to refrain from directing the client toward certain insights.

Believing that most people already possess the resources for growth, Rogers (1961, 1980) encouraged therapists to exhibit genuineness, acceptance, and empathy. When therapists drop their facades and genuinely express their true feelings, when they enable their clients to feel unconditionally accepted, and when they empathically sense and reflect their clients’ feelings, the clients may deepen their self-understanding and self-acceptance (Hill & Nakayama, 2000). As Rogers (1980, p. 10) explained,

Hearing has consequences. When I truly hear a person and the meanings that are important to him at that moment, hearing not simply his words, but him, and when I let him know that I have heard his own private personal meanings, many things happen. There is first of all a grateful look. He feels released. He wants to tell me more about his world. He surges forth in a new sense of freedom. He becomes more open to the process of change.

I have often noticed that the more deeply I hear the meanings of the person, the more there is that happens. Almost always, when a person realizes he has been 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 what it’s like to be me.”

“We have two ears and one mouth that we may listen the more and talk the less.”

Zeno, 335–263 B.C.E., Diogenes Laertius

“Hearing” refers to Rogers’ technique of active listening—echoing, restating, and seeking clarification of what the person expresses (verbally or nonverbally) and acknowledging the expressed feelings. Active listening is now an accepted part of therapeutic counseling practices in many high schools, colleges, and clinics. The counselor listens attentively and interrupts only to restate and confirm feelings, to accept what is being expressed, or to seek clarification. The following brief excerpt between Rogers and a male client illustrates how he sought to provide a psychological mirror that would help clients see themselves more clearly.

Rogers: Feeling that now, hm? That you’re just no good to yourself, no good to anybody. 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?

Client: Yeah. (Muttering in low, discouraged voice) That’s what this guy I went to town with just the other day told me.

Rogers: 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?

Client: M-hm.

Rogers: I guess the meaning of that if I get it right is that here’s somebody that—meant something to you and what does he think of you? Why, he’s told you that he thinks you’re no good at all. And that just really knocks the props out from under you. (Client weeps quietly.) It just brings the tears. (Silence of 20 seconds)

Client:(Rather defiantly) I don’t care though.

Rogers: You tell yourself you don’t care at all, but somehow I guess some part of you cares because some part of you weeps over it.

(Meador & Rogers, 1984, p. 167)

Active listening Carl Rogers (right) empathized with a client during this group therapy session. Michael Rougier/Life Magazine © Time Warner, Inc.

Can a therapist be a perfect mirror, without selecting and interpreting what is reflected? Rogers conceded that one cannot be totally nondirective. Nevertheless, he believed that the therapist’s most important contribution is to accept and understand the client. Given a nonjudgmental, grace-filled environment that provides unconditional positive regard, people may accept even their worst traits and feel valued and whole.

If you want to listen more actively in your own relationships, three hints may help: