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019 - Chapter 17 - Therapy 0001

019 - Chapter 17 - Therapy 0001

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Published by Joseph Eulo

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Published by: Joseph Eulo on Feb 08, 2009
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01/27/2013

 
Therapy
AN OVERVIEW OF TREATMENT
Why Do People Seek Therapy?Who Provides Psychotherapeutic Services?The Therapeutic Relationship
MEASURING
SUCCESS IN
PSYCHOTHERAPY
Objectifying and QuantifyingChange WouldChange Occur Anyway? Can TherapyBe Harmful?
WHAT THERAPEUTIC APPROACHESSHOULD BE USED?
Evidence-Based TreatmentsMedicationor Psychotherapy? CombinedTreatments
PHARMACOLOGICAL APPROACHESTO TREATMENT
Antipsychotic Drugs Antidepressant Drugs AntianxietyDrugs Lithiumand Other Mood-Stabilizing Drugs Electroconvulsive Therapy Neurosurgery
PSYCHOLOGICAL APPROACHES TO TREATMENT
BehaviorTherapy Cognitiveand Cognitive-Behavioral Therapy Humap:stic-ExperientialTherapies Psychodynamic TherapiesMarital and FamilyTherapy Eclecticism and Integration
PSYCHOTHERAPY AND SOCIETY
Social Valuesand Psychotherapy PsychotherapyandCultural Diversity
UNRESOLVED ISSUES:
Is There Bias in the Reporting of Drug Trials?
 
ost of ~s hav.e experienced a time or situation when we were dramaticallyhelped by talking thingsover with a relative or friend.Most therapists, like all good lis- teners,rely on receptiveness, warmth,and empathy and take a nonjudgmental approachto the problems their clients present. But there ismore to therapy thanjust giving someone an opportunitytotalk. Therapists also introduce into the relationship psychologicalinterventions that are designed to promote new understandings, behaviors, or both,onthe client's part.The fact that these interventions are deliberately planned and systematically guided by certaintheoretical preconceptionsis what distinguishesprofessional therapy from more informal helping relationships.
AN OVERVIEW
OF
TREATMENT
The belief that people with psychological problems can change-canlearnmore adaptive ways of perceiving, eval- uating, and behaving-is the conviction underlying all
psychotherapy.
Achieving these changes isby no means easy.Sometimes a person'sview of the world andher or his self-concept are distorted from pathological early relation-ships reinforced by years of negative life experiences. In other instances, environmental factors such as an unsatis-fyingjob, an unhappy marriage, or financial stresses mustbe a focus of attention inadditionto psychotherapy. Because change can be hard, people sometimes find iteasier to bear their present problems than to challengethemselves to chart a different life course. Therapy alsotakes time. Even a highly skilled andexperienced therapist cannot undo a person's entire past history and prepare himor her to cope adequately with difficult life situations within a short time.Therapy offers no magicaltransformations. Nevertheless, it holds promise even for the most severementaldisorders. Moreover, contrary to common opinion, psychotherapy can be less expensive in the long run thanalternative modes of intervention(Gabbard et al., 1997). It has been estimated that severalhundred therapeutic approaches exist, ranging from psychoanalysis to Zen meditation. However, the era of managed care hasprompted new and increasingly stringent demands that the efficacy of treatments be empirically demonstrated.This chapter will explore some of the most widely acceptedpharmacological and psychologicaltreatment approachesin use today. Although we recognize that different groupsof mental health professionals often have their own prefer-ences with respect to the use of the terms
client 
and
patient,
in this chapter we use the terms interchangeably.
Why Do People Seek Therapy?
STRESSFUL CURRENT LIFE CIRCUMSTANCES
Peoplewho seek therapy vary widely in their problems andintheirmotivations to solve them.Perhapsthe most obvious candidates for psychological treatment are people experi- encing suddenandhighly stressulsituations such as a divorce or unemployment-people who feel so over- whelmed by a crisisthat they cannot manage on their own. Thesepeople often feelquite vulnerable and tend to be opento psychologicaltreatment because they are moti- vatedto altertheir present intolerable mental states. In such situations, clientsmay gainconsiderably, in a brie time, from the perspective provided by their therapist.
PEOPLE WITH LONG-STANDING PROBLEMS
Otherpeople entering therapy have experienced long-term psy-chological distress andhavelengthy histories of maladjust- ment. They may havehad interpersonal problems such as an inability to be comfortable withintimacy, or they may have felt susceptible to low moods that are difficult forthemto shake. Chronic unhappiness and theinability to feel confident and secure may finally prompt them to seek outside help.These people seek psychological assistance out of dissatisfactionand despair.They may enter treat- ment with a high degree of motivation, but as therapy pro-ceeds, their persistent patterns of maladaptive behavior may generate resistance with which a therapist must con- tend. For example, a narcissistic client who expects to bepraisedby his or her therapist may become disenchantedand hostile when such"strokes" are not forthcoming.
RELUCTANT CLIENTS
Some people enter therapy by amore indirect route.Perhaps they hadconsulted a physi- cian for their headaches or stomachpains, only to be told that nothing was physically wrong with them. After they are referredto a therapist, theymay at first resist the idea that their physicalsymptoms are emotionally based. Moti- vation to enter treatment differs widely among psy-chotherapy clients. Reluctantclients may come from many sources-for example, an alcoholic whose spouse threat-ens"either therapy or divorce," or a suspected felon whose attorney advises thatthings will go better at trialif it can be announced that the suspect has "entered therapy." In gen- eral, males are more reluctant to enter therapy than
 
17.1
C
ompared to women,menare muchmorelikely toresistseeking treatment fromhealth profes- sionals when theyareexperiencingdifficulties. For example, they visit theirprimaryphysi- cians less frequently; they also visitmental health specialists less often, and they are less likely toenter psychotherapy or counseling than women are.Inthe case of depression,far more men than women say that they would neverconsider seeing a therapist; when men are depressedthey are evenreluctant to seek informal help fromtheir friends.Moreover, whenmen do seek pro- fessional help, theytend to askfewerquestions than women do (see Addis
&
Mahalik,
2003).
Why is the average man, regardless of age, socialbackground,and ethnicity,so much more reluctant than the average woman to utilize health services? One answer is thatmenare less ablethan womento recognize and labelfeelings ofdistress and toidentifythese feelings as emotional problems.In addition,men who subscribeto masculine stereotypes emphasizing self-reliance andlack of emotionality also tend to experience more gender-role conflict when they consider traditional counseling, with itsfocus on emotions and emotional disclosure. For a manwho prideshimself on being emotionally stoic, seeking
emales are(see The World AroundUs17.1). A substantial numberof angryparentsbringtheir children to therapists with demandsthat theirchild's "uncontrollable behavior," which they view as independentof the family context, be "fixed."Theseparentsmaybe surprisedand reluctant to recognizetheir own roleinshaping theirchild'sbehavior patterns.
PEOPLE WHO SEEK PERSONAL GROWTH
Ainal group opeoplewho entertherapyhaveproblemsthat would beconsidered relativelynormal.That is, they appear tohaveachieved success,haveinancialstability, havegen- erally acceptingand loving families, and haveaccom- plished many of theirlife goals. Theyenter therapynotout of personaldespairor impossibleinterpersonal involve- ments,butoutoa sensethattheyhavenot livedupto theirown expectationsand realized theirown potential. These people, partlybecausetheir problems aremore manageablethan the problems of others,maymak esub- stantialgainsin personalgrowth. Psychotherapy,however, isnot just or people who have clearlydefined problems,high levels of motivation, and anabilitytogainreadyinsight intotheirbehavior. Psychotherapeutic interventionshavebeenapplied toa
Why Are Men So Reluctant toEnter Therapy?
help for a problem like depressionmaypresent a major threattohis self-esteem. Seekinghelp also requires giving upsome control. andmay run counter to the ideologythat " areal man helpshimself." How can men be encouraged to seekhelp when they havedifficulties? One basicproblemis that the kinds of ser- vices that are available may not be the kinds of services that men who endorsetraditional masculine roles can read- ilyaccept.In otherwords,forsome men, there may be a mismatch betweenwhatis available andwhatthey canpsy- chologicallytolerate. Part of the solution may betodevelop treatment approaches thatarebasedon theories ofhow men are socialized and that provide a better fit for men who are constrained by gender-role expectations. Another strat- egy is to use more creative approaches to encourage men to seek help and support.For example, television commer- cials forerectiledysfunction useprofessional basketball players andfootballcoaches to encourage menwithsimilar problemsto "step up totheplate" andtalk to theirdoctors. Making men more aware of other "masculine men" whohave been "man enough"to go for help when they needed it maybe an important step toward educating those whoseadherence to masculine gender roles makes it difficult for them toacknowledge and seekhelpfortheir problems.
wide variety of chronicproblems.Evena severelydis- turbed,psychoticclient mayprof itfromatherapeutic relationshipthattaesinto account his orher levelof func- tioning and maintains therapeutic subgoalsthatare within theclient'spresentcapabilities(e.g., seeHogartyet al., 1997a, 1997b;Kendler,1999b). Itshould beclear from these brief descriptionsthat there is no"typical"client.Neither isthere a"model"ther- apy. No currentlyused form of therapyis applicableto all types of clients, andall othe standard therapies can docu- mentsomesuccesses. Mostauthorities agree thatclient variables suchasmotivationtochange and the severity of  symptomsareexceedinglyimportant tothe outcomeof  therapy(Clarkin
&
Levy,2004). As we willsee,the various therapieshave relatively greater success whena therapist taesthe characteristics of a particularclientinto account in determining treatment approaches.
Who ProvidesPsychotherapeutic Services?
Membersof manydierentproessionshavetraditionally providedadvice andcounselto individuals in emotional distress. Physicians,inaddition tocaring for their patients'

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