Psychological Therapies

1. Psychoanalysis

Psychoanalysis is derived from Freud’s theory of personality, which is also sometimes called his theory of psychoanalysis. Thus, psychoanalysis is both the theory and the method for dealing with mental disorders. Freud believed that mental disorder arises from early experiences that create anxiety and so the associated feelings are repressed into the unconscious mind.

Psychological therapies (or psychotherapies) are all derived from psychology approaches to explaining abnormality, i.e. they propose that psychological, rather than physical, factors underlie mental disorder and, therefore, treatments should target the way people think, feel and behave.

However, unconscious thoughts and feelings affect behaviour and create mental disorder. Cure relies on the therapist’s ability to make the unconscious conscious and guide the patient in resolving their conflicts. The therapist uses the following techniques to achieve this:

1. Free association – The therapist introduces a topic and the patient talks freely about anything that comes into his/her mind. This enables unconscious thoughts and feelings to be uncovered.
2. Rich interpretation – The therapist explains the patient’s thoughts and feelings using Freud’s dynamics of personality development. If a patient resists the interpretation offered, this can be taken as evidence that the therapist is correct because he/she has uncovered issues that create anxiety and are repressed.
3. Analysis of dreams – Dreams express the innermost workings of the mind. By talking through a patient’s dreams the therapist accesses the ‘royal road to the unconscious’. In Freudian therapy, dreams are repressed ‘wishes’. Freud did not subscribe to the idea of dream dictionaries. He believed that some items symbolised particular things (for example, a lighthouse might symbolise a penis). But such symbolism was not universal because it depends on experience – a lighthouse would have a different meaning for a lighthouse keeper (it might symbolise the power of a person’s employer).
4. Transference – The patient transfers their feelings about others onto the therapist, therefore, recreating some of the original anxieties. For example, the therapist may become the hated parent. The therapist then has to deal with these transferred feelings and, therefore, deals with the original repressed anxieties.

Evaluation of psychoanalysis:

• Eysenck (1952) examined 10,000 patient histories and found a 44% improvement in patients receiving psychoanalysis, but higher rates for mixed therapies. However, when Bergin (1971) reanalysed the same data using different outcome criteria the psychoanalysis success rose to 83% and the mixed group fell to 65%. When two researchers find completely different results using the same data, it is worrying! It suggests that possibly the researcher’s expectations affected the analysis performed on the data. Researchers sometimes appear to find what they want to find.
• The emphasis on early conflicts means that present conflicts may be overlooked.
• Psychoanalysis has limited applicability. It is suitable for intelligent and verbally-able patients, and for wealthy clients with time on their hands, as appointments are usually several times a week over a period of years (sometimes called YAVIS – young, attractive, verbal, intelligent, successful).
• It is only suitable for those mental illnesses where some insight is retained, i.e. it is not helpful with schizophrenics.
• Therapy may create false memories. This has led to some serious court cases in the USA.

2. Systematic de-sensitisation (SD)

Systematic de-sensitisation (SD) is mainly used to treat phobias, such as fear of flying or snake phobias. It was a method devised by Wolpe (1958) in which a patient learns to pair the feared thing with relaxation, rather than anxiety.

1. Relaxation – The patient is taught deep muscle relaxation. Relaxation will later become associated with the feared object, replacing the existing link between feared object and anxiety. Relaxation also works through reciprocal inhibition – the fact that it is impossible to maintain two incompatible emotional responses simultaneously (anxiety and relaxation). Systematic de-sensitisation is derived from the behavioural approach and is based on the principles of classical conditioning. At the start of therapy, the S–R link is: feared object (stimulus) anxiety (learned response).

   Through SD the patient learns to associate the stimulus with a new response – relaxation.

2. De-sensitisation hierarchy – The patient constructs a hierarchy of increasingly threatening situations. Typically, there might be 15 items in the hierarchy, such as looking at a picture of the feared object, watching someone else holding it, touching it and so on.
3. Visualisation – The patient is asked to imagine each scene whilst deeply relaxed. At any time, if the patient feels anxious, the image is stopped and relaxation is regained. This may take several attempts.
4. Progression – When a particular scene can be imagined without creating anxiety, then the patient can move on to the next step in the hierarchy, finally mastering the feared situation.

The whole process typically takes three or four weeks with two sessions per week, but it can be completed more quickly.

Evaluation of SD:

• SD has been demonstrated to be successful for a certain range of disorders, such as phobias. For example, McGrath et al. (1990) found that 75% of patients with phobias recover after a course of SD. However, people may recover spontaneously from phobias so the recovery rate would be almost as good without treatment.
• SD does not require a therapist. It can be self-administered by reading about what to do and following the instructions. This makes it a highly accessible method.
• The success of SD may have nothing to do with relaxation. Other therapies (e.g. flooding) just expose a person to the feared thing with no hierarchy and no relaxation. Marks (1973) suggests that SD works because of exposure to the feared stimulus, which can be achieved by flooding. Flooding may be rather traumatic, but quicker. An alternative way to explain why SD works is that cognitive restructuring takes place.
• There is some evidence that SD only works with ‘acquired’ phobias, rather than those with an innate component, such as fear of open spaces, rather than fear of being bitten by a dog. This would explain why it works for some people (who have learned their phobias) and not others (whose phobias are based on innate fears).

3. Cognitive Behaviour Therapy (CBT)

Stress inoculation therapy is an example of a Cognitive Behaviour Therapy – a method of treatment that targets the way a person thinks, as well as the way he/she behaves.

The cognitive approach suggests that mental disorders are due to faulty thinking. Therefore, the therapy aims to change the way the person thinks. This is a particularly useful approach when you cannot change the problem itself – but you can always change the way you think about something.

Perhaps one of the best known forms of CBT is rational-emotional behaviour therapy (REBT). Ellis (1957) suggested that patients develop a set of irrational beliefs that lead them to react to situations with undesirable emotions. He used the ABC model to describe what happens:

Activating event → Beliefs about the activating event → Consequences

For example:

A. a boy fails on an important school test

B. he believes that he must be competent in everything he does in order to be a worthwhile person

C. so, he is plunged into despair.

The therapist is directive and aggressive and challenges beliefs (called ‘disputing’), e.g. by asking, ‘Who says you must be perfect?’. This leads the patient to ask the same questions and ultimately exchange irrational beliefs for rational ones. There are various types of disputing, such as logical disputing (questioning whether a belief follows logically from available information), and pragmatic disputing (questioning whether a belief is useful). CBT combines the cognitive and behavioural approaches. The therapies aim to change the way a person thinks and behaves.

Evaluation of CBT:

• CBT and REBT are successful methods. Ellis (1957) claimed a 90% success rate for REBT, and Smith and Glass (1975) reported that REBT was second only to systematic de-sensitisation as a successful therapy (they reviewed 475 studies).
• CBTs are popular because they are relatively quick and do not require any search for deep meanings. However, they do require effort from the patient to be successful and, therefore, they do not appeal to everyone.
• The same methods can be applied by the person to many different situations once the principles (such as ‘disputing’) are understood. Therefore, the therapy has a wide application.
• REBT is a fairly aggressive therapy and is also judgemental because the therapist’s values may not be shared by the client. This raises ethical issues.

PROGRESS CHECK

1. What is the primary aim of psychoanalysis?
2. What is transference?
3. Which method of psychotherapy is Wolpe associated with?
4. What does ABC stand for in REBT?