Chapter 13

Overview and Challenges of Psychological Treatment

Definition of Psychotherapy: Systematic efforts to apply psychosocial interventions to reduce distress, maladaptive behavior, or enhance adaptive functioning. * Contrast to Medical/Biological Interventions: Unlike medication or surgery, psychosocial interventions focus on change through interpersonal interaction and systematic experiences such as role-playing, practice, homework, and advice. * Goal: To address social, emotional, and behavioral problems that impair everyday life, ranging from formal psychiatric disorders to impairment caused by stress or life transitions.
Prevalence of Mental Disorders: * In a given year, approximately $25\%$ of the US population (about $77.5$ million out of $310$ million people) meets criteria for one or more psychiatric disorders. * Over a lifetime, approximately $50\%$ of the population meets criteria for at least one disorder. * These are likely conservative estimates as they exclude individuals who narrowly miss diagnostic criteria but still experience impairment.
Unmet Need for Services: * Approximately $70\%$ of individuals with a diagnosable mental disorder in the US do not receive treatment. * Disparities in Care: Members of minority groups have significantly less access. African Americans are less likely to have access ( $12.5\%$ vs. $25.4\%$ for European Americans), and Hispanic Americans are less likely to have adequate care ( $10.7\%$ vs. $22.7\%$ ).
Societal and Personal Costs: * Substance Abuse: Costs approximately $\$500$ billion annually in medical, criminal justice, accident, and lost earning costs. * Anxiety Disorders: Costs approximately $\$42$ billion annually in health-care and lost productivity. * Individual Impairment: Mental disorders are often more impairing than common chronic medical disorders, particularly in home, social, and relationship functioning. Depression has one of the largest impacts on disability.

Behavioral Techniques: Emergence and Evolution

Behavior Therapy Background: * Dominance of "talk therapy" and psychoanalysis (Freud, $1856$ - $1939$ ) in the early $20$ th century relied on internal psychological workings and the therapeutic relationship. * Eysenck ( $1952$ , $1966$ ) and Levitt ( $1957$ , $1963$ ) Findings: About two-thirds ( $2/3$ ) of patients improved with therapy, but about two-thirds ( $2/3$ ) also improved without treatment, leading to skepticism about psychotherapy's effectiveness.
The Behaviorism Movement: * Effort to bring a scientific, objective approach to psychology (e.g., Bechterev, $1913$ ; Watson, $1919$ ). * Focused on classical conditioning (Pavlov) and operant conditioning over subjective experience. * Delineation of Behavior Therapy occurred in the $1950$ s and $1960$ s as isolated efforts (US, Canada, England, South Africa) coalesced into professional organizations (AABT, now ABCT).
Cognitive-Behavior Therapy (CBT): * Transition: Shift from strict behaviorism to include internal cognitive processes (thoughts, beliefs, expectations). * S-R vs. S-O-R Learning: * Stimulus-Response (S-R): Learning by pairing stimuli or behaviors and consequences. * Stimulus-Organism-Response (S-O-R): Emphasizes internal processes (the " $O$ ") to explain learning, illustrated by Tolman's ( $1948$ ) "cognitive maps" in rats. * CBT Characteristics: * Assumes maladaptive cognitions underlie clinical problems. * Cognitive processes are central to change. * Often utilizes behavioral methods (practice, reinforcement) to change thoughts.
Third Wave Expansion: * Focuses on mindfulness, acceptance, and the therapeutic relationship. * Mindfulness: Awareness of current experience (e.g., Buddhist meditation roots). * Acceptance: Embracing private thoughts/experiences as legitimate reactions. * Acceptance and Commitment Therapy (ACT): Combines current experience attention with strategies for behavior change.

Evidence-Based Treatments (EBTs)

History: In the $1990$ s, the focus shifted from theoretical allegiance to empirical support.
Common Criteria for EBT Designation (Table 13-1): 1. Random assignment to conditions. 2. Careful specification of the patient population. 3. Use of treatment manuals. 4. Multiple outcome measures with naïve raters. 5. Statistically significant differences compared to a comparison group. 6. Replication by independent investigators.
Status of Psychotherapy: Most therapies ( $>90\%$ ) have never been studied. EBTs are prioritized as a "first line of attack."

Specific Evidence-Based Treatments and Illustrations

Exposure-Based Treatments for Anxiety

Historical Foundation: Pavlov's laboratory research on "experimental neurosis" in dogs. Watson and Rayner's ( $1920$ ) study of "Little Albert" (conditioning anxiety) and Jones' ( $1924a$ ) study of "Peter" (deconditioning anxiety).
Systematic Desensitization (Wolpe, $1958$ ): Pairing deep relaxation with a hierarchy of anxiety-provoking situations (imagery or real-life).
Flooding: Exposure to high-intensity, anxiety-provoking situations without relaxation until habituation occurs.
Graduated Exposure: Successive approximations toward feared stimuli without necessary relaxation or maximized intensity.
Case Illustration (Vlaeyen et al., $20$ 02 $): *$ 45 $-year-old female with low back pain and fear of movement. * Hierarchical exposure using$ 98 $photographs of daily activities (lifting, walking). *$ 15 $sessions of$ 90 $minutes over$ 5 $weeks. * Results: Dramatic reduction in pain intensity and fear of movement measured in an$ AB $design.</li></ul><h4 id="fa330e76-a9be-4e91-9e08-9526ac973721" data-toc-id="fa330e76-a9be-4e91-9e08-9526ac973721" collapsed="false" seolevelmigrated="true">Parent Management Training (PMT)</h4><ul><li>Focus: Training parents to use operant conditioning (ABCs, shaping) to alter child behavior in the home.</li><li>Target: Oppositional, aggressive, and antisocial behavior (e.g., Conduct Disorder).</li><li>Rationale: Aggressive behavior is often sustained by "Coercion" (Patterson et al.,$ 1992 $), where deviant behavior is reinforced by the parent, or by harsh physical punishment.</li><li>Techniques: Parents learn to define problems, observe behaviors, use praise/tokens, and deliver mild punishment (time out).</li></ul><h4 id="3e4bbc48-80d2-4958-9fbf-0f7ae562b495" data-toc-id="3e4bbc48-80d2-4958-9fbf-0f7ae562b495" collapsed="false" seolevelmigrated="true">Early and Intensive Behavioral Intervention (EIBI) for Autism</h4><ul><li>Origin: Pioneered by Ivar Lovaas in the$ 1960 $s.</li><li>Format: Intensive individualized training ($ 20 $-$ 40 $hours per week) for$ 2 $or more years for children under age$ 4 $.</li><li>Stages: Starts with simple commands and reducing tantrums, then imitative speech, then complex social interactions.</li><li>Evidence: Replicated studies show gains in IQ ($ IQ $), school placement, and communication skills.</li></ul><h4 id="5905e2d8-7b4b-4e32-946e-74a93fa141d9" data-toc-id="5905e2d8-7b4b-4e32-946e-74a93fa141d9" collapsed="false" seolevelmigrated="true">Pivotal Response Training (PRT) for Autism</h4><ul><li>Pivotal Response: A target functional domain that, when changed, leads to widespread changes in un-targeted behaviors.</li><li>Three Key Domains: 1. Motivation. 2. Self-initiation. 3. Socializing.</li><li>Unique Features: Use of child-selected stimuli, natural reinforcers (e.g., throwing the "ball" when the child says "ball"), and reinforcing attempts rather than only terminal responses.</li></ul><h4 id="73247cba-74e8-41fb-9230-738567e47a8f" data-toc-id="73247cba-74e8-41fb-9230-738567e47a8f" collapsed="false" seolevelmigrated="true">Rational-Emotive Behavior Therapy (REBT)</h4><ul><li>Creator: Albert Ellis.</li><li>Theory: Psychological problems stem from irrational thought patterns and implicit verbalizations (self-talk).</li><li>Common Irrational Beliefs: Needing universal approval, needing total competence, viewing life as disastrous when goals aren't met.</li><li>Case Illustration (Bernard et al.,$ 19 $83$ ): * $17$ -year-old girl with trichotillomania (hair pulling). * Identified beliefs: Fear of father's disapproval, need for absolute competence. * Treatment: Weekly therapy to dispute cognitions, followed by self-instruction training (coping statements). * Outcome: Hair pulling reduced to near zero.

Cognitive Therapy (CT) for Depression

Creator: Aaron Beck ( $1967$ ).
Negative Cognitive Triad: Negative thoughts toward (1) oneself, (2) the world, and (3) the future.
Method: Treating beliefs as hypotheses to be tested. Homework assignments to record negative thoughts and practice goal-directed activities.
Case Illustration (Chadwick & Trower, $1996$ ): * $31$ -year-old male with schizophrenia, paranoid delusions, and depression. * Beliefs: "I am a bad person," "God is punishing me." * Multiple-baseline design across three beliefs. * Results: Conviction in beliefs and clinical depression dropped significantly.

Problem-Solving Skills Training (PSST)

Skills Deficits (Table 13-3): 1. Alternative solution thinking. 2. Means-end thinking. 3. Consequential thinking. 4. Causal thinking. 5. Sensitivity to interpersonal problems.
Case Illustration (Dawson et al., $1986$ ): * Neglectful mothers referred by courts. * Trained via vignettes using modeling, shaping, and feedback. * Outcome: Improved child-rearing practices and restored custody for participants.

Dialectical Behavior Therapy (DBT)

Creator: Marsha Linehan ( $1993$ ) for Borderline Personality Disorder (BPD) and suicidality.
Synthesis: Acceptance (Zen/mindfulness) and Change (CBT).
Hierarchical Order of Targets: 1. Life-threatening behaviors. 2. Therapy-interfering behaviors. 3. Quality-of-life interfering behaviors. 4. Life skills (distress tolerance, mindfulness etc.).
Case Illustration (Low et al., $20$ 01 $): *$ 25 $-year-old woman with history of$ 75 $suicide attempts and physical/sexual abuse. * Focus: Self-harm (ingesting objects). * Outcome: Self-harm reached$ 0 $incidents by month$ 5 $of treatment.</li></ul><h3 id="5175f38a-131c-463c-b529-31f70281ba17" data-toc-id="5175f38a-131c-463c-b529-31f70281ba17" collapsed="false" seolevelmigrated="true">Challenges in Delivery and Implementation</h3><ul><li>Getting EBTs to Clinicians: * There are$ 700,000 $mental-health professionals in the US. * Missing Incentives: Unlike pharmaceutical companies, no profit motive exists to advertise psychotherapies. Training programs often fail to teach EBTs. * Inertia: Clinicians have little incentive to stop their practice and income to learn new techniques.</li><li>Getting Treatments to People in Need: * One-on-one therapy model cannot scale to the$ 70\% $untreated. * Solutions: Technology (Internet, smart phones). * Quitlines: Standardized phone counseling for tobacco use utilized by$ 1\% of US smokers annually, reaching underserved minorities effectively. * Self-Help: Internet-based modules for panic disorder and depression show effects comparable to individual therapy but are difficult for the public to differentiate from "quackery."

Questions & Discussion

Scenario 1 (Agoraphobia): A project to develop a concrete graduated exposure plan for a 23$$-year-old student afraid of open spaces.
Question 2 (Defining CBT): Identifying the specific "cognitive" and "behavioral" components of a selected technique.
Scenario 3 (Social Problem-Solving): Generating three socially appropriate solutions for: (a) meeting a new person in a lecture, and (b) resolving an accusation of theft from a friend.
Question 4 (Technology Design): Designing a tablet/smart phone app to deliver a stress intervention in daily life.