Factors That Impact Psychotherapy Outcomes and Treatment Approaches

learning objectives 16 16.1 Who seeks therapy and what are the
goals of therapy? 16.2 How is the success of psychotherapy
measured? 16.3 What are some of the factors that must be
considered to provide optimal treatment? 16.4 What
psychological approaches are used to treat abnormal behavior?
16.5 What roles do social values and culture play in
psychotherapy? 16.6 What biological approaches to treating
abnormal behavior are available? Most of us have experienced a
time or situation when we were dramatically helped by talking
things over with a relative or friend. Most therapists, like all
good listeners, rely on receptiveness, warmth, and empathy and
take a nonjudgmental approach to the problems their clients
present. But there is more to therapy than just giving someone
an opportunity to talk. Therapists also introduce into the
relationship psychological interventions that are designed to
promote new understandings, behaviors, or both on the client’s
part. The fact that these interventions are deliberately planned
and systematically guided by certain theoretical preconceptions
is what distinguishes professional therapy from more informal
helping relationships. An Overview of Treatment The belief that
people with psychological problems can change—can learn
more adaptive ways of perceiving, evaluating, and behaving—is
the conviction underlying all psychotherapy. Achieving these
changes is by no means easy. Sometimes a person’s view of the
world and her or his self-concept are distorted because of
pathological early relationships that have been reinforced by
years of negative life experiences. In other instances,
environmental factors such as an unsatisfying job, an unhappy
relationship, or financial stresses must be the focus of attention
in addition to psychotherapy. Because change can be hard,
people sometimes find it easier to bear their present problems
than to challenge themselves to chart a different life course.
Therapy also takes time. Even a highly skilled and experienced
therapist cannot undo a person’s entire past history and, within

a short time, prepare him or her to cope adequately with
difficult life situations. Therapy offers no magical
transformations. Nevertheless, it holds promise even for the
most severe mental disorders. Moreover, contrary to common
opinion, psychotherapy can be less expensive in the long run
than alternative modes of intervention (Dobson et al., 2008;
Gabbard et al., 1997). Numerous therapeutic approaches exist,
ranging from psychoanalysis to Zen meditation. However, the
era of managed care has prompted new and increasingly
stringent demands that the efficacy of treatments be empirically
demonstrated. This chapter will explore some of the most
widely accepted psychological and biological treatment
approaches in use today. Although we recognize that different
groups of mental health professionals often have their own
preferences with respect to the use of the terms client and
patient, in this chapter we use the terms interchangeably. Why
Do People Seek Therapy? People who seek therapy vary widely
in their problems and in their motivations to solve them. Below
we explore a few such motivations. STRESSFUL CURRENT
LIFE CIRCUMSTANCES Perhaps the most obvious candidates
for psychological treatment are people experiencing sudden and
highly stressful situations such as a divorce or unemployment—
people who feel so overwhelmed by a crisis that they cannot
manage on their own. These people often feel quite vulnerable
and tend to be open to psychological treatment because they are
motivated to alter their present intolerable mental states. In
such situations, clients may gain considerably—and in a brief
time—from the perspective provided by their therapists.
PEOPLE WITH LONG-STANDING PROBLEMS Other people
entering therapy have experienced long-term psychological
distress and have lengthy histories of maladjustment. They may
have had interpersonal problems such as an inability to be
comfortable with intimacy, or they may have felt susceptible to
low moods that are difficult for them to shake. Chronic
unhappiness and the inability to feel confident and secure may
finally prompt them to seek outside help. These people seek

psychological assistance out of dissatisfaction and despair.
They may enter treatment with a high degree of motivation, but
as therapy proceeds, their persistent patterns of maladaptive
behavior may generate resistance with which a therapist must
contend. For example, a narcissistic client who expects to be
praised by his or her therapist may become disenchanted and
hostile when such ego “strokes” are not forthcoming.
RELUCTANT CLIENTS Some people enter therapy by a more
indirect route. Perhaps they had consulted a physician for their
headaches or stomach pains, only to be told that nothing was
physically wrong with them. After they are referred to a
therapist, they may at first resist the idea that their physical
symptoms are emotionally based. Motivation to enter treatment
differs widely among psychotherapy clients. Reluctant clients
may come from many situations—for example, a person with a
substance abuse problem whose spouse threatens “either therapy
or divorce,” or a suspected felon whose attorney advises that
things will go better at trial if it can be announced that the
suspect has “entered therapy.” A substantial number of angry
parents bring their children to therapists with demands that their
child’s “problematic behavior,” which they view as independent
of the family context, be “fixed.” These parents may be
surprised and reluctant to recognize their own roles in shaping
their child’s behavior patterns. In general, males are more
reluctant to seek help of any kind when they are experiencing
problems than females are. In the case of depression, far more
men than women say that they would never consider seeing a
therapist; when men are depressed they are even reluctant to
seek informal help from their friends. Moreover, when men do
seek professional help, they tend to ask fewer questions than
women do (see Addis & Mahalik, 2003). Why should this be?
One answer is that men are less able than women to recognize
and label feelings of distress and to identify these feelings as
emotional problems. In addition, men who subscribe to
masculine stereotypes emphasizing self-reliance and lack of
emotionality also tend to experience more gender-role conflict

when they consider traditional counseling, with its focus on
emotions and emotional disclosure. For a man who prides
himself on being emotionally stoic, seeking help for a problem
like depression may present a major threat to his self-esteem.
Seeking help also requires giving up some control and may run
counter to the ideology that “a real man helps himself.” How
can men be encouraged to seek help when they have
difficulties? Part of the solution may be to develop new
treatment approaches that provide a better fit for men who see
little value in talking about their problems. An example here
might be the use of virtual reality therapy to treat soldiers with
posttraumatic stress disorder (PTSD; see Chapter 5). Another
strategy is to use more creative approaches to encourage men to
seek help and support. For example, television commercials for
erectile dysfunction use professional basketball players and
football coaches to encourage men with similar problems to
“step up to the plate” and talk to their doctors. Making men
more aware of other “masculine men” who have been “man
enough” to go for help when they needed it may be an important
step toward educating those whose adherence to masculine
gender roles makes it difficult for them to acknowledge and
seek help for their problems. PEOPLE WHO SEEK PERSONAL
GROWTH A final group of people who enter therapy have
problems that would be considered relatively normal. That is,
they appear to have achieved success, have financial stability,
have generally accepting and loving families, and have
accomplished many of their life goals. They enter therapy not
out of personal despair or impossible interpersonal
involvements but out of a sense that they have not lived up to
their own expectations and realized their own potential. These
people, partly because their problems are more manageable than
the problems of others, may make substantial gains in personal
growth. Psychotherapy, however, is not just for people who
have clearly defined problems, high levels of motivation, and an
ability to gain insight into their behavior. Psychotherapeutic
interventions have been applied to a wide variety of chronic

problems. Even severely disturbed clients with psychosis may
profit from a therapeutic relationship that takes into account
their level of functioning and maintains therapeutic subgoals
that are within their capabilities (e.g., Kendler, 1999;
Valmaggia et al., 2008). It should be clear from these brief
descriptions that there is no typical client. Neither is there a
model therapy. No currently used form of therapy is applicable
to all types of clients, and all of the standard therapies can
document some successes. Most authorities agree that client
variables such as motivation to change and severity of
symptoms are exceedingly important to the outcome of therapy
(Clarkin & Levy, 2004). As we will see, the various therapies
have relatively greater success when a therapist takes the
characteristics of a particular client into account in determining
treatment approaches. Who Provides Psychotherapeutic
Services? Members of many different professions have
traditionally provided advice and counsel to individuals in
emotional distress. Physicians, in addition to caring for their
patients’ physical problems, often become trusted advisers in
emotional matters as well. Many physicians are trained to
recognize psychological problems that are beyond their
expertise and to refer patients to psychological specialists or to
psychiatrists. Another professional group that deals extensively
with emotional problems is the clergy. A minister, priest, or
rabbi is frequently the first professional to encounter a person
experiencing an emotional crisis. Although some clergy are
trained mental health counselors, most limit their counseling to
religious matters and spiritual support and do not attempt to
provide psychotherapy. Rather, like general-practice physicians,
they are trained to recognize problems that require professional
management and to refer seriously disturbed people to mental
health specialists. Often the first person that someone
experiencing an emotional crisis will talk to is a trusted member
of his or her religious community. The three types of mental
health professionals who most often administer psychological
treatment in mental health settings are clinical psychologists,

psychiatrists, and psychiatric social workers. In addition to their
being able to provide psychotherapy, the medical training and
licensure qualifications of psychiatrists enable them to prescribe
psychoactive medications and also to administer other forms of
medical treatment such as electroconvulsive therapy. In some
states, appropriately supervised psychologists and other clinical
specialists may prescribe medications if they have received
additional training. Although mental health professionals differ
with respect to their training and approach to treatment,
generally, psychiatrists differ from psychologists insofar as they
treat mental disorders using biological approaches (e.g.,
medications), whereas psychologists treat patients’ problems by
examining and in some cases changing their patients’ behaviors
and thought patterns. In a clinic or hospital (as opposed to an
individual practice), a wide range of treatment approaches may
be used. These range from the use of medications, to individual
or group psychotherapy, to home, school, or job visits aimed at
modifying adverse conditions in a client’s life—for example,
helping a teacher become more understanding and supportive of
a child-client’s needs. Often the latter is as important as
treatment directed toward modifying the client’s personality,
behavior, or both. This willingness to use a variety of
procedures is reflected in the frequent use of a team approach to
assessment and treatment, particularly in group practice and
institutional settings. This approach ideally involves the
coordinated efforts of medical, psychological, social work, and
other mental health personnel working together as the needs of
each case warrant. Also of key importance is the current
practice of providing treatment facilities in the community.
Instead of considering maladjustment to be an individual’s
private misery, which in the past often required confinement in
a distant mental hospital, this approach integrates family and
community resources in a total treatment approach. The
Therapeutic Relationship The therapeutic relationship evolves
out of what both client and therapist bring to the therapeutic
situation. The outcome of psychotherapy normally depends on

whether the client and therapist are successful in achieving a
productive working alliance. The client’s major contribution is
his or her motivation. Clients who are pessimistic about their
chances of recovery or who are ambivalent about dealing with
their problems and symptoms respond less well to treatment
(e.g., Mussell et al., 2000). The establishment of an effective
working alliance between client and therapist is seen by most
investigators and practitioners as essential to psychotherapeutic
gain. Our experiences as therapists affirm this basic
observation, as does the research literature. In a very real sense,
the relationship with the therapist is therapeutic in its own
right. Studies of the therapeutic relationship show that how well
patients do over the course of therapy is predicted by the ability
of their therapist to form a strong alliance with them (Baldwin
et al., 2007). Although definitions of the therapeutic alliance
vary, its key elements are (1) a sense of working collaboratively
on the problem, (2) agreement between patient and therapist
about the goals and tasks of therapy, and (3) an affective bond
between patient and therapist (see Constantino et al., 2001;
Martin et al., 2000). Clear communication is also important.
This is no doubt facilitated by the degree of shared experience
in the backgrounds of client and therapist. Almost as important
as motivation is a client’s expectation of receiving help. This
expectancy is often sufficient in itself to bring about substantial
improvement, perhaps because patients who expect therapy to
be effective engage more in the process (Meyer et al., 2002).
Just as a placebo often lessens pain for someone who believes it
will do so, a person who expects to be helped by therapy is
likely to be helped, almost regardless of the particular methods
used by a therapist. The downside of this fact is that if a therapy
or therapist fails for whatever reason to inspire client
confidence, the effectiveness of treatment is likely to be
compromised. What are some of the key elements of an
effective therapeutic alliance between client and therapist? To
the art of therapy, a therapist brings a variety of professional
skills and methods intended to help people see themselves and

their situations more objectively—that is, to gain a different
perspective. Besides helping provide a new perspective, most
therapy situations also offer a client a safe setting in which he
or she is encouraged to practice new ways of feeling and acting,
gradually developing both the courage and the ability to take
responsibility for acting in more effective and satisfying ways.
To bring about such changes, an effective psychotherapist must
help the client give up old and dysfunctional behavior patterns
and replace them with new, functional ones. Because clients
will present varying challenges in this regard, the therapist must
be flexible enough to use a variety of interactive styles. in
review • Why do people seek therapy? • What kinds of
professionals provide help to people in psychological distress?
In what kinds of settings does treatment occur? • What factors
are important in determining how well patients do in therapy?
Measuring Success in Psychotherapy Evaluating treatment
success is not always as easy as it might seem (Hill & Lambert,
2004). Attempts at estimating clients’ gains in therapy generally
depend on one or more of the following sources of information:
(1) a therapist’s impression of changes that have occurred, (2) a
client’s reports of change, (3) reports from the client’s family
or friends, (4) comparison of pretreatment and posttreatment
scores on personality tests or other instruments designed to
measure relevant facets of psychological functioning, and (5)
measures of change in selected overt behaviors. Unfortunately,
each of these sources has its own limitations. A therapist may
not be the best judge of a client’s progress because any therapist
is likely to be biased in favor of seeing himself or herself as
competent and successful (after all, therapists are only human).
In addition, the therapist typically has only a limited
observational sample (the client’s in-session behavior) from
which to make judgments of overall change. Furthermore,
therapists can inflate improvement averages by deliberately or
subtly encouraging difficult clients to discontinue therapy. The
problem of how to deal with early dropouts from treatment
further complicates many studies of therapy outcomes. Should

these patients be excluded from analyses of outcome? (After all,
they have received little or none of the therapy being
evaluated.) Or should they be included and counted as treatment
failures? These issues have been at the heart of much debate and
discussion. Also, a client is not necessarily a reliable source of
information on therapeutic outcomes. Not only may clients want
to believe for various personal reasons that they are getting
better, but in an attempt to please the therapist they may report
that they are being helped. In addition, because therapy often
requires a considerable investment of time, money, and
sometimes emotional distress, the idea that it has been useless
is a dissonant one. Relatives of the client may also be inclined
to “see” the improvement they had hoped for, although they
often seem to be more realistic than either the therapist or the
client in their evaluations of outcome. Clinical ratings by an
outside, independent observer are sometimes used in research
on psychotherapy outcomes to evaluate the progress of a client;
these ratings may be more objective than ratings made by those
directly involved in the therapy. Another widely used objective
measure of client change is performance on various
psychological tests. A client evaluated in this way takes a
battery of tests before and after therapy, and the differences in
scores are assumed to reflect progress, or lack of progress, or
occasionally even deterioration. However, some of the changes
that such tests show may be artifactual, as with regression to the
mean, wherein very high (or very low) scores tend on repeated
measurement to drift toward the average of their own
distributions, yielding a false impression that some real change
has been documented. Also, the particular tests selected are
likely to focus on the theoretical predictions of the therapist or
researcher. Thus they are not necessarily valid predictors of the
changes, if any, that the therapy actually induces or of how the
client will behave in real life. And without follow-up
assessment, they provide little information on how enduring any
change is likely to be. Objectifying and Quantifying Change
Generalized terms such as recovery, marked improvement, and

moderate improvement, which were often used in outcome
research in the past, are open to considerable differences in
interpretation. Today the emphasis is on using more quantitative
methods of measuring change. For example, the Beck
Depression Inventory (a self-report measure of depression
severity) and the Hamilton Rating Scale for Depression (a set of
rating scales used by clinicians to measure the same thing) both
yield summary scores and have become almost standard in the
pre- and post-therapy assessment of depression. Changes in
preselected and specifically denoted behaviors that are
systematically monitored, such as how many times a client with
obsessions about contamination washes his or her hands, are
often highly valid measures of outcome. Such techniques,
including client self-monitoring, have been widely and
effectively used, mainly by behavioral and cognitive-behavioral
therapists. research CLOSE-UP: Regression to the Mean This
reflects the statistical tendency for extreme scores (e.g., very
high or very low scores) on a given measure to look less
extreme at a second assessment (as occurs in a repeated-
measures design). Because of this statistical artifact, people
whose scores are farthest away from the group mean to begin
with (e.g., people who have the highest anxiety scores or the
lowest scores on self-esteem) will tend to score closer to the
group mean at the second assessment, even if no real clinical
change has occurred. In research settings, functional magnetic
resonance imaging (fMRI) can be used to examine brain activity
before and after treatment. For example, Nakao and colleagues
(2005) studied 10 outpatients with obsessive-compulsive
disorder (OCD). At the start of the study, all the patients
received a brain scan while they were engaged in a task that
required them to think about words (e.g., sweat, urine, feces)
that triggered their obsessions and compulsions. Patients were
then treated for 12 weeks either with the SSRI (selective
serotonin reuptake inhibitor) fluvoxamine (Luvox) or with
behavior therapy. At the end of this treatment period, the brain
scanning was repeated. The results showed that, before

treatment, certain areas of the brain thought to be involved in
OCD (e.g., a brain region in the frontal lobe called the
orbitofrontal cortex) were activated during the symptom-
provocation task. However, after therapy, these same regions
showed much less activation when the patients were challenged
to think about the provocative trigger words. In subsequent
research these scientists have also shown that, after 12 weeks of
behavior therapy, patients with OCD again show changes in
several brain regions that are implicated in this disorder
(Nabeyama et al., 2008). Research of this type suggests that
physiological changes may indeed accompany the clinical gains
that occur in psychotherapy (see Siegle et al., 2012). It is
important to keep in mind, however, that changes on rating
scales (or on MRI scans) do not necessarily tell us how well the
patient is functioning in everyday life (Kazdin, 2008). Would
Change Occur Anyway? What happens to disturbed people who
do not obtain formal treatment? In view of the many ways in
which people can help each other, it is not surprising that
improvement often occurs without professional intervention.
Moreover, some forms of psychopathology such as depressive
episodes or brief psychotic disorder sometimes run a fairly short
course with or without treatment. In other instances, disturbed
people improve over time for reasons that are not apparent.
Even if many emotionally disturbed persons tend to improve
over time without psychotherapy, psychotherapy can often
accelerate improvement or bring about desired behavior change
that might not otherwise occur. Most researchers today would
agree that psychotherapy is more effective than no treatment
(see Shadish et al., 2000), and indeed the pertinent evidence,
widely cited throughout this entire text, confirms this strongly.
The chances of an average client benefiting significantly from
psychological treatment are, overall, impressive (Lambert &
Ogles, 2004). Research suggests that about 50 percent of
patients show clinically significant change after 21 therapy
sessions. After 40 sessions, about 75 percent of patients have
improved (Lambert et al., 2001). But why do patients improve?

Remarkably, we know very little about the mechanisms through
which therapeutic change occurs, or about the “active
ingredients” of effective therapy (Kazdin, 2008; Hayes et al.,
2011). We do know that progress in therapy is not always
smooth and linear, however. Sudden gains can occur between
one therapy session and another (Tang & DeRubeis, 1999; Tang
et al., 2002). These clinical leaps appear to be triggered by
cognitive changes or by psychodynamic insights that patients
experience in certain critical sessions. Researchers are now
actively exploring how such factors as therapist adherence (how
well a therapist delivers a particular type of therapy) and
therapist competence (how skillfully the therapist administers
the therapy) impact how well the patient does (see Webb et al.,
2010). For patients receiving cognitive therapy for depression,
therapist competence has been shown to be a predictor of better
clinical outcome, as might be expected (Strunk et al., 2010).
Can Therapy Be Harmful? The outcomes of psychotherapy are
not invariably either neutral (no effect) or positive. Some
clients are actually harmed by their encounters with
psychotherapists (see The World Around Us box). According to
one estimate, somewhere between 5 and 10 percent of clients
deteriorate during treatment (Lambert & Ogles, 2004). Patients
suffering from borderline personality disorder and from OCD
typically have higher rates of negative treatment outcomes than
do patients with other problems (Mohr, 1995). Problems in the
therapeutic alliance account for some instances of treatment
failure. For example, a mismatch of therapist and client
personality characteristics may produce deteriorating outcomes.
Our impression, supported by some evidence (see Beutler et al.,
2004; Castonguay et al., 2010), is that certain therapists,
probably for reasons of personality or lack of interpersonal
skills, just do not do well with certain types of client problems.
In light of these intangible factors, it is ethically required of all
therapists (1) to monitor their work with various types of clients
to discover any such deficiencies and (2) to refer to other
therapists those clients with whom they may be ill-equipped to

work (American Psychological Association, 2002).
Unfortunately, clinicians are often quite bad at recognizing
when their clients are not doing well (Whipple & Lambert,
2011). To address this problem, research-based measures to
assess clinical deterioration are now being developed. If
clinicians are willing to use these in their routine clinical
practice, they will be able to be warned when their clients are
not progressing in an expected manner. A major hurdle,
however, is implementation. We would not be surprised to learn
that the worst therapists are the ones most reluctant to use such
patient-monitoring methods. the WORLD around us: When
Therapy Harms There are many ways in which therapy can be
detrimental. For example, a particular therapy might make
certain symptoms worse, make a person more concerned about
the symptoms they do have, or make the client excessively
dependent on the therapist in order to function. Encounters with
some therapists or forms of therapy may also make a person less
willing to seek therapy in the future. Lilienfeld (2007) has
developed a list of therapies that have potentially harmful
consequences. One example is “rebirthing” therapy for children
with attachment problems. This approach, which involves
therapists wrapping children in blankets, sitting on them, and
squeezing them in an attempt to mirror the birth process, has
resulted in several children dying of suffocation. Another
problematic technique is facilitated communication, which is
based on the premise that children with autism can communicate
if they have the assistance of a facilitator who helps the child
communicate using a computer keyboard. Facilitated
communication has been linked to dozens of child sexual abuse
allegations against the parents of children with autism. This has
exposed these families to a great deal of needless emotional
pain and suffering because studies show that the
communications in facilitated communication do not come from
the children themselves. Rather, they are unknowingly
generated by the facilitators themselves as they guide the
child’s hands over the keyboard. All practicing clinicians and

therapists owe it to their clients (and to the families of their
clients) to educate themselves about research on potentially
harmful treatments. They should also monitor their own
behavior and adhere to high ethical standards of practice. In this
way they can minimize the likelihood that they will cause
damage to the people who come to them seeking help. A special
case of therapeutic harm concerns what are called boundary
violations. This is when the therapist behaves in ways that
exploit the trust of the patient or engages in behavior that is
highly inappropriate (e.g., taking the patient to dinner, giving
the patient gifts). One case involved a patient who had been
treated by a psychiatrist for 10 years. During this time the
patient gave the therapist gifts of a refrigerator and a dining
table and six chairs. She also sold him her Waterford crystal,
her china, and a silver service. The silver had an appraised
value of $1,600. However, it was purchased by the psychiatrist
for only $200. The psychiatrist also sold the patient two of his
boats, without her even having seen them (Norris et al., 2003).
A sexual relationship between the patient and the therapist
represents perhaps the most obvious and extreme example of a
serious boundary violation. This is highly unethical conduct.
Given the frequently intense and intimate quality of therapeutic
relationships, it is not surprising that sexual attraction arises.
However, it is the therapist’s professional responsibility to
maintain the appropriate boundaries at all times. When
exploitive and unprofessional behavior on the part of therapists
does occur, it results in great harm to patients (Norris et al.,
2003). Anyone seeking therapy needs to be sufficiently aware
enough to determine that the therapist she or he has chosen is
committed to high ethical and professional standards. For the
vast majority of therapists, this is indeed the case. in review
What approaches can be used to evaluate treatment success?
What are the advantages and limitations of these approaches?
Do people who receive psychological treatment always show a
clinical benefit? What is a boundary violation? Give three
examples. What Therapeutic Approaches Should Be Used?

Before optimal treatment can be provided, a number of
important decisions must be made. In the sections below we
consider some of the factors that are important. Evidence-Based
Treatment When a pharmaceutical company develops a new
drug, it must obtain approval of the drug from the federal Food
and Drug Administration (FDA) before that drug can be
marketed. This involves, among other things, demonstrating
through research on human subjects that the drug has efficacy—
that is, the drug does what it is supposed to do in curing or
relieving some target condition. These tests, using voluntary
and informed patients as subjects, are called randomized
clinical trials (RCTs) or, more simply, efficacy trials. Although
these trials may become quite elaborate, the basic design is one
of randomly assigning (e.g., by the flip of a coin) half the
patients to the supposedly “active” drug and the other half to a
visually identical but physiologically inactive placebo. Usually,
neither the patient nor the prescriber is informed which is to be
administered; that information is recorded in code by a third
party. This double-blind procedure (see Chapter 1) is an effort
to ensure that expectations on the part of the patient and
prescriber play no role in the study. After a predetermined
treatment interval, the code is broken and the active-drug or
placebo status of all subjects is revealed. If subjects on the
active drug have improved in health significantly more than
subjects on the placebo, the investigator has evidence of the
drug’s efficacy. Obviously, the same design could be modified
to compare the efficacy of two or more active drugs, with the
option of adding a placebo condition. Thousands of such studies
are in progress daily across the country. They usually take place
in academic medical settings, and many are financially
supported by the pharmaceutical industry. Investigators of
psychotherapy outcomes have attempted to apply this research
design to their own field of inquiry, with necessary
modifications (see Chambless & Ollendick, 2001). A source of
persistent frustration has been the difficulty of creating a
placebo condition that will appear credible to patients. Most

such research has thus adopted the strategy of either comparing
two or more purportedly “active” therapies or using a no-
treatment (“wait list”) control of the same duration as the
active-drug treatment. However, withholding treatment from
patients in need (even temporarily) by placing them on a wait
list sometimes raises ethical concerns. Another problem is that
therapists, even those with the same theoretical orientations,
often differ markedly in the manner in which they deliver
therapy. (In contrast, pills of the same chemical compound and
dosage do not vary.) To test a given therapy, it therefore
becomes necessary to develop a treatment manual to specify just
how the therapy under examination will be delivered. Therapists
in the research trial are then trained (and monitored) to make
sure that their therapy sessions do not deviate significantly from
the procedures outlined in the manual (e.g., see Blum et al.,
2008). Efforts to “manualize” therapy represent one way that
researchers have tried to minimize the variability in patients’
clinical outcomes that might result from characteristics of the
therapist themselves (such as personal charisma). Although
manualized therapies originated principally to standardize
psychosocial treatments to fit the RCT paradigm, some
therapists recommend extending their use to routine clinical
practice after efficacy for particular disorders has been
established (e.g., see Wilson, 1998). Practicing clinicians,
however, vary in their attitudes toward treatment manuals
(Addis & Krasnow, 2000). Efficacy, or RCT, studies of
psychosocial treatments are increasingly common. These time-
limited studies typically focus on patients who have a single
DSM diagnosis (patients with comorbid diagnoses are
sometimes excluded) and involve two or more treatment or
control (e.g., wait list) conditions, where at least one of the
treatment conditions is psychosocial (another could be some
biological therapy, such as a particular drug). Client-
participants are randomly assigned to these conditions, whose
effects, if any, are evaluated systematically with a common
battery of assessment instruments, usually administered both

before and after treatment. Efficacy studies of the outcomes of
specific psychosocial treatment procedures are considered the
most rigorous type of evaluation researchers have for
establishing that a given therapy “works” for clients with a
given diagnosis. Treatments that meet this standard are often
described as evidence based or empirically supported.
Medication or Psychotherapy? Advances in
psychopharmacology have allowed many people who would
otherwise need hospitalization to remain with their families and
function in the community. These advances have also reduced
the time patients need to spend in the hospital and have made
restraints and locked wards largely relics of the past. In short,
medication has led to a much more favorable hospital climate
for patients and staff alike. Nevertheless, certain issues arise in
the use of psychotropic drugs. Aside from possible unwanted
side effects, there is the complexity of matching drug and drug
dosage to the needs of the specific patient. It is also sometimes
necessary for patients to change medication in the course of
treatment. In addition, the use of medications in isolation from
other treatment methods may not be ideal for some disorders
because drugs themselves generally do not cure disorders.
Nonetheless, there is now a national trend toward greater use of
psychiatric medications at the expense of psychotherapy. This
may be problematic because, as many investigators have pointed
out, drugs tend to alleviate symptoms by inducing biochemical
changes, not by helping the individual understand and change
the personal or situational factors that may be creating or
reinforcing maladaptive behaviors. Moreover, when drugs are
discontinued, patients may be at risk of relapsing (Dobson et
al., 2008). For many disorders, a variety of evidence-based
forms of psychotherapy may produce more long-lasting benefits
than medications alone unless the medications are continued
indefinitely. Combined Treatments The integration of
medication and psychotherapy remains common in clinical
practice, particularly for disorders such as schizophrenia and
bipolar disorder (Olfson & Marcus, 2010). Such integrated

approaches are also appreciated and regarded as essential by the
patients themselves. The integrative approach is a good example
of the biopsychosocial perspective that best describes current
thinking about mental disorders and that is reflected throughout
this book. Medications can be combined with a broad range of
psychological approaches. In some cases, they can help patients
benefit more fully from psychotherapy. For example, patients
with social anxiety disorder who receive exposure therapy do
much better if they are given an oral dose of D-cycloserine
before each session. D-cycloserine is an antibiotic used in the
treatment of tuberculosis. When taken alone, it has no effect on
anxiety. However, D-cycloserine activates a receptor that is
critical in facilitating extinction of anxiety. By making the
receptor work better, the therapeutic benefits of exposure
training are enhanced in people taking D-cycloserine versus
placebo (Guastella et al., 2008; Hofman et al., 2006). Typically,
psychosocial interventions are combined with psychiatric
medications. This may be especially beneficial for patients with
severe disorders (see Gabbard & Kay, 2001). Keller and
colleagues (2000) compared the outcomes of 519 depressed
patients who were treated with an antidepressant (nefazodone),
with psychotherapy (cognitive-behavioral), or with a
combination of both of these treatments. In the medication-
alone condition, 55 percent of patients did well. In the
psychotherapy-alone condition, 52 percent of patients responded
to treatment. However, patients for whom the two treatments
were combined did even better, with an overall positive
response rate of 85 percent. Quite possibly, combined treatment
is effective because medications and psychotherapy may target
different symptoms and work at different rates. As Hollon and
Fawcett (1995) have noted, “Pharmaco-therapy appears to
provide rapid, reliable relief from acute distress, and
psychotherapy appears to provide broad and enduring change,
with combined treatment retaining the specific benefits of each”
(p. 1232). It is important to note that combined treatments are
not always superior to single treatments. Adding psychiatric

medications does not generally improve the clinical efficacy of
psychosocial treatments for anxiety disorders, for example.
However, for people suffering from chronic or recurrent
depression, combined treatments often result in better clinical
outcomes (Aaronson et al., 2007). in review What are the
advantages and drawbacks of using a manualized therapy? What
does it mean to describe a treatment as evidence based? For
what kinds of disorders is combination therapy superior?
Psychosocial Approaches To Treatment People are fascinated by
psychotherapy. As practicing therapists, we are often asked
about the work that we do and the kinds of patients we see. In
this section, we try to give you a sense of the different clinical
approaches that therapists sometimes use. Although we have
discussed treatment in the earlier chapters in the context of
specific disorders, our goal here is to provide you with a better
sense of the different therapeutic approaches, illustrating them
with case studies whenever possible. Behavior Therapy
Behavior therapy is a direct and active treatment that recognizes
the importance of behavior, acknowledges the role of learning,
and includes thorough assessment and evaluation. Instead of
exploring past traumatic events or inner conflicts, behavior
therapists focus on the presenting problem—the problem or
symptom that is causing the patient great distress. A major
assumption of behavior therapy is that abnormal behavior is
acquired in the same way as normal behavior—that is, by
learning. A variety of behavioral techniques have therefore been
developed to help patients “unlearn” maladaptive behaviors by
one means or another. EXPOSURE THERAPY As you know, a
behavior therapy technique that is widely used in the treatment
of anxiety disorders is exposure (see Chapter 6). If anxiety is
learned, then, from the behavior therapy perspective, it can be
unlearned. This is accomplished through guided exposure to
anxiety-provoking stimuli. During exposure therapy, the patient
or client is confronted with the fear-producing stimulus in a
therapeutic manner. This can be accomplished in a very
controlled, slow, and gradual way, as in systematic

desensitization, or in a more extreme manner, as in flooding, in
which the patient directly confronts the feared stimulus at full
strength. (An example is a housebound patient with agoraphobia
being accompanied outdoors by the therapist.) Moreover, the
form of the exposure can be real (also known as in vivo
exposure) or imaginary (imaginal exposure). The rationale
behind systematic desensitization is quite simple: Find a
behavior that is incompatible with being anxious (such as being
relaxed or experiencing something pleasant) and repeatedly pair
this with the stimulus that provokes anxiety in the patient.
Because it is difficult if not impossible to feel both pleasant and
anxious at the same time, systematic desensitization is aimed at
teaching a person, while in the presence (real or imagined) of
the anxiety-producing stimulus, to relax or behave in some
other way that is inconsistent with anxiety. It may therefore be
considered a type of counterconditioning procedure. The term
systematic refers to the carefully graduated manner in which the
person is exposed to the feared stimulus. The prototype of
systematic desensitization is the classic experiment of Mary
Cover Jones (1924), in which she successfully eliminated a
small boy’s fears of a white rabbit and other furry animals. She
began by bringing the rabbit just inside the door at the far end
of the room while the boy, Peter, was eating. On successive
days, the rabbit was gradually brought closer until Peter could
pat it with one hand while eating with the other. Joseph Wolpe
(1958; Rachman & Hodgson, 1980) elaborated on the procedure
developed by Jones and coined the phrase systematic
desensitization to refer to it. On the assumption that most
anxiety-based patterns are, fundamentally, conditioned
responses, Wolpe worked out a way to train a client to remain
calm and relaxed in situations that formerly produced anxiety.
Wolpe’s approach is elegant in its simplicity, and his method is
equally straightforward. Exposure therapy involves confronting
anxiety-provoking situations. It can be done in vivo (in real
life) or in thoughts or imagination. In vivo is preferable
whenever practically possible. A client is first taught to enter a

state of relaxation, typically by progressive concentration on
relaxing various muscle groups. Meanwhile, patient and
therapist collaborate in constructing an anxiety hierarchy that
consists of imagined scenes graded as to their capacity to elicit
anxiety. For example, for a dog-phobic patient, a low-anxiety
step might be imagining a small dog in the distance being
walked on a leash by its owner. In contrast, a high-anxiety step
might be imagining a large and exuberant dog running toward
the patient. Therapy sessions consist of the patient’s repeatedly
imagining, under conditions of deep relaxation, the scenes in
the hierarchy, beginning with low-anxiety images and gradually
working toward those in the more extreme ranges. Treatment
continues until all items in the hierarchy can be imagined
without notable discomfort, at which point the client’s real-life
difficulties typically have shown substantial improvement.
Imaginal procedures have some limitations, an obvious one
being that not everybody is capable of vividly imagining the
required scenes. In an influential early study of clients with
agoraphobia, Emmelkamp and Wessels (1975) conclude that
prolonged exposure in vivo is superior to imaginal exposure.
Since then, therapists have sought to use in vivo exposure
whenever practical, encouraging clients to confront anxiety-
provoking situations directly. As practicing clinicians, we
sometimes receive requests from behavior therapists using
electronic mailing lists for instructions on making concoctions
that look like vomit. In these cases the therapist is treating
someone who has a vomiting phobia and has a need for
something that looks realistic for an in vivo exposure. Of
course, in vivo exposure is not possible for all stimuli. In
addition, occasionally a client is so fearful that he or she cannot
be induced to confront the anxiety-arousing situation directly.
Imaginal procedures are therefore a vital part of the therapeutic
exposure repertoire. An important development in behavior
therapy is the use of virtual reality to help patients overcome
their fears and phobias (Rothbaum, Hodges, et al., 2000). Such
approaches are obviously needed when the source of the

patient’s anxiety is something that is not easily reproduced in
real life, such as flying. Overall, the outcome record for
exposure treatments is impressive (Barlow et al., 2007;
Emmelkamp, 2004). It is also encouraging that the results from
virtual reality exposure are comparable to the results obtained
from in vivo exposure (Powers & Emmelkamp, 2008).
AVERSION THERAPY Aversion therapy involves modifying
undesirable behavior by the old-fashioned method of
punishment. Probably the most commonly used aversive stimuli
today are drugs that have noxious effects, such as Antabuse,
which induces nausea and vomiting when a person who has
taken it ingests alcohol. In another variant, the client is
instructed to wear a substantial elastic band on the wrist and to
“snap” it when temptation arises, thus administering self-
punishment. In the past, painful electric shock was commonly
employed in programs that paired it with the occurrence of the
undesirable behavior, a practice that certainly contributed to
aversion therapy’s negative image among some segments of the
public. Although aversive conditioning has been used to treat a
wide range of mal-adaptive behaviors including smoking,
drinking, overeating, drug dependence, gambling, sexual
deviance, and bizarre psychotic behavior, interest in this
approach has declined as other treatment options have become
available (see Emmelkamp, 2004). MODELING As the name
implies, in modeling the client learns new skills by imitating
another person, such as a parent or therapist, who performs the
behavior to be acquired. A younger client may be exposed to
behaviors or roles in peers who act as assistants to the therapist
and then be encouraged to imitate and practice the desired new
responses. For example, modeling may be used to promote the
learning of simple skills such as self-feeding for a child with
profound mental retardation or more complex skills such as
being more effective in social situations for a shy, withdrawn
adolescent. In work with children especially, effective decision
making and problem solving may be modeled when the therapist
“thinks out loud” about everyday choices that present

themselves in the course of therapy (Kendall, 1990; Kendall &
Braswell, 1985). Modeling and imitation are adjunctive aspects
of various forms of behavior therapy as well as other types of
therapy. For example, in an early classic work, Bandura (1964)
found that live modeling of fearlessness, combined with
instruction and guided exposure, was the most effective
treatment for snake phobia, resulting in the elimination of
phobic reactions in over 90 percent of the cases treated. The
photographs taken during the treatment of spider phobia (see
Chapter 6) provide a graphic example of a similar approach.
SYSTEMATIC USE OF REINFORCEMENT Systematic
programs that use reinforcement to suppress (extinguish)
unwanted behavior or to elicit and maintain desired behavior
have achieved notable success. Often called contingency
management programs, these approaches are often used in
institutional settings, although this is not always the case.
Suppressing problematic behavior may be as simple as removing
the reinforcements that support it, provided, of course, that they
can be identified. Sometimes identification is relatively easy, as
in the following case. In other instances, it may require
extremely careful and detailed observation and analysis for the
therapist to learn what is maintaining the maladaptive behavior.
Showing Off in Class Billy, a 6-year-old first grader, was
brought to a psychological clinic by his parents because he
hated school and because his teacher had told them that his
showing off was disrupting the class and making him unpopular.
It became apparent in observing Billy and his parents during the
initial interview that both his mother and his father were
noncritical and approving of everything Billy did. After further
assessment, a three-phase program of therapy was undertaken:
(1) Billy’s parents were helped to discriminate between
showing-off behavior and appropriate behavior on Billy’s part.
(2) They were instructed to ignore Billy when he engaged in
showing-off behavior while continuing to show their approval
of appropriate behavior. (3) Billy’s teacher was also instructed
to ignore Billy, insofar as it was feasible, when he engaged in

showing-off behavior and to devote her attention at those times
to children who were behaving more appropriately. Although
Billy’s showing off in class increased during the first few days
of this behavior therapy program, it diminished markedly after
his parents and teacher no longer reinforced it. As his
maladaptive behavior diminished, he was better accepted by his
classmates. This helped reinforce more appropriate behavior
patterns and changed Billy’s negative attitude toward school.
Billy’s was a case in which unwanted behavior was eliminated
by eliminating its reinforcers. On other occasions, therapy is
administered to establish desired behaviors that are missing.
Examples of such approaches are response shaping and use of
token economies. In response shaping, positive reinforcement is
used to establish, by gradual approximation, a response that is
actively resisted or is not initially in an individual’s behavioral
repertoire. This technique has been used extensively in working
with children’s behavior problems (Kazdin, 2007). For example,
a child who refuses to speak in front of others (selective
mutism) may be first rewarded (with praise or a more tangible
treat) for making any sound. Later, only complete words, and
later again only strings of words, would be rewarded. TOKEN
ECONOMIES Years ago, when behavior therapy was in its
infancy, token economies based on the principles of operant
conditioning were developed for use with chronic psychiatric
inpatients. When they behaved appropriately on the hospital
ward, patients earned tokens that they could later use to receive
rewards or privileges (Paul, 1982; Paul & Lentz, 1977). Token
economies have been used to establish adaptive behaviors
ranging from elementary responses such as eating and making
one’s bed to the daily performance of responsible hospital jobs.
In the latter instance, the token economy resembles the outside
world, where an individual is paid for his or her work in tokens
(money) that can later be exchanged for desired objects and
activities. Although sometimes the subject of criticism and
controversy, token economies remain a relevant treatment
approach for the seriously mentally ill and those with

developmental disabilities (see Higgins et al., 2001; Le Blanc et
al., 2000). Similar reinforcement-based methods are now being
used to treat substance abuse. In one study, people being treated
for cocaine dependence were rewarded with vouchers worth 25
cents if their urine tests came back negative (see Higgins,
Wong, et al., 2000). Patients could then ask a staff member to
purchase for them items from the community with the vouchers
they had accumulated. Patients who received the incentive
vouchers based on their abstinence from cocaine had better
clinical outcomes than a comparison group of patients who also
received vouchers but whose vouchers were not contingent on
their abstinent behavior. EVALUATING BEHAVIOR
THERAPY Compared with some other forms of therapy,
behavior therapy has some distinct advantages. Behavior
therapy usually achieves results in a short period of time
because it is generally directed to specific symptoms, leading to
faster relief of a client’s distress and to lower costs. The
methods to be used are also clearly delineated, and the results
can be readily evaluated. Overall, the outcomes achieved with
behavior therapy compare very favorably with those of other
approaches (Emmelkamp, 2004; Nathan & Gorman, 2007). As
with other approaches, behavior therapy works better with
certain kinds of problems than with others. Generally, the more
pervasive and vaguely defined the client’s problem, the less
likely behavior therapy is to be useful. For example, it appears
to be only rarely employed to treat complex personality
disorders, although dialectical behavior therapy (see Chapter
10) for patients with borderline personality disorder is an
exception (Crits-Christoph & Barber, 2007). On the other hand,
behavioral techniques remain central to the treatment of anxiety
disorders (Barlow et al., 2007; Franklin & Foa, 2007). Because
behavioral treatments are often quite straightforward, behavior
therapy can be used with psychotic patients (Kopelowicz et al.,
2007). Recent research also shows that behavior therapy is an
effective treatment for the vocal and motor tics that are found in
people with Tourette’s syndrome (Wilhelm et al., 2012). This is

welcome news because the alternative treatment approach
involves the use of antipsychotic medications. A recent
development in the treatment of depression is a brief and
structured form of therapy called behavioral activation (see
Chapter 7). In this treatment the patient and the therapist work
together to help the patient find ways to become more active
and engaged with life. The patient is encouraged to engage in
activities that will help improve mood and lead to better ways
of coping with specific life problems. Although this sounds
quite simple, it is not always that easy to accomplish. However,
evidence to date suggests that this form of therapy is very
beneficial for patients and can lead to enduring change
(Dimidjian et al., 2011; Dobson et al., 2008). Cognitive and
Cognitive-Behavioral Therapy The early behavior therapists
focused on observable behavior and regarded the inner thoughts
of their clients as unimportant. However, starting in the 1970s,
a number of behavior therapists began to reappraise the
importance of “private events”—thoughts, perceptions,
evaluations, and self-statements—and started to see them as
processes that mediated the effects of objective stimulus
conditions to determine behavior and emotions (Borkovec,
1985; Mahoney & Arnkoff, 1978). Cognitive and cognitive-
behavioral therapy (terms for the most part used
interchangeably) stem from both cognitive psychology (with its
emphasis on the effects of thoughts on behavior) and
behaviorism (with its rigorous methodology and performance-
oriented focus). No single set of techniques defines cognitively
oriented treatment approaches. However, two main themes are
important: (1) the conviction that cognitive processes influence
emotion, motivation, and behavior; and (2) the use of cognitive
and behavior-change techniques in a pragmatic (hypothesis-
testing) manner. In the following discussion, we briefly
describe the rational emotive behavior therapy of Albert Ellis
and then focus in more detail on the cognitive therapy approach
of Aaron Beck. RATIONAL EMOTIVE BEHAVIOR THERAPY
The first form of behaviorally oriented cognitive therapy was

developed by Albert Ellis and called rational emotive behavior
therapy (REBT) (see Ellis & Dryden, 1997). REBT attempts to
change a client’s maladaptive thought processes, on which
maladaptive emotional responses, and thus behavior, are
presumed to depend. Ellis posited that a well-functioning
individual behaves rationally and in tune with empirical reality.
Unfortunately, however, many of us have learned unrealistic
beliefs and perfectionistic values that cause us to expect too
much of ourselves, leading us to behave irrationally and then to
feel that we are worthless failures. For example, a person may
continually think, “I should be able to win everyone’s love and
approval” or “I should be thoroughly adequate and competent in
everything I do.” Such unrealistic assumptions and self-
demands inevitably spell problems. The task of REBT is to
restructure an individual’s belief system and self-evaluation,
especially with respect to the irrational “shoulds,” “oughts,”
and “musts” that are preventing the individual from having a
more positive sense of self-worth and an emotionally satisfying,
fulfilling life. Several methods are used. One method is to
dispute a person’s false beliefs through rational confrontation
(“Why should your failure to get the promotion you wanted
mean that you are worthless?”). REBT therapists also use
behaviorally oriented techniques. For example, homework
assignments might be given to encourage clients to have new
experiences and to break negative chains of behavior. Although
the techniques differ dramatically, the philosophy underlying
REBT has something in common with that underlying
humanistic therapy (discussed later) because both take a clear
stand on personal worth and human values. Rational emotive
behavior therapy aims to increase an individual’s feelings of
self-worth and clear the way for self-actualization by removing
the false beliefs that have been stumbling blocks to personal
growth. BECK’S COGNITIVE THERAPY Beck’s cognitive
therapy approach was originally developed for the treatment of
depression and later for anxiety disorders. Now, however, this
form of treatment is used for a broad range of conditions,

including eating disorders and obesity, personality disorders,
substance abuse, and even schizophrenia (Beck, 2005; Beck &
Rector, 2005; Hollon & Beck, 2004). The cognitive model is
basically an information-processing model of psychopathology.
A fundamental assumption of the cognitive model is that
problems result from biased processing of external events or
internal stimuli. These biases distort the way that a person
makes sense of the experiences that she or he has in the world,
leading to cognitive errors. According to the cognitive model,
how we think about situations is closely linked to our emotional
responses to them. If this young man is having automatic
thoughts such as, “I’ll never get to play. I’m such a loser,” he is
likely to be more emotionally distressed about waiting on the
sideline than if he has a thought such as, “There’s a lot I can
learn from watching how this game is going.” But why do
people make cognitive errors at all? According to Beck (2005),
underlying these biases is a relatively stable set of cognitive
structures or schemas that contain dysfunctional beliefs. When
these schemas become activated (by external or internal
triggers), they bias how people process information. In the case
of depression, people become inclined to make negatively
biased interpretations of themselves, their world, and their
future. In the initial phase of cognitive therapy, clients are made
aware of the connection between their patterns of thinking and
their emotional responses. They are first taught simply to
identify their own automatic thoughts (such as, “This event is a
total disaster”) and to keep records of their thought content and
their emotional reactions (see Wright et al., 2006). With the
therapist’s help, they then identify the logical errors in their
thinking and learn to challenge the validity of these automatic
thoughts. The errors in the logic behind their thinking lead them
(1) to perceive the world selectively as harmful while ignoring
evidence to the contrary; (2) to overgeneralize on the basis of
limited examples—for example, seeing themselves as totally
worthless because they were laid off from work; (3) to magnify
the significance of undesirable events—for example, seeing the

job loss as the end of the world for them; and (4) to engage in
absolutistic thinking—for example, exaggerating the importance
of someone’s mildly critical comment and perceiving it as proof
of their instant descent from goodness to worthlessness. In the
case study below, the therapist describes some of these errors in
thinking to a depressed patient. Cognitive Therapy
THERAPIST: You have described many instances today where
your interpretations led to particular feelings. You remember
when you were crying a little while ago and I asked you what
was going through your mind? You told me that you thought
that I considered you pathetic and that I wouldn’t want to see
you for therapy. I said you were reading my mind and putting
negative thoughts in my mind that were not, in fact, correct.
You were making an arbitrary inference, or jumping to
conclusions without evidence. This is what often happens when
one is depressed. One tends to put the most negative
interpretations on things, even sometimes when the evidence is
contrary, and this makes one even more depressed. Do you
recognize what I mean? PATIENT: You mean even my thoughts
are wrong? THERAPIST: No, not your thoughts in general, and
I am not talking about right and wrong. As I was explaining
before, interpretations are not facts. They can be more or less
accurate, but they cannot be right or wrong. What I mean is that
some of your interpretations, in particular those relating to
yourself, are biased negatively. The thoughts you attributed to
me could have been accurate. But there were also many other
conclusions you could have reached that might have been less
depressing for you, in that they would reflect less badly on you.
For example, you could have thought that since I was spending
time with you, that meant I was interested and that I wanted to
try and help. If this had been your conclusion, how do you think
that you would have felt? Do you think that you would have felt
like crying? PATIENT: Well, I guess I might have felt less
depressed, more hopeful. THERAPIST: Good. That’s the point I
was trying to make. We feel what we think. Unfortunately, these
biased interpretations tend to occur automatically. They just pop

into one’s head and one believes them. What you and I will do
in therapy is to try and catch these thoughts and examine them.
Together we will look at the evidence and correct the biases to
make the thoughts more realistic. Does this sound all right with
you? PATIENT: Yes. Source: From I-M. Blackburn and K. M.
Davidson. (1990). Cognitive therapy for depression and anxiety:
A practitioner’s guide (pp. 106–7). Copyright © 1995 Blackwell
Science. Much of the content of the therapy sessions and
homework assignments is analogous to experiments in which a
therapist and a client apply learning principles to alter the
client’s biased and dysfunctional cognitions and continuously
evaluate the effects that these changes have on subsequent
thoughts, feelings, and overt behavior. It is important to note,
however, that in Beck’s cognitive therapy, clients do not change
their beliefs by debate and confrontation as is common in
REBT. Rather, they are encouraged to gather information about
themselves. For example, a young man who believes that he will
be rejected by any attractive woman he approaches would be led
to a searching analysis of the reasons why he holds this belief.
The client might then be assigned the task of “testing” this
dysfunctional “hypothesis” by actually approaching seemingly
appropriate women whom he admires. The results of the “test”
would then be discussed with the cognitive therapist, and any
cognitive “errors” that may have interfered with a skillful
performance would be identified and corrected. In addition, the
client is encouraged to discover the faulty assumptions or
dysfunctional schemas that may be leading to problem behaviors
and self-defeating tendencies (Young et al., 2008). These
generally become evident over the course of therapy as the
client and the therapist examine the themes of the client’s
automatic thoughts. Because these dysfunctional schemas are
seen as making the person vulnerable (e.g., to depression), this
phase of treatment is considered essential in ensuring resistance
to relapse when the client faces stressful life events in the
future. That is, if the underlying cognitive vulnerability factors
are not changed, the client may show only short-term

improvement and will still be subject to recurrent depression.
For disorders other than depression, the general approach is
quite similar. However, the nature of the patient’s automatic
thoughts and underlying beliefs is obviously quite different
across disorders. In panic disorder, for example, the focus is on
identifying the automatic thoughts about feared bodily
sensations and on teaching the client to “decatastrophize” the
experience of panic (Craske & Barlow, 2008). In bulimia
nervosa, the cognitive approach centers on the person’s
overvalued ideas about body weight and shape, which are often
fueled by low self-esteem and fears of being unattractive. In
addition, faulty cognitions about which foods are “safe” and
which are “dangerous” are explored (Fairburn et al., 2008;
Wilson, 2005). EVALUATING COGNITIVE-BEHAVIORAL
THERAPIES In spite of the widespread attention that Ellis’s
REBT has enjoyed, it has been less well assimilated into the
mainstream than Beck’s cognitive therapy (David et al., 2005).
Nonetheless, REBT is still very much alive and well. In general,
this approach may be most useful in helping basically healthy
people to cope better with everyday stress and perhaps in
preventing them from developing full-blown anxiety or
depressive disorders (Haaga & Davison, 1989, 1992). With
respect to controlled research studies with carefully diagnosed
clinical populations, REBT appears to be inferior to exposure-
based therapies in the treatment of anxiety disorders such as
agoraphobia, social phobia (Haaga & Davison, 1989, 1992), and
probably obsessive-compulsive disorder (Franklin & Foa, 1998).
In contrast, the efficacy of Beck’s cognitive treatment methods
has been well documented. Research suggests that these
approaches are extremely beneficial in alleviating many
different types of disorders (see Hollon & Beck, 2004). For all
but the most severe cases of depression (e.g., psychotic
depression), cognitive-behavioral therapy is at least comparable
to drug treatment. It also offers long-term advantages,
especially with regard to the prevention of relapse (Craighead et
al., 2007). Cognitive therapy also produces dramatic results in

the treatment of panic disorder and generalized anxiety disorder
(Hollon & Beck, 2004), and cognitive-behavioral therapy is now
the treatment of choice for bulimia (Wilson, 2010; Wilson &
Fairburn, 2007). Finally, cognitive approaches have promise in
the treatment of conduct disorder in children (Kazdin, 2007),
substance abuse (Beck et al., 1993), and certain personality
disorders (Beck et al., 1990; Linehan, 1993). The combined use
of cognitive and behavior therapy approaches is now quite
routine. Some disagreement remains about whether the effects
of cognitive treatments are actually the result of cognitive
changes as the cognitive theorists propose (Hollon & Beck,
2004; Jacobson et al., 1996). At least for depression and panic
disorder, it does appear that cognitive change is the best
predictor of long-term outcome, just as cognitive theory
maintains (Hollon et al., 1990). Exactly what the “active
ingredients” of cognitive treatments really are, however,
remains a source of debate and research (e.g., Garratt et al.,
2007; Teasdale et al., 2001). Humanistic-Experiential Therapies
The humanistic-experiential therapies emerged as significant
treatment approaches after World War II. In a society dominated
by self-interest, mechanization, computerization, mass
deception, and mindless bureaucracy, proponents of the
humanisticexperiential therapies see psychopathology as
stemming in many cases from problems of alienation,
depersonalization, loneliness, and a failure to find meaning and
genuine fulfilment. Problems of this sort, it is held, are not
likely to be solved either by delving into forgotten memories or
by correcting specific maladaptive behaviors. The humanistic-
experiential therapies are based on the assumption that people
have both the freedom and the responsibility to control their
own behavior—that they can reflect on their problems, make
choices, and take positive action. Humanistic- experiential
therapists feel that a client must take most of the responsibility
for the direction and success of therapy, with the therapist
serving merely as counselor, guide, and facilitator. Although
humanistic-experiential therapies differ in their details, their

central focus is always expanding a client’s “awareness.”
CLIENT-CENTERED THERAPY The client-centered (person-
centered) therapy of Carl Rogers (1902–1987) focuses on the
natural power of the organism to heal itself (Rogers, 1951,
1961). Rogers saw therapy as a process of removing the
constraints and restrictions that grow out of unrealistic demands
that people tend to place on themselves when they believe, as a
condition of self-worth, that they should not have certain kinds
of feelings such as hostility. By denying that they do in fact
have such feelings, they become unaware of their actual “gut”
reactions. As they lose touch with their own genuine
experience, the result is lowered integration, impaired personal
relationships, and various forms of maladjustment. The primary
objective of Rogerian therapy is to resolve this incongruence—
to help clients become able to accept and be themselves. To this
end, client-centered therapists establish a psychological climate
in which clients can feel unconditionally accepted, understood,
and valued as people. Within this context, the therapist employs
nondirective techniques such as empathic reflecting, or
restatement of the client’s descriptions of life difficulties. If all
goes well, clients begin to feel free, for perhaps the first time,
to explore their real feelings and thoughts and to accept hates
and angers and ugly feelings as parts of themselves. As their
self-concept becomes more congruent with their actual
experience, they become more self-accepting and more open to
new experiences and new perspectives; in short, they become
better-integrated people. In contrast to most other forms of
therapy, the client-centered therapist does not give answers,
interpret what a client says, probe for unconscious conflicts, or
even steer the client toward certain topics. Rather, he or she
simply listens attentively and acceptingly to what the client
wants to talk about, interrupting only to restate in different
words what the client is saying. Such restatements, devoid of
any judgment or interpretation by the therapist, help the client
to clarify further the feelings and ideas that he or she is
exploring—really to look at them and acknowledge them. The

following excerpt from a therapist’s second interview with a
young woman will serve to illustrate these techniques of
reflection and clarification. Client-Centered Therapy JENNY: I
was thinking about how I always try to make people around me
feel at ease. It’s so important for me to make things go along
smoothly. THERAPIST: In other words, you are always trying
to make other people feel better and to do all you can to keep
things on an even keel and going well. JENNY: Yes. That’s
right. I mean, it’s not because I am such a kind person and all I
want to see is other people being happy. I think the reason I do
it is probably because that has always been the role that has felt
the easiest for me to play. It’s the role I played at home. I didn’t
stand up for my own convictions. And now I’m at the point
where I don’t really know whether I have any convictions to
stand up for. THERAPIST: So you feel this is a role you have
been playing for a long time, smoothing out frictions and
avoiding saying anything that might be challenging in any way.
JENNY: I think that’s right. THERAPIST: And so now you
aren’t sure if you even have any genuine opinions or reactions
of your own. Is that right? JENNY: That’s it. Or maybe I
haven’t really been honest with myself and let myself even
consider what I really think about things. I’ve just been playing
a sort of a false role—being a people-pleaser. Whatever I felt
other people needed me to be, that’s who I was. And in the
process I just got lost. Pure client-centered psychotherapy, as
originally practiced, is rarely used today in North America,
although it is still relatively popular in Europe. Motivational
interviewing is a new form of therapy that is based on this
empathic style. MOTIVATIONAL INTERVIEWING People tend
to be ambivalent about making changes in their lives. They want
to change, but they also don’t want to change. Motivational
interviewing (MI; see Hettema, Steele, & Miller, 2005) is a
brief form of therapy that can be delivered in one or two
sessions. It was developed as a way to help people resolve their
ambivalence about change and make a commitment to treatment
(Miller, 1983). At its center is a supportive and empathic style

of relating to the client that has its origins in the work of Carl
Rogers. However, MI differs from client-centered counseling
because it also employs a more direct approach that explores the
client’s own reasons for wanting to change. The therapist
encourages this “change talk” by asking the client to discuss his
or her desire, ability, reasons, and need for change. These are
reflected back by the therapist, thus exposing the client to
periodic summaries of his or her own motivational statements
and thoughts about change. The result is that clients can
develop and strengthen their commitment to change in an active,
accepting, and supportive atmosphere. Motivational
interviewing is most often used in the areas of substance abuse
and addiction. When added to the beginning of a treatment
program, it appears to benefit patients, perhaps because it
facilitates patients’ staying in treatment and following the
treatment plan. Hettema and colleagues’ (2005) meta-analysis of
the MI literature has also shown that MI has a large effect when
it is used with ethnic minorities. In one alcoholism-treatment
trial, Native American participants did better if they received
four sessions of MI than if they received 12 sessions of
cognitive-behavior therapy or else participated in a 12-step
program (Villanueva et al., 2003). Quite possibly, the
supportive and nonconfrontational style of MI may be more
congruent with the typical and culturally sanctioned
communication style of Native Americans and thus represent a
culturally appropriate intervention. The collaborative and
nonconfrontational style of MI may also make it acceptable to
adolescents. Even a very small number of sessions of MI can
promote behavior change in adolescents who use drugs and
alcohol (Jensen et al., 2011). GESTALT THERAPY In German,
the term gestalt means “whole,” and gestalt therapy emphasizes
the unity of mind and body—placing strong emphasis on the
need to integrate thought, feeling, and action. Gestalt therapy
was developed by Frederick (Fritz) Perls (1969) as a means of
teaching clients to recognize the bodily processes and emotions
they had been blocking off from awareness. As with the client-

centered and humanistic approaches, the main goal of gestalt
therapy is to increase the individual’s self-awareness and self-
acceptance. Motivational interviewing is a brief intervention
that helps people resolve their ambivalence about making
change. It is often used in the treatment of substance abuse and
addiction. Although gestalt therapy is commonly used in a
group setting, the emphasis is on one person at a time, with
whom a therapist works intensively, trying to help identify
aspects of the individual’s self or world that are not being
acknowledged in awareness. The individual may be asked to act
out fantasies concerning feelings and conflicts or to represent
one side of a conflict while sitting in one chair and then switch
chairs to take the part of the adversary. Often the therapist or
other group members will ask such questions as, “What are you
aware of in your body now?” and “What does it feel like in your
gut when you think of that?” In Perls’s approach to therapy, a
good deal of attention is also paid to dreams, but with an
emphasis very different from that of classical psychoanalysis. In
gestalt theory, all elements of a dream, including seemingly
inconsequential, impersonal objects, are considered to be
representations of unacknowledged aspects of the dreamer’s
self. The therapist urges the client to suspend normal critical
judgment, to “be” the object in the dream, and then to report on
the experience. This is illustrated in the following case study.
Gestalt Therapy A college professor was preoccupied with his
academic promotion and tenure and found himself unable to
experience any joy. He sought the assistance of a friend who
was a gestalt therapist. She asked him to conjure up a daydream
rather than a dream. The daydream that emerged spontaneously
was one of skiing. The therapist asked him to be the mountain,
and he began to experience how warm he was when he was at
his base. As he got closer to the top, what looked so beautiful
was also very cold and frozen. The therapist asked the professor
to be the snow, and he experienced how hard and icy he could
be near the top. But near the bottom, people ran over him easily
and wore him out. When the session was finished, the professor

did not feel like crying or shouting; he felt like skiing. So he
went, leaving articles and books behind. In the sparkle of the
snow and sun, he realized that joy in living emerges through
deeds and not through words. In his rush to succeed, he had
committed one of the cardinal sins against himself—the sin of
not being active. Source: Adapted from Prochaska & Norcross,
2003, p. 183. EVALUATING HUMANISTIC-EXPERIENTIAL
THERAPIES Many of the humanistic-experiential concepts—the
uniqueness of each individual, the importance of therapist
genuineness, the satisfaction that comes from realizing one’s
potential, the importance of the search for meaning and
fulfilment, and the human capacity for choice and self-
direction—have had a major impact on our contemporary views
of both human nature and the nature of good psychotherapy.
However, humanistic-experiential therapies have been criticized
for their lack of agreed-upon therapeutic procedures and their
vagueness about what is supposed to happen between client and
therapist. In response, proponents of such approaches argue
against reducing people to abstractions, which can diminish
their perceived worth and deny their uniqueness. Because
people are so different, they argue, we should expect different
techniques to be appropriate for different cases. Controlled
research on the outcomes achieved by many forms of
humanistic-existential therapy was lacking in the past.
However, research in this area is now on the increase. There is
evidence to suggest that these treatment approaches are helpful
for patients with a variety of problems including depression,
anxiety, trauma, and marital difficulties (Elliot et al., 2004).
And, as we have already noted, motivational interviewing is
now established as an effective method for promoting behavior
change in people with substance abuse problems (Ball et al.,
2007; Jensen et al., 2011). Psychodynamic Therapies
Psychodynamic therapy is a broad treatment approach that
focuses on individual personality dynamics, usually from a
psychoanalytic or some psychoanalytically derived perspective.
Psychoanalytic therapy is the oldest form of psychological

therapy and began with Sigmund Freud. The therapy is mainly
practiced in two basic forms: classical psychoanalysis and
psychoanalytically oriented psychotherapy. As developed by
Freud and his immediate followers, classical psychoanalysis is
an intensive (at least three sessions per week), long-term
procedure for uncovering repressed memories, thoughts, fears,
and conflicts presumably stemming from problems in early
psychosexual development—and helping individuals come to
terms with them in light of the realities of adult life. For
example, excessive orderliness and a grim and humorless focus
on rigorous self-control would probably be viewed as deriving
from difficulties in early toilet training. In psychoanalytically
oriented psychotherapy, the treatment and the ideas guiding it
may depart substantially from the principles and procedures laid
out by orthodox Freudian theory, yet the therapy is still loosely
based on psychoanalytic concepts. For example, many
psychoanalytically oriented therapists schedule less frequent
sessions (e.g., once per week) and sit face-to-face with the
client instead of having the latter recline on a couch with the
analyst out of sight behind him or her. Likewise, the relatively
passive stance of the analyst (primarily listening to the client’s
“free associations” and rarely offering “interpretations”) is
replaced with an active conversational style in which the
therapist attempts to clarify distortions and gaps in the client’s
construction of the origins and consequences of his or her
problems, thus challenging client “defenses” as they present
themselves. It is widely believed that this more direct approach
significantly shortens total treatment time. We will first
examine Freud’s original treatment methods, in part because of
their historical significance and enormous influence; we will
then look briefly at some of the contemporary modifications of
psychodynamic therapy, which for the most part focus on
interpersonal processes. Before we do so, however, let’s
consider the case of Karen. Psychodynamic Therapy Karen was
about to be terminated from her nursing program if her
problems were not resolved. She had always been a competent

student who seemed to get along well with peers and patients.
Now, since the beginning of her rotation on 3 South, a surgical
ward, she was plagued by headaches and dizzy spells. Of more
serious consequence were the two medical errors she had made
when dispensing medications to patients. She realized that these
errors could have proved fatal, and she was as concerned as her
nursing faculty about why such problems had begun in this final
year of her education. Karen knew she had many negative
feelings toward the head nurse on 3 South, but she did not
believe these feelings could account for her current dilemma.
She entered psychotherapy. After a few weeks of
psychotherapy, the therapist realized that one of Karen’s
important conflicts revolved around the death of her father
when she was 12 years old. Karen had just gone to live with her
father after being with her mother for 7 years. She remembered
how upset she was when her father had a heart attack and had to
be rushed to the hospital. For a while it looked as though her
father was going to pull through, and Karen began enjoying her
daily visits to see him. During one of these visits, her father
clutched his chest in obvious pain and told Karen to get a nurse.
She remembered how helpless she felt when she could not find a
nurse, although she did not recall why this was so difficult. Her
search seemed endless, and by the time she finally found a
nurse, her father was dead. The therapist asked Karen the name
of the ward on which her father had died. She paused and
thought, and then she blurted out, “3 South.” She cried at length
as she told how confused she was and how angry she felt toward
the nurses on the ward for not being more readily available,
although she thought they might have been involved with
another emergency. After weeping and shaking and expressing
her resentment, Karen felt calm and relaxed for the first time in
months. Her symptoms disappeared, and her problems in the
nursing program were relieved. Source: Adapted from
Prochaska & Norcross, 2003, p. 28. In classical (Freudian)
psychoanalysis the technique of free association may be used to
explore the contents of the preconscious. FREUDIAN

PSYCHOANALYSIS Psychoanalysis is a system of therapy that
evolved over a period of years during Freud’s long career.
Psychoanalysis is not easy to describe, and the problem is
complicated by the fact that many people have inaccurate
conceptions of it based on cartoons and other forms of
caricature. The best way to begin our discussion is to describe
the four basic techniques of this form of therapy: (1) free
association, (2) analysis of dreams, (3) analysis of resistance,
and (4) analysis of transference. Then we will note some of the
most important changes that have taken place in psychodynamic
therapy since Freud’s time. Free Association The basic rule of
free association (see Chapter 2) is that an individual must say
whatever comes into her or his mind regardless of how personal,
painful, or seemingly irrelevant it may be. Usually a client lies
in a relaxed position on a couch and gives a running account of
all the thoughts, feelings, and desires that come to mind as one
idea leads to another. The therapist normally takes a position
behind the client so as not to disrupt the free flow of
associations in any way. Although such a running account of
whatever comes into one’s mind may seem random, Freud did
not view it as such; rather, he believed that associations are
determined just like other events. The purpose of free
association is to explore thoroughly the contents of the
preconscious—that part of the mind considered subject to
conscious attention but largely ignored. Analytic interpretation
involves a therapist’s tying together a client’s often
disconnected ideas, beliefs, and actions into a meaningful
explanation to help the client gain insight into the relationship
between his or her maladaptive behavior and the repressed
(unconscious) events and fantasies that drive it. Analysis of
Dreams Another important, related procedure for uncovering
unconscious material is the analysis of dreams. When a person
is asleep, repressive defenses are said to be lowered, and
forbidden desires and feelings may find an outlet in dreams. For
this reason, dreams have been referred to as the “royal road to
the unconscious.” Some motives, however, are so unacceptable

to an individual that even in dreams they are not revealed
openly but are expressed in disguised or symbolic form. Thus a
dream has two kinds of content: (1) manifest content, which is
the dream as it appears to the dreamer, and (2) latent content,
which consists of the actual motives that are seeking expression
but are so painful or unacceptable that they are disguised. It is a
therapist’s task, in conjunction with the associations of the
patient, to uncover these disguised meanings by studying the
images that appear in the manifest content of a client’s dream
and in the client’s associations to them. For example, a client’s
dream of being engulfed in a tidal wave may be interpreted by a
therapist as indicating that the client feels in danger of being
overwhelmed by inadequately repressed fears or hostilities.
Analysis of Resistance During the process of free association or
of associating to dreams, an individual may evidence
resistance—an unwillingness or inability to talk about certain
thoughts, motives, or experiences. For example, a client may be
talking about an important childhood experience and then
suddenly switch topics, perhaps stating, “It really isn’t that
important” or “It is too absurd to discuss.” Resistance may also
be evidenced by the client’s giving a too-glib interpretation of
some association, or coming late to an appointment, or even
“forgetting” an appointment altogether. Because resistance
prevents painful and threatening material from entering
awareness, its sources must be sought if an individual is to face
the problem and learn to deal with it in a realistic manner
(Horner, 2005). Analysis of Transference As client and therapist
interact, the relationship between them may become complex
and emotionally involved. Often people carry over, and
unconsciously apply to their therapist, attitudes and feelings
that they had in their relations with a parent or other person
close to them in the past, a process known as transference. Thus
clients may react to their analyst as they did to that earlier
person and feel the same love, hostility, or rejection that they
felt long ago. If the analyst is operating according to the
prescribed role of maintaining an impersonal stance of detached

attention, the often affect-laden reactions of the client can be
interpreted, it is held, as a type of projection—inappropriate to
the present situation yet highly revealing of central issues in the
client’s life. For example, should the client vehemently (but
inaccurately) condemn the therapist for a lack of caring and
attention to the client’s needs, this would be seen as a
“transference” to the therapist of attitudes acquired (possibly on
valid grounds) in childhood interactions with parents or other
key individuals. In helping the client to understand and
acknowledge the transference relationship, a therapist may
provide the client with insight into the meaning of his or her
reactions to others. In doing so, the therapist may also introduce
a corrective emotional experience by refusing to engage the
person on the basis of his or her unwarranted assumptions about
the nature of the therapeutic relationship. If the client expects
rejection and criticism, for example, the therapist is careful to
maintain a neutral manner. Or contrarily, the therapist may
express positive emotions at a point where the client feels
particularly vulnerable, thereby encouraging the client to
reframe and rethink her or his view of the situation. In this way
it may be possible for the client to recognize these assumptions
and to “work through” the conflict in feelings about the real
parent or perhaps to overcome feelings of hostility and self-
devaluation that stem from the earlier parental rejection. In
essence, the negative effects of an undesirable early relationship
are counteracted by working through a similar emotional
conflict with the therapist in a therapeutic setting. A person’s
reliving of a pathogenic past relationship in a sense recreates
the neurosis in real life, and therefore this experience is often
referred to as a transference neurosis. It is not possible here to
consider at length the complexities of transference
relationships, but a client’s attitudes toward his or her therapist
usually do not follow such simple patterns as our examples
suggest. Often the client is ambivalent—distrusting the therapist
and feeling hostile toward him or her as a symbol of authority,
but at the same time seeking acceptance and love. In addition,

the problems of transference are not confined to the client, for
the therapist may also have a mixture of feelings toward the
client. This countertransference, wherein the therapist reacts in
accord with the client’s transferred attributions rather than
objectively, must be recognized and handled properly by the
therapist. For this reason, it is considered important that
therapists have a thorough understanding of their own motives,
conflicts, and “weak spots”; in fact, all psychoanalysts undergo
psychoanalysis themselves before they begin independent
practice. The resolution of the transference neurosis is said to
be the key element in effecting a psychoanalytic “cure.” Such
resolution can occur only if an analyst successfully avoids the
pitfalls of countertransference. That is, the analyst needs to
keep track of his or her own transference or reaction to a
client’s behavior. Failure to do so risks merely repeating, in the
therapy relationship, the typical relationship difficulties
characterizing the client’s adult life. Analysis of transference
and the phenomenon of countertransference are also part of
most psychodynamic derivatives of classical psychoanalysis, to
which we now turn. Psychodynamic Therapy Since Freud The
original version of psychoanalysis is practiced only rarely
today. Arduous and costly in time, money, and emotional
commitment, it may take several years before all major issues in
the client’s life have been satisfactorily resolved. In light of
these heavy demands, psychoanalytic or psychodynamic
therapists have worked out modifications in procedure designed
to shorten the time and expense required. A good review of
some of these approaches can be found in Prochaska and
Norcross (2003). Object Relations, Attachment-Based
Approaches, and Self-Psychology The most extensive revisions
of classical psychoanalytic theory undertaken within recent
decades have been related to the object-relations perspective (in
psychoanalytic jargon, “objects” are other people) and, to a
lesser extent, the attachment and self-psychology perspectives
(see Prochaska & Norcross, 2003). Whether or not
psychotherapy investigators and clinicians use the term object

relations (or attachment or self-psychology) to denote their
approach, increasing numbers of them describe procedures that
focus on interpersonal relationship issues, particularly as they
play themselves out in the client–therapist relationship.
Interpersonally oriented psychodynamic therapists vary
considerably in their time focus: whether they concentrate on
remote events of the past, on current interpersonal situations
and impasses (including those of the therapy itself), or on some
balance of the two. Most seek to expose, bring to awareness,
and modify the effects of the remote developmental sources of
the difficulties the client is currently experiencing. These
therapies generally retain, then, the classical psychoanalytic
goal of understanding the present in terms of the past. What
they ignore are the psychoanalytic notions of staged libidinal
energy transformations and of entirely internal (and impersonal)
drives that are channeled into psychopathological symptom
formation. EVALUATING PSYCHODYNAMIC THERAPIES
The practice of classical psychoanalysis is routinely criticized
by outsiders for being relatively time consuming and expensive;
for being based on a questionable, stultified, and sometimes
cult-like approach to human nature; for neglecting a client’s
immediate problems in the search for unconscious conflicts in
the remote past; and for there being no adequate proof of its
general effectiveness. Concerning this, we note that there have
been no rigorous, controlled outcome studies of classical
psychoanalysis. This is understandable, given the intensive and
long-term nature of the treatment and the methodological
difficulties inherent in testing such an approach. Nonetheless,
there are some hints that this treatment approach has some value
(Gabbard et al., 2002). Psychoanalysts also argue that
manualized treatments unduly limit treatment for a disorder.
They note that simply because a treatment cannot be
standardized does not mean that it is invalid or unhelpful.
Whether the clinical benefits justify the time and expense of
psychoanalysis, however, remains uncertain. In contrast, there
is much more research on some of the newer psychodynamically

oriented approaches. There are signs that psychodynamic
approaches may be helpful in the treatment of depression, panic
disorder, PTSD, and substance abuse disorders (Gibbons et al.,
2008). Recent research also supports the idea that increases in
insight (“insight” is a key construct in psychodynamic theory
and involves cognitive and emotional understanding of inner
conflicts) must occur before there is long-term clinical change
(Johansson et al., 2010). Psychoanalytically oriented treatments
are also showing promise in the treatment of borderline
personality disorder. One example is transference-focused
psychotherapy, or TFP. Developed by Kernberg and colleagues,
this treatment approach uses such techniques as clarification,
confrontation, and interpretation to help the patient understand
and correct the distortions that occur in his or her perception of
other people, including the therapist. In a clinical trial, patients
with borderline personality disorder who received TFP did as
well as those who were assigned to receive dialectical behavior
therapy (Clarkin et al., 2007). A recent meta-analysis provides
further support for the idea that long-term psychodynamic
psychotherapy (50 sessions or more) may be more beneficial
than less intensive forms of treatment for patients with complex
mental disorders (Leichsenring & Rabung, 2011). Findings such
as these are creating renewed interest in psychodynamic forms
of psychotherapy and energizing the field of treatment research.
Couple and Family Therapy Many problems that therapists deal
with concern distressed relationships. A common example is
couple or marital distress. Here, the maladaptive behavior exists
between the partners in the relationship. Extending the focus
even further, a family systems approach reflects the assumption
that the within-family behavior of any particular family member
is subject to the influence of the behaviors and communication
patterns of other family members. It is, in other words, the
product of a “system” that may be amenable to both
understanding and change. Addressing problems deriving from
the in-place system thus requires therapeutic techniques that
focus on relationships as much as, or more than, on individuals.

Factors That Impact Psychotherapy Outcomes and Treatment Approaches

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