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137 Psychological Approaches to Treatment

Learning Objectives

By the end of this section, you will be able to:

  • Outline and differentiate the psychodynamic, humanistic, behavioural, and cognitive approaches to psychotherapy.
  • Distinguish between cognitive therapy and cognitive behavioural therapy.

Treatment for psychological disorder begins when the individual who is experiencing distress visits a counsellor or therapist, perhaps in a church, a community centre, a hospital, or a private practice. The therapist will begin by systematically learning about the patient’s needs through a formal psychological assessment, which is an evaluation of the patient’s psychological and mental health. During the assessment the psychologist may give personality tests such as the Minnesota Multiphasic Personal Inventory (MMPI-2), Millon Adolescent Clinical Inventory (MACI), or projective tests, and will conduct a thorough interview with the patient. The therapist may get more information from family members or school personnel.

In addition to the psychological assessment, the patient is usually seen by a physician to gain information about potential Axis III (physical) problems. In some cases of psychological disorder — and particularly for sexual problems — medical treatment is the preferred course of action. For instance, men who are experiencing erectile dysfunction disorder may need surgery to increase blood flow or local injections of muscle relaxants. Or they may be prescribed medications (Viagra, Cialis, or Levitra) that provide an increased blood supply to the penis, and are successful in increasing performance in about 70% of men who take them.

After the medical and psychological assessments are completed, the therapist will make a formal diagnosis using the detailed descriptions of the disorder provided in the Diagnostic and Statistical Manual of Mental Disorders (DSM; see below). The therapist will summarize the information about the patient on each of the five DSM axes, and the diagnosis will likely be sent to an insurance company to justify payment for the treatment.

DSM-5-TR Criteria for Diagnosing Attention-Deficit/Hyperactivity Disorder (ADHD)

To be diagnosed with ADHD the individual must display either A or B below (American Psychiatric Association, 2013):

A.  Six or more of the following symptoms of inattention have been present for at least six months to a point that is disruptive and inappropriate for developmental level:

  • Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities
  • Often has trouble keeping attention on tasks or play activities
  • Often does not seem to listen when spoken to directly
  • Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behaviour or failure to understand instructions)
  • Often has trouble organizing activities
  • Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework)
  • Often loses things needed for tasks and activities (e.g., toys, school assignments, pencils, books, or tools)
  • Is often easily distracted
  • Is often forgetful in daily activities

B.  Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least six months to an extent that is disruptive and inappropriate for developmental level:

  • Often fidgets with hands or feet or squirms in seat
  • Often gets up from seat when remaining in seat is expected
  • Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless)
  • Often has trouble playing or enjoying leisure activities quietly
  • Is often “on the go” or often acts as if “driven by a motor”
  • Often talks excessively
  • Often blurts out answers before questions have been finished
  • Often has trouble waiting one’s turn
  • Often interrupts or intrudes on others (e.g., butts into conversations or games)

If a diagnosis is made, the therapist will select a course of therapy that he or she feels will be most effective. One approach to treatment is psychotherapy, the professional treatment for psychological disorder through techniques designed to encourage communication of conflicts and insight. The fundamental aspect of psychotherapy is that the patient directly confronts the disorder and works with the therapist to help reduce it. Therapy includes assessing the patient’s issues and problems, planning a course of treatment, setting goals for change, the treatment itself, and an evaluation of the patient’s progress. Therapy is practised by thousands of psychologists and other trained practitioners in Canada and around the world, and is responsible for billions of dollars of the health budget.

To many people therapy involves a patient lying on a couch with a therapist sitting behind and nodding sagely as the patient speaks. Though this approach to therapy (known as psychoanalysis) is still practised, it is in the minority. It is estimated that there are over 400 different kinds of therapy practised by people in many fields, and the most important of these are psychodynamic, humanistic, cognitive behavioural therapy, and eclectic (i.e., a combination of therapies). The therapists who provide these treatments include psychiatrists (who have a medical degree and can prescribe drugs) and clinical psychologists, as well as social workers, psychiatric nurses, and couples, marriage, and family therapists.

TRICKY TOPIC: PSYCHOLOGICAL TREATMENTS

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Psychodynamic Therapy

Psychodynamic therapy (psychoanalysis) is a psychological treatment based on Freudian and neo-Freudian personality theories in which the therapist helps the patient explore the unconscious dynamics of personality. The analyst engages with the patient, usually in one-on-one sessions, often with the patient lying on a couch and facing away. The goal of the psychotherapy is for the patient to talk about their personal concerns and anxieties, allowing the therapist to try to understand the underlying unconscious problems that are causing the symptoms (the process of interpretation). The analyst may try out some interpretations on the patient and observe how he or she responds to them.

The patient may be asked to verbalize their thoughts through free association, in which the therapist listens while the client talks about whatever comes to mind, without any censorship or filtering. The client may also be asked to report on his or her dreams, and the therapist will use dream analysis to analyze the symbolism of the dreams in an effort to probe the unconscious thoughts of the client and interpret their significance. On the basis of the thoughts expressed by the patient, the analyst discovers the unconscious conflicts causing the patient’s symptoms and interprets them for the patient.

The goal of psychotherapy is to help the patient develop insight — that is, an understanding of the unconscious causes of the disorder (Epstein, Stern, & Silbersweig, 2001; Lubarsky & Barrett, 2006), but the patient often shows resistance to these new understandings, using defence mechanisms to avoid the painful feelings in his or her unconscious. The patient might forget or miss appointments, or act out with hostile feelings toward the therapist. The therapist attempts to help the patient develop insight into the causes of the resistance. The sessions may also lead to transference, in which the patient unconsciously redirects feelings experienced in an important personal relationship toward the therapist. For instance, the patient may transfer feelings of guilt that come from the father or mother to the therapist. Some therapists believe that transference should be encouraged, as it allows the client to resolve hidden conflicts and work through feelings that are present in the relationships.

One problem with traditional psychoanalysis is that the sessions may take place several times a week, go on for many years, and cost thousands of dollars. To help more people benefit, modern psychodynamic approaches frequently use shorter-term, focused, and goal-oriented approaches. In these brief psychodynamic therapies, the therapist helps the client determine the important issues to be discussed at the beginning of treatment and usually takes a more active role than in classic psychoanalysis (Levenson, 2010).

Humanistic Therapies

Just as psychoanalysis is based on the personality theories of Freud and the neo-Freudians, humanistic therapy is a psychological treatment based on the personality theories of Carl Rogers and other humanistic psychologists. Humanistic therapy is based on the idea that people develop psychological problems when they are burdened by limits and expectations placed on them by themselves and others, and the treatment emphasizes the person’s capacity for self-realization and fulfillment. Humanistic therapies attempt to promote growth and responsibility by helping clients consider their own situations and the world around them and how they can work to achieve their life goals.

Carl Rogers developed person-centred therapy (or client-centred therapy), an approach to treatment in which the client is helped to grow and develop as the therapist provides a comfortable, nonjudgmental environment. In his book A Way of Being (1980), Rogers argued that therapy was most productive when the therapist created a positive relationship with the client — a therapeutic alliance. The therapeutic alliance is a relationship between the client and the therapist that is facilitated when the therapist is genuine (i.e., he or she creates no barriers to free-flowing thoughts and feelings), when the therapist treats the client with unconditional positive regard (i.e., he or she values the client without any qualifications, displaying an accepting attitude toward whatever the client is feeling at the moment), and when the therapist develops empathy with the client (i.e., he or she actively listens to and accurately perceives the personal feelings that the client experiences).

The development of a positive therapeutic alliance has been found to be exceedingly important to successful therapy. The ideas of genuineness, empathy, and unconditional positive regard in a nurturing relationship in which the therapist actively listens to and reflects the feelings of the client is probably the most fundamental part of contemporary psychotherapy (Prochaska & Norcross, 2007).

Psychodynamic and humanistic therapies are recommended primarily for people suffering from generalized anxiety or mood disorders, and who desire to feel better about themselves overall. But the goals of people with other psychological disorders, such as phobias, sexual problems, and obsessive-compulsive disorder (OCD), are more specific. A person with a social phobia may want to be able to leave their house, a person with a sexual dysfunction may want to improve their sex life, and a person with OCD may want to learn to stop letting their obsessions or compulsions interfere with everyday activities. In these cases it is not necessary to revisit childhood experiences or consider our capacities for self-realization — we simply want to deal with what is happening in the present.

Psychotherapy: Play Therapy

Play therapy is often used with children since they are not likely to sit on a couch and recall their dreams or engage in traditional talk therapy. This technique uses a therapeutic process of play to “help clients prevent or resolve psychosocial difficulties and achieve optimal growth” (O’Connor, 2000, p. 7). The idea is that children play out their hopes, fantasies, and traumas while using dolls, stuffed animals, and sandbox figurines (Figure T.10). Play therapy can also be used to help a therapist make a diagnosis. The therapist observes how the child interacts with toys (e.g., dolls, animals, and home settings) in an effort to understand the roots of the child’s disturbed behaviour. Play therapy can be nondirective or directive. In nondirective play therapy, children are encouraged to work through their problems by playing freely while the therapist observes (LeBlanc & Ritchie, 2001). In directive play therapy, the therapist provides more structure and guidance in the play session by suggesting topics, asking questions, and even playing with the child (Harter, 1977).

This photograph shows a person playing with objects in a small box filled with sand. The person is organizing these objects and small play figures in a form of treatment called sandplay.

Figure T.10 This type of play therapy is known as sandplay or sandtray therapy. Children can set up a three-dimensional world using various figures and objects that correspond to their inner state (Kalff, 1991). (credit: Kristina Walter)

Psychotherapy: Behaviour Therapy

In psychoanalysis, therapists help their patients look into their past to uncover repressed feelings. In behaviour therapy, a therapist employs principles of learning to help clients change undesirable behaviours—rather than digging deeply into one’s unconscious. Therapists with this orientation believe that dysfunctional behaviours, like phobias and bedwetting, can be changed by teaching clients new, more constructive behaviours. Behaviour therapy employs both classical and operant conditioning techniques to change behaviour.

One type of behaviour therapy utilizes classical conditioning techniques. Therapists using these techniques believe that dysfunctional behaviours are conditioned responses. Applying the conditioning principles developed by Ivan Pavlov, these therapists seek to recondition their clients and thus change their behaviour. Emmie is eight years old, and frequently wets her bed at night. Emmie’s been invited to several sleepovers, but won’t go because of this problem. Using a type of conditioning therapy, Emmie begins to sleep on a liquid-sensitive bed pad that is hooked to an alarm. When moisture touches the pad, it sets off the alarm, waking up Emmie. When this process is repeated enough times, Emmie develops an association between urinary relaxation and waking up, and this stops the bedwetting. Emmie has now gone three weeks without wetting her bed and is looking forward to her first sleepover this weekend.

One commonly used classical conditioning therapeutic technique is counterconditioning: a client learns a new response to a stimulus that has previously elicited an undesirable behaviour. Two counterconditioning techniques are aversive conditioning and exposure therapy. Aversive conditioning uses an unpleasant stimulus to stop an undesirable behaviour. Therapists apply this technique to eliminate addictive behaviours, such as smoking, nail biting, and drinking. In aversion therapy, clients will typically engage in a specific behaviour (such as nail biting) and at the same time are exposed to something unpleasant, such as a mild electric shock or a bad taste. After repeated associations between the unpleasant stimulus and the behaviour, the client can learn to stop the unwanted behaviour.

Aversion therapy has been used effectively for years in the treatment of alcoholism (Davidson, 1974; Elkins, 1991; Streeton & Whelan, 2001). One common way this occurs is through a chemically based substance known as Antabuse. When a person takes Antabuse and then consumes alcohol, uncomfortable side effects result including nausea, vomiting, increased heart rate, heart palpitations, severe headache, and shortness of breath. Antabuse is repeatedly paired with alcohol until the client associates alcohol with unpleasant feelings, which decreases the client’s desire to consume alcohol. Antabuse creates a conditioned aversion to alcohol because it replaces the original pleasure response with an unpleasant one.

In exposure therapy, a therapist seeks to treat clients’ fears or anxiety by presenting them with the object or situation that causes their problem, with the idea that they will eventually get used to it. This can be done via reality, imagination, or virtual reality. Exposure therapy was first reported in 1924 by Mary Cover Jones, who is considered the mother of behaviour therapy. Jones worked with a boy named Peter who was afraid of rabbits. Her goal was to replace Peter’s fear of rabbits with a conditioned response of relaxation, which is a response that is incompatible with fear (Figure T.11). How did she do it? Jones began by placing a caged rabbit on the other side of a room with Peter while he ate his afternoon snack. Over the course of several days, Jones moved the rabbit closer and closer to where Peter was seated with his snack. After two months of being exposed to the rabbit while relaxing with his snack, Peter was able to hold the rabbit and pet it while eating (Jones, 1924).

This figure, titled “Exposure Therapy,” illustrates the exposure therapy strategy of Mary Cover Jones to rid a person of the fear of rabbits. The first of four levels depicts an image of a person and a rabbit with an equals sign between them. Under the rabbit reads “conditioned stimulus (CS),” and under the person reads “fear of rabbits.” The second level depicts an image of milk and cookies, labeled “unconditioned stimulus (US),” and on the other side of an equals sign there is a picture of the same person labeled “unconditioned response (UR).” The third level shows the milk and cookies, labeled “unconditioned stimulus (US),” and rabbit, labeled “conditioned stimulus (CS),” to the left and right of a plus sign, with the person on the other side of an equals sign. The label “unconditioned response (UR) is below the person.” The final level shows the person and the rabbit separated by an equals sign. This time the rabbit is labeled “conditioned stimulus (CS)” and the person is labeled “conditioned response (CR).”

Figure T.11 Exposure therapy seeks to change the response to a conditioned stimulus (CS). An unconditioned stimulus is presented over and over just after the presentation of the conditioned stimulus. This figure shows conditioning as conducted in Mary Cover Jones’ 1924 study.

Thirty years later, Joseph Wolpe (1958) refined Jones’s techniques, giving us the behaviour therapy technique of exposure therapy that is used today. A popular form of exposure therapy is systematic desensitization, wherein a calm and pleasant state is gradually associated with increasing levels of anxiety-inducing stimuli. The idea is that you can’t be nervous and relaxed at the same time. Therefore, if you can learn to relax when you are facing environmental stimuli that make you nervous or fearful, you can eventually eliminate your unwanted fear response (Wolpe, 1958) (Figure T.12).

A close-up picture of a very large spider on a person’s arm is shown. The person is using its other hand to hold up two of the spider’s legs.

Figure T.12 This person suffers from arachnophobia (fear of spiders). Through exposure therapy he is learning how to face his fear in a controlled, therapeutic setting. (credit: “GollyGforce – Living My Worst Nightmare”/Flickr)

How does exposure therapy work? Jayden is terrified of elevators. Nothing bad has ever happened to Jayden on an elevator, but they’re so afraid of elevators that they will always take the stairs. That wasn’t a problem when Jayden worked on the second floor of an office building, but now they have a new job—on the 29th floor of a skyscraper in downtown Los Angeles. Jayden knows they can’t climb 29 flights of stairs in order to get to work each day, so they decided to see a behaviour therapist for help. The therapist asks Jayden to first construct a hierarchy of elevator-related situations that elicit fear and anxiety. They range from situations of mild anxiety such as being nervous around the other people in the elevator, to the fear of getting an arm caught in the door, to panic-provoking situations such as getting trapped or the cable snapping. Next, the therapist uses progressive relaxation, teaching Jayden how to relax each of their muscle groups so that they achieves a drowsy, relaxed, and comfortable state of mind. Once Jayden’s in this state, the therapist asks Jayden to imagine a mildly anxiety-provoking situation. Jayden is standing in front of the elevator thinking about pressing the call button.

If this scenario causes Jayden anxiety, then they lifts their finger. The therapist would then tell Jayden to forget the scene and return to their relaxed state. The therapist repeats this scenario over and over until Jayden can imagine themselves pressing the call button without anxiety. Over time the therapist and Jayden use progressive relaxation and imagination to proceed through all of the situations on Jayden’s hierarchy until they becomes desensitized to each one. After this, Jayden and the therapist begin to practice what Jayden only previously envisioned in therapy, gradually going from pressing the button to actually riding an elevator. The goal is that Jayden will soon be able to take the elevator all the way up to the 29th floor of their office without feeling any anxiety.

Sometimes, it’s too impractical, expensive, or embarrassing to re-create anxiety- producing situations, so a therapist might employ virtual reality exposure therapy by using a simulation to help conquer fears. Virtual reality exposure therapy has been used effectively to treat numerous anxiety disorders such as the fear of public speaking, claustrophobia (fear of enclosed spaces), aviophobia (fear of flying), and post-traumatic stress disorder (PTSD), a trauma and stressor-related disorder (Gerardi, Cukor, Difede, Rizzo, & Rothbaum, 2010).

Some behaviour therapies employ operant conditioning. Recall what you learned about operant conditioning: We have a tendency to repeat behaviours that are reinforced. What happens to behaviours that are not reinforced? They become extinguished. These principles, defined by Skinner as operant conditioning, can be applied to help people with a wide range of psychological problems. For instance, operant conditioning techniques designed to reinforce desirable behaviours and punish unwanted behaviours are effective behaviour modification tools to help children with autism (Lovaas, 1987, 2003; Sallows & Graupner, 2005; Wolf & Risley, 1967). This technique is called Applied Behavior Analysis (ABA). In this treatment, a child’s behaviour is charted and analyzed. The ABA therapist, along with the caregivers, determines what reinforces the child, what sustains a behaviour to continue, and how best to manage a behaviour. For example, Nur may become overwhelmed and run out of the room when the classroom is too noisy. Whenever Nur runs out of the classroom, the teacher’s aide chases after them and places Nur in a special room where they can relax. Going into the special room and getting the aide’s attention are reinforcing for Nur. In order to change Nur’s behaviour, Nur must be presented with other options before they become overwhelmed, and they cannot receive reinforcement for displaying maladaptive behaviours.

One popular operant conditioning intervention is called the token economy. This involves a controlled setting where individuals are reinforced for desirable behaviours with tokens, such as a poker chip, that can be exchanged for items or privileges. Token economies are often used in psychiatric hospitals to increase patient cooperation and activity levels. Patients are rewarded with tokens when they engage in positive behaviours (e.g., making their beds, brushing their teeth, coming to the cafeteria on time, and socializing with other patients). They can later exchange the tokens for extra TV time, private rooms, visits to the canteen, and so on (Dickerson, Tenhula, & Green-Paden, 2005).

Psychotherapy: Cognitive Therapy

Cognitive therapy is a form of psychotherapy that focuses on how a person’s thoughts lead to feelings of distress. The idea behind cognitive therapy is that how you think determines how you feel and act. Cognitive therapists help their clients change dysfunctional thoughts in order to relieve distress. They help a client see how they misinterpret a situation (cognitive distortion). For example, a client may overgeneralize. Because Rey failed one test in Psychology 101, Rey feels they are stupid and worthless. These thoughts then cause their mood to worsen. Therapists also help clients recognize when they blow things out of proportion. Because Rey failed their Psychology 101 test, they have concluded that they’re going to fail the entire course and probably flunk out of college altogether. These errors in thinking have contributed to Rey’s feelings of distress. Rey’s therapist will help them challenge these irrational beliefs, focus on their illogical basis, and correct them with more logical and rational thoughts and beliefs.

Cognitive therapy was developed by psychiatrist Aaron Beck in the 1960s. His initial focus was on depression and how a client’s self-defeating attitude served to maintain a depression despite positive factors in her life (Beck, Rush, Shaw, & Emery, 1979) (Figure T.13). Through questioning, a cognitive therapist can help a client recognize dysfunctional ideas, challenge catastrophizing thoughts about themselves and their situations, and find a more positive way to view things (Beck, 2011).

This graphic depicts two three-box flowcharts showing reactions to failing a test. The first flowchart flows from “Failed test” to “Internal beliefs: I’m worthless and stupid” to “Depression.” The second flowchart flows from “Failed test” to “Internal beliefs: I’m smart, but I didn’t study for this test. I can do better.” to “No depression.”

Figure T.13 Your emotional reactions are the result of your thoughts about the situation rather than the situation itself. For instance, if you consistently interpret events and emotions around the themes of loss and defeat, then you are likely to be depressed. Through therapy, you can learn more logical ways to interpret situations.

Psychotherapy: Cognitive-Behavioural Therapy

Cognitive-behavioural therapists focus much more on present issues than on a patient’s childhood or past, as in other forms of psychotherapy. One of the first forms of cognitive-behavioural therapy was rational emotive therapy (RET), which was founded by Albert Ellis and grew out of his dislike of Freudian psychoanalysis (Daniel, n.d.). Behaviourists such as Joseph Wolpe also influenced Ellis’s therapeutic approach (National Association of Cognitive-Behavioural Therapists, 2009).

Cognitive-behavioural therapy (CBT) helps clients examine how their thoughts affect their behaviour. It aims to change cognitive distortions and self-defeating behaviours. In essence, this approach is designed to change the way people think as well as how they act. It is similar to cognitive therapy in that CBT attempts to make individuals aware of their irrational and negative thoughts and helps people replace them with new, more positive ways of thinking. It is also similar to behaviour therapies in that CBT teaches people how to practice and engage in more positive and healthy approaches to daily situations. In total, hundreds of studies have shown the effectiveness of cognitive-behavioural therapy in the treatment of numerous psychological disorders such as depression, PTSD, anxiety disorders, eating disorders, bipolar disorder, and substance abuse (Beck Institute for Cognitive Behavior Therapy, n.d.). For example, CBT has been found to be effective in decreasing levels of hopelessness and suicidal thoughts in previously suicidal teenagers (Alavi, Sharifi, Ghanizadeh, & Dehbozorgi, 2013). Cognitive-behavioural therapy has also been effective in reducing PTSD in specific populations, such as transit workers (Lowinger & Rombom, 2012).

Cognitive-behavioural therapy aims to change cognitive distortions and self-defeating behaviours using techniques like the ABC model. With this model, there is an Action (sometimes called an activating event), the Belief about the event, and the Consequences of this belief. Let’s say Jude and Zain both go to a party. Jude and Zain each have met an interesting person at the party and spend a few hours chatting with them. At the end of the party, Jude and Zain ask to exchange phone numbers with the person they’ve been talking to, and the request is refused. Both Jude and Zain are surprised, as they thought things were going well. What can Jude and Zain tell themselves about why the person was not interested? Let’s say Jude tells themselves that they are a loser, or are ugly, or “has no game.” Jude then gets depressed and decides not to go to another party, which starts a cycle that keeps him depressed. Zain tells themselves that they had bad breath, goes out and buys a new toothbrush, goes to another party, and meets someone new.

Jude’s belief about what happened results in a consequence of further depression, whereas Zain’s belief does not. Jude is internalizing the attribution or reason for the rebuffs, which triggers their depression. On the other hand, Zain is externalizing the cause, so their thinking does not contribute to feelings of depression. Cognitive-behavioural therapy examines specific maladaptive and automatic thoughts and cognitive distortions. Some examples of cognitive distortions are all-or-nothing thinking, overgeneralization, and jumping to conclusions. In overgeneralization, someone takes a small situation and makes it huge—for example, instead of saying, “This particular person was not interested in me,” Jude says, “I am ugly, a loser, and no one is ever going to be interested in me.”

All or nothing thinking, which is a common type of cognitive distortion for people suffering from depression, reflects extremes. In other words, everything is black or white. After being turned down for a date, Jude begins to think, “No one will ever go out with me. I’m going to be alone forever.” Jude then begins to feel anxious and sad as they contemplate their future.

The third kind of distortion involves jumping to conclusions—assuming that people are thinking negatively about you or reacting negatively to you, even though there is no evidence. Consider the example of Carrigan and Chao, who recently met at a party. They have a lot in common, and Carrigan thinks they could become friends. Carrigan calls Chao to invite Chao for coffee. Since Chao doesn’t answer, Carrigan leaves a message. Several days go by and Carrigan never hears back from their potential new friend. Maybe Chao never received the message because they lost their phone or they are too busy to return the phone call. But if Carrigan believes that Chao didn’t like Carrigan or didn’t want to be their friend, then Carrigan is demonstrating the cognitive distortion of jumping to conclusions.

How effective is CBT? One client said this about his cognitive-behavioural therapy:

I have had many painful episodes of depression in my life, and this has had a negative effect on my career and has put considerable strain on my friends and family. The treatments I have received, such as taking antidepressants and psychodynamic counselling, have helped [me] to cope with the symptoms and to get some insights into the roots of my problems. CBT has been by far the most useful approach I have found in tackling these mood problems. It has raised my awareness of how my thoughts impact on my moods. How the way I think about myself, about others and about the world can lead me into depression. It is a practical approach, which does not dwell so much on childhood experiences, whilst acknowledging that it was then that these patterns were learned. It looks at what is happening now, and gives tools to manage these moods on a daily basis. (Martin, 2007, n.p.)

Integrative (Eclectic) Approaches to Therapy

Consider this description, typical of the type of borderline patient who arrives at a therapist’s office:

Even as an infant, it seemed that there was something different about Aadia. Aadia was an intense baby, easily upset and difficult to comfort. Aadia had very severe separation anxiety — if their parent left the room, Aadia would scream until the parent returned. In their early teens, Aadia became increasingly sullen and angry. They started acting out more and more — yelling at their parents and teachers and engaging in impulsive behaviour such as promiscuity and running away from home. At times Aadia would have a close friend at school, but some conflict always developed and the friendship would end.

By the time Aadia turned 17, their mood changes were totally unpredictable. Aadia was fighting with their parents almost daily, and the fights often included violent behaviour on Aadia’s part. At times they seemed terrified to be without their parent, but at other times they would leave the house in a fit of rage and not return for a few days. One day, Aadia’s parent noticed scars on Aadia’s arms. When confronted about them, Aadia said that one night they just got more and more lonely and nervous about a recent breakup until they finally stuck a lit cigarette into their arm. When asked why, Aadia said “I didn’t really care for the relationship that much, but I had to do something dramatic.”

When they were 18, Aadia rented a motel room where they took an overdose of sleeping pills. The suicide attempt was not successful, but the authorities required that Aadia seek psychological help.

Most therapists will deal with a case such as Aadia’s using an eclectic approach. First, because Aadia’s negative mood states are so severe, they will likely recommend that Aadia start taking antidepressant medications. These drugs are likely to help Aadia feel better and will reduce the possibility of another suicide attempt, but they will not change the underlying psychological problems. Therefore, the therapist will also provide psychotherapy.

The first sessions of the therapy will likely be based primarily on creating trust. Person-centred approaches will be used in which the therapist attempts to create a therapeutic alliance conducive to a frank and open exchange of information.

If the therapist is trained in a psychodynamic approach, they will probably begin intensive face-to-face psychotherapy sessions at least three times a week. The therapist may focus on childhood experiences related to Aadia’s attachment difficulties but will also focus in large part on the causes of the present behaviour. The therapist will understand that because Aadia does not have good relationships with other people, Aadia will likely seek a close bond with the therapist, but the therapist will probably not allow the transference relationship to develop fully. The therapist will also realize that Bethany will probably try to resist the work of the therapist.

Most likely the therapist will also use principles of CBT. For one, cognitive therapy will likely be used in an attempt to change Aadia’s distortions of reality. Aadia feels that people are rejecting them, but they are probably bringing these rejections on themselves. If they can learn to better understand the meaning of other people’s actions, they may feel better. And the therapist will likely begin using some techniques of behaviour therapy, for instance, by rewarding Aadia for successful social interactions and progress toward meeting their important goals.

The eclectic therapist will continue to monitor Aadia’s behaviour as the therapy continues, bringing into play whatever therapeutic tools seem most beneficial. Hopefully, Aadia will stay in treatment long enough to make some real progress.

One example of an eclectic treatment approach that has been shown to be successful in treating BPD is dialectical behavioural therapy (DBT) (Linehan & Dimeff, 2001). DBT is essentially a cognitive therapy, but it includes a particular emphasis on attempting to enlist the help of the patient in their own treatment. A dialectical behavioural therapist begins by attempting to develop a positive therapeutic alliance with the client, and then tries to encourage the patient to become part of the treatment process. In DBT the therapist aims to accept and validate the client’s feelings at any given time while nonetheless informing the client that some feelings and behaviours are maladaptive, and showing the client better alternatives. The therapist will use both individual and group therapy, helping the patient work toward improving interpersonal effectiveness, emotion regulation, and distress tolerance skills.

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Psychological Approaches to Treatment by Edited by Leanne Stevens is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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