Eclectic Treatment

Introduction

Prior to this point we have considered the different approaches to psychotherapy under the assumption that a therapist will use only one approach with a given patient. But this is not the case; the most commonly practiced approach to therapy is an eclectic therapy, an approach to treatment in which the therapist uses whichever techniques seem most useful and relevant for a given patient. For bipolar disorder, for instance, the therapist may both use psychological skills training to help the patient cope with the severe highs and lows and also suggest that the patient consider biomedical drug therapies (Newman, Leahy, Beck, Reilly-Harrington, & Gyulai, 2002). Treatment for major depressive disorder usually involves antidepressant drugs as well as CBT to help the patient deal with particular problems (McBride, Farvolden, & Swallow, 2007).

One example of an eclectic treatment approach that has been shown to be successful in treating BPD is dialectical behavioral 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 his or her own treatment.

In this section we will also explore group, couples and family therapy. Practitioners sometimes incorporate the social setting in which disorder occurs by conducting therapy in groups. Group therapy is psychotherapy in which clients receive psychological treatment together with others. A professionally trained therapist guides the group, usually between 6 and 10 participants, to create an atmosphere of support and emotional safety for the participants (Yalom & Leszcz, 2005).

Linehan, M. M., & Dimeff, L. (2001). Dialectical behavior therapy in a nutshell. The California Psychologist, 34, 10–13.

McBride, C., Farvolden, P., & Swallow, S. R. (2007). Major depressive disorder and cognitive schemas. In L. P. Riso, P. L. du Toit, D. J. Stein, & J. E. Young (Eds.), Cognitive schemas and core beliefs in psychological problems: A scientist-practitioner guide (pp. 11–39). Washington, DC: American Psychological Association.

Newman, C. F., Leahy, R. L., Beck, A. T., Reilly-Harrington, N. A., & Gyulai, L. (2002). Clinical management of depression, hopelessness, and suicidality in patients with bipolar disorder. In C. F. Newman, R. L. Leahy, A. T. Beck, N. A. Reilly-Harrington, & L. Gyulai (Eds.),
Bipolar disorder: A cognitive therapy approach (pp. 79–100). Washington, DC: American Psychological Association. doi:10.1037/10442-004

Stangor, C. (2017). Introduction to psychology. Boston, MA: Flatworld.

Eclectic Treatment

One of the most commonly diagnosed disorders is borderline personality disorder (BPD). 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 Bethany. She was an intense baby, easily upset and difficult to comfort. She had very severe separation anxiety—if her mother left the room, Bethany would scream until she returned. In her early teens, Bethany became increasingly sullen and angry. She started acting out more and more—yelling at her parents and teachers and engaging in impulsive behavior such as promiscuity and running away from home. At times, Bethany would have a close friend at school, but some conflict always developed and the friendship would end.

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

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

Most therapists will deal with a case such as Bethany’s using an eclectic approach. First, because her negative mood states are so severe, they will likely recommend that she start taking antidepressant medications. These drugs are likely to help her 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-centered 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, he or she will probably begin intensive face-to-face psychotherapy sessions at least three times a week. The therapist may focus on childhood experiences related to Bethany’s attachment difficulties, but will also focus on the causes of the present behavior. The therapist will understand that because Bethany does not have good relationships with other people, she 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 Bethany’s distortions of reality. She feels that people are rejecting her, but she is probably bringing these rejections on herself. If she can learn to better understand the meaning of other people’s actions, she may feel better. And the therapist will likely begin using some techniques of behavior therapy, for instance, by rewarding Bethany for successful social interactions and progress toward meeting her important goals.

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

One example of an eclectic treatment approach that has been shown to be successful in treating BPD is dialectical behavioral 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 his or her own treatment. A dialectical behavioral 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 behaviors 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.

Linehan, M. M., & Dimeff, L. (2001). Dialectical behavior therapy in a nutshell. The California Psychologist, 34, 10–13.

Stangor, C. (2017). Introduction to psychology. Boston, MA: Flatworld.

Group, Couples and Family Counseling

Group therapy provides a safe place where people come together to share problems or concerns, to better understand their own situations, and to learn from and with each other. Group therapy is often cheaper than individual therapy, as the therapist can treat more people at the same time, but economy is only one part of its attraction.  Group therapy allows people to help each other, by sharing ideas, problems, and solutions. It provides social support, offers the knowledge that other people are facing and successfully coping with similar situations, and allows group members to model the successful behaviors of other group members. Group therapy makes explicit the idea that our interactions with others may create, intensify, and potentially alleviate disorders.

Group therapy has met with much success in the more than 50 years it has been in use, and it has generally been found to be as or more effective than individual therapy (McDermut, Miller, & Brown, 2001). Group therapy is particularly effective for people who have a life-altering illness, as it helps them cope better with their disease, enhances the quality of their lives, and in some cases has even been shown to help them live longer (American Group Psychotherapy Association, 2000).

Sometimes group therapy is conducted with people who are in close relationships. Couples therapy is treatment in which two people who are cohabitating, married, or dating meet together with the practitioner to discuss their concerns and issues about their relationship. These therapies are in some cases educational, providing the couple with information about what is to be expected in a relationship. The therapy may focus on such topics as sexual enjoyment, communication, or the symptoms of one of the partners (e.g., depression).

Family therapy involves families meeting together with a therapist. In some cases the meeting is precipitated by a particular problem with one family member, such as a diagnosis of bipolar disorder in a child. Family therapy is based on the assumption that the problem, even if it is primarily affecting one person, is the result of an interaction among the people in the family.

Self-Help Groups

Group therapy is based on the idea that people can be helped by the positive social relationships that others provide. One way for people to gain this social support is by joining a self-help group, which is a voluntary association of people who share a common desire to overcome psychological disorder or improve their well-being (Humphreys & Rappaport, 1994). Self-help groups have been used to help individuals cope with many types of addictive behaviors. Three of the best-known self-help groups are Alcoholics Anonymous, of which there are more than two million members in the United States, Gamblers Anonymous, and Overeaters Anonymous.

Image © Thinkstock.Stangor, C. (2017). Introduction to psychology. Boston, MA: Flatworld.

The idea behind self-help groups is very similar to that of group therapy, but the groups are open to a broader spectrum of people. As in group therapy, the benefits include social support, education, and observational learning. Religion and spirituality are often emphasized, and self-blame is discouraged. Regular group meetings are held with the supervision of a trained leader.

Community Mental Health: Service and Prevention

The social aspect of disorder is also understood and treated at the community level. Community mental health services are psychological treatments and interventions that are distributed at the community level. Community prevention programs are designed to provide support during childhood or early adolescence with the hope that the interventions will prevent disorders from appearing or will keep existing disorders from expanding. Interventions include such things as help with housing, counseling, group therapy, emotional regulation, job and skills training, literacy training, social responsibility training, exercise, stress management, rehabilitation, family therapy, or removing a child from a stressful or dangerous home situation.

The goal of community interventions is to make it easier for individuals to continue to live a normal life in the face of their problems. Community mental health services are designed to make it less likely that vulnerable populations will end up in institutions or on the streets. Their goal is to allow at-risk individuals to continue to participate in community life by assisting them within their own communities.

Community mental health services are provided by nurses, psychologists, social workers, and other professionals in sites such as schools, hospitals, police stations, drug treatment clinics, and residential homes. The goal is to establish programs that will help people get the mental health services that they need (Gonzales, Kelly, Mowbray, Hays, & Snowden, 1991).

Retrieved from https://commons.wikimedia.org/wiki/File:Boca_culture_003.jpg. Licensed under CC0.

Unlike traditional therapy, the primary goal of community mental health services is prevention. Just as widespread vaccination of children has eliminated diseases such as polio and smallpox, mental health services are designed to prevent psychological disorder (Institute of Medicine, 1994). Community prevention can be focused on one of three levels: primary prevention, secondary prevention, and tertiary prevention.

Primary prevention is prevention in which all members of the community receive the treatment. Examples of primary prevention are programs designed to encourage all pregnant women to avoid cigarettes and alcohol because of the risk of health problems for the fetus, and programs designed to remove dangerous lead paint from homes.

Secondary prevention is more limited and focuses on people who are most likely to need it—those who display risk factors for a given disorder. Risk factors are the social, environmental, and economic vulnerabilities that make it more likely than average that a given individual will develop a disorder (Werner & Smith, 1992).

Finally, tertiary prevention is treatment, such as psychotherapy or biomedical therapy that focuses on people who are already diagnosed with disorder.

Gonzales, L. R., Kelly, J. G., Mowbray, C. T., Hays, R. B., & Snowden, L. R. (1991). Community mental health. In M. Hersen, A. E. Kazdin, & A. S. Bellack (Eds.), The clinical psychology handbook (2nd ed., pp. 762–779). Elmsford, NY: Pergamon Press.

Humphreys, K., & Rappaport, J. (1994). Researching self-help/mutual aid groups and organizations: Many roads, one journey. Applied and Preventative Psychology, 3(4), 217–231.

Institute of Medicine. (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research. Washington, DC: National Academy Press.

McDermut, W., Miller, I. W., & Brown, R. A. (2001). The efficacy of group psychotherapy for depression: A meta-analysis and review of the empirical research. Clinical Psychology: Science and Practice, 8(1), 98–116.

Stangor, C. (2017). Introduction to psychology. Boston, MA: Flatworld.

Werner, E. E., & Smith, R. S. (1992). Overcoming the odds: High risk children from birth to adulthood. New York, NY: Cornell University Press.

Yalom, I., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books.

Acceptance and Mindfulness-Based Approaches

Unlike the preceding therapies, which were developed in the 20th century, this next one was born out of age-old Buddhist and yoga practices. Mindfulness, or a process that tries to cultivate a nonjudgmental, yet attentive, mental state, is a therapy that focuses on one’s awareness of bodily sensations, thoughts, and the outside environment. Whereas other therapies work to modify or eliminate these sensations and thoughts, mindfulness focuses on nonjudgmentally accepting them (Kabat-Zinn, 2003; Baer, 2003). For example, whereas CBT may actively confront and work to change a maladaptive thought, mindfulness therapy works to acknowledge and accept the thought, understanding that the thought is spontaneous and not what the person truly believes. There are two important components of mindfulness: (1) self-regulation of attention, and (2) orientation toward the present moment (Bishop et al., 2004). Mindfulness is thought to improve mental health because it draws attention away from past and future stressors, encourages acceptance of troubling thoughts and feelings, and promotes physical relaxation.

Retrieved from https://commons.wikimedia.org/wiki/File:Meditate_Tapasya_Dhyana.jpg. Licensed under CC BY-SA-2.0.

Techniques in Mindfulness-Based Therapy

Psychologists have adapted the practice of mindfulness as a form of psychotherapy, generally called mindfulness-based therapy (MBT). Several types of MBT have become popular in recent years, including mindfulness-based stress reduction (MBSR) (e.g., Kabat-Zinn, 1982) and mindfulness-based cognitive therapy (MBCT) (e.g., Segal, Williams, & Teasdale, 2002).

MBSR uses meditation, yoga, and attention to physical experiences to reduce stress. The hope is that reducing a person’s overall stress will allow that person to more objectively evaluate his or her thoughts. In MBCT, rather than reducing one’s general stress to address a specific problem, attention is focused on one’s thoughts and their associated emotions. For example, MBCT helps prevent relapses in depression by encouraging patients to evaluate their own thoughts objectively and without value judgment (Baer, 2003). Although cognitive behavioral therapy (CBT) may seem similar to this, it focuses on “pushing out” the maladaptive thought, whereas mindfulness-based cognitive therapy focuses on “not getting caught up” in it. The treatments used in MBCT have been used to address a wide range of illnesses, including depression, anxiety, chronic pain, coronary artery disease, and fibromyalgia (Hofmann, Sawyer, Witt & Oh, 2010).

Mindfulness and acceptance—in addition to being therapies in their own right—have also been used as “tools” in other cognitive-behavioral therapies, particularly in dialectical behavior therapy (DBT) (e.g., Linehan, Amstrong, Suarez, Allmon, & Heard, 1991). DBT, often used in the treatment of borderline personality disorder, focuses on skills training. That is, it often employs mindfulness and cognitive behavioral therapy practices, but it also works to teach its patients “skills” they can use to correct maladaptive tendencies. For example, one skill DBT teaches patients is called distress tolerance—or, ways to cope with maladaptive thoughts and emotions in the moment. For example, people who feel an urge to cut themselves may be taught to snap their arm with a rubber band instead. The primary difference between DBT and CBT is that DBT employs techniques that address the symptoms of the problem (e.g., cutting oneself) rather than the problem itself (e.g., understanding the psychological motivation to cut oneself). CBT does not teach such skills training because of the concern that the skills—even though they may help in the short-term—may be harmful in the long-term, by maintaining maladaptive thoughts and behaviors.

Another form of treatment that also uses mindfulness techniques is acceptance and commitment therapy (ACT) (Hayes, Strosahl, & Wilson, 1999). In this treatment, patients are taught to observe their thoughts from a detached perspective (Hayes et al., 1999). ACT encourages patients not to attempt to change or avoid thoughts and emotions they observe in themselves, but to recognize which are beneficial and which are harmful. However, the differences among ACT, CBT, and other mindfulness-based treatments are a topic of controversy in the current literature.

Boettcher, H., Hofmann, S. G., & Wu, Q. J. (2018). Therapeutic orientations. In R. Biswas-Diener & E. Diener (Eds), Noba textbook series: Psychology. Champaign, IL: DEF publishers. DOI: nobaproject.com. Retrieved from http://nobaproject.com/modules/therapeutic-orientations. Licensed under CC BY-NC-SA-4.0.

Eclectic Treatment – Video

Summary

The most commonly used approaches to therapy are eclectic, such that the therapist uses whichever techniques seem most useful and relevant for a given patient. In this section we explored eclectic treatment approaches, including dialectical behavioral therapy, group, couples and family therapy, self-help groups, and community mental health prevention.

Dialectical behavioral therapy (DBT), developed by Marsha Linehan, is essentially cognitive therapy, but it includes a particular emphasis on attempting to enlist the help of the patient in his or her own treatment. DBT has been found to be an effective form of treatment, particularly with individuals diagnosed with borderline personality disorder.

Group therapy is psychotherapy in which clients receive psychological treatment together with other patients while being guided by a psychological professional. Types of group therapy include couple’s therapy and group therapy. Self-help groups have been used to help individuals cope with many types of disorders, including addiction.

The goal of community mental health service and prevent programs is to establish programs that will help people get the mental health services that they need. The prevention provided can be primary, secondary or tertiary.

Two key advantages of mindfulness-based therapies are their acceptability and accessibility to patients. Because yoga and meditation are already widely known in popular culture, consumers of mental healthcare are often interested in trying related psychological therapies. Currently, psychologists have not come to a consensus on the efficacy of MBT, though growing evidence supports its effectiveness for treating mood and anxiety disorders. For example, one review of MBT studies for anxiety and depression found that mindfulness-based interventions generally led to moderate symptom improvement (Hofmann et al., 2010). (Boettcher, 2018)