The Psychotherapy of Hope: The Legacy of Persuasion and Healing

11 Behavioral and Condition-Specific Approaches to Psychotherapy

CHAPTER 11 Behavioral and ConditionSpecific Approaches to Psychotherapy Diane McNally Forsyth, R.N., Ph.D., and Virginia Nash, D.N.P., R.N., C.N.S. There are many opportunities . . . for aiding patients to become aware of their difficulties in living, and for developing participant skills that are needed for solving problems that will recur in the future. —hildegard e. peplau, 1952, p. 258 Specific psychotherapies are those that aim to relieve symptoms, complexes of symptoms, dysfunctional behaviors, or disorders, as well as general distress . Such therapies typically engage patients directly, without seeking to understand their nonconscious or cryptic symbolic lives. These treatments involve measuring symptoms systematically and often quantitatively and instructing patients to take steps toward recovery. In Persuasion and Healing, Jerome Frank, borrowing from the former Hopkins Psychiatry chairman, John Whitehorn , termed these therapies “directive” approaches, in contrast to the “evocative ” therapies now loosely grouped as “psychodynamic,” “narrative,” or “holistic .” In Frank’s view, even these broad distinctions were somewhat arbitrary, as directive therapies produce nonspecific improvements, and evocative therapies sometimes relieve specific symptoms. The unique aspect of the directive approaches, which developed in the twentieth century under the influence of academic psychology, is that most were designed, from the outset, to be testable. In contemporary terminology, Frank’s directive therapies fall mostly into the domain of cognitive behavioral therapies. Not surprisingly, many, though not all, are now supported by multiple randomized studies using replicable Curtsey while you’re thinking what to say, it saves time. —Through the Looking Glass 216 Diane McNally Forsyth and Virginia Nash diagnostic and outcome criteria. They consequently occupy a prominent place in the era of evidence-based medicine. Beyond proving their efficacy, the creators of these approaches have refined and revised them in light of the studies that test the therapies and their components. Today, many therapies are subclassified according to the conditions they aim to relieve. In this chapter, after a brief conceptual overview, we discuss behavioral therapies in general and cognitive behavioral therapy (CBT) approaches in particular. We also review the applications of these techniques and of some newer methods or technical variants (such as dialectical behavioral therapy [DBT], or behavioral activation therapy [BAT]), as well as essential aspects of the research that supports their use in several clinical conditions. What Are Behavioral and Condition-Specific Approaches in Psychotherapy? One of the essential general principles in the practice of behavioral therapy is that therapist and patient together plan interventions that the patient carries out. Later, both evaluate the effects of these steps and revise the plan as needed. Similar steps occur in research: therapies are tested and modified in light of their impact on target symptoms or behaviors. Since the time of Pavlov (Goodwin 1999), behavioral therapies have benefited from their scientific links with experimental animal models whose components can be rigorously tested. In the 1960s and 1970s, behavioral therapy research emphasized the application of general principles such as systematic desensitization (Foa and Rothbaum 1998). More contemporary therapies have targeted specific symptoms, using both general and closely focused techniques. Both therapists and patients have access to well worked out, often manualized therapeutic protocols aimed at encouraging specific skills, such as enhancing assertiveness, overcoming phobias, fears, and panic, and increasing positive social behaviors (Kanfer and Goldstein 1991). Strictly behavioral therapies typically relieve discrete, measurable symptoms , such as phobic avoidance. Though patients must be persuaded to engage in the treatment, improvement is attributed to the effects of behavioral interventions that do not depend on the human capacity for language and can be analogized to the results of animal research. Cognitive therapy has a broader focus: it engages patients in reflection about their conscious thought processes, Behavioral and Condition-Specific Psychotherapy 217 along with behavioral practice and advice. Cognitive behavioral therapy, furthermore , has evolved beyond an early, strict focus on present experience and thought. Contemporary variants include limited investigation into the historical roots of the patient’s thinking patterns and discussion of less rational or more symbolic elements of his or her experience, particularly imagery and strong emotion, as determinants of behavior (Beck 2005, p. 324). In contrast to traditional psychodynamic approaches, both behavioral and cognitive behavioral therapies assume that patients’ symptoms are the problems in need of resolution, rather than a manifestation of underlying unconscious motives or conflicts. As Jerome Frank and Julia Frank emphasized in the 1991 edition of Persuasion and Healing, though the term cognitive behavioral therapy implies...