Learning Objectives
- Describe the benefits of different types of treatment modalities and how they are used to address specific problems and populations
So far in this module, we have explored the biopsychosocial model of mental disorders, how disorders arise as explained by the diathesis-stress and gene-environment correlation model, and the role of epigenetics. We have also looked at the separate parts of the biopsychosocial model—the biological and psychological/social models of therapy that seek to understand symptoms and how to treat them with a variety of treatment approaches or orientations. In this section, we will be exploring treatment modalities. Treatment modalities are not based on any specific theory or model of psychotherapy; instead, they are different environments in which treatment takes place. Couples therapy, for example, can be approached from a range of different therapeutic models like psychodynamic, CBT, interpersonal, or forms of integrated therapy. What is unique is that the environment in which those approaches are used now involves two people, already in a relationship, interacting with the therapist and each other. Each modality is different, may address different populations or needs, and requires specific skills and training on the part of the clinician to increase the chances of success.
Treatment Modalities
There are several modalities, or environments, in which psychotherapeutic treatments take place: individual therapy, group therapy, couples therapy, and family therapy are the most common. In an individual therapy session, a client works one-on-one with a trained therapist. In group therapy, usually five to 10 people meet with a trained group therapist to discuss a common issue (e.g., divorce, grief, eating disorders, substance abuse, or anger management). Couples therapy involves two people in an intimate relationship who are having difficulties and are trying to resolve them. The couple may be dating, partnered, engaged, or married. The therapist helps them resolve their problems as well as implement strategies that will lead to a healthier and happier relationship. Family therapy is a special form of group therapy made up of one or more families. The goal of this approach is to enhance the growth of each individual family member and enhance the functioning of the family as a whole.
Once a person seeks treatment, whether voluntarily or involuntarily, they have an intake assessment done to assess the person’s clinical needs. An intake is the therapist’s first meeting with the client. The therapist gathers specific information to address the client’s immediate needs and to arrive at a diagnosis, such as the presenting problem, symptoms, the client’s support system, and insurance status. Depending on the setting, the intake therapist may also carry out brief aspects of assessment such as those described in Module 1. The therapist informs the client about confidentiality, fees, and what to expect in treatment. Confidentiality means the therapist cannot disclose confidential communications to any third party without the client’s consent unless mandated or permitted by law to do so. During the intake, the therapist and client will work together to discuss treatment goals. Then a treatment plan will be formulated, usually with specific measurable objectives. Also, the therapist and client will discuss how treatment success will be measured and the estimated length of treatment and cost. It is common in mental health centers or in other treatment facilities for one clinician to carry out the initial intake and, depending on the results, to recommend more in-depth assessment, or a specific modality of treatment usually carried out by another clinician. For instance, a client may go through an intake that leads to a preliminary diagnosis and referral to another clinician for group therapy that targets clients with that diagnosis.
Figure 1. Therapy may occur (a) one-on-one between a therapist and client or (b) in a group setting. (credit a: modification of work by Connor Ashleigh, AusAID/Department of Foreign Affairs and Trade)
Individual Therapy
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Group Therapy
Figure 2. In group therapy, usually five to 10 people meet with a trained therapist to discuss a common issue such as divorce, grief, an eating disorder, substance abuse, or anger management. (credit: Cory Zanker)
In group therapy, a clinician meets together with several clients with similar problems (Figure 2). When children are placed in group therapy, it is particularly important to match clients by age as well as the nature of their problems. One benefit of group therapy is that it can help decrease a client’s shame and isolation about a problem while offering needed support, both from the therapist and other members of the group (American Psychological Association, 2014). A nine-year-old sexual abuse victim, for example, may feel very embarrassed and ashamed to talk about his situation. If he is placed in a group with other sexually abused boys, he will realize that he is not alone. A child struggling with poor social skills would likely benefit from a group with a specific curriculum to foster interpersonal skills. The group environment would give the child the opportunity not only to learn along with others, but to practice the skills together in a supportive environment. A woman suffering from post-partum depression could feel less guilty and more supported by being in a group with similar women.
Group therapy also has some specific areas of concern. Members of the group may be afraid to speak in front of other people because sharing secrets and problems with complete strangers can be stressful and overwhelming, especially at first. There may be personality clashes and arguments among group members. There could also be concerns about confidentiality: someone from the group might share what another participant said to people outside of the group. Especially among adults, many of these issues should be specifically addressed and discussed by the therapist at the start of the group. If a client is added soon after a group has already begun, the therapist may meet with them individually to explain the basic aspects of participating in the group, answer questions, and then introduce the client into the group environment and other members.
Another benefit of group therapy is that members can confront each other about their patterns. For those with some types of problems, such as sexual abusers, group therapy is the recommended treatment for this very reason. Group treatment for this population is considered to have several benefits:
Group treatment is more economical than individual, couples, or family therapy. Sexual abusers often feel more comfortable admitting and discussing their offenses in a treatment group where others are modeling openness. Clients often accept feedback about their behavior more willingly from other group members than from therapists. Finally, clients can practice social skills in group treatment settings. (McGrath, Cumming, Burchard, Zeoli, & Ellerby, 2009)
During a group session, the entire group could reflect on an individual’s problem or difficulties, and others might disclose what they have done in that situation. When a clinician is facilitating a group, the focus is always on making sure that everyone benefits and participates in the group and that no one person is the focus of the entire session. Groups can be organized in various ways: some have an overarching theme or purpose, some are time-limited, some have open membership that allows people to come and go, and some are closed. Some groups are structured with planned activities and goals, while others are unstructured: There is no specific plan, and group members themselves decide how the group will spend its time and on what goals it will focus. This can become a complex and emotionally charged process, but it is also an opportunity for personal growth (Page & Berkow, 1994).
Psychoeducation Group Treatment
Groups that have a strong educational component are called psychoeducation groups. For example, a group for children who have a parent with cancer might discuss in depth what cancer is, types of treatments are used for cancer, the side effects of treatments such as hair loss, as well as ways to support the family member, and ways to cope with the emotional impact on themselves. For children, group therapy sessions often take place in school. They are led by a school counselor, a school psychologist, or a school social worker. Groups might focus on test anxiety, social isolation, self-esteem, bullying, or school failure (Shechtman, 2002). Whether the group is held in school or in a clinician’s office, group therapy has been found to be effective with children facing numerous kinds of challenges (Shechtman, 2002).
Other examples include psychoeducation family therapy with the family members of a person diagnosed with schizophrenia. One of the major goals of such treatment is to allow family members to express their concerns and feel supported, but it is also to receive educational information regarding schizophrenia and to dispute and reduce misinformation, especially because there are many social stereotypes about persons with schizophrenia (such as that they are all violent and dangerous). Psychoeducation in this situation is also intended to educate the family about expressed emotion, meaning emotionally charged interactions with the person with schizophrenia; lowering the level of expressed emotion in the family is important in preventing relapse. Psychoeducational groups often take place as well in inpatient or residential facilities where the goal is to teach patients about life skills such as applying for a job or how to find a dentist, discussions about medications and treatments, or assertiveness training.
Couples Therapy
Couples therapy involves two people in an intimate relationship who are having difficulties and are trying to resolve them (Figure 3). The couple may be dating, partnered, engaged, or married. The primary therapeutic orientation used in couples counseling is cognitive-behavioral therapy (Rathus & Sanderson, 1999), although other orientations also are used depending on the therapist. Couples meet with a therapist to discuss conflicts and/or aspects of their relationship that they want to change. The therapist helps them see how their individual backgrounds, beliefs, and actions are affecting their relationship. Often, a therapist tries to help the couple resolve these problems, as well as implement strategies that will lead to a healthier and happier relationship, such as how to listen, how to argue productively, and how to express feelings. However, sometimes, after working with a therapist, a couple will realize that they are too incompatible and will decide to separate. Some couples seek therapy to work out their problems, while others attend therapy to determine whether staying together is the best solution. Counseling couples in a high-conflict and volatile relationship can be difficult. In fact, psychologists Peter Pearson and Ellyn Bader, who founded the Couples Institute in Palo Alto, California, have compared the experience of the clinician in couples’ therapy to be like “piloting a helicopter in a hurricane” (Weil, 2012, para. 7). As with group therapists, being an effective therapist in this modality requires specialized training; couples therapy is not simply conducting individual therapy with two people present. With proper training, it can be a fulfilling, although challenging, occupation.
Figure 3. In couples counseling, a therapist helps people work on their relationship. (credit: Cory Zanker)
Family Therapy
Family therapy is a special form of group therapy, consisting of one or more families. Although there are many theoretical orientations in family therapy, one of the most predominant is the systems approach. The family is viewed as an organized system, and each individual within the family is a contributing member who creates and maintains processes within the system that shape behavior (Minuchin, 1985). It may help you to think back to our discussion of systems and how they work at the start of the module. Each member of the family influences and is influenced by the others; they are all interdependent in their relationships. The goal of this approach is to enhance the growth of each family member as well as that of the family as a whole.
Often, dysfunctional patterns of communication that develop between family members can lead to conflict. These patterns will likely be evident in the interactions of family members during sessions and can be addressed directly by the therapist as they are happening. In many cases, one member of the family has problems that detrimentally affect everyone. For example, a mother’s depression, a teen daughter’s eating disorder, or a father’s alcohol dependence could affect all members of the family. The therapist would work with all members of the family to help them cope with the issue, support each other, and to encourage resolution and growth for the individual family member with the problem.
With family therapy, the nuclear family (i.e., parents and children) or the nuclear family plus whoever lives in the household (e.g., grandparent) come into treatment. Family therapists work with the whole family unit to heal the family. In addition to the systems approach, there are other types of family therapy. For example, in structural family therapy, the therapist examines and discusses the boundaries and structures within the family: who makes the rules, who sleeps in the bed with whom, how decisions are made, and what are the boundaries within the family. In some families, the parents do not work together to make rules, or one parent may undermine the other, leading the children to act out. The therapist helps them resolve these issues and learn to communicate more effectively.
In strategic family therapy, the goal is to address specific problems within the family that can be dealt with in a relatively short amount of time. Typically, the therapist would guide what happens in the therapy session and design a detailed approach to resolving each member’s problem (Madanes, 1991). As with other forms of treatment described in this section of the module, family therapists receive specialized training and supervision beyond that of individual therapy in order to work within this treatment modality.
Other Treatment Environments
In addition to the modalities mentioned above, there are other, broader environments in which psychotherapy takes place:
- inpatient hospitalization: treatment occurs within a hospital providing 24-hour care and observation; patients who are sent for inpatient hospitalization have usually been evaluated by a court to represent a risk of harm or danger to themselves or others. A multidisciplinary treatment team usually including a psychiatrist, psychologist, social worker, nursing staff, recreation therapists, and others as needed work together to formulate a plan for careful assessment and treatment of the patient; these treatment plans frequently involve medications, individual and group therapy, possibly psychoeducation, and other treatments including recreation therapy and medical treatment for other problems. These professionals have to communicate effectively with each other and closely coordinate their efforts for the best treatment outcomes. In many states, a person can be confined to an inpatient hospital for a period of observation and assessment lasting 48 or 72 hours with a follow-up report to the court regarding whether there is need for more sustained confinement and extended treatment. Most states also permit a person to voluntarily choose hospitalization for treatment; if the person does not have health insurance, they may be admitted, if space is available, to state-run psychiatric hospitals. Voluntary patients can leave if they choose to do so unless the treatment team believes they could harm themselves or others, in which case the court would have to evaluate the situation and make a decision.
- partial hospitalization: usually this type of environment may be chosen if a patient no longer requires 24-hour inpatient care (which is very expensive), but still requires a high degree of coordination among professionals and a variety of both psychiatric and psychotherapeutic care. The patient usually attends treatment only during the day. In addition to the others treatments mentioned above, the patient may receive specialized forms of treatment, such as behavioral training and support to help a patient learn life skills to be able to successfully live on their own and/or skills to be able to secure a job in the near future. At the end of the day, the patient returns home or to a supervised living arrangement where they care for themselves.
- residential treatment center: a residential treatment center (RTC), sometimes called a rehab, is a live-in health care facility providing therapy for substance abuse, mental illness, or other behavioral problems. Residential treatment is a more restrictive option than outpatient therapy; however, it is less restrictive than inpatient psychiatric hospitals. For adolescents, most RTCs use a behavior modification paradigm. Others are relationally oriented, focusing on community and interpersonal relationships. Some utilize a community or positive peer-culture model. Generalist programs are usually large (80-plus clients and as many as 250) and level-focused in their treatment approach. That is, in order to manage clients’ behavior, they frequently put systems of rewards and punishments in place. Specialist programs are usually smaller (less than 100 clients and as few as 10 or 12). Specialist programs typically are not as focused on behavior modification as generalist programs are. Different RTCs work with different types of problems, and the structure and methods of RTCs varies. Some RTCs are lock-down facilities; that is, the residents are locked inside the premises. In a locked residential treatment facility, clients’ movements are restricted. By comparison, an unlocked residential treatment facility allows them to move about the facility with relative freedom, but they are only allowed to leave the facility under specific conditions. Adult RTC programs are similar in many ways, but focus primarily on either adults who have been discharged from inpatient hospitals but who are not yet ready to live on their own, or adults with substance dependence who have struggled to avoid relapse and need a more structured environment.
- outpatient care: this environment is the “default” for most persons with mental disorders. It can include a range of treatment modalities usually chosen by the client themselves, although some may be court-ordered, especially for persons with lesser criminal offenses or drug charges. The client arranges to meet with an appropriate therapist or psychiatrist for an intake session and together, they decide which modality of treatment would be most effective. This form of treatment is mostly covered through health insurance. Many clients at least initially seek outpatient care from primary care physicians who often begin treatment with medications; some psychiatrists, depending on the diagnosis, may recommend a psychotherapy modality as the primary treatment.
- forensic psychiatric units: unlike the other environments described above, forensic psychiatric units represent a blend of criminal justice and mental health treatment environments. Individuals are sent to these units by the court system, and the unit, which is often part of a larger psychiatric inpatient hospital, is frequently stand alone; everyday procedures are managed very much like a jail or prison environment with increased security compared to a typical inpatient treatment unit. The goal and function of this type of facility is also distinctive. Inmates on the unit are defendants charged with criminal offenses and the purpose of the unit is to carry out thorough assessments, most commonly for competency to stand trial or for insanity at the time of the offense and report the results to the court. Some individuals are receiving treatment to restore them to legal competence, meaning that the focus of both psychiatric and psychological care is to enable defendants to be returned to the criminal justice system in order to stand trial. These units may also house some individuals who have been found not guilty by reason of insanity and are ordered for treatment until they are judged safe to return to a regular inpatient treatment or to be released. In addition to medications, inmates may also receive individual therapy to reduce symptoms and improve functioning and often group therapy that frequently involves psychoeducation regarding the court system, to help them understand the charges against them, how the legal system functions, and how to work with an attorney to prepare their defense. An alternate form of this environment is found in prisons with individuals who may have been found guilty but mentally ill (depending on state law); these individuals receive the equivalent of inpatient treatment, but in a prison setting and will continue to serve their sentence even when treatment is successful.
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Watch this video to learn more about a structural family session. At the five-minute mark, you’ll see an example of a therapy session with the family and a counselor.
You can view the transcript for “Family Therapy” here (opens in new window).
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Treatment for AddictioN
Addiction and substance abuse disorders are difficult to treat because chronic substance use can permanently alter the neural structure in the prefrontal cortex, an area of the brain associated with decision-making and judgment, thus driving a person to continue to use drugs and/or alcohol in spite of negative consequences (Muñoz-Cuevas, Athilingam, Piscopo, & Wilbrecht, 2013). This helps explain why relapse rates tend to be high. About 40–60% of individuals relapse, which means they return to abusing drugs and/or alcohol after a period of improvement (National Institute on Drug Abuse [NIDA], 2008).
The goal of substance-related treatment is to help an addicted person stop compulsive drug-seeking behaviors (NIDA, 2012). This means an addicted person will need long-term treatment, similar to a person battling a chronic physical disease such as hypertension or diabetes. Treatment usually includes behavioral therapy and/or medication, depending on the individual (NIDA, 2012). Specialized therapies have also been developed for specific types of substance-related disorders, including alcohol, cocaine, and opioids (McGovern & Carroll, 2003). Substance-related treatment is considered much more cost-effective than incarceration or not treating those with addictions (NIDA, 2012).
Figure 2. Substance use and abuse costs the United States over $600 billion a year (NIDA, 2012). This addict is using heroin. (credit: “jellymc – urbansnaps”/Flickr)
Specific factors make substance-related treatment much more effective. One factor is the duration of treatment. Generally, the addict needs to be in treatment for at least three months to achieve a positive outcome (Simpson, 1981; Simpson, Joe, & Bracy, 1982; NIDA, 2012). This is due to the psychological, physiological, behavioral, and social aspects of abuse (Simpson, 1981; Simpson et al., 1982; NIDA, 2012).
While individual therapy is used in the treatment of substance-related disorders, group therapy is the most widespread treatment modality (Weiss, Jaffee, de Menil, & Cogley, 2004). The rationale behind using group therapy for addiction treatment is that addicts are much more likely to maintain sobriety in a group format. It has been suggested that this is due to the rewarding and therapeutic benefits of the group, such as support, affiliation, identification, and even confrontation (Center for Substance Abuse Treatment, 2005).
Treatment also usually involves medications to detox the addict safely after an overdose, to prevent seizures and agitation that often occur in detox, to prevent reuse of the drug, and to manage withdrawal symptoms. Getting off drugs often involves the use of drugs—some of which can be just as addictive. Detox can be difficult and dangerous.
Frequently, a person who is addicted to drugs and/or alcohol has comorbid disorders, meaning they may have additional diagnoses of other psychological disorders. In cases of comorbidity, the best treatment is thought to address both (or multiple) disorders simultaneously (NIDA, 2012). Behavior therapies are used to treat comorbid conditions, and in many cases, medications are used along with psychotherapy.
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GlossarY
comorbid disorder: individual who has two or more diagnoses, which often includes a substance abuse diagnosis and another psychiatric diagnosis, such as depression, bipolar disorder, or schizophrenia
confidentiality: therapist cannot disclose confidential communications to any third party, unless mandated or permitted by law
couples therapy: two people in an intimate relationship, such as husband and wife, who are having difficulties and are trying to resolve them with therapy
family therapy: special form of group therapy consisting of one or more families
group therapy: treatment modality in which five to 10 people with the same issue or concern meet together with a trained clinician
individual therapy: treatment modality in which the client and clinician meet one-on-one
intake: therapist’s first meeting with the client in which the therapist gathers specific information to address the client’s immediate needs
modality: a specific environment in which treatment takes place; it can vary from the number of people involved and the physical setting in which treatment takes place.
psychoeducation: a form of group or family therapy where a large emphasis is placed on educating the participants about symptoms, social skills, and ways to cope with mental disorders
relapse: resumption of drug and/or alcohol use after a period of improvement from substance abuse
strategic family therapy: therapist guides the therapy sessions and develops treatment plans for each family member for specific problems that can be addressed in a short amount of time
structural family therapy: therapist examines and discusses with the family the boundaries and structure of the family: who makes the rules, who sleeps in the bed with whom, how decisions are made, and what are the boundaries within the family
