Freud's psychological theories and contributions

Psychotherapy

Theories and Practice of Counseling and Psychotherapy

The cognitive behavioral and person-centered approaches regarding counseling and psychotherapy come from a much different developmental history and theoretical underpinnings. Cognitive behavior therapy (CBT) is a psychological approach that addresses problematic behaviors that occur from the recurrence of bad thoughts and has shown useful to treat anxiety, depression, and substance abuse disorders among others. However, there are also many psychotherapy practices that can integrated with the counseling strategies to provide a more comprehensive approach to treatment. This analysis will provide a theoretical background of cognitive behavioral therapy and psychotherapy. These foundations will be applied to the treatment of depression as well as try to pinpoint opportunities in which they could be used in conjunction.

Background

Psychoanalysis

The psychoanalytical approach began with Sigmund Freud's and his theories of human psychology. He identified three primary drivers of an individual's personality: the id, the ego and the superego. He explained that the individual's behavior was an explanation of how these three psychological forces worked together or in some cases failed to work together. These relationships were thought to serve as the basis for human instincts and the decision making process in general. The theory of the ego has been constantly evolving since Freud's time and still uses psychoanalysis, a counseling approach Freud pioneered, to help identify these forces in a therapy sessions.

In Freud's original theory, he conceptualized three distinct regions of the mind. The first was the id which was thought of as the completely unconscious region which also serves as a pleasure center that seeks immediate gratification. The ego, which is something of a secondary process, tries to reconcile the demands of ego with the limitations of both the natural world as well as the social systems in which the person must also adhere to. Finally, the superego is something of an ideological voice or what is thought of commonly as the human consciousness which is referred to as the "conscience" or "voice of reason." The interactions between these three forces are dynamic and they are constantly grappling within the mind which results in the individual's personality and the behaviors that can be witnessed by others.

Using this conceptual model, Freud continued to expand on his theories. He suggested that the ego was the mechanism that helps establish the division between yourself and others. It is in this division in which the personality is displayed. The individual expression, or the balance of forces, is displayed externally through expressions in behaviors. The ego sort of acts as a connection between the id and superego and decides which force will ultimately manifest. Thus the superego is the primary mechanism that represents a person's moral fabric and their opinions about what is good and bad in different situations. When any of the three forces become unbalanced in any way, this can led to a variety of psychological disorders.

The original concept of the ego has been explained through a variety of metaphors; however Freud's (1923) concept was elegantly defined in its origination (Berzoff, Flanagan, & Hertz, 2008):

In its relation to the id (the ego) is like a person on horseback, who has to hold in check the superior strength of the horse; with this difference, that the rider tries to do so with his own strength while the ego uses borrowed forces. The analogy may be carried a little further. Often a rider, if he is not to be parted from his horse, is obliged to guide it where IT wants to go; so in the same way the ego is in the habit of transforming the id's will into action as if it were his own (p. 25).

According to Freud, the id, ego and superego are distributed differently across three levels of awareness: the conscious, the preconscious and the unconscious. The unconscious mind contains thoughts, memories and desires that are not easily accessible yet greatly influence our behavior. Furthermore, Freud believed that people must successfully pass through five stages of development in order to become healthy, well-adjusted adults. The different phases each have an objective that must be accomplished successfully or else if the goal is not reached, the person becomes fixated at the uncompleted stage, which creates a psychological imbalance. The five stages are: oral, anal, phallic, latent, and genital (Cherry, N.d.). Although many of these different theories have been largely discredited, there is still much value that can be gained by understand the theoretical model and it still has many pragmatic benefits in counseling today.

Cognitive Behavioral

While Freud explained behaviors by the forces underneath the conscious level, BF Skinner looked at the issue from an entirely different perspective when he was developing his behavioral theory. Behaviorism is a theory takes more of a scientific approach that works under the assumption that psychology should study only the observable behavior without further speculation. Skinner believed anything that could not be observed was mere speculation and virtually untestable; as interesting as they may be. Therefore, he did not include any subconscious forces like Freud's id, ego and superego that constitute the inner psychological processes. Skinner was less interested in what is going on inside people, because this was unobservable. He was more interested in the observable data that did not require any kind of subjective appraisal. He believed that reinforcement of behavioral patterns is the one of the primary factors that a personality and this is largely due to external consequences.

Skinner's behavioral theory tries to explain the development of personality by the amassing of the individual's experience through the interactions with their environment. This accumulation is referred to as learning throughout individual's developmental path. To test his theories, Skinner constructed a 'box' in which he was able to teach animals to receive food by pecking or tapping a bar or light and as a result he is commonly referred to as the father of Operant Conditioning. However, his work was based on Thorndike's law of effect and Skinner introduced a new term into the Law of Effect - Reinforcement. Behavior which is reinforced tends to be repeated (i.e. strengthened); behavior which is not reinforced tends to die out-or be extinguished (i.e. weakened) (McLeod, 2007). Although humans are certainly more complex, Skinner believed that most human responses are shaped by a similar process of conditioning.

Even though humans are behaviorally more complex, there are many examples that can point to Skinners effectiveness such as the individuals who enjoy playing slot machines. People who use slot machines definitely at least resemble the white rats who press on a lever in a Skinner box. Both are programmed to provide reinforcement on what's called a variable ratio schedule: a reward occurring, say, every fifth or tenth response, on the average. This leads to a high rate of responding, and the human being in the casino is behaving exactly like the rat or pigeon in the Skinner box. (Incidentally, he always felt uncomfortable when someone used that term in his presence and would say, "You mean operant conditioning chamber (Sherman, 2010).")

Cognitive behavioral theory asserts that different types of reinforcements will affect the likelihood of whether a particular behavior will be repeated or not. The variety of reinforcements include: positive reinforcement, negative reinforcement, extinction and punishment. Positive reinforcement is simply a reward given for a particular response while a negative reinforcement works to take away the reinforcer. The extinction process occurs when the reinforcement stops which will lead to the responses to the stimuli diminishing. Finally, punishment is causing some form of pain aimed at an unwanted behavior with the idea that it will suppress an unwanted behavior. Furthermore, Skinner believed that reinforcement must be provided in an immediate manner, ideally about half a second, and this makes the process of conditioning more effective as a whole.

Modern Counseling Applications

There are many different approaches that a counselor can take to try to assist a patient with any kind of behavioral problems. Different theoretical models such as the two presented make major contributions to psychology. However, there are many subsequent models that represent something of a bridge between these two poles. The cognitive behavioral theories have attempted to apply many of the principles of reinforcement to mental processes to promote more rational thinking and decision making. Another deviation that has at least some connection with Freud's work would be the person-centered approach that postulates that each individual is working towards self-actualization and can be adequately guided along that path.

The role of the counselor obviously depends on the individual perspective and professional identity that the counselor has developed with the patient among a multitude of other factors. The professional identity process is dynamic and develops over time. One qualitative study focused on the development of this professional identity and found that conflict resolution was one of the most salient factors that influence the development of a professional identity (Brott & Myers, 2011). Thus, outside of the theoretical approaches, it should also be noted that interpersonal factors can also influence the effectiveness of counseling towards various outcomes.

One of the more common uses of counseling is to address depression in both children and adults. According to the National Institute of Mental Health (NIH), mental disorders are common in the United States and internationally at an estimated rate of 26.2% of Americans ages 18 and older -- about one in four adults -- suffer from a diagnosable mental disorder in a given year (NIH, N.d.). There are a multitude of different methods and techniques that are used to treat depression. The most common methods in most advanced countries include psychotherapy, counseling and medication or some combination of the three. The rates of depression among the population have expanded quite rapidly in the last couple of decades; especially in industrialized countries. The lifetime risk of developing a depressive episode now approaches 15% and the World Health Organization ranks depression as the world's fourth greatest public health problem.

This is consider as a significant issue due to the fact that depression is a leading cause of disability, lost productivity, as well as a contributor to increased health care expenditures. As more and more drugs are introduced, there have been a lesser rate of individuals seeking psychotherapy as a means of alleviating there depressive episodes. Furthermore, since depression is a leading cause of disability, lost productivity and health care expenditure and among those who were treated, the use of antidepressant medications increased from 37.3% to 74.5%, and the use of psychotherapy decreased from 71.1% to 60.2% (Marcus & Offson, 2010). The NIH also provides the following statistics on major depressive disorder (NIH, N.d.):

Major Depressive Disorder is the leading cause of disability in the U.S. For ages 15-44.

Major depressive disorder affects approximately 14.8 million American adults, or about 6.7% of the U.S. population age 18 and older in a given year.

While major depressive disorder can develop at any age, the median age at onset is 32.

Major depressive disorder is more prevalent in women than in men.

Beyond the NIH estimates, other estimates that include a broader definition of depression have also provided figures that are even more pervasive and estimate the rates significantly higher. For example, in another study, current depression was defined as meeting criteria for either major depression or "other depression" (fewer symptoms than major depression, but still meet criteria for a depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, could be classified as non-specified depression or minor depression or dysthymia) (CDC, 2012). With a more liberal definition of depression, it is estimated that in the United States there is somewhere in the neighborhood of one in ten adults who suffer some depression symptoms.

There are many different ways to address the instances of depression that can be found in the population. One method is to try to treat depression with medication because of the fact that is both convenient and simple. When patients visit their family doctor, as opposed to promoting the benefits of counseling, it is commonly the case that they will prescribe some form of medication to attempt to relieve the symptoms of depression. Many studies have suggested that this is often an effective option; especially for certain demographics.

One study collected data on impoverished minority in the Washington DC area between 1997 and 2002 and found that medication can be used effectively in some scenarios (Miranda, et al., 2003). Guideline-concordant care for major depression is effective for these ethnically diverse and impoverished patients. More women engaged in a sufficient duration of treatment with medications compared with psychotherapy, and outcome gains were more extensive and robust for medications (Miranda, et al., 2003). However, most of the literature agrees that counseling is a less invasive and better way to address depression symptoms when resources are not as large of a limitation.

However, despite the popularity of medical interventions to treat depression, there is also a substantial amount of conflicting results in academic literature. For example another study that compared a group of cardiac patients that took different medications for depression, to those who simply exercised as a way to reduce depression (Blumenthal, 2011). Depression has been associated with increased mortality and nonfatal cardiac events in patients with CHD; it is also associated with worse outcomes in patients who undergo coronary artery bypass graft surgery and those who have heart failure. The study found that exercise is an established component of cardiac rehabilitation and it efficacy should grow as an treatment for depression though randomized controlled trials are needed to determine the clinical effects of exercise in this population and to compare the effects of exercise with those of antidepressants (Blumenthal, 2011).

Treating depression with counseling at the center seems to be more of a holistic approach; especially when combined with other types of interventions. Although using medication can be inexpensive and somewhat effective, it does more to manage the symptoms rather than address the causes. One study that analyzed a collection of independent studies in a meta-analysis found that out of a sample of over eight hundred and fifty patients the differences between the combination of psychotherapy and pharmacotherapy and the combination of psychotherapy and placebo did not provide any statistical difference among the subgroups (Culijpers, Straten, Hollon, & Andersson, 2009). This study suggests that treating patients with medication has no effective advantage over treating patients with psychotherapy alone.