Psychoanalytic Theories Five Stages of Psychosexual Development.

Freuds based his theory of childhood development on the belief that sexual energy, termed libido, was the driving force of human behavior. He proposed that children progress through five stages of psychosexual development: Phase Age Focus Major site of tension and gratification is the mouth, lips, and tongue; Oral 0-18 includes biting and sucking activities. month Anal Phalli c/ Oedip al Laten cy Genit al 18-36 moths 3-5 years
Id present at birth Ego develops gradually from rudimentary structure present at birth. Anus and surrounding area are major source of interest. Acquisition of voluntary sphincter control (toilet training) Genital focus of interest, stimulation, and excitement Penis is organ of interest for both sexes. Masturbation is common. Penis envy (wish to possess penis) seen in girls; oedipal complex (wish to marry opposite-sex parent and be rid of same-sex parent) seen in boys and girls Resolution of oedipal complex Sexual drive channeled into socially appropriate activities such as school work and sports Formation of the superego Final stage of psychosexual development Begins with puberty and the biologic capacity for orgasm; involves the capacity for true intimacy

5-11/or 13 year 11-13

Transference and Countertransference.

Freud developed the concept of transference and countertransference. Transference occurs when the client displaces onto the therapist attitudes and feelings that the client originally experienced in other relationships (Gabbard, 2000). Transference patterns are automatic and unconscious in the therapeutic relationship. For example, an adolescent female client working with a nurse who is about the same age as the teens parents might react to the nurse like she reacts to her parents. She might experience intense feelings of rebellion or make sarcastic remarks; these reactions are actually based on her experiences with her parents, not the nurse.
Countertransference occurs when the therapist displaces onto the client attitudes or feelings from his or her past. For example, a female nurse who has teenage children and who is experiencing extreme frustration with an adolescent client may respond by adopting a parental or chastising tone. The nurse is countertransfering her own attitudes and feelings toward her children onto the client. Nurses can deal with countertransference by examining their own feelings and responses, using self-awareness, and talking with colleagues.

CURRENT PSYCHOANALYTIC PRACTICE

Psychoanalysis focuses on discovering the causes of the clients unconscious and repressed thoughts, feelings, and conflicts believed to cause anxiety and helping the client to gain insight into and resolve these conflicts and anxieties. The analytic therapist uses the techniques of free association, dream analysis, and interpretation of behavior.

Developmental Theories
1. ERIK ERIKSON AND PSYCHOSOCIAL [STAGES OF DEVELOPMENT] Erik Erikson (19021994) was a German-born psychoanalyst who extended Freuds work on personality development across the life span while focusing on social development as well as psychological development in the life stages. Phase Virtue Task
Trust vs. mistrust (infant) Autonomy vs. shame and doubt (toddler) Initiative vs. guilt (preschool) Industry vs. inferiority (school age) Identity vs. role confusion (adolescence) Intimacy vs. isolation (young adult) Generativity vs. stagnation (middle adult) Ego integrity vs. despair (maturity) Hope

Will Purpose Compete nce

Fidelity Love Care Wisdom

Viewing the world as safe and reliable; relationships as nurturing, stable, and dependable Achieving a sense of control and free will Beginning development of a conscience; learning to manage conflict and anxiety Emerging confidence in own abilities; taking pleasure in accomplishments Formulating a sense of self and belonging Forming adult, loving relationships and meaningful attachments to others Being creative and productive; establishing the next generation Accepting responsibility for ones self and life

2. JEAN PIAGET AND COGNITIVE STAGES OF DEVELOPMENT Jean Piaget (18961980) explored how intelligence and cognitive functioning developed in children. He believed that human intelligence progresses through a series of stages based on age with the child at each successive stage demonstrating a higher level of functioning than at previous stages. In his schema, Piaget strongly believed that biologic changes and maturation were responsible for cognitive development. Piagets four stages of cognitive development are as follows: 1. Sensorimotorbirth to 2 years: The child develops a sense of self as separate from the environment and the concept of object permanence; that is, tangible objects dont cease to exist just because they are out of sight. He or she begins to form mental images. 2. Preoperational2 to 6 years: The child develops the ability to express self with language, understands the meaning of symbolic gestures, and begins to classify objects. 3. Concrete operations6 to 12 years: The child begins to apply logic to thinking, understands spatiality and reversibility, and is increasingly social and able to apply rules; however, thinking is still concrete. 4. Formal operations12 to 15 years and beyond: The child learns to think and reason in abstract terms, further develops logical thinking and reasoning, and achieves cognitive maturity.

Interpersonal Theories
1. HARRY STACK SULLIVAN: INTERPERSONAL/ RELATIONSHIPS AND MILIEU THERAPY Harry Stack Sullivan (18921949; Fig. 3-2) was an American psychiatrist who extended the theory of personality development to include the significance of interpersonal relationships. Sullivan believed that ones personality involved more than individual characteristics, particularly how one interacted with others. He thought that inadequate or nonsatisfying relationships produced anxiety, which he saw as the basis for all emotional problems (Sullivan, 1953). The importance and significance of interpersonal relationships in ones life was probably Sullivans greatest contribution to the field of mental health. Five Life Stages. Sullivan established five life stages of development (infancy, childhood, juvenile, preadolescence, and adolescence), each focusing on various interpersonal relationships (Table 3-4). Sullivan also described three developmental cognitive modes of experience and believed that mental disorders were related to the persistence of one of the early modes. Phase Age Focus
Infancy Birth to onset of language Primary need for bodily contact and tenderness Prototaxic mode dominates (no relation between experiences) Primary zones are oral and anal. If needs are met, infant has sense of well-being; unmet needs lead to dread and anxiety. Parents viewed as source of praise and acceptance Shift to parataxic mode (experiences are connected in sequence to each other) Primary zone is anal. Gratification leads to positive self-esteem. Moderate anxiety leads to uncertainty and insecurity; severe anxiety results in self-defeating patterns of behavior. Shift to the sytaxic mode begins (thinking about self and others based on analysis of experiences in a variety of situations). Opportunities for approval and acceptance of others Learn to negotiate own needs Severe anxiety may result in a need to control or restrictive, prejudicial attitudes. Move to genuine intimacy with friend of the same sex Move away from family as source of satisfaction in relationships Major shift to syntaxic mode Capacity for attachment, love, and collaboration emerges or fails to develop. Need for special sharing relationship shifts to the opposite sex. New opportunities for social experimentation lead to the consolidation of self-esteem or self-ridicule. If the self-system is intact, areas of concern expand to include values, ideals, career decisions, and social concerns.

Childhood

Language to 5 years

Juvenile

58 years

Preadolescen ce

812 years

Adolescence

Puberty to adulthood

The prototaxic mode, characteristic of infancy and childhood, involves brief unconnected experiences that have no relationship to one another. Adults with schizophrenia exhibit persistent prototaxic experiences. The parataxic mode begins in early childhood as the child begins to connect experiences in sequence. The child may not make logical sense of the experiences and may see them as coincidence or chance events. The child seeks to relieve anxiety by repeating familiar experiences, although he or she may not

understand what he or she is doing. Sullivan explained paranoid ideas and slips of the tongue as a person operating in the parataxic mode. In the syntaxic mode, which begins to appear in schoolage children and becomes more predominant in preadolescence, the person begins to perceive himself or herself and the world within the context of the environment and can analyze experiences in a variety of settings. Maturity may be defined as predominance of the syntaxic mode (Sullivan, 1953).

Therapeutic Community or Milieu. Sullivan envisioned the goal of treatment as the establishment of satisfying interpersonal relationships. The therapist provides a corrective interpersonal relationship for the client. Sullivan coined the term participant observer for the therapists role, meaning that the therapist both participates in and observes the progress of the relationship. The concept of milieu therapy, originally developed by Sullivan, involved clients interactions with one another; i.e., practicing interpersonal relationship skills, giving one another feedback about behavior, and working cooperatively as a group to solve day-to-day problems.

Humanistic Theories
Humanism represents a significant shift away from the psychoanalytic view of the individual as a neurotic, impulse-driven person with repressed psychic problems and away from the focus on and examination of the clients past experiences. Humanism focuses on a persons positive qualities, his or her capacity to change (human potential), and the promotion of self-esteem. Humanists do consider the persons past experiences, but they direct more attention toward the present and future. 1. ABRAHAM MASLOW: HIERARCHY OF NEEDS Abraham Maslow (19211970) was an American psychologist who studied the needs or motivations of the individual. He differed from previous theorists in that he focused on the total person, not just one facet of the person, and emphasized health instead of simply illness and problems. Maslow (1954) formulated the hierarchy of needs in which he used a pyramid to arrange and illustrate the basic drives or needs that motivate people. 1. The most basic needsthe physiologic needs of food, water, sleep, shelter, sexual expression, and freedom from painmust be met first. 2. The second level involves safety and security needs, which include protection, security, and freedom from harm or threatened deprivation. 3. The third level is love and belonging needs, which include enduring intimacy, friendship, and acceptance. 4. The fourth level involves esteem needs, which include the need for selfrespect and esteem from others. 5. The highest level is self-actualization, the need for beauty, truth, and justice. Maslow hypothesized that the basic needs at the bottom of the pyramid would dominate the persons behavior until those needs were met, at which time the next level of needs would become dominant. For example, if needs for food and shelter are not met, they become the overriding concern in life: the hungry person risks danger and social ostracism to find food. Maslows theory explains individual differences in terms of a persons motivation, which is not necessarily stable throughout life. Traumatic life circumstances or compromised health can cause a person to regress to a lower level of motivation. For example, if a 35-year-old woman who is functioning at the love and belonging level discovers she has cancer, she may regress to the safety level to undergo treatment for the cancer and preserve her own health. This theory helps nurses understand how clients motivations and behaviors change during life crises. 2. CARL ROGERS: CLIENT-CENTERED THERAPY Carl Rogers (19021987) was a humanistic American psychologist who focused on the therapeutic relationship and developed a new method of client-centered therapy. Rogers was one of the first to use the term client rather than patient.

Client-centered therapy focused on the role of the client, rather than the therapist, as the key to the healing process. Rogers believed that each person experiences the world differently and knows his or her own experience best (Rogers, 1961). According to Rogers, clients do the work of healing, and within a supportive and nurturing clienttherapist relationship, clients can cure themselves. Clients are in the best position to know their own experiences and make sense of them, to regain their self-esteem, and to progress toward selfactualization. The therapist takes a person-centered approach, a supportive role, rather than a directive or expert role. Rogers viewed the client as the expert on his or her life.

The therapist must promote the clients selfesteem as much as possible through three central concepts: Unconditional positive regarda nonjudgmental caring for the client that is not dependent on the clients behavior Genuinenessrealness or congruence between what the therapist feels and what he or she says to the client Empathetic understandingin which the therapist senses the feelings and personal meaning from the client and communicates this understanding to the client

Behavioral Theories
Behaviorism as a school of psychology grew out of a reaction to introspection models that focused on the contents and operations of the mind. Behaviorism is a school of psychology that focuses on observable behaviors and what one can do externally to bring about behavior changes. It does not attempt to explain how the mind works. Behaviorists believe that behavior can be changed through a system of rewards and punishments. For adults, receiving a regular paycheck is a constant positive reinforcer that motivates people to continue to go to work every day and to try to do a good job. It helps motivate positive behavior in the workplace. If someone stops receiving a paycheck, he or she is most likely to stop working. If a motorist consistently speeds (negative behavior) and does not get caught, he or she is likely to continue to speed. If the driver receives a speeding ticket (a negative reinforcer), he or she is likely to slow down. However, if the motorist does not get caught for speeding for the next 4 weeks (negative reinforcer is removed), he or she is likely to resume speeding. 1. IVAN PAVLOV: CLASSICAL CONDITIONING Laboratory experiments with dogs provided the basis for the development of Ivan Pavlovs theory of classical conditioning: behavior can be changed through conditioning with external or environmental conditions or stimuli. His experiment with dogs involved his observation that dogs naturally began to salivate (response) when they saw or smelled food (stimulus). Pavlov (18491936) set out to change this salivating response or behavior through conditioning. He would ring a bell (new stimulus) then produce the food, and the dogs would salivate (the desired response). Pavlov repeated this ringing of the bell along with the presentation of food many times. Eventually he could ring the bell and the dogs would salivate without seeing or smelling food. The dogs had been conditioned or had learned a new responseto salivate when they heard the bell. Their behavior had been modified through classical conditioning or a conditioned response. 2. B. F. SKINNER: OPERANT CONDITIONING One of the most influential behaviorists was B. F. Skinner (19041990), an American psychologist. He developed the theory of operant conditioning, which says people learn their behavior from their history or past experiences, particularly those experiences that were repeatedly reinforced. Although some criticize his theories for not considering the role that thoughts, feelings, or needs play in motivating behavior, his work has provided several important principles still used today. Skinner did not deny the existence of feelings and needs in motivation; however, he viewed behavior as only that which could be observed, studied, and learned or unlearned. He maintained that if the behavior could be changed then so too could the accompanying thoughts or feelings. Changing the behavior was what was important. The following principles of operant conditioning described by Skinner (1974) form the basis for behavior techniques in use today: 1. All behavior is learned.

2. Consequences result from behavior broadly speaking, reward and punishment. 3. Behavior that is rewarded with reinforcers tends to recur. 4. Positive reinforcers that follow a behavior increase the likelihood that the behavior will recur. 5. Negative reinforcers that are removed after a behavior increase the likelihood that the behavior will recur. 6. Continuous reinforcement (a reward every time the behavior occurs) is the fastest way to increase that behavior, but the behavior will not last long after the reward ceases. 7. Random, intermittent reinforcement (an occasional reward for the desired behavior) is slower to produce an increase in behavior, but the behavior continues after the reward ceases.

These behavioral principles of rewarding or reinforcing behaviors are used to help people change their behavior in a therapy known as behavior modification. Behavior modification is a method of attempting to strengthen a desired behavior or response by reinforcement, either positive or negative. For example, if the desired behavior is assertiveness, whenever the client uses assertiveness skills in a communication group, the group leader provides Positive reinforcement by giving the client attention and positive feedback. Negative reinforcement involves removing a stimulus immediately after a behavior occurs so that the behavior is more likely to occur again. For example, if a client becomes anxious when waiting to talk in a group, he or she may volunteer to speak first to avoid the anxiety. In a group home setting, operant principles may come into play in a token economy, a way to involve residents in performing activities of daily living. A chart of desired behaviors, such as getting up on time, taking a shower, and getting dressed, is kept for each resident. Each day, the chart is marked when the desired behavior occurs. At the end of the day or the week, the resident gets a reward or token for each time each of the desired behaviors occurred. The resident can redeem the tokens for items such as snacks, TV time, or a relaxed curfew. Conditioned responses, such as fears or phobias, can be treated with behavioral techniques. Systematic desensitization can be used to help clients overcome irrational fears and anxiety associated with a phobia. The client is asked to make a list of situations involving the phobic object, from the least to the most anxietyprovoking. The client learns and practices relaxation techniques to decrease and manage anxiety. The client then is exposed to the least anxiety provoking situation and uses the relaxation techniques to manage the resulting anxiety. The client is gradually exposed to more and more anxiety-provoking situations until he or she can manage the most anxiety provoking situation.

Existential Theories
Existential theorists believe that behavioral deviations result when a person is out of touch with himself or herself or the environment. The person who is self-alienated is lonely and sad and feels helpless. Lack of self-awareness, coupled with harsh self-criticism, prevents the person from participating in satisfying relationships. The person is not free to choose from all possible alternatives because of self-imposed restrictions. Existential theorists believe that the person is avoiding personal responsibility and giving in to the wishes or demands of others. All existential therapies have the goal of helping the person discover an authentic sense of self. They emphasize personal responsibility for ones self, feelings, behaviors, and choices. These therapies encourage the person to live fully in the present and to look forward to the future. Carl Rogers is sometimes grouped with existential therapists. Table 3-7 summarizes existential therapies. 1. COGNITIVE THERAPY Many existential therapists use cognitive therapy, which focuses on immediate thought processing how a person perceives or interprets his or her experience and determines how he or she feels and behaves. For example, if a person interprets a situation as dangerous, he or she experiences anxiety and tries to escape. Basic emotions of sadness, elation, anxiety, and anger are reactions to perceptions of loss, gain, danger, and wrongdoing by others (Beck & Rush, 1995). Aaron Beck is credited with pioneering cognitive theory in persons with depression. 2. RATIONAL EMOTIVE THERAPY

Albert Ellis, founder of rational emotive therapy, identified 11 irrational beliefs that people use to make themselves unhappy. An example of an irrational belief is, If I love someone, he or she must love me back just as much. Ellis claimed that continuing to believe this patently untrue statement will make the person utterly unhappy, but he or she will blame it on the person who does not return his or her love. Ellis also believes that people have automatic thoughts that cause them unhappiness in certain situations. He used the ABC technique to help people identify these automatic thoughts: A is the activating stimulus or event, C is the excessive inappropriate response, and B is the blank in the persons mind that he or she must fill in by identifying the automatic thought.

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3. VIKTOR FRANKL AND LOGOTHERAPY Viktor Frankl based his beliefs on his observations of people in Nazi concentration camps during World War II. His curiosity about why some survived and others did not led him to conclude that survivors were able to find meaning in their lives even under miserable conditions. Hence the search for meaning (logos) is the central theme in logotherapy. Counselors and therapists who work with clients in spirituality and grief counseling often use the concepts that Frankl developed. 4. GESTALT THERAPY Gestalt therapy, founded by Frederick Fritz Perls, emphasizes identifying the persons feelings and thoughts in the here and now. Perls believed that self-awareness leads to selfacceptance and responsibility for ones own thoughts and feelings. Therapists often use gestalt therapy to increase clients self awareness by writing and reading letters, journaling, and other activities designed to put the past to rest and focus on the present. 5. REALITY THERAPY William Glasser devised an approach called reality therapy that focuses on the persons behavior and how that behavior keeps him or her from achieving life goals. He developed this approach while working with persons with delinquent behavior, unsuccessful school performance, and emotional problems. He believed that persons who were unsuccessful often blame their problems on other people, the system, or society. He believed they needed to find their own identity through responsible behavior. Reality therapy challenges clients to examine the ways in which their own behavior thwarts their attempts to achieve life goals. Rational emotive therapy Logotherapy Gestalt therapy Reality therapy Albert Ellis Viktor E. Frankl Frederick S. Perls William Glasser A cognitive therapy using confrontation of irrational beliefs that prevent the individual from accepting responsibility for self and behavior A therapy designed to help individuals assume personal responsibility. The search for meaning (logos) in life is a central theme. A therapy focusing on the identification of feelings in the here and now, which leads to self-acceptance Therapeutic focus is need for identity through responsible behavior. Individuals are challenged to examine ways in which their behavior thwarts their attempts to achieve life goals.

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Crisis Intervention

A crisis is a turning point in an individuals life that produces an overwhelming emotional response. Individuals experience a crisis when they confront some life circumstance or stressor that they cannot effectively manage through use of their customary coping skills. Caplan (1964) identified the stages of crisis: (1) the person is exposed to a stressor, experiences anxiety, and tries to cope in a customary fashion; (2) anxiety increases when customary coping skills are ineffective; (3) the person makes all possible efforts to deal with the stressor including attempts at new methods of coping; and (4) when coping attempts fail, the person experiences disequilibrium and significant distress. Crises can occur in response to a variety of life situations and events, and fall into three categories: Maturational crises, sometimes called developmental crises, are predictable events in the normal course of life such as leaving home for the first time, getting married, having a baby, and beginning a career. Situational crises are unanticipated or sudden events that threaten the individuals integrity such as the death of a loved one, loss of a job, and physical or emotional illness in the individual of family member. Adventitious crises, sometimes called social crises, include natural disasters like floods, earthquakes, or hurricanes; war; terrorist attacks; riots; and violent crimes such as rape or murder. Note that not all events that result in crisis are negative in nature. Events like marriage, retirement, and childbirth are often desirable for the individual but may still present overwhelming challenges. Aguilera (1998) identified three factors that influence whether or not an individual experiences a crisis: 1. the individuals perception of the event; 2. the availability of emotional supports; and 3. the availability of adequate coping mechanisms. When the person in crisis seeks assistance, these three factors represent a guide for effective intervention. 1. The person can be assisted to view the event or issue from a different perspective, for example, as an opportunity for growth or change rather than a threat. 2. Assisting the person to use existing supports or helping the individual find new sources of support can decrease the feelings of being alone or overwhelmed. 3. Finally, assisting the person to learn new methods of coping will help to resolve the current crisis and give him or her new coping skills to use in the future. Crisis is described as self-limiting; that is, the crisis does not last indefinitely but usually exists for 4 to 6 weeks. At the end of that time, the crisis is resolved in one of three ways: 1. In the first two, the person either returns to his or her precrisis level of functioning or begins to function at a higher level; both are positive outcomes for the individual. 2. The third resolution is that the persons functioning stabilizes at a level lower than precrisis functioning, which is a negative outcome for the individual.

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Positive outcomes are more likely when the problem (crisis response and precipitating event or issue) is clearly and thoroughly defined. Likewise, early intervention is associated with better outcomes. Persons experiencing a crisis usually are distressed and likely to seek help for their distress. They are ready to learn and even eager to try new coping skills as a way to relieve their distress. This is an ideal time for intervention that is likely to be successful. Hemingway, Ashmore, and Askoorum (2000) identified two categories of crisis intervention: authoritative and facilitative. Authoritative interventions are designed to assess the persons health status and promote problem-solving such as offering the person new information, knowledge, or meaning; raising the persons self-awareness by providing feedback about behavior; and directing the persons behavior by offering suggestions or courses of action. Facilitative interventions aim at dealing with the persons needs for empathetic understanding such as encouraging the person to identify and discuss feelings, serving as a sounding board for the person, and affirming the persons self-worth. Techniques and strategies that include a balance of these different types of intervention are the most effective.

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Groups

A group is a number of persons in a face-to-face setting to accomplish tasks that require cooperation, collaboration, or working together. STAGES OF GROUP DEVELOPMENT A group may be established to serve a particular purpose in a specified period such as a work group to complete an assigned project or a therapy group that meets with the same members to explore ways to deal with depression. Group structure includes where and how often the group will meet, identification of a group leader, and the rules of the groupfor example, can members join the group after it begins, how to handle absences, and expectations for group members. The beginning stage of group development, or the initial stage, commences as soon as the group begins to meet. Members introduce themselves, a leader can be selected (if not done previously), the group purpose is discussed, and rules and expectations for group participation are reviewed. Group members begin to check out one another and the leader as they determine their levels of comfort in the group setting. The working stage of group development begins as members begin to focus their attention on the purpose or task the group is trying to accomplish. This may happen relatively quickly in a work group with a specific assigned project, but may take two or three sessions in a therapy group because members must develop some level of trust before sharing personal feelings or difficult situations. During this phase, several group characteristics may be seen. Group cohesiveness is the degree to which members work together cooperatively to accomplish the purpose. Cohesiveness is a desirable group characteristic and is associated with positive group outcomes. The final stage or termination of the group occurs before the group disbands. The work of the group is reviewed with the focus on group accomplishments, growth of group members, or both depending on the purpose of the group. GROUP THERAPY In group therapy, clients participate in sessions with a group of people. The members share a common purpose and are expected to contribute to the group to benefit others and receive benefit from others in return. Group rules are established that all members must observe. These rules vary according to the type of group. Being a member of a group allows the client to learn new ways of looking at a problem or ways of coping or solving problems and also helps him or her to learn important interpersonal skills. For example, by interacting with other members, clients often receive feedback on how others perceive and react to them and their behavior. This is extremely important information for many clients with mental disorders, who often have difficulty with interpersonal skills. The therapeutic results of group therapy (Yalom, 1995) include the following: Gaining new information or learning Gaining inspiration or hope Interacting with others Feeling acceptance and belonging Becoming aware that one is not alone and that others share the same problems Gaining insight into ones problems and behaviors and how they affect others Giving of oneself for the benefit of others (altruism) Therapy groups vary with different purposes, degrees of formality, and structures. Our discussion will include psychotherapy groups, family therapy, education groups, support groups, and self-help groups. Psychotherapy Groups. The goal of a psychotherapy group is for members to learn about their behavior and to make positive changes in their behavior by interacting and communicating with others as a member of a group. Groups may be organized around a specific

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medical diagnosis, such as depression, or a particular issue such as improving interpersonal skills or managing anxiety. Group techniques and processes are used to help group members learn about their behavior with other people and how it relates to core personality traits. Members also learn that they have responsibilities to others and can help other members achieve their goals (Alonso, 2000). Psychotherapy groups are often formal in structure, with one or two therapists as the group leaders. One task of the group leader or the entire group is to establish the rules for the group. These rules deal with confidentiality, punctuality, attendance, and social contact between members outside of group time. There are two types of groups: open groups and closed groups. Open groups are ongoing and run indefinitely, allowing members to join or leave the group as they need to. Closed groups are structured to keep the same members in the group for a specified number of sessions. If the group is closed, the members decide how to handle members who wish to leave the group and the possible addition of new group members (Yalom, 1995). Family Therapy. Family therapy is a form of group therapy in which the client and his or her family members participate. The goals include understanding how family dynamics contribute to the clients psychopathology, mobilizing the familys inherent strengths and functional resources, restructuring maladaptive family behavioral styles, and strengthening family problem-solving behaviors (Gurman & Lebow, 2000). Family therapy can be used both to assess and treat various psychiatric disorders. Although one family member usually is identified initially as the one who has problems and needs help, it often becomes evident through the therapeutic process that other family members also have emotional problems and difficulties. Family Education. The National Alliance for the Mentally Ill (NAMI) has developed a unique 12-week Family-to-Family Education course taught by trained family members. The curriculum focuses on schizophrenia, bipolar disorder, clinical depression, panic disorder, and obsessive-compulsive disorder (OCD). The course discusses the clinical treatment of these illnesses and teaches the knowledge and skills that family members need to cope more effectively. The specific features of this education program include emphasis on emotional understanding and healing in the personal realm, and power and action in the social realm. NAMI also conducts Provider Education programs taught by two consumers, two family members, and a mental health professional who is also a family member or consumer. This course is designed to help providers realize the hardships that families and consumers endure and to appreciate the courage and persistence it takes to reconstruct lives that must be lived, through no fault of the consumer or family, on the verge (NAMI, 2002, p. 1). Education Groups. The goal of an education group is to provide information to members on a specific issuefor instance, stress management, medication management, or assertiveness training. The group leader has expertise in the subject area and may be a nurse, therapist, or other health professional. Education groups usually are scheduled for a specific number of sessions and retain the same members for the duration of the group. Typically the leader presents the information, then members can ask questions or practice new techniques.

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In a medication management group, the leader may discuss medication regimens and possible side effects, screen clients for side effects, and in some instances actually administer the medication (for instance, depot injections of haloperidol [Haldol] decanoate or fluphenazine [Prolixin] decanoate). Support Groups. Support groups are organized to help members who share a common problem cope with it. The group leader explores members thoughts and feelings and creates an atmosphere of acceptance so that members feel comfortable expressing themselves. Support groups often provide a safe place for group members to express their feelings of frustration, boredom, or unhappiness and also to discuss common problems and potential solutions. Rules for support groups differ from those in psychotherapy in that members are allowedin fact, encouragedto contact one another and socialize outside the sessions. Confidentiality may be a rule for some groups; the members decide this. Support groups tend to be open groups in which members can join or leave as their needs dictate. Common support groups include those for cancer or stroke victims, persons with AIDS, and family members of someone who has committed suicide. One national support group, Mothers Against Drunk Driving (MADD), is for family members of someone killed in a car accident caused by a drunk driver.

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Self-Help Groups. In a self-help group, members share a common experience, but the group is not a formal or structured therapy group. Although professionals organize some selfhelp groups, many are run by members and do not have a formally identified leader. Various self-help groups are available. Some are locally organized and announce their meetings in local newspapers. Other groups are nationally organized, such as Alcoholics Anonymous, Parents Without Partners, Gamblers Anonymous, or Al-Anon (a group for spouses and partners of alcoholics), and have national headquarters and Internet websites (see Internet Resources). Most self-help groups have a rule of confidentiality: whoever is seen at a meeting or what is said at the meetings cannot be divulged to others or discussed outside the group. In many 12-step programs, such as Alcoholics Anonymous and Gamblers Anonymous, people use only their first names so their identities are not divulged (although in some settings, group members do know one anothers names).

CHILD ABUSE
Child abuse or maltreatment generally is defined as the intentional injury of a child. It can include physical abuse or injuries, neglect or failure to prevent harm, failure to provide adequate physical or emotional care or supervision, abandonment, sexual assault or intrusion, and overt torture or maiming (Biernet, 2000).

Types of Child Abuse

Physical abuse of children often results from unreasonably severe corporal punishment or unjustifiable punishment such as hitting an infant for crying or soiling his or her diapers. Intentional deliberate assaults on children include burning, biting, cutting, poking, twisting limbs, or scalding with hot water. The victim often has evidence of old injuries (e.g., scars, untreated fractures, multiple bruises of various ages) that the history given by parents or caregivers does not explain adequately. Sexual abuse involves sexual acts performed by an adult on a child younger than 18 years. Examples include incest, rape, and sodomy performed directly by the person or with an object; oral-genital contact; and acts of molestation such as rubbing, fondling, or exposing the adults genitals. Sexual abuse may consist of a single incident or multiple episodes over a protracted period. A second type of sexual abuse involves exploitation, such as making, promoting, or selling pornography involving minors, and coercion of minors to participate in obscene acts. Neglect is malicious or ignorant withholding of physical, emotional, or educational necessities for the childs well-being. Child abuse by neglect is the most prevalent type of maltreatment and includes refusal to seek health care or delay doing so; abandonment; inadequate supervision; reckless disregard for the childs safety; punitive, exploitive, or abusive emotional treatment; spousal abuse in the childs presence; giving the child permission to be truant; or failing to enroll child in school. Psychological abuse (emotional abuse) includes verbal assaults, such as blaming, screaming, name-calling, and using sarcasm; constant family discord characterized by fighting, yelling, and chaos; and emotional deprivation or withholding of affection, nurturing, and normal experiences that engender acceptance, love, security, and self-worth. Emotional abuse often accompanies other types of abuse (e.g., physical or sexual abuse). Exposure to parental alcoholism, drug use, or prostitution, and the neglect that results also fall within this category.

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Treatment A number of treatments are available to victims of child abuse. Trauma-focused cognitive behavioral therapy, first developed to treat sexually abused children, is now used for victims of any kind of trauma. It targets trauma-related symptoms in children including post-traumatic stress disorder (PTSD), clinical depression, and anxiety. It also includes a component for non-offending parents. Several studies have found that sexually abused children undergoing TF-CBT improved more than children undergoing certain other therapies. Data on the effects of TF-CBT for children who experienced only non-sexual abuse was not available as of 2006. Abuse-focused cognitive behavioral therapy was designed for children who have experienced physical abuse. It targets externalizing behaviors and strengthens prosocial behaviors. Offending parents are included in the treatment, to improve parenting skills/practices. It is supported by one randomized study. Child-parent psychotherapy was designed to improve the child-parent relationship following the experience of domestic violence. It targets trauma-related symptoms in infants, toddlers, and preschoolers, including PTSD, aggression, defiance, and anxiety. It is supported by two studies of one sample. Other forms of treatment include 1. group therapy, 2. play therapy, and 3. art therapy. Each of these types of treatment can be used to better assist the client, depending on the form of abuse they have experienced. Play therapy and art therapy are ways to get children more comfortable with therapy by working on something that they enjoy (coloring, drawing, painting, etc.). The design of a child's artwork can be a symbolic representation of what they are feeling, relationships with friends or family, and more. Being able to discuss and analyze a child's artwork can allow a professional to get a better insight of the child.

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