Approaches to Treatment and Therapy

Chapter 17

Approaches to Treatment and Therapy Biological treatments for mental disorders Kinds of psychotherapy Evaluating psychotherapy

Biological Treatments The question of drugs Surgery and electroshock

The Question of Drugs

Antipsychotic Drugs Many block or reduce sensitivity of brain

receptors that respond to dopamine. Some increase levels of serotonin, a

neurotransmitter that inhibits dopamine activity.

Can relieve positive symptoms of schizophrenia but are ineffective for or even worsen negative symptoms.

Antidepressant Drugs Monoamine oxidase inhibitors (MAOIs)

Elevate norepinephrine and serotonin in brain by blocking an enzyme that deactivates these neurotransmitters.

Tricyclic antidepressants Boost norepinephrine and serotonin in brain by

preventing normal reuptake of these substances.

Selective serotonin reuptake inhibitors (e.g, Prozac) work same way as tricyclic

antidepressants but target serotonin.

Tranquilizers Increase the activity of the neurotransmitter

gamma-aminobutyric acid (GABA). Developed for treatment of mild anxiety

and often overprescribed by general physicians for patients who complain of any mood disorder.

Not effective for depression.

Lithium Carbonate Used to treat bipolar disorder. Moderates levels of norepinephrine or by

protecting cells from being overstimulated by the neurotransmitter, glutamate.

Must be given in right dose and bloodstream levels need to be monitored.

Newer drug treatments for bipolar disorder include Tegetrol and Depakote.

Cautions About Drug Treatment

Placebo effect High Relapse and dropout rates Dosage problems Long-term risks

Placebo Effect The apparent success of a treatment that is

due to the patient’s expectation of hopes rather than to the drug or treatment itself.

Meta-analyses indicate that clinicians considered medication helpful yet patient ratings in treatment groups were no greater than patient ratings in placebo groups.

High Relapse and Dropout Rate There may be short term success but many

patients (50% to 66%) stop taking medication due to side effects.

Individuals who take antidepressants without learning to cope with problems are more likely to relapse.

Dosage Problems Finding the therapeutic window or the amount

of medication that is enough but not too much. Drugs may be metabolized differently in:

men and women, old and young, and in different ethnic groups.

Groups may differ in tolerable dosages due to variations in metabolic rates, amount of body fat, number or type of drug receptors in the brain, smoking and eating habits.

Long-Term Risks Antipsychotic drugs can be dangerous,

even fatal if taken for many years. Tardive dyskinesia

Antidepressants are assumed to be safe but no long term studies have been conducted.

Many doctors and the public overlook the possibility of long-term dangers when a drug shows short run benefits.

Surgery and Electroshock Psychosurgery

Any surgical procedure that destroys selected areas of the brain believed to be involved in emotional disorders or violent, impulsive behaviour.

Electroconvulsive Therapy (ECT) A procedure used in cases of prolonged and

severe major depression, in which a brief brain seizure is induced.

Kinds of Psychotherapy Psychodynamic therapy Behavioural and cognitive therapy Humanist and existential therapy Family and couples therapy

Psychodynamic Therapy Goal is exploring the unconscious

Free Association In psychoanalysis, a method of uncovering

unconscious conflicts by saying freely whatever comes to mind.

Transference In psychodynamic therapies, a critical step in which

the client transfers unconscious emotions or reactions, such as conflicts about his or her parents, onto the therapist.

Behaviour and Cognitive Therapy Behaviour therapy

Systematic desensitization Exposure treatments Behavioural records Skills training

Cognitive therapy

Behaviour Therapy A form therapy that applies principles and

techniques of classical and operant conditioning to help people change self-defeating or problematic behaviours.

Systematic Desensitization A step by step process of desensitizing a

client to a feared object or experience, based on counterconditioning.

Exposure (Flooding) A technique whereby a person suffering

from an anxiety disorder such as a phobia or panic attack, is taken directly into the feared situation until the anxiety subsides.

Behavioural Records A method of keeping careful data on the

frequency and consequences of the behaviour to be changed.

Skills Training An effort to teach a client skills he or she

may lack, as well as new more constructive behaviours to replace self-defeating ones.

Cognitive Techniques Examine the evidence for beliefs. Consider other explanations for the

behaviour of others. Identify assumptions and biases. Rational Emotive Behaviour Therapy

(REBT): a form of cognitive therapy designed to

challenge the client’s unrealistic or irrational thoughts.

Cognitive Techniques

Meichenbaum developed a form of cognitive therapy to treat excessive anxiety called “stress inoculation.” Involves 3 stages:

Education phase Rehearsal phase Implementation phase

Humanist Therapy Humanist therapy

Based on the assumption that people seek self-actualization and self-fulfillment.

Emphasized people’s free will to change, not past conflicts.

Client-Centered (Nondirective) Therapy Developed by Carl Rogers and emphasizes the

therapist’s empathy with the client, seeing the world as client does, and creating climate of Unconditional Positive Regard.

Existential Therapy Helps clients explore the meaning of existence

and face with courage the great issues of life such as death, freedom, free will, alienation and loneliness.

Family and Couples Therapy Problems develop in the context of family, are

sustained by the dynamics of the family and any changes made will affect all members of the family.

Can look for patterns of behaviour across generations and create a family tree of psychologically significant events.

Family-System Perspective Therapy with individuals or families that focuses

on how each member forms part of a larger interacting system.

One Family’s Genogram

Primary Goals of Therapies Psychodynamic

Insight into unconscious motives and feelings. Cognitive-Behavioural

Modification of behaviour and irrational beliefs. Humanist

Insight; self-acceptance and self-fulfillment. Family

Modification of individual habits and family patterns.

Primary Methods of Therapies Psychodynamic

Probing the unconscious through dream analysis, free association, transference.

Cognitive-behavioural Behavioural techniques such as systematic desensitization,

flooding; cognitive exercises to identify and change faulty beliefs. Humanist

Providing a safe, non-judgmental setting in which to discuss life issues.

Family Working with couples, families, and sometimes individuals to

identify and change patterns that perpetuate problems.

Evaluating Psychotherapy The scientist-practitioner gap The therapeutic alliance When therapy helps When therapy harms

The Scientist-Practitioner Gap Many psychotherapists believe that

evaluating therapy using research methods is futile.

Scientists find that therapists who do not keep up with empirical findings are less effective and can do harm to clients.

Economic pressures require empirical assessment of therapies.

Is More Psychotherapy Better? With additional therapy

sessions, the percentage of people improved increased up to 26 sessions.

Rate of improvement then levels off Based on a summary of 15

studies, 2400 clients (Howard, et al., 1996).

Patients’ sense of improvement slower but more steady.

Psychotherapy Research Questions What are the common ingredients in

successful therapies? What kinds of therapy are best suited for

which problems? Under what conditions can therapy be

harmful?

The Therapeutic Alliance Qualities of the Participants

Motivation to improve and solve problems. Support from families and actively deal with

problems. Empathic, warm, and genuine therapists.

Culture and the Therapeutic Connection In Canada, group therapy is popular with

Indigenous clients, in part because it bears more similarity to traditional healing practices in these groups.

When Therapy Helps Problems of assessing therapy

Justification of effort effect Clinical researchers conduct randomized

controlled trials designed to determine the effectiveness of a new medication or form of therapy, in which people with a given problem are randomly assigned to one or more treatment groups or to a control group.

What works? Depression

Cognitive therapy’s greatest success has come in treatment of mood disorders.

Anxiety Disorders Exposure techniques are more effective than

others. Anger and Impulsive Violence

Cognitive therapy is extremely successful.

What works? Health Problems

Cognitive and Behaviour therapies are effective for a wide range of health problems.

Childhood and Adolescent Behaviour Problems Behaviour therapy is the most effective

treatment.

Successful Therapy

Psychotherapy outcome depends not only on method of therapy.

Qualities of client and therapist, and their alliance, also determine success.

When Therapy Harms Sexual intimacies, or other unethical

behaviour on the part of the therapist. Prejudice or cultural ignorance on the part

of the therapist. Inappropriate or coercive influence, which

can create new problems for the client. The use of empirically unsupported,

potentially dangerous techniques.