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Treatment
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Overview Brief History
Psychological Treatments
Biomedical Treatments
Client-Therapist Relationship
Is Treatment Effective?
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History
Earliest history
Mental illness believed to be caused by evil spirits
Treatments were harsh, ineffective Drill holes in skulls to create exits for spirits Make the body horribly uncomfortable for the spirits Purge demons through inducing vomiting
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History
Middle Ages
Mental illness viewed more like a disease
Mental institutions were created Purpose: confine madmen Included other social “undesirables” Inhumane treatment (shackles and chains)
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Beginning of Reform
Early to Mid 1800s
Philippe Pinel put in charge of Paris’ hospital system
Removed shackles and chains Patients allowed to exercise, venture outside
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Beginning of Reform
Dorthea Dix Fought for humane
treatment of patients in U.S.
19th century Freud’s “talking cure”
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Psychological TreatmentOverview Treatment involves addressing three
major components of the illness: Biological Psychological Social
Something to keep in mind: These three major components are not
necessarily black-and-white
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Who provides treatment? Clinical psychologists
Psychologists
Neurologists
Psychiatric Nurses
Marriage and Family Counselors
Social workers
School counselors
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Who seeks treatment? People with mental illness, hoping to relieve
pain and dysfunction
People with subsyndromal disorders
People looking for assistance in recovering from grief, anxiety, confusion, relationship issues… Women European Americans Financially well off
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Psychological Treatments
Focused on changing the way the patient thinks and behaves
Involves discussion, instruction, or training
Over 500 different forms of such treatment Psychodynamic Humanistic Behavioral Cognitive
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Psychodynamic Approaches Illness result of unconscious conflicts
developed early in childhood
Defense mechanisms shield from the inner conflict This can lead to symptoms of mental
illness
Treatment: Uncovering unconscious desires and conflicts, and resolving them Integrate thoughts and memories
coherently
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Psychodynamic Approaches
“Working through” the conflict Transference
Used as a therapeutic tool In order to be effective, therapist must remain
neutral
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Humanistic Approaches Based off of Freud’s “talking cure”
However, less focused on basic drives
Instead, focus on creating meaning
Clients need to take responsibility for their lives and actions, and live in the “here and now”
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Humanistic Approaches Client-Centered Therapy
(Carl Rogers) Focuses on achieving
self-acceptance
Does not pass judgment, or provide instruction
Aim is to create an environment in which the client feels understood and valued
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Humanistic Approach Creating the therapeutic environment
Genuineness- sharing authentic reactions
Unconditional positive regard Non-judgmental, accepting
Empathic Understanding- putting oneself in the patients’ shoes
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Humanistic Approaches Gestalt Therapy (Fritz Perls)
Mental illness is result of inconsistencies in one’s understanding of the self
Increase self-awareness and self-acceptance
Ask how clients felt, and point out discrepancies in the way they appeared
Empty chair technique
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Behavioral Approaches
Reaction to Freud’s psychoanalysis
Viewed Freud’s approach as too unscientific
Treatment directed at reducing or eliminating problematic behaviors
Approach involves replacing old habits with more effective or adaptive behaviors Classical conditioning, operant conditioning, modeling
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Behavioral ApproachesClassical Conditioning Techniques Treatment of Phobias
Extinguish the association between the neutral stimulus and the fearful stimulus
Exposure Therapy Train clients in deep muscle relaxation, pair
relaxation with the fearful stimulus
Create a hierarchy of progressively more frightening stimuli
Systematic desensitization: gradual exposure to the real phobic stimulus
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Systematic Desensitization
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Behavioral ApproachesOperant Conditioning Techniques Token economies
Earn tokens for positive behaviors, which can be exchanged for prizes
Shaping
Contingency Management Strict consequences for certain behaviors
Successful for shaping communicative behavior in children with autism
Modeling Techniques Therapist perceived as role model
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Cognitive-Behavioral Approaches
Rational Emotive Behavioral Therapy (Albert Ellis)
People typically think that an event causes them to behave a certain way
But…beliefs matter A (acting event) B (belief) C
(consequence)
Focused therapy on changing beliefs
Teacher-like
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Cognitive Therapy Aaron Beck
Focused on changing dysfunctional thought
Cognitive Restructuring Challenge a person’s unhealthy
beliefs or interpretations
Used persuasion and confrontation
Brief, problem-focused
Initially treated depression
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Cognitive-Behavioral Therapy Followers of Ellis and Beck blended the
two therapies to form CBT
Focus on addressing problems the patient wishes to solve
Often clients are assigned homework Practice new ways skills or thought techniques
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Eclecticism Modern therapy tends
to blend aspects from many of these perspectives
Makes sense, since there are often many causes of mental illness
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Group Therapies Often groups are chosen
because they share similar problems (e.g., Alcoholics Anonymous)
Focus on the shared problems, less on the individuals’ emotions
Advantages Social support Share advice, information Observe other peoples’
successes Realize that not alone, others
share similar problems
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Couple and Family Therapy
Views the family or relationship as a complex system One person’s negative behavior or cognitions
may reflect a larger issue for the entire family or relationship
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Biomedical TreatmentsThe Early Gruesome Years Trephination
Allowed “evil spirits” to escape the skull
Hot or Cold Baths
Spinning
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Biomedical TreatmentsPsychosurgery
Prefrontal Lobotomy Sever connections between
thalamus and frontal lobes
Disrupted higher cognitive functions
Modern techniques are more precise and used as a last resort treatment
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Electroconvulsive Therapy (ECT) Brief electrical current
passed through the brain causing a convulsive seizure
Originally developed to treat schizophrenia
Very effective for treating severe depression (70-90% effective)
Memory impairment
Mechanisms are not known
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Pharmacological Treatments Psychotropic drugs
Not only helped treat patients, but also further understanding of the illness
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Pharmacological Treatments Antipsychotics
Treat positive symptoms of schizophrenia Not effective for treating the negative symptoms Most common are Thorazine, Haldol and Stelazine
Block dopamine receptors in particular brain pathways
Atypical Antipsychotics Treat negative symptoms of schizophrenia, too Risperdal, Clozaril, Seroquel
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Antipsychotics and Deinstitutionalization Movement in the 1950s shortly after development
of the first antipsychotics Aimed to provide less expensive mental health care at
local community centers instead of institutions
Pros Fewer people spending their lives in institutions Shorter stays
Downside Lack of appropriate care in community settings Lack of integration into the community (support
services, employment) Many mentally ill are now homeless, or in jail
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Deinstitutionalization
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Antidepressants Monoamine Oxidase Inhibitors (MAOIs)
Nardil
Tricyclic antidepressants Tofranil
Increase serotonin and norephinephrine for synaptic transmission
Both very effective (significant improvement in 65% of patients) Many negative side effects
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Antidepressants Selective Serotonin Reuptake Inhibitors (SSRIs)
Prozac, Zoloft, Paxil, Celexa, Lexapro
Minimally effect dopamine and norepinephrine, and maximally effect serotonin
Reduced side effects
Most commonly prescribed
Atypical Antidepressants
Effect serotonin, norepinephrine and dopamine in various ways
Wellbutrin (fewer side effects)
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Antidepressants
Downside Takes a while before effective (a month)
Trial-and-error
Side effects Weight gain, nausea, diarrhea, insomnia, reduced
sexual desire or response
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Mood Stabilizers Treat symptoms of bipolar disorder
Lithium carbonate Treats manic episodes as well as depressive episodes
Side Effects Weight gain, sedation, dry mouth, tremors
Adherence to medication Often patients do not wish to treat mania, only depression
Lethal at high doses
Effective for 60 – 70% of patients
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Anxiolytic Medications Treat anxiety disorders
Increase neurotransmission of GABA
Beta Blockers
Benzodiazepines
Tricyclic Antidepressants and SSRIs
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Anxiolytic Medications
Beta Blockers Controls autonomic arousal
Benzodiazepines Valium, Xanax, Klonopin
Short term treatments
Highly addictive
Interact dangerously with alcohol
New drugs are being developed to reduce these negative side effects
Rebound effect
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Medication: Costs and Benefits Can be highly effective
Only treats and controls the symptoms Relapse
Requires trial-and-error for correct drug and correct dosage
Side effects Reduce adherence to medication
Overprescription
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Emerging Biomedical Treatments
Repetitive TMS Areas of the brain stimulated
with magnetic coil for 20-30 minutes over several weeks
Effective for medication-resistant depression
No cognitive side effects
Deep Brain Stimulation Electrodes implanted in brain
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Client-Therapist Relationship Therapeutic Alliance
Support
Trust
Hope
Understanding
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Combined Treatments
Most therapists use a combination of treatments Drug treatments for short-term effects
Therapy for long-term effects
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Evaluating the Efficacy of Treatments Randomized Clinical Trial (RCT)
Treatment group
Placebo group
Symptoms and severity similar across participants
Follow participants over several months
Random assignment
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Efficacy vs. Utility Difficult to run RCT for psychotherapy
Waitlist Manualized Therapy
Controlled studies allow researchers to come to conclusions about the efficacy of particular treatments
In most circumstances, patients have more than one illness
Also, therapists typically use more than one approach
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Is therapy effective?
A meta-analysis found that 80% of patients who received treatment fared better than those without
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Are all Therapies Equally Effective?
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Who provides the most effective psychological treatment? Number of years of practice?
Not necessarily
Professional credentials? No
The rapport between therapist and client seems to be strongest predictor Respect, trust, comfort
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Who is most likely to benefit from treatment? Strong alliance with therapist
Shop around!
Motivated
Optimistic
More effective with more therapy
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Are All Treatments Equally Effective? A meta-analysis shows…
Drug treatment alone 55% effective
Therapy alone 52% effective
Drug AND therapy 85% effective! (New England Journal of Medicine, 2000)
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Are all Treatments Equally Effective? Treatment more effective than no
treatment
Combining treatments appears most beneficial
Some therapies seem particularly effective for specific disorders Exposure therapy phobias
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Moral of the Story Treatment is effective!
Modern treatments are much more effective and humane than past treatments
The relationship between therapist and client really matters!
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If you feel you need help… Seek it! Ask for advice, or set up an appointment
with a counselor. It’s not a weakness.
Make sure the therapist is a good match for you!
Remember it can take time and you may face some setbacks, but also…
Remember treatment is effective! Most people improve!
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Thank you! Thanks to Dr. Kotovsky, Jen H., Jen L.,
Scotty, Kim, Jordan, and Scott for a successful semester!
Good luck on the final! December 14th from 1-3pm
See you at the review session! December 11th 2-4pm