Types of Treatment of Psychological Disorders

• Mental health professionals fall into several categories:
  • Counseling and clinical psychologists – typically hold a Ph.D. or Psy.D.
  • Psychiatrists – medical doctors who specialize in psychotherapy and biomedical treatments
  • Therapist, counselor, psychotherapist, hypnotist are NOT protected terms
• APA membership: 29% eclectic (combined), 21% psychodynamic, 16% behavioural, 13% cognitive, 12% humanistic, 9% other

Psychodynamic Therapies

• Psychoanalysis
  • Goal is to help clients achieve insight (conscious awareness of psychodynamics that underlie their problems)
  • Free association – procedure of verbalizing all thoughts that enter consciousness without censorship
    • Freud sat out of sight from patient so thought processes would be determined by internal factors
  • Dream interpretation through free association of dream elements
  • Resistance – defensive maneuvers that hinder the process of therapy
  • Transference – psychoanalytic phenomenon in which a client responds irrationally to the analyst as if he were an important person from the client’s past who plays an important role in the client’s dynamics
    • Positive transference occurs when a client transfers intense affection, dependency, or love to the analyst
    • Negative transference occurs when a client transfers expressions of anger, hatred, or disappointment to the analyst
  • Interpretation – any statement by the therapist intended to provide the client with insight into their behaviour or dynamics
• Brief Psychodynamic Therapies
  • Clients seen a few times a week, rather than daily
  • Focus on current life situations, rather than on past childhood experiences
  • Interpersonal therapy – form of brief therapy that focuses on the client’s interpersonal problems and seeks to develop new interpersonal skills

Humanistic Psychotherapies

• Client-Centred Therapy
  • Most important part of therapy is relationship that develops between client and therapist
  • Three important and interrelated therapist attributes:
    • Unconditional positive regard – therapists show clients that they genuinely care about them and accept them, without judgment or evaluation
    • Empathy – willingness and ability to view the world through the client’s eyes
      • Therapist communicates understanding by reflecting back to client what they are communicating
      • Therapist cannot fake it, because client will realize this
    • Genuineness – therapist must honestly express his or her feelings, whether positive or negative
  • Non-directive approach (only person who can cure the client is client themselves)
• Gestalt Therapy
  • Term “gestalt” refers to perceptual principles through which people actively organize stimulus elements into meaningful “whole” patterns
    • Goals of therapy is to bring background figures into immediate awareness so that client can be “whole” again
  • Empty-chair technique involves client carrying on a conversation with his mother, where he alternately plays his mother and himself

Cognitive Therapies

• Ellis’s Rational-Emotive Therapy
  • Therapy is embodied in ABCD model:
    • Activating event – triggers the emotion
    • Belief system – underlies way in which a person appraises the activating event
    • Consequences – emotional and behavioural consequences of the appraisal
    • Disputing – challenging an erroneous belief system
  • People are accustomed to viewing emotions (consequences) as being caused directly by activating events
    • Emotions are actually caused by belief system, which must be countered and altered
• Beck’s Cognitive Therapy
  • Goal is to point out errors of thinking and logic that underlie emotional disturbances and to reprogram client’s automatic negative thought patterns
  • Self-instructional training – cognitive coping approach of giving adaptive self-instructions to oneself at crucial phases of the coping process

Behaviour Therapies

• Classical Conditioning Treatments
  • Most direct way to reduce a phobia is through process of classical extinction of anxiety response
    • Requires exposure to feared CS in absence of UCS while using response prevention (prevention of escape or avoidance responses during exposure so that extinction can occur)
    • Client may be exposed to real-life stimuli (flooding) or may be asked to imagine scenes involving the stimuli (implosion)
  • Systematic desensitization – attempt to eliminate anxiety using counterconditioning, in which a new response that is incompatible with anxiety is conditioned to the anxiety-arousing CS
    • Client must construct a stimulus hierarchy (a series of anxiety-arousing stimuli that are ranked in terms of amount of anxiety they evoke)
    • Client must relax, and then focus on first level of hierarchy, then next, until finished
      • Client can’t experience anxiety if relaxed strongly enough
      • Relaxation replaces anxiety as the CR
    • In vivo desensitization – exposure to a hierarchy of real life situations
  • Aversion therapy – therapist pairs a stimulus that is attractive to a person (and that stimulates deviant or self-defeating behaviour – the CS) with a noxious UCS in an attempt to condition an aversion to the CS
    • Example: to treat alcoholics, injecting the client with a drug that causes nausea upon consumption of alcohol
• Operant Conditioning Treatments
  • Behaviour modification – treatment techniques that involve the application of operant conditioning procedures in an attempt to increase or decrease a specific behaviour
  • Token economy – system for strengthening desired behaviours through the systematic application of positive reinforcement
    • Tokens rewarded upon observing desired behaviours, and are then traded in for various privileges
  • Therapists only use punishment after asking two important questions:
    • Are there alternative, less painful approaches that might be effective?
    • Is the behaviour to be eliminated sufficiently injurious to the individual or society to justify the severity of the punishment?
• Modelling and Social Skills Training
  • Social skills training – clients learn new skills by observing and then imitating a model who performs a socially skillful behaviour

Integrating and Combining Therapies

• Increasing clinicians are becoming eclectic (combining treatments and making use of orientations and techniques that seems appropriate to the client)
• Psychodynamic behaviour therapy – an integration of psychoanalysis and behaviour therapy

Cultural and Gender Issues in Psychotherapy

• Cultural Factors in Treatment Utilization
  • Utilization of mental health services is far less for minority groups than it is for the majority white population
    • Psychologists have identified several barriers that cause this:
      • Cultural norm against turning to professionals outside of one’s own culture for help
      • Inability to afford therapy
      • Too few skilled counselors who can provide culturally responsive forms of treatment
  • Culturally competent therapists – therapists who are able to use knowledge of the client’s culture to achieve a broad understanding of the client

Evaluating Psychotherapies

• Specificity question – Which types of therapy, administered by which kinds of therapists to which kinds of clients having which kinds of problems, produce which kinds of effects?
• Psychotherapy Research Methods
  • Hans Eysenck countered the assumption that without therapy, patients would not improve
    • Concluded that rate of spontaneous remission (symptom reduction in absence of treatment) was as high as success rates reported by psychotherapists
    • Came to conclusion that troubled people are equally likely to improve, with or without therapy
    • APA has now found effective therapies for specific disorders
  • Most psychotherapy researchers favour randomized clinical trials (research design that involves random assignment of clients with specific problems to an experimental group or control condition so as to draw sound conclusions about the therapy’s efficacy
    • Placebo control group – gets an intervention that is not expected to work, but controls for client expectation of improvement
  • Meta-analysis – statistical procedure for combining results of different studies that examine the same topic
    • Effect size statistic – measure of treatment effectiveness that indicates percentage of treated clients that improve more than average untreated client
    • Dodo bird effect – effect that widely differing therapies all are effective
    • Clinical significance – requires that for a treatment to be successful, a patient can no longer fall within the range of having a psychological disorder
      • Example: even if a deeply depressed person becomes significantly less depressed over the course of treatment, but still falls in the range of depression, the treatment is not considered successful
• Factors Affecting the Outcome of Therapy
  • Three factors influence the outcome of the treatment:
    • Openness – clients’ willingness to invest themselves in therapy and take risks required to change
    • Self-relatedness – ability to experience and understand internal states such as thoughts and emotions, to be attuned to processes in relationship with their therapist, and ability to apply what they learn in therapy to lives outside of treatment
    • Nature of the problem – how appropriate the therapy is to treat the disorder
  • Quality of relationship between therapist and client is important determinant of outcome
    • Hostile interchanges between client and therapist can lead to deterioration effect
  • Dose-response effect – relation between amount of treatment received and quality of outcome
  • Most patients do not remain in therapy long enough to realize potential benefits (average of 5 sessions with 20% improvement)
  • Experts have found common factors that contribute to therapy success:
    • Faith in therapist and belief on client’s part that they are receiving help
    • Plausible explanation for their problems, and alternative way of looking at themselves with their problems
    • Protective setting in which clients can experience and express deepest feelings
    • Opportunity to practice new behaviours
    • Increased optimism and self-efficacy

Biological (Somatic) Approaches to Treatment

• Drug Therapies
  • Anti-anxiety drugs designed to reduce anxiety without affecting alertness or concentration
    • One drawback is psychological and physical dependence
    • Newer drug called buspirone is slow acting, has fewer fatiguing side effects, and has less potential for abuse
      • Slows down excitatory synaptic activity by affecting GABA
  • Antidepressant drugs fall into three major categories:
    • Tricyclics – increase activity of excitatory neurotransmitters norepinephrine and serotonin
      • Prevent reuptake of transmitters
    • Monoamine oxidase inhibitors – same effect as tricyclics through different method
      • Reduces activity of monoamine oxidase, an enzyme that breaks down the neurotransmitters
      • Can cause dangerous elevations in blood pressure when taken with certain foods
    • Selective serotonin reuptake inhibitors – increases activity of only serotonin
      • Many patients experience nervousness, insomnia, sweating, joint pain, or sexual dysfunction
      • Gradually replacing tricyclics because of milder side effects and more rapid reducing of depressive symptoms
  • Antipsychotic drugs have allowed severely disordered people to leave the hospital setting
    • Reserpine, drug from root of snakeroot plant, found to calm psychotic patients
    • Synthetic antipsychotic drugs (major tranquilizers) used to treat schizophrenic disorders
      • Primary effect is to decrease action of dopamine
      • Have dramatic effect in reduction of positive symptoms, but little effect on negative symptoms
    • Tardive dyskinesia – an irreversible motor disorder that can occur as a side effect of certain antipsychotic drugs
    • New drug called clozapine reduces both positive and negative symptoms
• Electroconvulsive Therapy
  • Biomedical technique involving application of electrical current to brain, primarily used to reduce severe depression
    • Cannot relieve anxiety disorders, and is of questionable value for schizophrenics
  • Based on observation that schizophrenia and epilepsy rarely occur in the same person
  • Patient is given a sedative and muscle relaxant to prevent injuries from convulsions
• Psychosurgery
  • Refers to surgical procedures that remove or destroy brain tissue to change disordered behaviour
    • Least used of biomedical procedures
  • Egas Moniz reported that cutting nerve tracts connecting frontal lobes with subcortical areas of brain involved in emotion resulted in calming of violent patients
    • Follow up research found that lobotomy caused seizures, memory impairment, and other side effects
  • Cingulotomy – involves cutting a small fibre bundle near the corpus collosum that connects the frontal lobes with the limbic system
    • Seems effective in treating OCD

Psychological Disorders and Society

• Deinstitutionalization
  • In 1960s, concern about inadequacies of mental hospitals, and ability of antipsychotic drugs to normalize patient’s behaviour, led to movement to transfer primary focus of treatment from institution to community
  • Psychiatric units were added to many hospitals and community services were established
  • Revolving door phenomenon – patients respond well to medication in hospital, and are soon released into a community that cannot offer them care they require, and then are sent back to the hospital
• Preventive Mental Health
  • Preventing development of disorders is preferable to successful treatment
  • Two perspectives can prevent disorders:
    • Situation-focused prevention – directed at reducing or eliminating environmental causes of behaviour disorders or at enhancing situational factors that help prevent the development of disorders
    • Competency-focused prevention – designed to increase personal resources and coping skills