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Treatment of Psychological Disorders Unit 13 • History of treatment has ranged from beatings to warm baths… and everything between and beyond that. • 2 pioneers for ethical treatment were Philippe Pinel (France) and Dorothea Dix (USA/Canada/Scotland). • Hospitals constructed for more humane treatment options. History • 2 Main categories: • 1) Treatment of Learning-related disorders, such as phobias. • 2) Treatment of Biological-influenced disorders, such as Schizophrenia. • Fall under all encompassing branch of Psychotherapy treatment involving psychological techniques; consists of interactions between a trained therapist and someone seeking to overcome psychological difficulties or achieve personal growth. • Most psychologists today advocated for the eclectic approach an approach to psychotherapy that, depending on the client’s problems, uses techniques from various forms of therapy. • This allows each patient to be treated individually based on their specific needs. Current • Psychoanalysis Sigmund Freud’s therapeutic technique. Freud believed the patient’s free associations, resistances, dreams, and transferences – and the therapist’s interpretations of them – released previously repressed feelings, allowing the patient to gain self-insight. • As much as all of your roll your eyes at Freud, some of his treatment practices are still part of treatment today. This is most seen in the psychodynamic theories. Types of Therapies • Patients work through buried feelings and take responsibility for their own growth. • Presumes that healthier, less anxious living becomes possible when people release the energy they had previously devoted to id-ego-superego conflicts. • Childhood impulses and conflicts. Aim of Psychoanalysis Therapies Freud’s Office! • Free Association – To allow patients to focus on own thoughts and feelings, the therapist sits outside your field of view. Whatever comes to mind is expressed and he therapist tries to use questioning techniques to find the deeper meaning. • This can be difficult for the patient because rarely do you say anything without somehow editing it in your mind first. This leads to resistance in psychoanalysis, the blocking from consciousness of anxiety-laden material. • The therapist takes note of your resistance and then interprets ( in psychoanalysis, the analyst’s noting supposed dream meanings, resistances, and other significant behaviors and events in order to promote insight.) the meaning providing insight into your underlying wishes, conflicts and feelings. (ex. Not wanting to talk about your mother). • . Methods of Psychoanalysis Therapies • Freud encouraged using the latent content of dreams – their underlying, but censored meaning – for dream analysis to gain insight into the true meanings. • Over time, the patient will start to disclose more to their therapist as they become more comfortable with them. You start to feel strong negative or positive feelings towards your therapist. This leads to transference in psychoanalysis, the patient’s transfer to the analyst of emotions linked with other relationships (such as love or hatred for a parent). Methods of Psychoanalysis Therapies • Traditional psychoanalysis takes time up to several years with several sessions per week and costs can add up. (3x a week, for 2 years at $100 a session = $30,000). • Only common in France, Germany, Quebec and NYC because of insurance costs. Methods of Psychoanalysis Therapies • Psychodynamic therapy therapy deriving from the psychoanalytic tradition that views individuals as responding to unconscious forces and childhood experiences, and that seeks to enhance self-insight Psychoanalysis Psychodynamic Therapy • Aims of psychodynamic therapy – help the person explore and gain perspective on thoughts and feels. • Similarities with psychoanalysis – uses unconscious or ‘unsaid’ things to help interpret patients issues. • Differences with psychoanalysis – face to face with patient, one a week, only for a few weeks or months at a time. Psychodynamic and Humanistic Therapy • Insight Therapies ( a variety of therapies that aim to improve psychological functioning by increasing the client’s awareness of underlying motives and defenses) focus more on: • • • • • the present rather than the past conscious rather than the unconscious taking immediate responsibility promoting growth instead of curing Clients rather than patients Humanistic Therapies • Client Centered Therapy a humanistic therapy, developed by Carl Rogers, in which the therapist uses techniques such as active listening within a genuine, accepting, empathic environment to facilitate client’s growth. (Also called person-centered therapy.) • Nondirective therapy – therapist listens, without judgement or interpretation and seeks to refrain form directing the client towards certain insights. • Rogers encouraged therapists to exhibit genuineness, acceptance and empathy. • Clients can feel more accepted when the therapists empathetically sense and reflect their client’s feelings. Allows clients to deepen sense of self-understanding and selfacceptance. Humanistic Therapies • Rogers ideas included Active Listening empathic listening in which the listener echoes, restates, and clarifies. A feature of Roger’s client-centered therapy. Used in teaching, counselling and modern therapy techniques. Includes ideas of: 1) Paraphrase – Rather than saying ‘I know how you feel’, checking the understanding by summarizing the speaker’s words in your own words. 2) Invite clarification – ‘What might this be an example of?’ may encourage the speaker to say more. 3) Reflect feelings – “It sounds frustrating’ might mirror what you’re sensing from the speaker’s body language and intensity. • Rogers also advocated for Unconditional Positive Regard a caring, accepting, nonjudgmental attitude, which Carl Rogers believed would help clients to develop self-awareness and self-acceptance. • What differences do you see between Freud’s ideas and Rogers? Why might one work better than another in different treatment situations? DISCUSS • Behaviour Therapy therapy that applies learning principles to the elimination of unwanted behaviors. • Doubts the healing power of self-awareness. For example, you can become aware of why you are highly anxious during tests and still be anxious. • Assume that problem behaviours are the problems themselves and that applying learning principles can eliminate them. • View maladaptive symptoms –such as phobias – as learned behaviours that can be then replaced by constructive behaviours. • Based on Skinner and Pavlov’s animal research. Behaviour Therapies • Can maladaptive symptoms be examples of conditioned responses? If so, can we fix it with reconditioning? • Ex. Bed wetting alarm. • Counter-Conditioning a behavior therapy procedure that used classical conditioning to evoke new responses to stimuli that are triggering unwanted behaviors; includes exposure therapies and aversive conditioning. • Ex. Associate fear of elevator with a calming feeling to retrain the fear. Classical Conditioning Techniques • Ex. Rabbit and Snack – Page 611 • Exposure Therapies behavioral techniques, such as systematic desensitization, that treat anxieties by exposing people (in imagination or actuality) to the things they fear and avoid. • Systematic Desensitization a type of exposure therapy that associates a pleasant relaxed state with gradually increasing anxiety-triggering stimuli. Commonly used to treat phobias. • Cannot be simultaneously anxious and relaxed. Therefore if you can be repeatedly relaxed while facing anxiety provoking stimuli, anxiety can be gradually eliminated. Trick? Must be gradual. Exposure Therapies Treating Phobias • Virtual Reality Exposure Therapy an anxiety treatment that progressively exposes people to simulations of their greatest fears, such as airplane flying, spiders, or public speaking. • Avatars can be used to place oneself in situations and adjust to different phobias. (ex. Social phobias) • Averse Conditioning a type of counterconditioning that associates an unpleasant state (such as nausea) with an unwanted behavior (such as drinking alcohol). • Works in the short run. The problem is that cognition influences conditioning. Ex. People know that outside of the therapists office, they can drink without nausea. Thus, averse conditioning must be used in combination with other treatments to ensure success. Averse Conditioning Behavior Therapies Aversion Therapy • Voluntary behaviours are strongly influenced by their consequences. • Can use behaviour modification, by reinforcing desired behaviours and withholding reinforcement or enacting punishment for undesired behaviour. • Takes a lot of time and work initially but pays off later. Ex. 40 hours a week for 2 years with autistic 3 year olds. Operant Conditioning • Rewards used to modify behaviour vary. • Sometimes praise works, sometimes need concrete rewards, such as food. • In institutional settings therapists create token economy an operant conditioning procedure in which people earn a token of some sort for exhibiting a desired behavior and can later exchange the tokens for various privileges or treats. Concerns – How durable are behaviors? Will they stop when enforcers stop? Is it right for one human to control another’s behavior? • Cognitive Therapy therapy that teaches people new, more adaptive ways of thinking and acting; based on the assumption that thoughts intervene between events and our emotional reactions. • Thinking colours our feelings and in between the event and our response lies the mind. • If thinking patterns can be learned, then they must be able to be replaced. • Cognitive therapists try in various ways to teach people new, more constructive ways of thinking. • Client/Patient interaction – pg 615-616 Cognitive Therapies • Cognitive Behavioural Therapy a popular integrative therapy that combines cognitive therapy (changing selfdefeating thinking) with behavior therapy (changing behavior). • Seeks to make people aware of their irrational negative thinking, replace it with new ways of thinking and to practice a more positive approach to everyday settings. • How would a cognitive therapist treat a patient with an eating disorder? Cognitive Therapies Cognitive Behavioral Therapy OCD • Does not provide as much of a one on one with each patient, but is less expensive and time consuming and has been proven to be no less effective than individual therapy. • The social context of group therapy allows for people to both discover that others have similar problems to them and receive feedback as they try out new was of behaving. • What do you think is the most successful example of group therapy on record? Group and Family Therapy • Family Therapy therapy that treats the family as a system. Views an individual’s unwanted behaviors as influenced by, or directed at, other family members. • No one person is an island. We live and grow in relation to others, especially our families. • Sometimes we struggle to differentiate ourselves from our families, but we also need to connect with them emotionally. A lot of problem behaviours come from the tension between these 2 tendencies, which creates family stress. Family and Group Therapy Comparison of Psychotherapies • The question of evaluation lies in does psychotherapies work or not? • Perceptions fall under client, clinicians and outcome research. Evaluating Psychotherapies • Most people (about 85%) say that their therapy has helped them. • People often enter therapy in crisis – However, if the crisis is removed by natural causes, they attribute the solution to their therapy. • Clients may need to believe the therapy was worth the effort – To admit that investing time and money in self-justification and improvement is a powerful motive. • Clients generally speak kindly of their therapists – Clients feel therapists have lots of understanding, give new perspectives, allow them to communicate better, etc. Client Perceptions • Case studies of successful treatment abound. • However, a even the best clinician may not hear back from successful clients or do not know what clients went to another clinician. • Most people start therapy when they are in a low state, leave in a higher state. Does not mean they are ‘cured’. May repeat clients are the ‘successes’ in different clinicians files. Clinitians Perspective • Controlled observation studies used to legitimize success rates. • Over 5 dozen studies have been done to legitimize the effectiveness of psychotherapy. All reflect the same outcome – Those not undergoing therapy often improve, but those undergoing therapy are more likely to improve. Outcome Research • When outcome research is being conducted, 2 common practices are used: • Regression Towards the Mean the tendency for extreme or unusual scores to fall back (regress) toward their average. • Meta-analysis a procedure for statistically combining the results of many different research studies. • Placebo research plays a big role in determining the validly to therapies. Why? Outcome Research • Ones to avoid according to outcome research: • Energy Therapies – propose to manipulate people’s invisible energy fields. • Recovered-memory therapies – aim to unearth ‘expressed memories’ of early childhood abuse. • Rebirthing therapies – engage people in reenacting the supposed trauma of their birth. • Crisis debriefing – forces people to verbalize, rehearse and process their traumatic experiences. • Lets play… NAME THAT FLAW! The Relative Effectiveness of Different Therapies • What works in psychology? What does not? It comes down to used Evidence based practice clinical decision-making that integrates the best available research with clinical expertise and patient characteristics and preferences. The Relative Effectiveness of Different Therapies • No evidence for or against. • Eye movement desensitization and reprocessing (EMDR) – Can make anxious thoughts disappear when eyes spontaneously dart about. Relive tragedy while waving objects in front of the eyes. 70,000 people trained in this to date. • Light exposure therapy • Seasonal affective disorder (SAD) – Sunlamps used to boost light exposure. As effective as antidepressants in some cases. Evaluating Alternate Therapies • 3 elements shared by all psychologists: • Hope for demoralized people – things can and will get better, no matter how bad the start. • A new perspective – plausible explanation of symptoms. • An empathic, trusting, caring relationship – seek to understand the experience of others. Commonalities Among Psychotherapies Culture and Values in Psychotherapy • Similarities between cultures – want patients to get better overall • Differences between cultures – religion, values, expectations Types of Therapists • Biomedical Therapies (prescribed medications or medical procedures that act directly on the patient’s nervous system.) fall under 5 categories: • • • • • Drugs Electroconvulsive therapy Magnetic impulses Psychosurgery Psychiatrist Biomedical Therapies • Psychopharmacology the study of the effects of drugs on mind and behavior. • Factors to consider with drug therapy • Normal recovery rate of untreated patients • Placebo effect • Double blind procedure Drug Therapies Placebo Effect Drug Therapies Drug Therapies • Antipsychotic drugs Antipsychotic • PsychosesDrugs • • • • Chlorpromazine Dopamine Tardive dyskinesia Atypical antipsychotics (Thorazine) (Clozaril) • Positive and negative symptoms • xxx • xxx • Antipsychotic Drugs drugs used to treat schizophrenia and other forms of severe thought disorder. • Used with patients with psychoses – patients with loss of reality. • Chlorpromazine aka (Thorazine) dampens responsiveness to irrelevant stimuli. • Common side effect is Tardive dyskinesia involuntary movements of the facial muscles, tongue, and limbs; a possible neurotoxic side effect of long-term use of antipsychotic drugs that target certain dopamine receptors. • Atypical antipsychotic aka (Clozaril) for schizophrenia. Targets both dopamine and serotonin receptors. Antipsychotic Drugs • Antianxiety Drugs drugs used to control anxiety and agitation. Xanax, Ativan, Dcycloserine – depress central nervous system activity. Cannot e used in combination with alcohol. • Physiological dependence – after heavy use, stop taking them, nay experience increased anxiety, insomnia and withdrawal symptoms. • Antianxiety Drugs • Antidepressants drugs used to treat depression; also increasingly prescribed for anxiety. Different types work by altering the availability of various neurotransmitters. • Use with mood and anxiety disorders as they increase the availability of norepinephrine or serotonin. • Fluoxetine (Prozac), Paxil - SSRIs • Selective-serotonin-reuptake inhibitors • Side effects of antidepressants – dry mouth, weight gain, hypertension, dizziness, etc. Antidepressant Drugs Drug Therapies Antidepressant Drugs • Lithium – emotion highs and lows of bipolar. • Depakote – originally for seizures, works well for bio-polar as well. Mood Stabilizing Medications • Electroconvulsive Therapy a biomedical therapy for severely depressed patients in which a brief electric current is sent through the brain of an anesthetized patient. Procedure – general anesthetic, muscle relaxant, 30-60 seconds of electrical impulse to the brain. Wakens within 30 minutes, with no memory. May work like ‘restarting a computer’. • Severe depression – extremely effective in those who do not respond to drugs. • Electroconvulsive Therapy Brain Stimulation Electroconvulsive Therapy • Repetitive transcranial magnetic stimulation (rTMS) the application of repeated pulses of magnetic energy to the brain; used to stimulate or suppress brain activity. • Deep brain stimulation • Major depression treatment. Alternative Neurostimulation Therapies Brain Stimulation Alternative Neurostimulation Therapies • • Psychosurgery surgery that removes or destroys brain tissue in an effort to change behavior. Lobotomy a now-rare psychosurgical procedure once used to calm uncontrollably emotional or violent patients. The procedure cut the nerves connecting the frontal lobes to the emotion-controlling centers of the inner brain. • History – crude, inexpensive, goal to disconnect emotion from thought. • Procedure – shock patient into coma, hammer icepick like instrument through each eye socket, then wiggle to sever connections. • Side effects – decreased misery or tension, but produced lethargic, immature, uncreative people. • Use today – No lobotomies. Surgery only for seizure disorders and very precise. Psychosurgery • Integrated biopsychosocial system – everything that is psychological is also biological. • Therapeutic life-style change • • • • • • Aerobic exercise – 30 mins per day, 3 times a week. Adequate sleep – 7-8 hours per night Light exposure – 30 mins each morning (light box) Social connection – less alone time and at least 2 meaningful social engagements weekly. Anti-rumination – identify and redirect negative thoughts. Nutritional supplements – fish oil – omega 3 fatty acids healthy brain! Therapeutic Lifestyle Changes • Resilience the personal strength that helps most people cope with stress and recover from adversity and even trauma. • Understand that there are connections – ex stress. • River analogy – Page 638. • Preventative is not as in place as it should be. May lead to better treatment quicker. Preventing Psychological Disoders Early Treatment Drug Addiction