Download Chapter 15 - Dr. Saadia McLeod

Chapter 15
Psychotherapy
©2015 Cengage Learning.
All Rights Reserved.
The Treatment Process, continued
Treatments: How many types are there?
• Therapeutic Relationship: essential
• There are three main categories of therapy:
1. Insight therapies
2. Behavior therapies
3. Psychiatric: Medication
—As shown in Figure 15.1, many are treated with
medication only.
©2015 Cengage Learning.
All Rights Reserved.
The Treatment Process, continued
Clients: Who seeks therapy?
• Coping with loss: deaths, loss, relationships
• Anxiety, Depression, Substance Abuse
• Women
• People with medical insurance
©2015 Cengage Learning.
All Rights Reserved.
The Treatment Process, continued
Clients: Who seeks therapy?, continued
• Many who need therapy, do not get it
• Common barriers to seeking treatment include:
– Lack of health insurance.
– The “stigma” associated with receiving mental
health services.
• What is the stigma associated with treatment?
©2015 Cengage Learning.
All Rights Reserved.
The Treatment Process, continued
Therapists: Who provides treatment?
• Psychologists and psychiatrists are the most
common providers of treatment.
• However, therapy is also provided by other
professionals, including:
– Social Workers (LCSW)
– Psychiatric nurses (LVM)
– Counselors: Marriage-Family Therapist
©2015 Cengage Learning.
All Rights Reserved.
The Treatment Process, continued
Therapists, continued
• Clinical psychologists and counseling
psychologists “specialize in the diagnosis and
treatment of psychological disorders and
everyday behavioral problems."
• Both require a doctoral degree (Ph.D., Psy.D., or
Ed.D).
• Psychologists also conduct psychological testing
and carry out research.
• Do not prescribe medication in California
©2015 Cengage Learning.
All Rights Reserved.
The Treatment Process, continued
Therapists, continued
• Psychiatrists “are physicians who specialize in
the treatment of psychological disorders."
• Treat with medication only
• Treat a wide variety of mental illnesses: Anxiety,
PTSD, OCD, Schizophrenia, Depression.
©2015 Cengage Learning.
All Rights Reserved.
The Treatment Process, continued
Therapists, continued
• Other mental health professionals
– Psychiatric social workers
– They have a master’s degree and usually help
patients integrate back into the community.
• Discharged hospitalized patients
• Homeless population
– Psychiatric nurses : are able to prescribe
medication with the support of a Psychiatrist
– See Figure 15.3 for a full list.
©2015 Cengage Learning.
All Rights Reserved.
Insight Therapies, continued
Insight therapies : Explore the impact of early family
dynamics on adult issues and relationships
• Insight therapies include:
– Psychoanalysis: Freud
– Client-centered therapy: Carl Rogers
– Group therapy
©2015 Cengage Learning.
All Rights Reserved.
Insight Therapies, continued
• Psychoanalysis
– Probing the unconscious: look for
unconscious conflicts
• Therapists use two techniques :
– In free association: clients spontaneously
express their thoughts and feelings exactly as
they occu
– In dream analysis, interpret the symbolic
meaning in dreams
– interpret the clues that these methods provide
about unconscious conflicts.
©2015 Cengage Learning.
All Rights Reserved.
Insight Therapies, continued
Psychoanalysis, continued
– Interpretation “involves the therapist’s
attempts to explain the inner significance of
the client’s thoughts, feelings, memories, and
behaviors."
– Resistance “unconscious defensive maneuvers
intended to hinder the progress of therapy."
o Clients may resist by “forgetting”
appointments or being hostile toward the
therapist.
©2015 Cengage Learning.
All Rights Reserved.
Insight Therapies, continued
Psychoanalysis, continued
– Transference clients start relating to their
therapists in ways that mimic significant
relationships in their lives:
• Therapist as mother, father, ex-boyfriend, etc.
• psychodynamic approaches: newer therapies in
psychoanalytic tradition
©2015 Cengage Learning.
All Rights Reserved.
Insight Therapies, continued
Client-centered therapy : A safe and accepting
relationship is curative
• Carl Rogers: Therapist is collaborative not the
expert as with Psychoanalysis
• Use of reflection as primary intervention:
– Therapist reflects back and clarifies what the client
states
©2015 Cengage Learning.
All Rights Reserved.
Insight Therapies, continued
Client-centered therapy, continued
• Therapeutic climate
1. Genuineness (honest communication)
2. Unconditional positive regard (therapist
remains supportive, non-judgmental)
3. Empathy (therapist understands issues from
client’s point of view)
©2015 Cengage Learning.
All Rights Reserved.
Insight Therapies, continued
Group therapy : Self-help or Clinician led
-several or more clients (typically five to ten
people) in a group."
• Participants’ roles
– Participants share and provide support
– Share their experiences and insight (exp: share
about interventions that worked, insights into
how to manage an ill family member, etc.)
©2015 Cengage Learning.
All Rights Reserved.
Insight Therapies, continued
Group therapy, continued
• Advantages of the group experience
1. Do not feel alone
2. Social support: key to health and recovery
3. Types:
1.
2.
3.
4.
Grief Support
Alcoholics Anonymous, Narcotics Anonymous
Depression Support Group
Sexual Abuse Support Group
©2015 Cengage Learning.
All Rights Reserved.
Insight Therapies, continued
Couples and family therapy
• Couples, or marital therapy
– The focus is on the relationship conflict or
distress
• Family therapy “involves the treatment of a
family unit as a whole
•
May be part of individual therapy or couples
therapy
©2015 Cengage Learning.
All Rights Reserved.
Insight Therapies, continued
• What makes therapy effective?
1. Good therapeutic relationship with therapist
2. Emotional support and empathic
3. The cultivation of hope, positive expectations.
4. Express feelings, receive insights and clarity
©2015 Cengage Learning.
All Rights Reserved.
Behavior Therapies, continued
• Insight therapists believe that behaviors are
symptoms of underlying psychological issues.
• behavior therapies :
– Treat the symptoms
– Stay in the here and now
– Have a structure and direction to treatment
©2015 Cengage Learning.
All Rights Reserved.
Behavior Therapies, continued
Systematic desensitization “is a behavior therapy
used to reduce clients’ anxiety responses through
counterconditioning."
• Phobia a result of pairing anxiety with a neutral
stimulus (exp. Spider)
• Goal: Associate Relaxation with Neutral Stimulus
©2015 Cengage Learning.
All Rights Reserved.
Behavior Therapies, continued
Systematic desensitization, continued
• Before beginning, the therapist helps the client
build a anxiety hierarchy, or a list of progressively
more frightening versions of the conditioned
stimulus.
• Then, the client is trained in deep muscle
relaxation.
• Gradually expose to the stimulus while staying
relaxed and calm.
– In vivo or imaginary or virtual
©2015 Cengage Learning.
All Rights Reserved.
Behavior Therapies, continued
Cognitive-behavioral treatments blend verbal and
behavioral interventions.
Cognitive therapy “is a treatment that emphasizes
recognizing and changing negative thoughts and
maladaptive beliefs."
• It emerged from the work of two former
psychoanalysts: Albert Ellis and Aaron Beck (this
chapter will focus on the work of Aaron Beck).
©2015 Cengage Learning.
All Rights Reserved.
Behavior Therapies, continued
Cognitive therapy, continued
• “Depression is errors in thinking”:
1. Irrational self-blame
2. Selective recall of negative memories
3. Negative about self, others, and future
©2015 Cengage Learning.
All Rights Reserved.
Behavior Therapies, continued
Cognitive therapy, continued
• Goal: change the way clients think.
• Teach client to become aware of their negative
thinking and actively challenge it
-Test their negative assumptions or beliefs
-Actively “talk back” to negative self-talk
©2015 Cengage Learning.
All Rights Reserved.
Behavior Therapies, continued
Evaluating behavior / cognitive therapies
• Recommended Treatment Approach for:
(good empirical support)
– Depression, anxiety problems, phobias, OCD,
and schizophrenia.
– Sexual dysfunction.
– Drug-related problems and eating disorders.
– Hyperactivity.
– Autism and mental retardation.
©2015 Cengage Learning.
All Rights Reserved.
Biomedical Therapies
LEARNING OBJECTIVES
• Describe the principal drug therapies used in the
treatment of psychological disorders, and
summarize evidence regarding their efficacy.
• Identify some of the problems associated with drug
therapies and drug research.
• Describe ECT, and discuss its efficacy and risks.
©2015 Cengage Learning.
All Rights Reserved.
Biomedical Therapies, continued
Biomedical therapies “are physiological
interventions intended to reduce symptoms
associated with psychological disorders."
• Two prominent biomedical therapies are:
– Drug therapy
– Electroconvulsive (ECT)
©2015 Cengage Learning.
All Rights Reserved.
Biomedical Therapies, continued:
Treatment with drugs
• Psychopharmacotherapy (or drug therapy) “is
the treatment of mental disorders with
medication."
• Therapeutic drugs fall into four main categories:
1. Antianxiety drugs
2. Antipsychotic drugs
3. Antidepressant drugs
4. Mood stabilizers
©2015 Cengage Learning.
All Rights Reserved.
Biomedical Therapies, continued
Treatment with drugs, continued
Antianxiety drugs “relieve tension, apprehension,
and nervousness."
• Two common antianxiety drugs are Valium and
Xanax.
• These drugs provide fast relief.
• However there is the risk for abuse, dependency,
overdose, and withdrawal effects.
©2015 Cengage Learning.
All Rights Reserved.
Biomedical Therapies, continued
Treatment with drugs, continued
Antipsychotic drugs “are used to gradually reduce
psychotic symptoms, including hyperactivity, mental
confusion, hallucinations, and delusions."
• They are typically used to treat schizophrenics or
other patients in a delusional state.
• Traditional antipsychotics include Thorazine,
Mellaril, and Haldol.
©2015 Cengage Learning.
All Rights Reserved.
Biomedical Therapies, continued
Treatment with drugs, continued
• Antipsychotics work gradually (one to three
weeks), and reduce symptoms in about 70% of
patients.
• They do have unpleasant side effects, however,
including:
– Dry mouth, constipation
– Drowsiness
– Tremors, muscular rigidity, and impaired
coordination
©2015 Cengage Learning.
All Rights Reserved.
Biomedical Therapies, continued
Treatment with drugs, continued
• A more serious, but rare, side effect is a condition
called tardive dyskinesia, “a neurological disorder
marked by chronic tremors and involuntary spastic
movements”, which is irreversible.
• Atypical antipsychotics are a newer class of drugs
with a lower risk of these side effects.
– However, these drugs may increase risk for
diabetes and cardiovascular disease.
©2015 Cengage Learning.
All Rights Reserved.
Biomedical Therapies, continued
Treatment with drugs, continued
Antidepressant drugs “gradually elevate mood and
help bring people out of a depression."
• Reliance on antidepressants has increased
dramatically in the past 15 years.
– They are the most frequently prescribed
medication in the U.S.
• The most commonly used antidepressants today are
SSRIs (selective serotonin reuptake inhibitors) that
work by affecting the brain chemical, serotonin
(e.g., Zoloft).
©2015 Cengage Learning.
All Rights Reserved.
Biomedical Therapies, continued
Treatment with drugs, continued
• SSRIs also work for some anxiety disorders.
• Side effects of SSRIs include:
– Weight gain
– Sleep problems
– Sexual dysfunction
• More recently, research has raised concern that
SSRIs may possibly increase the risk for suicide,
especially in adolescents.
• Effective within 12 weeks or less
©2015 Cengage Learning.
All Rights Reserved.
Biomedical Therapies, continued
Treatment with drugs, continued
Mood stabilizers “are drugs used to control mood
swings in patients with bipolar mood disorders."
• Lithium, Depakote
– Toxicity or death at high concentrations
– Kidney and thyroid gland problems
• Important to have regular blood monitor
©2015 Cengage Learning.
All Rights Reserved.
Biomedical Therapies, continued
Electroconvulsive therapy (ECT) “is a biomedical
treatment in which electric shock is used to produce
a cortical seizure accompanied by convulsions."
• ECT is primarily used to treat depression.
• Patients are given a light anesthetic and muscle
relaxers to prevent spinal fractures.
• Electric current is applied for about a second,
which triggers a brief seizure.
• Typically, patients receive 3 treatments a week,
over two to seven weeks.
©2015 Cengage Learning.
All Rights Reserved.
Biomedical Therapies, continued
ECT, continued
Effectiveness of ECT
• Proponents of ECT claim it is very effective for
depression in patients that do not respond to
medication.
• Opponents argue that it is not more effective than
placebo and carries serious risks.
• In addition, relapse rates are very high.
– In one well-controlled study, 64% of patients
relapsed within 6 months (Prudic et al. 2004).
©2015 Cengage Learning.
All Rights Reserved.
Biomedical Therapies, continued
ECT, continued
Risks associated with ECT
• ECT proponents admit that memory loss and
impaired attention are mild, temporary side
effects of the treatment.
• Critics argue that these cognitive problems are
more serious and sometimes permanent.
©2015 Cengage Learning.
All Rights Reserved.
Current Trends and Issues, continued
Blending approaches to treatment
• Increasingly, therapists describe their theoretical
approach as eclectic (see Figure 15.13).
• Eclectic therapists “borrow ideas, insights, and
techniques from a variety of sources while tailoring
their intervention strategy to the unique needs of
each client."
• Eclectic approaches are particularly common when a
treatment team provides therapy.
• Studies show that there is, indeed, merit to this idea.
©2015 Cengage Learning.
All Rights Reserved.
Based on data from Norcross, Hedges, & Castle, 2002
Current Trends and Issues, continued
Increasing multicultural sensitivity in treatment
• Minority groups are especially unlikely to seek and
utilize therapy.
1. Cultural barriers
– Some cultures emphasize assistance from
family, clergy, etc., over mental health
professionals.
– Some cultures have difficulty trusting the
medical (and mental health) establishment.
©2015 Cengage Learning.
All Rights Reserved.
Current Trends and Issues, continued
Increasing multicultural sensitivity, continued
2. Language barriers
– Effective communication is critical to
therapy, and cultural differences in
language can act as a barrier to treatment.
3. Institutional barriers
– Most therapists have only been trained to
interact with white, middle-class clients
and are unfamiliar with the cultural
backgrounds of various ethnic groups.
©2015 Cengage Learning.
All Rights Reserved.
Current Trends and Issues, continued
Increasing multicultural sensitivity, continued
• What can be done?
– Recruit and train minority therapists.
– Train therapists how to work more
effectively with a culturally diverse
clientele.
– Research how to modify current
approaches so that they are more
compatible with a diverse clientele.
©2015 Cengage Learning.
All Rights Reserved.
Application: Looking for a Therapist
LEARNING OBJECTIVES
• Discuss where to seek therapy and the importance
of a therapist’s gender and professional
background.
• Evaluate the importance of a therapist’s theoretical
approach and understand what one should expect
from therapy.
©2015 Cengage Learning.
All Rights Reserved.
Application: Looking for a Therapist, continued
Where do you find therapeutic services?
• Contrary to popular belief, most therapists do not
operate in private practice.
• In fact, many work in:
– Institutional settings (such as community mental
health centers)
– Human service agencies
– See Figure 15.15 for more information
©2015 Cengage Learning.
All Rights Reserved.
Application: Looking for a Therapist, continued
• Is therapy always expensive?
– Not necessarily. Costs can be reduced by:
• Seeking treatment from providers who are not
in private practice (e.g., human service
agencies).
• Using health insurance.
©2015 Cengage Learning.
All Rights Reserved.
Application: Looking for a Therapist, continued
Is the therapist’s theoretical approach important?
• For certain types of problems, certain theoretical
approaches are a better fit.
• For example:
– Cognitive therapy is best for panic disorders.
– Behavior therapy (systematic desensitization) is
best for phobias.
– OCD is best treated with behavior therapy and
medication.
©2015 Cengage Learning.
All Rights Reserved.
Application: Looking for a Therapist, continued
What is therapy like?
• It is important to have realistic expectations about
therapy.
• Therapy is usually a slow process.
• Therapy is hard work.
• Your therapist is only a facilitator. Ultimately, you have
to make changes in your behavior or personality in
order to see improvement.
©2015 Cengage Learning.
All Rights Reserved.