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Psy 239 Chapter 5 Wayne Hooke Chapter 5 Treatments for Abnormality Learning Objectives 1. Give examples of antipsychotic, antidepressant, mood stabilizing, and antianxiety drugs, and know their appropriate uses and limitations. 2. Distinguish among MAO inhibitors, tricyclic antidepressants, and SSRIs. 3. Identify the appropriate and inappropriate uses of ECT, psychosurgery, and repetitive transcranial magnetic stimulation. 4. Give examples of herbal remedies for the treatment of psychological problems and discuss what is known about their effectiveness 5. Describe the components of psychodynamic therapy and how it is thought to work. 6. Describe humanistic therapy and how it is conducted. 7. Describe techniques used in behavior therapy. 8. Describe the elements of cognitive therapy and how it is similar to behavior therapy. 9. Discuss IPT and how it is both similar to and different from psychodynamic therapy. 10. Discuss alternatives to individual therapy (e.g., family and group therapy). 11. Describe how mental health treatment may be carried out in the community 12. Discuss how cultural issues may affect treatment and the extent to which research suggests that these issues should affect therapist-client matching. 13. Summarize the common components of successful therapies. 14. Discuss the special issues that can arise when treating children. 1 Psy 239 Chapter 5 Wayne Hooke Biological Treatments: Drug Therapies z Antipsychotic Drugs z Reduce symptoms of psychosis. Examples: Thorazine, Clozaril, Haldol z Antidepressant z Reduce symptoms of depression. • Examples: Parnate, Elavil, Prozac z Stabilize mood. • Examples: Lithobid, Cibalith-S z Reduce symptoms of anxiety. • Examples: Nembutal, Valium Drugs z Lithium/Mood Stabilizers z Antianxiety Drugs Biological Treatments: Drug Therapies Antipsychotic/neuroleptic drugs • • • • Aka: major tranquilizers Atypicals: risperidone, olanzapine, clozapine not known as major tranquilizers Typical neuropleptics may work on the brain’s dopamine system (http://en.wikipedia.org/wiki/Dopamine) FACTS ABOUT ANTIPSYCHOTIC MEDICATIONS.pdf Antidepressants: SSRIs • • • Selective serotonin reuptake inhibitors 20% of Americans have a disorder treatable by means of an SSRI 2004 meta-analysis found a modest effect of SSRIs on the treatment of depression with substance abuse 2 Psy 239 Chapter 5 Wayne Hooke Antidepressants: SSRIs • • Recent systematic review that included almost 90,000 subjects found a 2x increase in suicide attempts with SSRIs compared to placebo 2004 systematic review found some evidence for using SSRIs rather than tricyclics* in bipolar disorder – “The exact mechanism of action is not well understood, however it is generally thought that tricylic antidepressants work by inhibiting the re-uptake of the neurotransmitters norepinephrine, dopamine or serotonin by nerve cells.” Wikipedia Antidepressants: SSRIs The Center for Science in the Public Interest’s review of studies on SSRI treatment for children found that industry-funded studies are 50 percent more likely to report positive treatment outcomes than government or university-funded studies. Antidepressants: SSRIs • • With the exception of Prozac, SSRIs may be more dangerous to adolescents than published data suggest Clomapramine (Anafranil - trycylic) seems more effective in treating childhood OCD Antidepressants: SSRIs • • • Initial studies found reports of reduced libido and anorgasmia in 10% of cases Recent studies and clinical experience find this side effect much more frequently Why? Antidepressants: SSRIs “The ‘best buys in second-generation antidepressants, based on safety, effectiveness and cost, are generic fluoxetine (Prozac and Sarafem), citalopram (Celexa) and buproprion (Wellbutrin), according to a 2005 Consumers Union report.’” SSRI effectiveness.pdf Lithium/Mood Stabilizers • • Medline Plus Drug Information_ Lithium (Systemic).pdf http://en.wikipedia.org/wiki/Mood_stabilizer 3 Psy 239 Chapter 5 Wayne Hooke Anti-anxiety Drugs: SSRIs and Social Anxiety • • Comprehensive review – 25 published studies – 8 randomized, double-blind, placebo-controlled “It may be concluded with a high degree of confidence that SSRI treatment for social anxiety disorder is effective, both in reducing total levels of social anxiety and in improving patients' overall clinical condition.” Activity: Treating a Fear of Giving Classroom Presentations Using a Biological Therapy Anxiety before having to give a presentation in class is very common among students but for some, it is more than just normal anxiety. Imagine a student so anxious about giving class presentations that she usually does not even sign up for classes in which such presentations are required. If she absolutely cannot avoid giving a class presentation, she gets so nervous the night before that she vomits and sleeps poorly, often calling in sick the day of the presentation so that she can avoid the stress of public speaking. At times she has refused to give a presentation, claiming that she forgot her materials, or that she had a sore throat and couldn't talk. While she is a very good student in all her classes, this problem has caused her to get less than satisfactory grades in those classes that require presentation. The student realizes that she has a problem and is thinking about getting professional help. You are a psychiatrist. What do you think is the cause of this student's problem, and how will you treat it Electroconvulsive Therapy • • • An alternative to drug therapies in the treatment of some disorders is ECT (electroconvulsive therapy). ECT consists of a series of treatments in which a brain seizure is induced by passing electrical current through the patient’s brain. http://en.wikipedia.org/wiki/Electroconvulsive_therapy Psychosurgery Prefrontal lobotomies were eventually criticized as a cruel and ineffective means of treating psychosis. Moniz & Lima (1935) Walter Freeman, his ice pick, and his lobotomobile 40-50,000 lobotomies, for a number of problems: including misbehavior in children http://www.cerebromente.org.br/n02/historia/psicocirg_i.htm 4 Psy 239 Chapter 5 Wayne Hooke Psychosurgery Psychosurgery declined after the 1950s, rarely used today and only with the most severe cases with patients who do not respond to other forms of treatment. Repetitive Transcranial Magnetic Stimulation Repeated, high-intensity magnetic pulses focused on specific brain structures • • Preliminary research supports use of RTMS for depression, auditory hallucinations, & migraine headaches Being researched as a treatment for mania, ptsd, & tinnitus The Social Impact of the Biological Approach to Therapy • • • • What is the responsibility of the sufferer? What side effects could produce unwanted social harms? Is there an ease to drugs that allows us to forget or over-look other issues? Are there alternatives within the biological approach to therapy? What about herbs or holistic approaches? Psychological Therapies 5 Psy 239 Chapter 5 Wayne Hooke Does therapy work? 80 70 60 50 No Therapy Psychoanalytic Eclectic 40 30 20 Eysenck’s 1952 review of 24 effectiveness studies 10 0 % Improved Does therapy work? Smith, Glass, & Miller (1980) • Created meta-analysis • 375 studies/25,000 clients • “average person who received therapy was 75% better” • What does “75%” better mean? • About the same improvement as is gained from one year of reading instruction in elementary school Does therapy work? • • • • Average duration of therapy is: 6 sessions Modal number of sessions is: 1 session After 58 sessions: 75% recovered After 11 sessions: 50% recovered 6 Psy 239 Chapter 5 Wayne Hooke Does therapy work? • • • Characterological improvement after 52 weeks: 50% Chronic distress after 52 weeks: 66-86% Acute distress after 52 weeks: 68-95% Consumer Reports Study z z z z z There was no substantial difference in terms of reported satisfaction for readers who saw a social worker, psychologist, or psychiatrist; but there was less satisfaction for those who saw marriage counselors. Family doctors also seemed to be able to provide help, but people who received help from a mental-health specialist for more than six months did much better than those who had shorter term therapy. There was little difference between psychotherapy and a combination of psychotherapy and medications such as Prozac or Xanax, although many persons on medications reported side effects. There was greater improvement over time with longer term therapy as opposed to short-term therapy. Members of self-help groups found the groups to be very helpful, and members of Alcoholics Anonymous were particularly grateful. Psychodynamic Therapies Therapeutic Alliance Free Association Concepts Working Through CounterTransference Resistance Transference 7 Psy 239 Chapter 5 Wayne Hooke Activity: Treating a Fear of Giving Classroom Presentations Using Psychodynamic Therapy Anxiety before having to give a presentation in class is very common among students but for some, it is more than just normal anxiety. Imagine a student so anxious about giving class presentations that she usually does not even sign up for classes in which such presentations are required. If she absolutely cannot avoid giving a class presentation, she gets so nervous the night before that she vomits and sleeps poorly, often calling in sick the day of the presentation so that she can avoid the stress of public speaking. At times she has refused to give a presentation, claiming that she forgot her materials, or that she had a sore throat and couldn't talk. While she is a very good student in all her classes, this problem has caused her to get less than satisfactory grades in those classes that require presentation. The student realizes that she has a problem and is thinking about getting professional help. You are a psychodynamic therapist. What do you think is the cause of this student's problem, and how will you treat it Humanistic Therapy • • Also known as person-centered therapy. Client-centered therapy is the best known of these therapies. Essential Ingredients of Client-Centered Therapy • • • The therapist communicates a genuineness in his or her role as helper to the client. The therapist shows unconditional positive regard for the client. The therapist communicates an empathic understanding of the client by making it clear that he or she understands and accepts the client’s underlying feelings and search for self. Activity: Treating a Fear of Giving Classroom Presentations Using Humanistic Therapy Anxiety before having to give a presentation in class is very common among students but for some, it is more than just normal anxiety. Imagine a student so anxious about giving class presentations that she usually does not even sign up for classes in which such presentations are required. If she absolutely cannot avoid giving a class presentation, she gets so nervous the night before that she vomits and sleeps poorly, often calling in sick the day of the presentation so that she can avoid the stress of public speaking. At times she has refused to give a presentation, claiming that she forgot her materials, or that she had a sore throat and couldn't talk. While she is a very good student in all her classes, this problem has caused her to get less than satisfactory grades in those classes that require presentation. The student realizes that she has a problem and is thinking about getting professional help. 8 Psy 239 Chapter 5 Wayne Hooke You are a humanistic therapist. What do you think is the cause of this student's problem, and how will you treat it Behavior Therapies • • The behavioral assessment is the foundation for behavior therapy. Therapist works with the client to identify the specific circumstances that seem to elicit the client’s negative behavior or emotional responses. Methods Used In Behavior Therapies • • • • • • • • • Removal of reinforcements Aversion therapy Relaxation exercises Distraction techniques Flooding or implosive therapy Systematic desensitization Response shaping through operant conditioning (What Shamu Taught Me About a Happy Marriage - New York Times.pdf) Behavioral contracting Modeling and observational learning Activity: Treating a Fear of Giving Classroom Presentations Using Behavioral Therapy Anxiety before having to give a presentation in class is very common among students but for some, it is more than just normal anxiety. Imagine a student so anxious about giving class presentations that she usually does not even sign up for classes in which such presentations are required. If she absolutely cannot avoid giving a class presentation, she gets so nervous the night before that she vomits and sleeps poorly, often calling in sick the day of the presentation so that she can avoid the stress of public speaking. At times she has refused to give a presentation, claiming that she forgot her materials, or that she had a sore throat and couldn't talk. While she is a very good student in all her classes, this problem has caused her to get less than satisfactory grades in those classes that require presentation. The student realizes that she has a problem and is thinking about getting professional help. You are a behavioral therapist. What do you think is the cause of this student's problem, and how will you treat it 9 Psy 239 Chapter 5 Wayne Hooke Cognitive Therapies Assist clients in identifying their irrational and maladaptive thoughts and replacing them with more adaptive ways of thinking. Techniques in Cognitive Therapies • • • • • • z z z z z z z Challenge idiosyncratic meanings Question the evidence Reattribution Examine options and alternatives “Decatastrophize” Fantasize consequences Examine advantages and disadvantages Turn adversity to advantage Guided association Scaling Thought stopping Distraction Labeling of distortions 10 Psy 239 Chapter 5 Wayne Hooke Cognitive Therapies CTRS.pdf Activity: Treating a Fear of Giving Classroom Presentations Using Cognitive Therapy Anxiety before having to give a presentation in class is very common among students but for some, it is more than just normal anxiety. Imagine a student so anxious about giving class presentations that she usually does not even sign up for classes in which such presentations are required. If she absolutely cannot avoid giving a class presentation, she gets so nervous the night before that she vomits and sleeps poorly, often calling in sick the day of the presentation so that she can avoid the stress of public speaking. At times she has refused to give a presentation, claiming that she forgot her materials, or that she had a sore throat and couldn't talk. While she is a very good student in all her classes, this problem has caused her to get less than satisfactory grades in those classes that require presentation. The student realizes that she has a problem and is thinking about getting professional help. You are a cognitive therapist. What do you think is the cause of this student's problem, and how will you treat it Group Therapy Should Provide Examples of appropriate conduct Information and advice for members A safe place to take risks and accept criticism Opportunities to acquire and improve skills Information that other people share the same problem Opportunities to express feelings and gain selfunderstanding Opportunities for growth and personal satisfaction by helping others 11 Psy 239 Chapter 5 Wayne Hooke Therapy for Groups and the Community • • • • • Must the therapist and the client come from the same ethnic group or nationality? How and when does it matter? Must the therapist and the client be of the same sex and gender? How and when does it matter? What values are important in each of these questions? Factors of Successful Therapy • • • A positive relationship with the therapist An explanation or interpretation of why the client is suffering Other factors – Encouragement to confront negative emotions – An integrative approach 12