Download PsychAP Notes pt 12 The difference between Psychiatrists and

PsychAP Notes pt 12
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The difference between Psychiatrists and Shrinks is that one can prescribe medicine. This breaks off
into two parts: psychotherapy (a clinician is talking to a client and reasoning their problems out, can be
medically based) and biomedical therapy (only medically based, entails a M.D.).
Psychotherapy implies an interaction between an interaction between a therapist and a client. If that
interaction is therapeutic, it’s psychotherapy. If you give them medication, then it’s biomedical therapy.
“Talk therapy” (not a clinical term) comes to mind. There is a therapeutic conversation between a
therapist and a client.
Many clinicians are eclectic: they’re going to use more than one approach (including both therapies).
This approach is also referred to by the book as the Biopsychosocial approach.
Psychotherapy starts with Psychoanalysis so it’s Freud. And if it’s Freud then it’s designed to bring
repressed feelings and thoughts to conscious awareness. Unconscious conflicts lead to psychological and
physical difficulties. If someone is OCD then they are punishing themselves for conflicts with their
parents. How do we uncover the unconscious? Free association (patient talks about whatever comes to
mind, therapist takes some notes), dream interpretation, projective tests (roar shock, TAT), Freudian
slips.
The therapist is looking for resistance, the blocking or anxiety-producing thoughts. If a client doesn’t
want to talk about something, or seems resistant, some defense mechanism is going on. The therapist is
eventually going to get more involved but in the beginning doesn’t say anything.
Eventually there’s this confrontation. Freud noticed these feelings towards the therapist (anger) and as
the client develops these feelings, it is developing these feelings out of the unconscious. The client’s
feelings about authority figures, both positive and negative, transferred to the therapist. This is called
transference. This is still carefully monitored. A client will be more comfortable with the therapist OR
they’ll be overly angry.
Traditional therapy is 600 sessions over two years. LONG WEEKENDD
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Psychoanalysis was the main form of therapy out there. There has been little research to improve the
research and Freud was difficult to empirically validate things. There are older people who have been in
psychoanalysis for years. Other clinicians should pay attention to transference. Defense mechanisms
and such.
The second mode of therapy is client-centered therapy (also referred to as “Person Therapy”),
developed by Carl Rogers, the number 1 name in humanistic theory: the belief that everyone is
inherently good. Client-centered takes everything off the clinician. Transference is completely off. It is
non-directive. The client must take the responsibility for change. Goal is to help clients become fully
functioning. Humanistic theory believes that people have potential for growth and that people can live
full lives if they can get past the bullshit. The therapist expresses unconditional (non-judgmental)
positive regard. If people are to heal and become a new person, they need this unconditional positive
regard. They need to know that they are cared for and accepted for someone to heal on their own. If the
therapist does not give advice or suggestions or any disapproval, the therapist is doing something called
active listening, involving reflecting as a way of demonstrating that people understand. It does two
things:
1. The therapist understands what the person is thinking.
2. The client hears things from another perspective.
Back in the 1960’s Rogers and a few other people all saw the same woman named Gloria. Gloria would
ask for advice but he would immediately turn it back on her. He reflects things, doesn’t get involved in
important events. Whether or not you believe in humanistic theory or not the value of active listening
has gone on and has been taken by other therapists.
Another mode of therapy is Gestalt Therapy. It says that the whole is greater than the sum of the parts.
We want to fill in the gaps and make sense of things. The guy behind the idea of Gestalt is Fritz Perls. It
emphasizes the wholeness of personality and attempts to reawaken people to their emotions and
sensations in the here-and-now. It also encourages confrontation with issues and the therapist is both
active and directive with direction towards the clients. Some people don’t like to be confronted in
therapy but the potential value is great.
The fourth psychotherapy is Behavioral Therapy. It suggests that problems are learned, thus they can
be unlearned. In the learning chapter, there were three ways to learn: Classical Conditioning, Operant
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Conditioning, and Observational Learning. Behaviorism only focuses on what is overt and visible. The
history of the problem is irrelevant. The objective of this therapy is to teach people new ways of
behaving.
In Classical Conditioning, an unconditioned stimulus leads to an unconditioned response. UCS  UCR.
It’s natural, instinctual, and unlearned. Loud noises will lead to flinching. When someone is born, spiders
are neutral. If every time there is a spider around your sister goes crazy, you will pair the spiders with
the loud noises and therefore flinching, thus making the spider a conditioned stimulus and the fear of
spiders a conditioned response.
From Classical Conditioning, we go to Counterconditioning, using Classical Conditioning to evoke new,
functional, healthy responses. If you rub their back, they are going to relax. In theory, if you pair the
spider with the back rub, with counter-conditioning, we’ve conditioned a new response and paired it
with a new stimulus.
Classical is Pavlov, Operant is Skinner. We are applying these principles.
Harry Potter: Harry goes from fear and apprehension to a new response. Afterwards he is exhilarated
and enjoys it. Classical and Observational learning is happening. When the other children see him, in
theory the other children have some sort of a shift. With regard to the classical conditioning, the initial
UCS for Buckbeak is fear. When it is paired with fun, the new conditioned response is exhilaration. This
is also called Exposure Therapy: exposing people to things that they fear or avoid, known as
systematic desensitization, particularly pertaining to phobias. Desensitization starts with a hierarchy
that starts a gradual process.
You’ve just been hired to take this job in NYC on the 70th floor of a building. You’re moving from Iowa
where the highest building is 5 floors. But you’re afraid of elevators. You must learn how to use
elevators. We can use exposure therapy. The hierarchy is structured as such: 1) When you walk by a
building with elevators 3) when you go into the building with elevators 5) when you step into an
elevator 8) going up 1 floor 12) going up 70 floors.
We want a feeling of relaxation when this guy’s in the elevator. Music, breathing exercises, meditation,
etc. They imagine themselves in each of these scenarios. This is great if you have some time. What if the
job starts next week? You need the person to agree to take a distinct step in that way. You need someone
to put a straightjacket on you and ride you in an elevator day in, day out. Being immediately and directly
exposed to the stimulus. The people have fear but they realize how irrational the fear is. This is called
flooding.
Review of Operant conditioning: a behavior  a consequence  a change in likelihood of behavior. A
person washing their hands. The behavior is the washing, the consequence is the germ free hands and
the reduced anxiety. The likelihood of washing happens more because the reduction of anxiety is greater
than the pain of the bloody and cracked hands. If a little child washes their hands 50x a day and their
parents praise them, it is positive reinforcement.
Harry Potter again: look for the new conditioned stimulus and the new conditioned response. With the
boggart, the new conditioned response is laughter. For Neville, the conditioned stimulus is the fear of
Snape. The conditioned response is fear. Naturally, ridiculous things (US) lead to laughter (UR). By
associated Snape with ridiculous things, laughter becomes the conditioned response when seeing Snape.
When we visualize things as ridiculous and funny we associate it with being harmless.
In “A Clockwork Orange” this guy’s a criminal and they try a technique to make him sick when he thinks
about violence. They give him some medicine and make him watch violence. He will then associate the
sickness with the violent images. They make sure he cannot close his eyes. In theory he will become
averse to violence. This is known as Averse conditioning, also known as Aversion Therapy. He takes
this pill (UCS) and becomes sick (UCR). These images of violence (CS) makes him feel sick (CR) from
now on. They also play Beethoven when he sees the films. He loves Beethoven and is now conditioned to
feel sick from Beethoven. Eliminating a behavior by associating with pain or discomfort.
Exposure therapy and counterconditioning are a bit more prominent than aversion therapy.
Operant conditioning involves Behavioral contracting, the idea that you reward people for doing
something good. Say you go to a clinician and you have trouble focusing and getting your homework
done. The clinician sets it up that you are going to set behavioral goals and reinforce those goals. In this
sense, you will spend 30 minutes on Facebook for every 2 pages you write. This is called behavioral
contracting. If you are able to wake up at 8:00 and start writing, you can reward yourself with a song on
iTunes. Therefore, if the behavior is writing 2 pages, the consequence is 30 minutes of Facebook, you are
therefore more likely to write more.
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A Token Economy is a form of behavioral contracting that you see in a hospital setting or a residential
setting. Clients earn tokens for desired behaviors and exchange them for items or privileges. A
consequence is leading to an increase in desired behavior, but the consequence is just a token, a symbol,
if you will. In impatient mental health setting you see this a lot. You are trying to make people be
compliant. Every time they take a shower they get a poker chip, here and then. This is part of the token
economy, reinforcing the behavior. Tobacco and nicotine are very motivating.
Our third form of learning is observational learning, proposed by Bandura: the buckbeak video. The
children don’t have to personally experience the classical conditioning but can get over their fears from
observational learning. In the elevator example, sit a guy in the lobby next to the elevators having fun. It
may be used in conjunction with operant conditioning. If you see someone get rewarded, even though
you are not being reinforced, learning has occurred. The person trying to learn is modeling the
behavior.
Psychoanalysis, Client-centered, Gestalt, Behavioral, now onto Cognitive Therapy.
Most therapists are eclectic, but cognitive techniques are the most widely used today. Problems and
disorders arise from disorders thought processes. To replace these thoughts with more reasonable
thoughts is the goal. Getting the person to think about the world in better ways. The two guys behind
cognitive therapy are Beck and Ellis. You’re going to want to know these names. You’re never going to
need to differentiate Beck and Ellis. It’s the same shit. They’re both trying to change disordered thoughts.
Beck suggested that we have automatic negative thoughts. We are programmed to think negatively at
times. That they are involuntary. We say it to ourselves without much notice and we repeat them. They
come as part of our normal stream of consciousness and we don’t notice it. This repeated of automatic
thoughts lead to distortions in how we perceive and interpret our world. It snowballs into something
bigger. It influences how we behave and feel. Negativity breeds negativity. The therapy is aimed at
identifying and changing negative and self-critical patterns of thought. Beck says that we overgeneralize.
That after one bad test you think that you’re not good at anything. You take it to other things. We
exaggerate. This polarized thinking (thinking things are black and white) is part of maladaptive
thoughts. You need to monitor your thoughts and know when you have those thoughts and involve
some Socratic questioning. You’re going to ask these things and wonder if it is actually at all that bad. It’s
self-challenging. Identifying and challenging those thoughts. In therapy the therapist show you how to
do it on your own. You are re-training your thinking and the pattern of negative thoughts. It is known to
be a good treatment of depression. People’s depression is often worsened because they don’t realize
that it’s not that bad.
Beck’s therapy used to be known as cognitive therapy. It is now known as Cognitive Behavioral
Therapy (CBT). It is a key term in your book.
Ellis is very similar, but more directive. Ellis has homework: go home and look at your day. Breaking
down your thinking in a directive way. Identifying these thoughts, etc. Ellis had his own therapy. It is
known as Rational-Emotive Therapy (RET). He believes that distress is caused by irrational and selfdefeating beliefs. The therapist is teaching the client to challenge those beliefs. Ellis talked about the
“musts” and “shoulds,” saying that it should leave no room for making mistakes. The over-use of should
doing things is called masturbation (funny guy). The therapist’s job is to challenge the client’s irrational
beliefs. Ellis talked about the ABC’s. The client’s homework was to identify the ABC’s. What were the
active events that led to an unhealthy belief that led to some bad consequence? When you do poorly
on a test, you create a feeling that is not legitimate. The person then goes through the D’s and E’s. You
then dispute the belief and replace it with an effective belief. It is much more commonly used today.
Group Therapies, also known as family therapy, is better than individual therapy. It is good because
they can reassure each other, they can normalize things and give people more hope, etc. In a nutshell,
when family therapy is recommended, it might have to do with an individual in the family suffering but
you cannot address the issue without the family there. It sees the family as at least party responsible for
the individual’s problems. How your crazy kid throws tantrums is dependent on the system, also known
as the systems approach. It seeks to change all family members’ behavior to the benefit of the family
and the individual.
Couple Therapy – support from another person.
Self-Help Groups are small, local gatherings of people who share common problems and provide
mutual assistance at low cost. One therapist is paid for one hour and 8 people get therapy. A good
example is Alcoholics Anonymous. This is part of psychotherapy: the interaction. But does it even
work? Scenario: 100 people need treatment for depression. None are suicidal or going crazy. You can
only have the resources for 50. You need random selection to choose which 50 get it. The 50 who get it
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are the experimental therapy. The 50 that don’t is the control therapy. When things play out that way,
that about 2/3s of people in the experimental group show improvement. Approximately 1/3 of people
improve without therapy. Why does no therapy work for these people? It’s the sports illustrated jinx. If
someone’s on the cover of a magazine, they don’t do as well afterwards. This is called Regression to the
Mean. If something really good or something really bad happens, things go back to normal. Extremes of
unusual scores regress back to normal. So this group of people who don’t receive therapy improve
because things go back to what’s normal.
Using a Meta-analysis (statistically combining research from many sources), statistics indicated that
therapy had an 80% success rate. Those undergoing on therapy are more likely to improve. People not
going through therapy, still improve.
Which type of Therapy is the Best? A whole combination is the most commonly used. Cognitive is the
most popular right now No one type of therapy is better. The key is to match the problem with the
appropriate therapy. Depression = cognitive therapy. Anxiety = Behavioral. Lack of Support =
Unconditional Positive Regard.
The last therapeutic approach is the Biomedical approach. In Biological treatments, it’s not about the
interaction. It’s about the drug therapies, or psychopharmacology. The effects of drugs on learning and
behaviors. Aspirin doesn’t change your ability to learn. Any medication used to treat a psychological
disorder will be studied.
Why are drug therapies so widespread? It may produce faster results than psychotherapy. It’s often less
expensive than psychotherapy. Drugs are effective at treating specific disorders. The best practice is to
accompany drug therapy with psychotherapy.
ANTIPSYCHOTIC DRUGS – used for schizophrenia (excess in dopamine) or psychosis. These drugs block
dopamine receptors in the brain. It alleviates these symptoms. Thorazine has a tranquilizing effect. In
some cases, when a person has been on Thorazine for a long time (many years), they may have a side
effect called Tardive Dyskinesia, involuntary movement and repetitive facial movements. For most
people it will subside if you start taking the medication. Other people don’t recover. It is due to longterm damage of the dopamine receptors. The first key is that you’re using the lowest effective dose. You
use the least amount of Thorazine available to start with.
ANTIDEPRESSANT DRUGS – Selective Serotonin Reuptake Inhibitors (SSRIs). Works by blocking the
reuptake of serotonin. Includes Prozac, 5-HTP, etc.
The next one is the MAOi. Any medication that can increase serotonin would alleviate symptoms of
depression. They were oxidation inhibitors. MAOi’s are naturally occurring. MAOi’s stop the breakdown
of serotonin. You therefore have increased serotonin activity. MAOi’s aren’t used as much anymore
because they have a long list of side effects. There are ways of increasing serotonin without MAOi’s. If
nothing else has been working then use it but it is not used widely for obvious reasons.
Lithium is used to treat bipolar disorder. It’s a naturally-occurring salt. In particular, it treats the manic
episodes. These people no longer had these spells of intense energy. So Lithium is commonly paired
with an SSRI. Lithium to deal with the manic episodes, SSRI’s to deal with the depression. Nobody knows
how lithium works to alleviate symptoms. There is a problem with people stopping medication when
symptoms ease.
Antianxiety medication – used to treat anxiety disorders. Produces a feeling of calm and mild euphoria.
Valium is a common antianxiety medication. It is commonly compared with the benzodiazepines.
Doctors are hesitant to give these out because of the possible dependence.
Electroconvulsive Therapy – sending electrical currents into the body to let the body and the mind to
convulse. Shock therapy – brief convulsions. Random, powerful, electricity into the brain. In the 50’s and
60’s shock therapy is used a lot. It causes brief convulsions and temporary loss of consciousness.
Memory loss is a side effect. Newer techniques work better and are less controversial because people
have to agree. As used today, it’s more precise. They can control which parts of the brain it goes to. It’s
like a hard reset on a computer. It’s a last resort.
Psychosurgery – brain surgery performed to change a person’s behavior or emotional state. A prefrontal
lobotomy is an example: the removal of the frontal lobe. Very rare, last resort type stuff. Back in the day
much more common. The side effects are harsh. The frontal lobe has planning, decision-making, impulse
issues, etc. The side effects include distractibility, loss of control of the bowels, etc. Historically it has led
people to be turned into vegetables.
20-25 multiple choice, 1 free response. Will not take the entire period.