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Therapies
Chapter 14
Psychotherapy
• Psychotherapy - use of psychological
techniques to treat problems in
personality and behavior (as opposed
to biological therapies)
• General categories
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insight therapies
behavioral therapies
cognitive therapies
group therapies
Insight Therapies
• A variety psychotherapies designed to
give people a better awareness and
understanding of their feelings,
motivations, and actions
• Types of insight therapies
– psychoanalysis
– client-centered therapy
– gestalt therapy
Psychoanalysis
• Based on Freud’s belief that anxiety
and other problems are symptoms of
inner conflicts
• Many of these conflicts have their
origins in childhood traumas
• These conflicts are “unconscious”
• The goal of therapy is to make them
conscious and understood
Techniques used in Psychoanalysis
• hypnosis: by Freud early in his career
• free association: patient is encouraged to
talk without inhibition about whatever
thoughts or fantasies come to mind.
• dream interpretation: therapist discovers
the real meaning “latent content” from
the patient’s description of his dreams
“manifest content”
Transference
• transference: an essential part of
psychoanalysis. Patient reacts to the
analyst with feelings held toward
childhood and other authority figures.
• positive transference: warn loving feelings
expressed toward the analyst
– usually happens early in the therapy process
• negative transference: angry hostile
feelings expressed toward the analyst
– usually happens later as therapy becomes harder
Transference (cont.)
• counter-transference: analyst
unintentionally tranfers HIS feelings for
others onto the patient
• insight: The goal of psychoanalysis.
Awareness of previously unconscious
feelings and how they influence present
behavior
• current status: psychoanalysis is NOT
among the more commonly used
therapies today
Client-Centered Therapy
• a “Nondirective” form of therapy developed by
the “humanist” Carl Rogers
• Rogers used the term “client” rather than
“patient” to highlight the more active and
equal role of the client
• goal is to make the client “fully functioning”
• One who is “fully functioning” is reaching his
full potential, taking responsibility, and living
life to its fullest
Client-Centered Therapy
• unconditional positive regard: the patient
is fully accepted by the therapist despite
his/her faults (within reason)
• The therapist must be nondirective and
reflect or “mirror” back to the client what
he/she has said
• current status: This client-therapist
relationship may be the “key” element in
therapy. Rogers’ ideas do not receive the
attention they should!
Gestalt Therapy
• a confrontive “in your face” style of therepy
developed by Frederick “Fritz” Perls
• emphasizes the “wholeness” of the
personality and living in the “here-and-now”
• recall that the term “Gestalt” means “whole”
• The GOAL is to make the person whole,
responsible and self sufficient (in all ways,
emotional, financial, etc.)
Gestalt Therapy
• therapy takes place in the “Here and Now”
• Fritz Perls encouraged face-to-face
confrontations to help people become more
genuine or “real” in their day-to-day
interactions
• The therapist is active and directive.
• current status: not a widely used method
Behavior Therapies
• All behavior is learned. Therefore, bad
behaviors can be unlearned and new more
adaptive behaviors learned.
• behavior therapies are based on the principles
of:
– classical conditioning
– operant conditioning
– modeling (social learning)
Use of Classical Conditioning
• systematic desensitization: Technique for
reducing fears and phobias by pairing a
new response (relaxation) with stimuli that
have been causing the fear and anxiety.
• Joseph Wolpe: is the developer of
systematic desensitization
• Wolpe’s focus is on promoting relaxation
because (he feels) you cannot be both
anxious and relaxed at the same time
Systematic desensitization involves 3 steps
1. the client learns relaxation techniques
such as deep breathing and muscle
relaxation
2. a “hierarchy” or listing of fearful
situations is created
3. the client is gradually exposed to more
fearful and difficult situations while
using the relaxation techniques
Other Uses of Classical Conditioning
• flooding: idea is to eliminate anxiety
through intense and prolonged exposure to
anxiety-producing stimuli. “Extinction” is
the mechanism of change
• example: someone with a fear of
contamination, as in OCD, might have to
handle garbage until their fears subside
• flooding can also be done “imaginally” as
opposed to “in vivo” (in reality)
Other Uses of Classical Conditioning
• aversive conditioning: eliminating
undesirable behaviors by associating them
with pain and discomfort
• examples:
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drug-induced nausea paired with alcohol
shock paired with puffing on a cigarette
bad tasting nail coating for nail biting
shock paired with a pedophile’s sexual response
Use of Operant Conditioning
• behavior contracting: client and therapist
agree on goals and reinforcements the client
will receive upon reaching those goals.
• token economy: Patients earn tokens
(reinforcers) for desired behaviors and
exchange them for desired items or privileges.
• token economy: the ONLY therapy
demonstrated effective with hospitalized
schizophrenics
Modeling
• based on Albert Bandura’s Social
Learning Theory
• the patient learns desired behaviors by
observing a “model” perform those
behaviors and imitating the behaviors
• uses include overcoming fears (e.g.,
snake phobia) or learning new skills
(social skills training)
Cognitive Therapies
Goal is to change “maladaptive belief
systems” held by the patient
• stress-inoculation therapy
• Albert Ellis’s rational-emotive-therapy
• Beck’s cognitive therapy
Stress-Inoculation Therapy
• helps clients prepare for stressful situations
• differs from systematic desensitization in that
it is “pre-emptive”
• Steps involved
– discussing beliefs and their accuracy with
therapist
– getting familiar (practice) with the situation
– actually entering and coping with the situation
• examples: dental work, air travel, surgery
Cognitive Therapy and RET
Both Ellis and Beck assume distress is
caused by irrational and self-defeating
beliefs and the therapist’s job is to
challenge those dysfunctional beliefs.
Examples ofIrrational/self-defeating beliefs:
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“musts” and “shoulds”
all or none (black and white) thinking
over-generalization
personalization
Cognitive Therapy and RET
• directive: cognitive therapists are
directive and tell the client what is
rational and what is not
• expert therapists: the therapists are the
experts (in contrast to Rogers’ approach)
• homework: the client may be sent out on
assignments to test his/her beliefs
• logical argument: is used to convince the
client of the irrationality of his beliefs
Group Therapies
• Many are modeled after individual therapies
(e.g., Gestalt, client centered)
• particularly well suited to problems involving
interaction with others (e.g., social phobia)
• Types of group therapies
– family therapy
– marital/couples therapy
– self-help/support groups
Advantages of Group Therapy
• Allows therapist to see how client acts
around others.
• Offers a client social support system.
• Client can develop new behaviors via
observational learning and modeling.
• Interaction with others may lead to
insight into one’s own behavior.
• Less expensive than individual therapy.
Self-help/Support Groups
• Come in a wide variety
• Usually there is NO professional leader
• Can provide information and support at
minimal or no charge
• Alcoholics Anonymous is one example
• In many cases, someone who has
suffered a disorder may have more
insight into problems than a professional
Family Therapy
• The family “system” is the patient.
• Often one person is the scapegoat for
the family’s problems.
• Family relationships (dynamics) are
targeted.
• Problems can cross generations (e.g.,
grandparents sabotaging parents’
efforts)
Marital/Couples Therapy
Focus is on improving:
1 poor communication: People often don’t
listen to each other. They may be
fighting about one thing when they are
really angry about something else.
2 correcting unrealistic expectations:
especially true for young couples. They
may have unrealistic ideas about what the
other is capable of or “should” be doing.
Effectiveness of Psychotherapy
Data from the Consumer
Reports Survey
Note: a change score of 180 (not 0) indicates “no change”
Does Psychotherapy Work?
• About 2/3 of people say therapy helped them.
• About 1/3 of people improve without therapy.
• Starting with Hans Eysenck in 1952, many have
questioned (and continue to question) the
effectiveness of psychotherapy
• Many studies supporting therapy (such as the
Consumer Reports Survey) may be flawed.
• This question continues to be difficult to answer
Does Psychotherapy Work?
• In general, no one therapy appears to be
more effective than another. Why?
• The “main ingredient” may be just having
someone to talk to (as in client centered
therapy)
• Experts agree that therapy may be more
effective for specific minor problems (fear
of flying) than for more general and severe
problems (major depression or OCD)
Biological Treatments
• A group of treatment that focus on
changing the “biology” of the brain.
• May be used alone or in conjunction with
psychotherapy.
• Types of biological treatments:
– medications/drugs
– electroconvulsive therapy (ECT)
– psychosurgery
Basic Categories of Drugs
• antipsychotics: used to treat very severe
disorders of thought such as schizophrenia.
• antidepressants: to combat depression (*as
well as panic, OCD, and social phobia).
• anxiolytics: to treat a wide variety of anxiety
and stress related problems
• pychostimulants: to treat ADHD and other
disorders involving impulsivity and conduct
Antipsychotics
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chemical class: neuroleptics, phenothiazines
examples: Thorazine, Mellaril, Prolixin
mechanism: blocking dopamine receptors
side effects: these drugs have many severe
side effects that cause people to not want to
take the drugs
• tardive dyskinesia: a severe irreversible side
effect involving disruption of motor activity
(movement), occurs with long term use
3 Classes of Antidepressants
1. Monoamine Oxidase Inhibitors (MAOs)
• the first group to be discovered
• examples: Parnate, Nardil
• mechanism: blocks MAO, increases levels of
norepinephrine and serotonin
• side effects: dry mouth, dizziness, sexual
dysfunction, digestive problems, etc.
• dietary restrictions: must avoid certain foods to
prevent high blood pressure and stroke
2. Tricyclic Antidepressants
the second major group to be discovered
• examples: Elavil, Anafranil
• mechanism: llike MAOs, increases levels of
norepinephrine and serotonin
• side effects: dry mouth, dizziness, sexual
dysfunction, digestive problems, etc.
• Side effects are similar to the MAOs except
for the dietary restrictions
3. Serotonin Reuptake Inhibitors (SSRIs)
the most recent group to be discovered (1987)
• examples: Prozac, Paxil, Zoloft
• mechanism: prevents reuptake of serotonin
leaving more in synapse
• side effects: fewer than MAO or Trichyclics
but still headache, anxiety, sexual dysfunction
• popularity: because of the less severe side
effects, more people are willing to take these.
Lithium Carbonate
• Lithium is a naturally occurring salt that is
used to treat bipolar disorder.
• Lithium helps level out the extreme highs of
mania and the extreme lows of depression.
• Exact mechanism is not known but may
involve NA (sodium) channels in CNS axons
• Narrow “window” of effectiveness, too little no effect, too much - danger
• Blood levels must be checked often
Anxiolytics (anti-anxiety) Drugs
Two basic categories
1 barbiturates: powerful sedatives, first
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anxiolytic to be developed
example: Seconal
mechanism: CNS depressant
side effects: sleepiness, slowed reflexes, very
dangerous when combined with alcohol
tolerance and dependence are potential
problems
2. Benzodiazepines
• safer: than barbiturates, highly prescribed
• examples: Valium, Xanax, Tranxene, Ativan
• mechanism: binds to GABA (gamma amino
butyric acid) receptors in the CNS
• side effects: few and minor, some drowsiness,
slowed reflexes, etc.
• tolerance and dependence: psychological and
physical dependence are possible. However,
many experts disagree on this issue
Psychostimulants
• in children and some adults these improve
attention, help the person “settle down,” and
reduce impulsivity
• example - Ritalin
• mechanism - these are CNS stimulants
• side effects - sedation, some long term physical
effects
• tolerance or dependence - usually not a problem
Other Biological Treatments
• Electroconvulsive therapy (ECT)
• Psychosurgery: brain surgery
performed to change a person’s
behavior and/or emotional state
– prefontal lobotomy
– modern psychosurgery
Electroconvulsive Therapy (ECT)
• An electrical current is passed through the
brain for a second or two
• This produces convulsions and temporary
coma. Today, muscle relaxants reduce
severity of convulsions
• Seen by most as a treatment of “last
resort” for the most severe depressions
• The mechanism by which ECT works
remains unknown.
Psychosurgery
• prefrontal lobotomy: “ice pick surgery”
widely used during the first half of this
century before modern medications
a crude operation in which axons connecting
the frontal lobes with lower brain areas were
severed, rarely used today.
• modern psychosurgery: in addition to
traditional methods, multi-source beams of
low energy radiation can modify brain tissue
with pinpoint accuracy
Deinstitutionalization
• treating people with severe
psychological disorders in the
community rather than in large public
hospitals.
• made possible largely by the
development of “anti-psychotic” drugs
in the 1950s
Problems with Deinstitutionalization
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Community mental-health centers are poorly
funded and understaffed.
Ex-patients are poorly prepared to live in the
community.
Not enough housing available.
Social stigma of having a mental disorder,
neighborhoods may resist these centers.
Large insurance companies would rather pay
for inpatient care.
Types of Mental Illness Prevention
• primary prevention
• secondary prevention
• tertiary prevention
Prevention
• Primary Prevention Improving the social
environment so that new cases of mental
disorders do not develop.
• Secondary Prevention identifying high
risk groups and intervening before
problems become serious.
• Tertiary Prevention helping people adjust
to community life after release from a
mental hospital.
Gender Differences in Treatment
• Women are more likely than men to be
in psychotherapy, possibly because is
more socially accepted for women.
• Women receive more psychotropic
medications than men.
• Men are more likely to self medicate
with alcohol and other drugs.
Cultural Differences in Treatment
• One’s ethnic and cultural background
may influence how he/she responds to
a therapist.
• A therapist who is more similar to the
client (e.g., gender, cultural group)
may be better able to understand and
relate to the problems of a particular
client.