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Therapy for Psychological Disorders Zhejiang University School of Medicine Ai-Min Bao M.D. Ph. D. Introduction Psychotharapy: An interpersonal, relational intervention used by trained psychotherapists to aid clients in problems of living. Goal: to increase individual sense of well-being and reduce subjective discomforting experience. Techniques: based on experiential relationship building, dialogue, communication and behavior change. Psychotherapists: psychologists, marriage and family therapists, licensed clinical social workers, licensed associate professional counselors (lapc), licensed professional counselors (lpc), psychiatric nurses, and psychiatrists. Only psychiatrists may administer medical treatments outside of the scope of psychotherapy such as psychosurgery, prescribe medications or give electroshock treatments. theoretically-based psychotherapy was probably first developed in the Middle East during the 9th century by the Persian physician and psychological thinker, Rhazes. Treatment of mental illnesses can take various forms: medication, talk-therapy, a combination of both, and can last only one session or take many years to complete. The core components of psychotherapy remain the same. Psychotherapy consists of the following: 1. 2. 3. 4. A positive, healthy relationship between a client or patient and a trained psychotherapist Recognizable mental health issues, whether diagnosable or not Agreement on the basic goals of treatment Working together as a team to achieve these goals The main broad systems of psychotherapy: Psychoanalysis the first practice to be called a psychotherapy. It encourages the verbalization of all the patient's thoughts, including free associations, fantasies, and dreams, from which the analyst formulates the nature of the unconscious conflicts which are causing the patient's symptoms and character problems. Cognitive behavioral based on cognitions, assumptions, beliefs, and behaviors, with the aim of influencing negative emotions that relate to inaccurate appraisal of events. Albert Ellis, founder of Psychodynamic Rational Emotive a form of depth psychology, the primary focus is to reveal the Behavior Therapy unconscious content of a client's psyche in an effort to alleviate psychic tension. Although it has its roots in psychoanalysis, psychodynamic therapy tends to be briefer and less intensive than traditional psychoanalysis. The main broad systems of psychotherapy: Existential based on the existential belief that human beings are alone in the world. This aloneness leads to feelings of meaninglessness which can be overcome only by Starting in the 1950s Carl Rogers: creating one's own values and meanings. Person-centered psychotherapy Humanistic concerned with the human context of the development of the individual with an emphasis on subjective meaning, a rejection of determinism, and a concern for positive growth rather than pathology. It posits an inherent human capacity to maximise potential, 'the selfactualing tendency'. The task: to create a relational environment where this tendency might flourish. The main broad systems of psychotherapy: Brief therapy an umbrella term for a variety of approaches to psychotherapy. differs from other types of therapy: it emphasizes a focus on a specific problem and direct intervention. solution-based rather than problem-oriented. Systemic Therapy to address people not at an individual level, but as people in relationship, dealing with the interactions of groups, their patterns and dynamics, including family therapy & marriage counseling. Somatic Psychotherapy also referred to as body psychotherapy, is a field in which the therapist uses touch in some way as part of therapy process. The main broad systems of psychotherapy: Transpersonal Psychotherapy a school that studies the transpersonal, the transcendent or spiritual aspects of the human experience. Hypno-Psychotherapy undertaken with a subject in hypnosis. Psychodrama/Dramatherapy explores, through dramatic action in groups , the problems, issues, concerns, dreams and highest aspirations of people. Type of Psychotherapy Treatment Approaches. When describing 'talk' therapy or psychotherapy: • First and foremost is empathy. It is a requirement for a successful practitioner to be able to understand his or her client's feelings, thoughts, and behaviors. • Second, being non-judgmental is vital if the relationship and treatment are going to work. Everybody makes mistakes, everybody does stuff they aren't proud of. If the therapist judges the patient, the patient doesn't feel safe talking about similar issues again. • Finally, expertise. The therapist must have experience with issues similar to yours, be abreast of the research, and be adequately trained. Treatment Approaches the same ultimate goal: to help the client reduce negative symptoms, gain insight into why these symptoms occurred and work through those issues, and reduce the emergence of the symptoms in the future. The three main branches include Cognitive, Behavioral, and Dynamic. • cognitive branch looks at dysfunctions and difficulties as arising from irrational or faulty thinking. • behavioral models look at problems as arising from our behaviors which we have learned to perform over years of reinforcement. • The dynamic or psychodynamic camp stem more from the teaching of Sigmund Freud and look more at issues beginning in early childhood which then motivate us as adults at an unconscious level. • Most mental health professionals nowadays are more eclectic in that they study how to treat people using different approaches. These professionals are sometimes referred to as integrationists. Treatment Modalities • Therapy is most often thought of as a one-on-one relationship (individual therapy) between a client or patient and a therapist. • can also take different forms: group therapy where individuals suffering from similar illnesses or having similar issues meet together with one or two therapists. The power of group is due to the need in all of us to belong, feel understood, and know that there is hope. It can be overwhelming in a very positive way and continues to be the second most utilized treatment after individual therapy. • Therapy can also take place in smaller groups consisting of a couple or a family, with the issues centered around the relationship, with often an educational component, e.g. to encourage the couple to work together as a team rather than against each other. Treatment Modalities • Sometimes therapy can include more than one treatment modality. For example: for a person with depression, social anxiety, and low selfesteem, individual therapy may be used to reduce depressive symptoms, work some on self-esteem and therefore reduce fears about social situations. Once successfully completed, this person may be transferred to a group therapy setting where he or she can practice social skills, feel a part of a supportive group, therefore improving selfesteem and further reducing depression. The treatment approach and modality are always considered, along with many other factors, in order to provide the best possible treatment for any particular person. Therapy Providers There are many different types of physicians and there are many nonphysicians who treat medical illnesses, the same holds true for mental illness. Although medication for mental illness is prescribed by a medical doctor, typically a psychiatrist, the vast majority of psychotherapy is performed by non-physician professionals. These mental health professionals typically have a minimum of a Master's Degree and complete internships, residencies, and state and federal testing just like all direct-care providers. Therapy Providers There are four most common mental health providers, including required education and training, and the populations with whom they typically work. Psychologist • A doctoral degree which means a minimum of four years of graduate training beyond the bachelors degree is required in most states, as well as one year of internship and at least one year of post-graduate residency. • Typically psychologists complete core coursework in therapy, assessment, and research and are required to pass competency exams and complete a dissertation prior to receiving their degree. To be licensed, psychologists must pass a national and state examination. • School psychologists usually work in Social Worker Therapy Providers Social workers • must hold a bachelors degree in social work although many complete a Master's program. • often referred to as the liaison between the patient or client and the community. • The Occupational Outlook Handbook (1998-1999), "Social work is a profession for those with a strong desire to help people. Social workers help people deal with their relationships with others; solve their personal, family, and community problems; and grow and develop as they learn to cope with or shape the social and environmental forces affecting daily life. Social workers often encounter clients facing a life-threatening disease or a social problem requiring a quick solution. These situations may include inadequate housing, unemployment, lack of job skills, financial distress, serious illness or disability, substance abuse, unwanted pregnancy, or antisocial behavior. They also assist families that have serious conflicts, including those involving child or spousal abuse." Therapy Providers Mental Health Counselor • typically have a Masters degree in psychology, social work, counseling, mental health counseling or related field and pass a state exam in order to be licensed. • can practice independently in some states, although most are employed in clinics and hospitals. • They perform individual, couples/family, and group therapy, and may assist psychologists with testing and other forms of treatment. Marriage and Family Therapist • a Master's degree is typically the minimal requirement. • They receive special training in the dynamics of families and relationships and often treat couples who are having marital or relationship difficulties and families struggling with dysfunctional interactions. • Many are provided more general training, allowing them to perform individual and group therapy as well for a variety of mental health related issues. Some specific approaches Psychoanalysis • developed in the late 1800s by Sigmund Freud. • explores the dynamic workings of a mind understood to consist of three parts: the hedonistic id, the rational ego, and the moral superego. • the majority of these dynamics are said to occur outside people's awareness, Freudian psychoanalysis seeks to probe the unconscious by way of various techniques, including dream interpretation and free association. • Freud maintained that the condition of the unconscious mind is profoundly influenced by childhood experiences. So, in addition to dealing with the defense mechanisms employed by an overburdened ego, his therapy addresses fixations and other issues by probing deeply into clients' youth. Psychoanalysis • free association: patients are asked to continually relate anything which comes into their minds, regardless of how superficially unimportant or potentially embarrassing the memory threatens to be. This technique assumes that all memories are arranged in a single associative network, and that sooner or later the subject will stumble across the crucial memory. • Defence mechanism: psychological strategies brought into play by various entities to cope with reality and to maintain self-image. • Fixation: a state in which an individual becomes obsessed with an attachment to another person, being or object. Freud theorized that humans may develop psychological fixation due to: A lack of proper gratification during one of the psychosexual stages of development, or Receiving too strong of an impression from one of these stages, in which case the person's personality would reflect that stage throughout adult life. Psychoanalysis---Variations in technique ‘Classical technique’ best summarized by Allan Compton, MD: • instructions (telling the patient to try to say what's on their mind, including interferences) • exploration (asking questions) • clarification (rephrasing and summarizing what the patient has been describing) • confrontation (bringing an aspect of functioning, usually a defense, to the patient's attention) • dynamic interpretation (explaining how being too nice guards against guilt, e.g. - defense vs. affect) • genetic interpretation (explaining how a past event is influencing the present) • resistance interpretation (showing the patient how they are avoiding their problems) • transference interpretation (showing the patient ways old conflicts arise in current relationships, including that with the analyst) • dream interpretation (obtaining the patient's thoughts about their dreams and connecting this with their current problems) • reconstruction (estimating what may have happened in the past that created some current day difficulty) Psychoanalysis---Variations in technique As object relations theory evolved, techniques with patients who had more severe problems with basic trust and a history of maternal deprivation led to new techniques with adults, sometimes called ‘interpersonal, relational, or corrective object relations techniques’: • • • • • expressing an experienced empathic attunement to the patient expressing a certain dosage of warmth exposing a bit of the analyst's personal life or attitudes to the patient allowing the patient autonomy in the form of disagreement with the analyst explanations of the motivations of others which the patient misperceives Psychoanalysis---Variations in technique ego psychological concepts of deficit in functioning led to refinements in supportive therapy. These techniques are particularly applicable to psychotic and near-psychotic patients: • • • • • discussions of reality encouragement to stay alive (including hospitalization) psychotropic medicines to relieve overwhelming depressive affect psychotropic medicines to relieve overwhelming fantasies (hallucinations and delusions) advice about the meanings of things (to counter abstraction failures) Some specific approaches Behavior therapy • used to treat depression, anxiety disorders, phobias, etc. • philosophical roots: the school of behaviorism, which states that psychological matters can be studied scientifically by observing overt behavior, without discussing internal mental states. • Without holding inner states as causal, Skinner's radical behaviorism accepted internal states as part of a causal chain of behavior, but continued to hold that the only way to improve the internal state was through environmental manipulation. • Scientific basis: the principles of classical conditioning developed by Ivan Pavlov and operant conditioning developed by B.F. Skinner. (confusions remain here) Behavior therapy---Systematic desensitization • used to help effectively overcome phobias and other anxiety disorders. • a type of Pavlovian therapy / classical conditioning therapy. • one must first be taught relaxation skills in order to control fear and anxiety responses to specific phobias. • Then use the skills to react towards and overcome situations in an established hierarchy of fears. The goal: an individual will learn to cope and overcome the fear in each step of the hierarchy, which will lead to overcoming the last step of the fear in the hierarchy. • Systematic desensitization is sometimes called graduated exposure therapy. Behavior therapy/ Behavior modification ---Aversion therapy • in which the patient is exposed to a stimulus while simultaneously being subjected to some form of discomfort. • Principle: punishment of operant conditioning, intend to cause the patient to associate the stimulus with unpleasant sensations in order to stop the specific behavior. • The major use: currently for the treatment of addiction to alcohol and other drugs For example: pairing the use of an emetic with the experience of alcohol; or pairing behavior with electric shocks of various intensities. placing unpleasant-tasting substances on the fingernails to discourage nail-chewing • • Key points: the stimulus is always available to the specific behavior; the stimulus indeed causes definite aversion; the therapy continues until the specific behavior disappears completely; reinforcement Behavior therapy/ behavior modification ---operant conditioning, Positive reinforcement • Set up new social behavior via e.g. reward, a stimulus immediately following a response. • Method, e.g. token economy, the original proposal for such a system emphasized reinforcing positive behavior by awarding "tokens" for meeting positive behavioral goals. • "Patients earn tokens, which they can exchange for privileges, such as time watching television or walks on the hospital grounds, by completing assigned duties (such as making their beds) or even just by engaging in appropriate conversations with others" • Early during the program, a participant would be required to spend all of his or her tokens daily to emphasize the reinforcement activity early, and as time passed and success was made, participants would be allowed (or required) to accumulate their tokens over the course of longer time periods. This, as a variable-rate scheduling system, helped prevent extinction of the behavior after the program's termination. Behavior therapy/ behavior modification ---Modeling (observational learning) Albert Bandura (social learning modeling): people can learn new information and behaviors by watching other people. Three basic models of observational learning: 1) 2) 3) A live model, which involves an actual individual demonstrating or acting out a behavior. A verbal instructional model, which involves descriptions and explanations of a behavior. A symbolic model, which involves real or fictional characters displaying behaviors in books, films, television programs, or online media. Four conditions required for a person to successfully model the behavior of someone else: 1) 2) 3) 4) Attention to the model: a person must first pay attention to a person engaging in a certain behavior (the model) Retention of details: Once attending to the observed behavior, the observer must be able to effectively remember what the model has done Motor reproduction: the observer must be able to replicate the behavior being observed. Motivation and Opportunity: the observer must be motivated to carry out the action they have observed and remembered, and must have the opportunity to do so. Some specific approaches Cognitive therapy • • • • • developed by psychiatrist Aaron T. Beck in the 1960s, seeks to identify and change "distorted" or "unrealistic" ways of thinking, and to influence emotion and behavior. the way in which the clients perceived and interpreted and attributed meaning— a process known scientifically as cognition—in their daily lives was a key to therapy. Schema-Focused Therapy, clinical depression is typically associated with negatively biased thinking and irrational thoughts---a patient acquire a negative schema of the world in childhood and adolescence through negative events. When encounters a situation that resembles the conditions in which the original schema was learned, the negative schemas of the person are activated. a negative triad: A negative schema helps give rise to the cognitive bias, and the cognitive bias helps fuel the negative schema. depressed people also often have the following cognitive biases: arbitrary inference, selective abstraction, overgeneralization, magnification and minimization. Cognitive therapy /The ABCs of Irrational Beliefs A major aid in cognitive therapy is what Albert Ellis called the ABC Technique of Irrational Beliefs. The first three steps analyze the process by which a person has developed irrational beliefs: • A - Activating Event or objective situation. The first column records the objective situation, that is, an event that ultimately leads to some type of high emotional response or negative dysfunctional thinking. • B - Beliefs. In the second column, the client writes down the negative thoughts that occurred to him or her. • C - Consequence. The third column is for the negative disturbed feelings and dysfunctional behaviors that ensued. The negative thoughts of the second column are seen as a connecting bridge between the situation and the distressing feelings. The third column C is next explained by describing emotions or negative thoughts that the client believes are caused by A. Cognitive therapy /THE A-B-C-D-E THERAPEUTIC APPROACH The therapeutic interventions referred to by D are three parts of disputation. When irrational beliefs are disputed, the client will experience E, a new effect. In essences, the client will have a logical philosophy that allows her to challenge her own irrational beliefs. Disputing irrational beliefs is the major therapeutic technique, often done in three parts: 1) Detecting – the client and therapist detect the irrational beliefs that underlie activating events. 2) Discriminating – the therapist and client discriminate irrational from rational beliefs. 3) Accepting 1 and 2, knowing that insight does not automatically change people, and working hard to effect change. • E (Effect): Developing an effective philosophy in which irrational beliefs have been replaced by rational beliefs. Some specific approaches Client-centered therapy • developed by the humanist psychologist Carl Rogers in the 1940s and 1950s. • The basic elements: to have a more personal relationship with the patient to help the patient reach a state of realization that they can help themselves. Carl Ransom Rogers(1902 -1987) • is used to help a person achieve personal growth and/or come to terms with a specific event or problem they are having. • based on the principle of talking therapy and is a non-directive approach. The therapist encourages the patient to express their feelings and does not suggest how the person might wish to change, but by listening and then mirroring back what the patient reveals to them, helps them to explore and understand their feelings for themselves. The patient is then able to decide what kind of changes they would like to make and can achieve personal growth. Some specific approaches Morita therapy (Japanese psychiatrist Shoma Morita) • People from different times and cultures actually do think differently. • Shinkeishitsu (an anxiety-based disorder), a world of which most of us at one time or another are living in, where we become lost in a stress, pain and the aftermath of trauma. Morita Therapy Methods (MTM) is structured for the person who needs a guide for self-rescue. It helps patients find, and use, a well of inner strength deep within themselves that enables them to make powerful changes in their life. Simple acceptance of what is, allows for active responding to what needs doing. • • • aims at building character to enable one to take action responsively in life regardless of symptoms, natural fears, and wishes. Morita therapy: The Four Areas of Treatment • Phase one: the “rest phase”, a period of learning to separate ourselves from the constant assault on our senses and thought processes by a loud and intrusive world. • Phase two: “light and monotonous work that is conducted in silence”. One of the keystones of this stage of self-treatment is journal writing. Our thoughts and feelings come to us in indistinguishable waves and flood our minds. Writing in our personal journals helps us learn to separate our thoughts from our feelings and define their different effects on our lives. In this phase we also go outside. • Phase three is one of more strenuous work. Dr. Morita had his patients engage in hard physical work outdoors. This is what we call the “chopping wood” phase. • Phase four is when Morita would send patients outside the hospital setting. They would apply what they had learned in the first three phases and use it to help the with the challenge of reintegration into the non-treatment world. Some specific approaches Hypnotherapy • therapy that is undertaken with a subject in hypnosis (means "sleep of the nervous system“), a wakeful state of focused attention and heightened suggestibility, with diminished peripheral awareness. • According to the American Psychological Association's Division 30, hypnosis may bring about "...changes in subjective experience, alterations in perception, sensation, emotion, thought or behavior.“ • The hypnotic state may also facilitate change in the body: it has been successfully used as a treatment for irritable bowel syndrome. Asklepios, Greek god of medicine, healing, and hypnosis, was said to oversee the treatment of sick people in "dream healing temples." Some Specific schools and approaches Hypnotherapy • Skeptics point out the difficulty distinguishing between hypnosis and the placebo effect, proposing that the state called hypnosis is "so heavily reliant upon the effects of suggestion and belief that it would be hard to imagine how a credible placebo control could ever be devised for a hypnotism study.“ • Self-hypnosis is popularly used by people who want to quit smoking and reduce stress, while stage hypnosis can be used to persuade people to perform unusual public feats. Professor Charcot (left) of Paris' Salpêtrière demonstrates hypnosis on a "hysterical" patient, "Blanche" (Marie) Wittman, who is supported by Dr. Joseph Babinski. Relaxation and Hypnosis Many internal and external factors affect how we think, feel, and behave. The internal factors influencing state of mind: relaxation and hypnosis. Relaxation • a focusing on the mind and a relaxing of the body's muscles. • being too tense and/or living with too much stress has significant negative impacts on lives: physical illnesses and many psychological issues. • different forms of relaxation: breathing exercises, deep muscle relaxation, imagery, meditation, yoga, etc. with the main goal to relax the body's muscles and focus the mind. • Since the body and the mind cannot be separated, both of the components must be present for any relaxation technique to work. Hypnosis • similar to relaxation: the same two components of physical and mental must be addressed together. • a very deep state of relaxation where your mind is more focused and the connection between your thoughts, emotions, and behaviors are more clear. • a hypnotherapist is typically a licensed professional who uses hypnosis as part of a treatment regimen for certain psychological disorders. • most beneficial when used with relaxation and talk-therapy for a more rounded therapeutic approach. • many factors affect individual susceptibility: belief in hypnosis, trust for the therapist, etc. and the absence of external factors such as noise, uncomfortable temperature, and physical comfort. • the key to successful hypnosis: the ability to focus on your body and mind and to trust and believe in your therapist. Some specific approaches Biofeedback therapy • providing the user access to physiological information about which he or she is generally unaware, allows users to gain control of physical processes previously considered an automatic response of the autonomous nervous system. • measuring a subject's quantifiable bodily functions (blood pressure, heart rate, skin temperature, muscle tension) conveying the information to the patient in real-time, which raises the patient's awareness and conscious control of their unconscious physiological activities. Some specific approaches Deep brain stimulation (DBS) • a surgical treatment involving the implantation of a medical device called a brain pacemaker, which sends electrical impulses to specific parts of the brain. • remarkable therapeutic benefits for otherwise treatmentresistant movement and affective disorders such as chronic pain, PD, tremor and dystonia. • Despite the long history of DBS, its underlying principles and mechanisms are still unclear. directly changes brain activity in a controlled manner, its effects are reversible (unlike those of lesioning techniques) and is one of only a few neurosurgical methods that allows blinded studies. has been used to treat various affective disorders, including major depression. there is potential for serious complications and side effects.