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QUIZ YOURSELF! What are the key components of the definition of psychological disorders? What is the difference between the medical model and the biopsychsocial model? What are the benefits and drawbacks to diagnostic labels? What are some positive and negative aspects to the DSM-IV-TR? Can you complete this table? Disorder Anxiety Somatoform Dissociative Mood Thought Personality Definition Example Cause (if discussed in class) Chaffee Winter 2013 CHAPTER 15 Therapy CHAPTER 15 OVERVIEW The Psychoanalysis Humanistic Therapies Behavior Therapies Cognitive Therapies Group and Family Therapies Evaluating Psychotherapies The Biomedical Therapies Drug Therapies Brain Stimulation Psychosurgery Therapeutic Life-Style Change Preventing Psychological Disorders Chaffee Winter 2013 Psychological Therapies EARLY TREATMENTS Transition from brutal to gentle treatments Reformers: Philippe Pinel Dorothea Dix 1950s: Therapeutic drugs Community-based treatment Smaller inpatient populations INTRODUCTION Today, mental health treatment is divided into two categories: Psychotherapy: trained therapists use psychological techniques to assist someone seeking to overcome difficulties or achieve personal growth 2. Biomedical therapy: a prescribed medication or medical procedure that acts directly on the patient’s nervous system Chaffee Winter 2013 1. INTRODUCTION The Psychotherapy: treatment consists of interactions between a trained therapist and someone seeking to overcome psychological difficulties or achieve personal growth. Chaffee Winter 2013 most common approach to psychotherapy is the eclectic approach, which uses techniques from various forms of therapy. THE PSYCHOLOGICAL THERAPIES Psychoanalysis 2. Humanistic Therapies 3. Behavior Therapies 4. Cognitive Therapies Group and Family Therapies 1. Chaffee Winter 2013 5. PSYCHOANALYSIS Psychoanalysis Sigmund Freud’s therapeutic technique. Freud believed the patient’s free associations, resistances, dreams, and transferences – and the therapist’s interpretations of them – released previously repressed feelings, allowing the patient to gain self-insight. Chaffee Winter 2013 AIMS OF PSYCHOANALYSIS Healthier, Chaffee Winter 2013 less anxious living becomes possible when people release the energy previously devoted to their inner conflicts. Bring patients’ repressed feelings into conscious awareness. Gain insight into origins of disorder and take responsibility to their own growth. METHODS OF PSYCHOANALYSIS Psychoanalysis = historical reconstruction Free association exercise: Blocks in free association (pauses, signs of discomfort) indicate resistance: blocking from consciousness of anxietyladen material. Freud used free association to examine his patients. In free association, patients are instructed to say anything that comes to mind, without censoring themselves. Try free association: Set a timer for two minutes and write down anything and everything that comes to mind. Do not censor yourself – just write down anything you think of. I find this exercise to be a bit tricky, what did you think? Did you have any areas of resistance while you tried free association? These blocks are noted and interpretation is used. Transference: the patient’s transfer to the analyst of emotions linked with other relationships Chaffee Winter 2013 Childhood experiences Excavate the past in hope of unmasking the present DRAWBACKS OF PSYCHOANALYSIS 1. 3. Typically, the process lasts several years, with several sessions per week The structure of health care in the U.S. dictates the types and lengths of insured mental health care. For instance, a standard medical insurance plan would dictate 12 outpatient visits per year for mental health care. Not many individuals are trained in Psychoanalysis Outside of NYC, France, Germany, and Quebec, it is extremely difficult to find a trained Psychoanalyst Chaffee Winter 2013 2. Interpretations by the therapist cannot be proven or disproven. The process of Psychoanalysis is lengthy – PSYCHODYNAMIC THEORY Influenced by Freud Derived from the psychoanalytic tradition: Individuals respond to unconscious forces and childhood experience Focus on important relationships Goal of therapy is to gain insight Example: page 640 Chaffee Winter 2013 Insight Psychoanalysis & Psychodynamic Humanistic therapy Humanistic perspective: Emphasizes people’s inherent potential for selffulfillment. Grow in self-awareness and self-acceptance Chaffee Winter 2013 therapies: variety of therapies which aim to improve psychological functioning by increasing the client’s awareness of underlying motives and defenses. HUMANISTIC THERAPY CONTINUED The Chaffee Winter 2013 humanistic perspective differs from psychoanalysis in focusing on… 1. The present and the future rather than the past 2. Conscious rather than unconscious thought 3. Taking immediate responsibility for one’s feelings and actions, rather than uncovering hidden determinants. 4. Promoting growth instead of curing illness – patients are referred to as clients. HUMANISTIC THERAPIES CONTINUED Carol Humanistic psychotherapist (right) Client-centered therapy: the therapist uses techniques such as active listening within a genuine, accepting, empathetic environment to facilitate client’s growth. (AKA person-centered therapy) Quote: page 641 Chaffee Winter 2013 Rogers (1902-1987) HUMANISTIC PRINCIPLES Active listening: empathic listening in which the listener echoes, restates, and clarifies. 2. 3. Paraphrase Invite clarification Reflect feelings Unconditional positive regard: a caring, accepting, and nonjudgmental attitude in which Rogers believed to be conducive to developing selfawareness and self-acceptance Insight therapies: problems diminish as selfacceptance grows. Chaffee Winter 2013 1. RECAP Insight 2. Historical reconstruction Excavate the past in hope of understanding the future Drawbacks/limitations to this approach Psychodynamic therapy – Psychoanalysis “lite” Humanistic therapy Roger’s Client-centered therapy Active listening and unconditional positive regard Chaffee Winter 2013 1. Therapies: Psychoanalysis BEHAVIOR THERAPIES Behaviorists doubt the healing power of selfawareness and assume the behaviors are the problem. Examples of classical conditioning Exposure therapy Systematic desensitization Aversive conditioning Chaffee Winter 2013 Behavior therapy is therapy that applies learning principles to the elimination of unwanted behaviors. BEHAVIOR THERAPIES Exposure therapies: behavioral techniques that treat anxieties by exposing people (in imagination or actuality) to the things they fear and avoid. Systematic desensitization: associates a pleasant relaxed state with gradually increasing anxietytriggering stimuli. Used to treat phobias. E.g. fear of public speaking Rank anxiety-triggering situations Progressive relaxation then imagine gradually more stressful stimuli. Substitute positive response to harmless stimulus. BEHAVIOR THERAPIES Aversive conditioning: Substitute a negative response to a harmful stimuli. Associates an unpleasant state with an unwanted behavior. Wiens & Menustick (1983) 1 year: 63% abstain 3 years: 33% abstain RECAP Systematic Substitute positive (relaxed) response for a negative (fearful) response Harmless stimulus Aversive Conditioning: Substitute a negative (aversive) response for a positive response Harmful stimulus Chaffee Winter 2013 Desensitization: BEHAVIOR THERAPIES CONTINUED Operant Behavior Modification: reinforcing desired behaviors and withholding reinforcement for, or punishing, undesired behaviors. Token economy: people earn a token of some sort for exhibiting a desired behavior and can later exchange the tokens for various privileges or treats. Concerns of behavior modification: How durable are the behaviors? Is it right for one human to control another’s behavior? Chaffee Winter 2013 Conditioning: COGNITIVE THERAPY Cognitive therapies assume that thinking colors our feelings. Cognitive therapists teach people more constructive and healthy ways of thinking Chaffee Winter 2013 Cognitive Therapy is therapy that teaches people new, more adaptive ways of thinking and acting, based on the assumption that thoughts intervene between events and our emotional reactions. COGNITIVE THERAPY Vicious cycle of depression: Self-blaming Over-generalized explanations of bad events Exchange between Beck and a client: Page 647 COGNITIVE-BEHAVIOR THERAPY Seeks to make clients aware of negative thinking and replace it with new ways of thinking AND to practice the more positive approach in everyday settings Chaffee Winter 2013 Cognitive-behavior therapy is a popular integrated therapy that combines cognitive therapy (to change selfdefeating thinking) with behavior therapy (to change behavior). CBT CONTINUED “Fake it til you make it” – the idea being that acting happy allows clients to practice and decreases symptoms of depression Chaffee Winter 2013 “The trouble with most therapy is that it helps you to feel better. But you don’t get better. You have to back it up with action, action, action” Cognitivebehavioral therapist Albert Ellis GROUP AND FAMILY THERAPIES All A benefit of group settings is they allow for social context: Clients can discover that others have similar problems Receive feedback to their situation Practice new ways of behaving Chaffee Winter 2013 forms of therapy, aside from traditional psychoanalysis, can be used in a small group setting. GROUP AND FAMILY THERAPIES CONTINUED Family Treats the family as a system Individual’s unwanted behaviors are influenced by and/or direct at other family members Support groups, where people with a similar problem, illness, or concern meet together. For example, AIDS patients and alcoholics have many support groups available to them. Chaffee Winter 2013 therapy: TYPES OF THERAPIES RECAP This table can be very helpful in studying: EVALUATING PSYCHOTHERAPIES Is People often enter therapy in crisis. Clients may need to believe the therapy is worth the time and money. Clients generally speak kindly of their therapists. Clinicians’ Perceptions Vulnerable to inflation… Placebo effect (Eric Mead: The magic of placebo) Regression toward the mean Outcome research objectively measures the effectiveness. Chaffee Winter 2013 psychotherapy effective? Client testimonials strongly indicate the effectiveness. OUTCOME RESEARCH Eysenck (1952) Randomized clinical trials Meta-analysis The average therapy client ends up better off than 80% of the untreated individuals (Smith et al., 1980). Those not undergoing therapy often improve, but those undergoing therapy are more likely to improve. Chaffee Winter 2013 CLINICAL DECISION-MAKING WHAT WORKS? Evidence-based practice is clinical decision-making that integrates the best available research with clinical expertise and patient characteristics and preferences. Evidence-based practice is not unique to mental health COMMONALITIES AMONG THERAPIES Hope A new perspective An empathic, trusting, caring relationship Chaffee Winter 2013 Things can and will get better Explains occasion efficacy of nonscientific methods RECAP Behavior therapy is therapy that applies learning principles to the elimination of unwanted behaviors. Cognitive Therapy is therapy that teaches people new, more adaptive ways of thinking and acting, based on the assumption that thoughts intervene between events and our emotional reactions. Cognitive-behavior therapy is a popular integrated therapy that combines cognitive therapy (to change self-defeating thinking) with behavior therapy (to change behavior). How do we judge whether psychotherapy is effective? What does the evidence show? Chaffee Winter 2013 CLOSE-UP: A CONSUMER’S GUIDE TO PSYCHOTHERAPISTS Although this will not be on future tests or quizzes, this information is incredibly useful. Note the APA’s common trouble signals RECAP: MATCHING A. Psychoanalysis 1. 2. Humanistic therapy C. Client-centered therapy 3. D. Behavioral therapy E. Cognitive therapy 4. F. CBT 5. G. Support Groups 6. 7. Chaffee Winter 2013 B. Therapy that applies learning principles to the elimination of unwanted behaviors. Therapists use techniques such as active listening within a genuine, accepting, empathetic environment to facilitate client’s growth. Teaches people new, more adaptive ways of thinking and acting, based on the assumption that thoughts intervene between events and our emotional reactions. People with a similar problem, illness, or concern meet together The patient’s free associations, resistances, dreams, and transferences are interpreted by the therapist. Emphasizes people’s inherent potential for self-fulfillment. Integrated therapy that combines cognitive therapy with behavior therapy. THE BIOMEDICAL THERAPIES Biomedical Biomedical therapy is used more often with serious disorders. Drug therapies are the most widely used biomedical treatments today Chaffee Winter 2013 therapy: prescribed medications or medical procedures that act directly on the nervous system THE BIOMEDICAL THERAPIES Psychopharmacology is the study of the effects of drugs on the mind and behavior. agents commonly help people to transition from a state of distress to effective therapy by bridging the gap for the first few weeks as symptoms improve. Chaffee Winter 2013 Pharmaceutical DRUG THERAPIES Since the introduction of drug therapy for psychological disorders, the resident population of U.S. state and county mental health hospitals has decreased. DRUG THERAPIES of a new pharmaceutical agent = initial wave of enthusiasm. However, this enthusiasm often diminishes after researchers consider: (1) the normal recovery among untreated persons with the condition (2) the recovery due to the placebo effect, which arises from the positive expectations of patients and health care suppliers alike. Chaffee Winter 2013 Introduction DRUG THERAPIES New 1. 2. 3. 4. Neither researchers nor patients know whether they are receiving the pharmaceutical agent or the placebo. In double-blind studies, several types of drugs have proven useful in treating psychological disorders Antipsychotic drugs Antianxiety drugs (anxiolytics) Antidepressant drugs Mood-stabilizing medications Chaffee Winter 2013 drugs are evaluated: Double-blind technique ANTIPSYCHOTIC DRUGS Conventional AKA: Typical, First-generation Treatment of positive symptoms: hallucinations, delusions e.g. chlorpromazine, haloperidol Atypical antipsychotics: antipsychotics: AKA: Second-generation Treatment of negative symptoms: atonal voice, lack of emotional expression, decreased movement e.g. clozapine Chaffee Winter 2013 Antipsychotic drugs Treat schizophrenia and other forms of severe thought disorders. ANTIPSYCHOTIC DRUGS CONTINUED Conventional antipsychotics act by blocking the synaptic receptors for dopamine, limiting its action: Dopamine: mesolimbic and nigrostriatal pathways Powerful side effects: appear similar to Parkinson’s disease such as sluggishness, tremors, and twitches. Long-term use can cause tardive dyskinesia: involuntary movements of the facial muscles, tongue, and limbs http://www.youtube.com/watch? v=UbBpt9uCXqc&feature=related ANTIPSYCHOTIC DRUGS Atypical antipsychotics target both dopamine and serotonin Prescribed to patients with negative symptoms and those who with positive symptoms who have not responded to other drugs. Despite the side effects, schizophrenia is a severe disorder and combination therapy, including antipsychotics, therapy, and family support, is the best form of treatment. We watched this Ted Talk earlier in the quarter, but it describes some unethical clinical trial research that occurred with the atypical antipsychotics. Please watch this again if you do not recall it: Ben Goldacre: Medical doctor and epidemiologist Battling bad science: http://www.ted.com/talks/lang/en/ ben_goldacre_battling_bad_science.html Chaffee Winter 2013 Fewer of the conventional side effects were originally reported, however, newer research shows similar side effects and efficacy. May increase the risk for diabetes and obesity ANTIANXIETY DRUGS Antianxiety Commonly used in combination with psychotherapy anxiolytics E.g. xanax, ativan The well-known and powerful antianxiety drug Valium acts on the same neurotransmitter receptor as alcohol: Explains the calming effect of a beer/wine after work Dangerous to use alcohol and anxiety medication together. Chaffee Winter 2013 drugs are used to control anxiety and agitation by depressing central nervous system activity. ANTIDEPRESSANTS Antidepressants are drugs used to treat depression The common antidepressant Prozac works by blocking the reuptake of serotonin so more of this neurotransmitter is available to bind receptors in the synapse. Called an SSRI (selective serotonin reuptake inhibitor) Other examples: Zoloft, Paxil Chaffee Winter 2013 Also prescribed for anxiety. Antidepressants are a very large category of drugs and different types alter the levels of different neurotransmitters. ANTIDEPRESSANTS Due to their action on serotonin, drugs such as Prozac are called selective serotonin reuptake inhibitors (SSRIs) ANTIDEPRESSANTS CONTINUED Others: SNRIs Side effects of SSRIs are plentiful: Decreased sexual desire, diarrhea, and weight gain Thus the market for other antidepressant drugs… The results from double-blind studies for antidepressants indicate their efficacy for individuals with severe depression, but not those with mild cases. Chaffee Winter 2013 Act on serotonin and norepinephrine These drugs take several weeks to reach their optimal concentration in the body, and thus several weeks to take full effect. MOOD STABILIZERS Mood-stabilizing drugs are effective in reducing mood swings in disorders like bipolar. It Lithium, the original mood stabilizer, is a simple salt with relatively poorly understood mechanisms of action. Lithium is cost effective Extremely useful in decreasing suicide, which is a concern in those with bipolar disorder (Tondo et al., 1997). is important to note that lithium treatment requires a fairly specific level of lithium within the body – frequent blood tests ensure the lithium does not reach dangerous levels. Chaffee Winter 2013 BRAIN STIMULATION: ECT Electroconvulsive therapy (ECT) is a biomedical therapy for severely depressed patients in which a brief electric current is sent through the brain of an anesthetized patient. BRAIN STIMULATION: ECT ECT http://www.ted.com/ talks/lang/en/ sherwin_nuland_on_el ectroshock_therapy.ht ml Chaffee Winter 2013 was originally barbaric, but the current application is much more benign. ECT is extremely effective yet poorly understood. Ted Talk: BRAIN STIMULATION: RTMS Repetitive Transcranial Magnetic Stimulation (rTMS) is the application of repeated pulses of magnetic energy to the brain. rTMS is painless and produces no significant side effects. rTMS is being used to treat depression and some more complicated disorders such as fibromyalgia and chronic pain. THERAPEUTIC LIFE-STYLE CHANGE Human Everything psychological is simultaneously biological Factors outside of the body can have strong effects. Therapeutic life-style change is a technique aimed at improving factors outside the body, developed by Stephen Ilardi and colleagues (2008). Chaffee Winter 2013 beings are integrated biopsychosystems – THERAPEUTIC LIFE-STYLE CHANGE “Simply Aims: increase aerobic exercise, adequate sleep and light exposure, improve social connections, decrease negative thoughts, and increase omega-3 levels. Although replication is necessary, initial results are promising. Chaffee Winter 2013 put, humans were never designed for the sedentary, disengaged, socially isolated, poorly nourished, sleep-deprived pace of the twenty first century American life” (Ilardi et al., 2008). PREVENTING PSYCHOLOGICAL DISORDERS The abundant evidence that poverty, meaningless work, constant criticism, unemployment, racism, and sexism undermine people’s sense of competence, personal control, and self-esteem. These stresses increase risk of depression, alcohol dependency and suicide. Preventing psychological problems means improving the human condition, making life more fulfilling and meaningful. Interesting Ted Talk on the subject http://www.ted.com/talks/ stuart_brown_says_play_is_more_than_fun_it_s_vital.html Chaffee Winter 2013 Rather than interpreting psychological disorders as a problem or abnormality, we could interpret them as understandable responses to a disturbing and stressful society. George Albee (1986) CHAPTER 15 RECAP What is psychotherapy?. Is therapy effective? What is evidence-based practice? Describe biomedical therapy. Why is a double-blind technique useful? What are antipsychotic drugs? Describe the mechanism of action for conventional and atypical antipsychotics. Describe antianxiety medications, antidepressants, and mood stabilizers. Describe the two types of brain stimulation discussed. Describe therapeutic life-style change. Chaffee Winter 2013 Psychoanalysis: describe the methods, aims, and drawbacks. Humanistic: Describe the client-centered approach, active listening, and unconditional positive regard. Behavior therapy: Describe the way classical conditioning and operant conditioning are used in the therapeutic setting. What is cognitive therapy? Describe the two components of cognitive-behavior therapy Group therapy: Benefits, examples.
