Transcript PowerPoint 演示文稿

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.