Transcript Places of Treatment - University of Alberta

This class…
Treatment
Care as a Social Issue
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What to do with the Severely
Disturbed?
throughout history, people with mental
disorders were often considered evil or
otherwise degenerate and were treated
accordingly
Attempts at Reform:
In and Out of Asylums
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Movement from religious (demonic
possession) towards secular
(degenerates)
at the beginning of the 19th Century,
humanitarian reform of mental
institutions really began
Attempts at Reform:
In and Out of Asylums
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at the beginning of the 19th Century,
humanitarian reform of mental
institutions really began
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Philippe Pinel's treatment of people in
mental hospitals, different from anything
tried before, had huge effects on their
mental health
Attempts at Reform:
In and Out of Asylums
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Dorothea Dix campaigned profusely as a
leader of the moral-treatment
movement in the US
Unfortunately, funding seldom held up for
long
Titicut Follies
Attempts at Reform:
In and Out of Asylums
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In the absence of long-term good
institutions, the deinstituionalization
movement began
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This was also partly inspired by the
development of effective drug treatments
for some disorders
In the early 70s, transition homes started
cropping up
Attempts at Reform:
In and Out of Asylums
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This wasn't necessarily working out too
well, either--just because you're out of the
hospital doesn't necessarily mean you're
cured
Hospital "Treatment" from a
Patient's-Eye View: Rosenhan's Study
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Rosenhan and some of his collaborators went
into hospital emergency rooms, complaining
of hearing voices saying "empty, hollow,
thud"
They were honest in every other respect,
acted normally while in hospital, and when
asked about the voices, claimed not to hear
them anymore
Hospital "Treatment" from a
Patient's-Eye View: Rosenhan's Study
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Other patients often detected them as
imposters, but hospital staff never did,
and sometimes even interpreted their
normal behaviours in the context of a
disorder
Hospital "Treatment" from a
Patient's-Eye View: Rosenhan's Study
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Their average time with psychiatrists
and psychologists, including group
meetings, was less than 7 minutes per
day
They noticed that staff tended not to
take patients seriously as thinking
individuals
Bright Spots
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social-learning wards have developed
residents (not "patients") here tend to:
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be treated with respect
interact closely with staff
receive and accept responsibilities
take part in decision-making
engage in a lot of skill learning activities
Bright Spots
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there's evidence of a high level of
success in these programmes
there are also some community-based
programmes out there now which
reduce the need for hospitalization
Structure of the
Mental Health System
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Places of Treatment
mental hospitals - provide custodial care
for people who can't care for
themselves or be cared for by family
members at home
general hospitals - often used for
patients whose stay will be short
Places of Treatment
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nursing homes - usually for older
patients; these usually don't employ
specialized personnel for treating
people with mental disorders
Places of Treatment
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halfway houses - people go to these
during transition from hospital back into
the community; they often provide help
in finding employment as well as a
more homey-type experience
Places of Treatment
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private office - run-of-the-mill
psychologist visits; outpatient care
community mental health centres cheaper versions of outpatient care
Providers of Treatment
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psychiatrists
clinical psychologists
counseling psychologists
counselors
psychiatric social workers
psychiatric nurses
Recipients of Treatment
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the number of people who’ve received
treatment for mental disorders is much
smaller (approx 1/4) than the number
who’ve had a mental disorder
this is particularly the case for men
the number's a little better for college
graduates, white people, and people
with incomes over $35,000
Clinical Assessment
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Assessment: the process by which a
mental health professional gather and
compiles information about a patient or
client for the purposes of developing a
plan of treatment
Diagnosis: the classifying and labeling
of a disorder according to some
standard set of guidelines
Assessment Interviews and
Objective Questionnaires
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assessment interview: basically a
dialogue through which the clinician
tries to learn about the client; by far,
this is the most common assessment
procedure
these range from quite structured to
rather unstructured
Verbal and non-verbal information
Assessment Interviews and
Objective Questionnaires
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objective questionnaire: these vary
widely in what they ask; some are
multiple choice or checklists
in some ways they can be considered
less biased than an assessment
interview, but they require a client who
is literate, reflective, and motivated to
answer honestly
A Psychometric Personality Test:
the MMPI
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true-false questions that have been
tested on inpatient and "normal"
samples to determine what question
distinguish between the two groups
This inventory also contains validity
scales to help pick out people who may
be trying to cover a disorder or maybe
even trying to fake one
Projective Tests
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Projective tests: designed to provide clues
about the unconscious mind
Free association: Freudian technique that
many projective tests stem from--he'd often
have his patients clear their heads, free their
minds of "shoulds", and say the first thing,
give the first image, that came to their minds
in response to words that he'd say to them
Projective Tests
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Rorschach:
classic ink-blot
test; people are
shown
symmetrical ink
blots and are
asked what they
see
Projective Tests
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Thematic
Apperception
Test: here, people
see a picture and
are asked to make
up a story to go with
the scene
Behavioural Monitoring
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this refers to any system for counting or
recording actual instances of desired or
undesired behaviors
self-monitoring: this is behavioural
monitoring when it's the client who's
keeping count
Assessment of Brain Damage and
Neuropsychological Functioning
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EEG - electroencephalogram - measures
the pattern of electrical activity in the
brain
CAT scan - computerized axial
tomography - a series of x-rays are
taken of the brain
Assessment of Brain Damage and
Neuropsychological Functioning
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MRI - magnetic resonance imaging pictures of brain sections are taken
using electromagnetic radiation given
off by specific molecules in the brain
when the brain is subjected to a strong
magnetic field
Assessment of Brain Damage and
Neuropsychological Functioning
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PET scan - positron emission
topography - measures the pattern of
blood flow and rate of oxygen use
across sections of the brain
There are also psychological tests,
including things like perception and
motor control, that can help identify
brain damage
Biological Treatments
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Drugs
the right drug, matched with the right
person, can be pretty much a miracle
worker, but there are potential problems
with overuse (i.e., unwarranted
prescription), dependency, and side
effects
Antipsychotic Drugs
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most antipsychotics are aimed at
reducing dopamine
a problem is that drugs often fail to
relieve negative symptoms, and in some
cases make them worse
also, possible side effects include
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dizziness
Antipsychotic Drugs
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nausea
dry mouth
blurred vision
constipation
sexual impotence (in males)
shaking
difficulty in controlling voluntary
movements
Antipsychotic Drugs
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in long-term users, tardive dyskinesia
there have also been suggestions that
they might, in some people, reduce the
chance of eventual full recovery
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possible rebound effect
Antipsychotic Drugs
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new drugs are constantly being
developed and tested in efforts to find
something that'll work without the
treatment being as bad as the disease
Antidepressant Drugs
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most are believed to work by increasing
the availability of monoamines,
especially serotonin and norepinephrine
Good effectiveness in treating
depression
Antidepressant Drugs
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there are, however (of course) side
effects, including:
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fatigue
dry mouth
blurred vision
Lithium for Bipolar Disorder
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Mood Stabilizer: helps control both the
manic and depressive phases of bipolar,
especially mania
it's not really known how this drug
works--most people believe it stabilizes
either the level of or the sensitivity to
monoamines
Lithium for Bipolar Disorder
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side effects - serious dehydration, at
high doses--an overdose of lithium can
be lethal
Antianxiety Drugs
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there are various types of these;
barbiturates used to be common, but
they've been replaced with safer drugs
drugs that are effective for GAD tend to
not be very effective for phobias, OCD,
or panic disorder
most antianxiety drugs augment GABA,
which is an inhibitor
Antianxiety Drugs
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side effects (yes, more) include:
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drowsiness
decline in motor coordination
increases in the effects of alcohol--it's very
dangerous to combine the two
Antianxiety Drugs
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just in case that wasn't enough, these
are also addictive; withdrawal
symptoms include:
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sleeplessness
shakiness
anxiety
headaches
nausea
Other Biologically Based Treatments
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non-drug biological therapies aren't
used that much for mental disorders
anymore--we're not big on drilling holes
in people's heads or scooping out parts
of their brains
biological therapies typically as last
resorts
Electroconvulsive Shock Therapy
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usually used only in cases of severe
depression when psychotherapy and
antidepressant drugs are unsuccessful
this has changed over the years - now
the patients are given drugs that block
nerve and muscle activity so it doesn't
hurt and they don't get injured by
convulsions
Electroconvulsive Shock Therapy
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an electric current passed through the
brain touches off a seizure that lasts
about a minute; this is usually
administered every 2-3 days for about 2
weeks
there's remission, sometimes
permanent, and sometimes lasting
several months, in about 70% of cases
Electroconvulsive Shock Therapy
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why it works is not understood
there are some temporary disruptions in
cognition, especially memory
Electroconvulsive Shock Therapy
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movement from bilateral to unilateral
(the right hemisphere) shock has
resulted in a treatment that causes little
apparent memory loss, but there's
some controversy about whether it's as
effective that way
Psychosurgery
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“I’d rather have a bottle in front of me
than a frontal lobotamy”
Psychosurgery
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this refers to the surgical cutting or
production of lesions in portions of the
brain to relieve a mental disorder;
typically (now) the destruction of a very
small area of the brain
prefrontal lobotomy is probably the
best-known, but these are generally not
done anymore
Psychosurgery
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any sort of psychosurgery is rare and
tends to be a last-ditch effort to help
someone for whom all other treatment
efforts have failed and who is suffering
and desperate, often suicidal
psychosurgery is sometimes successful
in reducing symptoms of major
depression and OCD
Varieties of Psychotherapy
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Psychotherapy: any formal, theorybased, systematic treatment for mental
problems or disorders that uses
psychological rather than physiological
means and is conducted by a trained
therapist
Varieties of Psychotherapy
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there are many different forms, most of
which fit (to a greater or lesser extent),
into one of several categories we'll
discuss in this section
most psychotherapists are eclectic in
orientation
Psychoanalysis and Other
Psychodynamic Therapies
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Psychoanalysis: Freud's term for both his
theory of personality and his approach to
psychotherapy
Psychodynamic therapy: any therapy
approach that's based on the premise that
psychological problems are manifestations of
inner mental conflicts and that conscious
awareness of those conflicts is a key to
recovery
Unconscious Wishes and
Repressed Memories
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emotional disorders as arising from an
interaction between a predisposing
experience and precipitating
experiences
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a predisposing experience, in Freud's
theory, would typically relate to infantile
sexual wishes and conflicts; this would
occur in the first 5-6 years of life
Unconscious Wishes and
Repressed Memories
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precipitating experiences occur later and
tend to immediately bring on the emotional
breakdown; typically, they're things that
activate repressed memories
Routes to the Unconcious: Free
Associations, Dreams, and Mistakes
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remember Freud's psychoanalysis-analysis of speech and behaviour for
clues to the unconscious
free association
dreams
Routes to the Unconcious: Free
Associations, Dreams, and Mistakes
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Freudian symbols
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king and queen as parents
prince or princess as the dreamer
elongated objects and long, sharp weapons
as "the male organ"
empty spaces, rooms, vessels of all kinds
as the uterus
slips of the tongue
Roles of Resistance and Transference
in Psychoanalysis
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resistance may take the form of
refusing to talk about certain topics,
"forgetting" to come to therapy
sessions, arguing incessantly in a way
that diverts the therapeutic process
this is a clue that therapy is going in the
right direction
Roles of Resistance and Transference
in Psychoanalysis
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transference is the phenomenon by
which the patient's unconscious feelings
about a significant person in his or her
life are experienced consciously as a
feeling about the therapist
Relationship Between
Insight and Cure
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the patient must see, acknowledge, and
accept insights in order to be freed of
defenses
once this happens, the person's feelings
can be expressed or channeled into
healthier pursuits
Post-Freudian
Psychodynamic Psychotherapies
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many psychodynamic therapies are
designed to get to unconscious material
quicker and to thus take fewer sessions
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often 10-40 sessions as opposed to the
hundreds of sessions Freud's patients
would attend
there's often less focus on early childhood
and repressed memories
Non-Freudian
Psychodynamic Therapies
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in many cases, this refers to a shift of
focus from the conflicts Freud thought
were important (like sex) to other
potential conflicts
Humanistic Therapy
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unlike Freud, humanistic therapists
generally share the belief that people
are basically good and that our inner
desires are generally positive things
that we need the freedom to express
and to try to achieve
Rogers's Client-Centred Therapy
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this sort of thing focuses on the
thoughts, abilities, and innate potential
of the client rather than those of the
therapist
the therapist often acts more as a
sounding-board
Rogers's Client-Centred Therapy
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from Rogers's perspective, psychological
problems originate when people learn
from their parents or other authorities
to deny their own feelings and to
distrust their own ability to make
decisions
incongruence
Rogers's Client-Centred Therapy
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in order to be an effective therapist,
you need:
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empathy: the therapist's attempt to
comprehend what the client is saying or
feeling at any given moment from the
client's point of view rather than as an
outside observer
Rogers's Client-Centred Therapy
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unconditional positive regard: a belief
on the therapist's part that the client is
worthy and capable even when the client
may not feel or act that way
Rogers's Client-Centred Therapy
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unconditional positive regard: a belief
on the therapist's part that the client is
worthy and capable even when the client
may not feel or act that way
genuineness: this reflects the belief that
it's impossible to fake empathy and positive
regard, so the therapist must really feel
them
Cognitive Therapy
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this is the therapeutic perspective that begins
with the assumption that people disturb
themselves through their own thoughts - the
goal is to identify maladaptive ways of
thinking and replace them with adaptive ways
that provide a base for more effective coping
with the real world
the focus tends to be on the problem at hand
Ellis's Rational-Emotive Therapy
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RET has the basic premise that negative
emotions arise from people's irrational
interpretations of their experiences
rather than from the objective
experiences themselves
Ellis's Rational-Emotive Therapy
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Musturbation: the irrational belief that
one must have some particular thing or
must act in some particular way in
order to be happy or worthwhile
Awfulizing: the mental exaggeration
of setbacks or inconveniences
Ellis's Rational-Emotive Therapy
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A.
B.
C.
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Ellis saw the generation of problems as
generally a 3-part process:
activating event
belief
consequent emotion
his job was to show people that A doesn't
directly cause C--by seeing and
acknowledging B, clients had the
opportunity to change it, thus changing C
Beck's Cognitive Therapy
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Beck found that depressed clients
tended to minimize positive
experiences, maximize negative
experiences, and misattribute negative
experiences to their own deficiencies
when they weren't really at fault
Beck's Cognitive Therapy
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Beck's therapy differs from Ellis's in that
it involves trying to lead people to
discover and correct their own irrational
thoughts instead of just pointing out to
them that they're being irrational
Behaviour Therapy
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this type of therapy focuses less on
mental phenomena and more on direct
relationships between observable
aspects of the environment and
observable behaviors
Behaviour Therapy
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sometimes is blended with cognitive
therapy to have a joint focus (thus the
term "cognitive-behavioural therapy")
like cognitive therapy, this is very
problem-centred--you work on the
immediate problems with the
assumption that what has been learned
can be unlearned
Exposure Treatments to Eliminate
Unwanted Fears
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this is based on the idea of habituation;
it basically aims at extinguishing a
response, like with classical conditioning
systematic desensitization involves
gradual, escalating, imagined exposure
to the feared object or event, combined
with relaxation techniques
Exposure Treatments to Eliminate
Unwanted Fears
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flooding involves exposing a person (in
large amounts) to the stimulus and the
fear until the fear declines and
disappears
there are techniques in between that
involve controlled exposure
Aversion Treatment
to Eliminate Bad Habits
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Habit: a learned action that has
become so ingrained that the person
performs it unconsciously and may even
feel compelled to perform it
Aversion Treatment
to Eliminate Bad Habits
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Aversion treatment: application of an
aversive stimulus immediately after the
person has made the unwanted habitual
response or immediately after the
person has experienced cues that would
normally elicit the response--basically,
you're changing the reinforcement
contingencies
Aversion Treatment
to Eliminate Bad Habits
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there are some ethical problems with
this treatment, and it also has mixed
results in terms of effectiveness, so it's
pretty controversial
Treatment of sexual deviance
Clockwork Orange
Some Other Behavioural Techniques
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Token economies--direct rewards for
"good" behaviour in institutions
Contingency contracts--contracts clearly
spelling out a behavioural agreement
between two people
Some Other Behavioural Techniques
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Assertiveness and social skills training
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Assertiveness: the ability to express one's
own desires and feelings and to maintain
one's rights in interactions with others,
while at the same time respecting the
others' rights
Can involve multiple techniques, including
role-playing
Some Other Behavioural Techniques
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Modeling: teaching people to do
something by having them watch
someone else do it
Therapies Involving
More Than One Client
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Group Therapies
this has the advantages of being less
costly in therapist's time and of the
therapeutic benefits of interactions
among group members
pretty much any kind of therapy that's
out there is also out there in group
format
Social Nature of Man
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“We are not only gregarious animals liking to
be in sight of our fellows, but we have an
innate propensity to get ourselves noticed,
and noticed favorably, by our kind. No more
fiendish punishment could be devised, were
such a thing physically possible, than that
one should be turned loose in society and
remain absolutely unnoticed by all the
members thereof”. William James
Yalom’s Therapeutic Factors
1.
2.
3.
4.
5.
6.
Instillation of hope
Universality (inadequacy, inability to
love, sexual secrets)
Imparting information
Altruism
Corrective recapitulation of family
Socialization
Yalom’s Therapeutic Factors
7.
8.
9.
10.
11.
Imitative behaviour
Interpersonal learning (social
microcosm)
Group cohesiveness
Catharsis
Existential factors
Couple and Family Therapies
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by observing interactions between or
among the couple or family members,
the therapist can gain insights about
their habitual ways of relating to one
another
interactions may also be videotapes so
they can observe themselves from each
other's perspective
Couple and Family Therapies
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the family systems perspective views
each person's behavioural style and problems
as in part an accommodation to the needs of
the family as a whole
an intergenerational approach focuses on
ways by which family members' behaviours
may be affected by events in previous
generations
Psychotherapy Research
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Does it work?
Eysenck (1952) summarized results of
24 outcome studies (1920-1950)
Concluded that effects of psychotherapy
are “small or nonexistent”
Any positive effects attributable to
spontaneous remission
Psychotherapy Research
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72% of neurotic adults in no-therapy
group showed improvement within 2
years of onset
66% of patients receiving eclectic
therapy showed substantial decrease
44% of patients in psychoanalytic
therapy
Psychotherapy Research
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Smith, Glass & Miller (1980)
Meta-analysis of 475 studies
Mean effect size of .85
Similar results from numerous other
studies
Consumer Reports Survey (1995)
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4,100 respondents
90% who felt “very poorly” at beginning
of therapy said therapy “helped
somewhat” or “helped a lot”.
Long-term treatment (> 6 months)
better than short term therapy
No particular therapeutic modality is
better than others
Consumer Reports Survey (1995)
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Psychologists, psychiatrists, social
workers are about equally effective and
more effective than marriage counselors
and family doctors
Patients whose treatment was limited
by insurance/managed care reported
fewer gains
Psychotherapy with children &
adolescents
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1.
The average treated child is better off than
70-75% of those with similar problems who
do not receive treatment
Behavioral techniques generally produce
greater effects than non-behavioral
techniques, regardless of type of problem,
therapist training, or child age/gender
Psychotherapy with children &
adolescents
2.
3.
Therapy is equally effective for
undercontrolled and overcontrolled
problems
Therapy outcome is better for
adolescents (especially girls) than for
children
Client Factors
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Intelligence: higher IQ predicts better
therapy outcome
Disturbance: more seriously disturbed
have poorer outcomes
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Clients suffering from depression or
anxiety, especially during initial therapy
sessions, tend to improve most
Client Factors
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Participation: Greater client
participation in therapy = more positive
effects
Age: unrelated to therapy outcome
Gender: Women more likely to seek
therapy, but no consistent relationship
between gender and therapy outcome
Client Factors
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Sexual Orientation: Gays and
lesbians more likely to seek therapy
than heterosexuals
Stay in therapy longer
Express more positive attitudes towards
seeking therapy
Therapist Factors
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Experience: Some evidence that
greater therapist experience related to
lower dropout rates and better
outcomes
Competence: more important than
specific treatment modality
Client-Therapist Factors
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Therapeutic Alliance
Attraction
Expectations
Similarity
Treatment Factors
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Duration of Treatment: longer
associated with better outcome to a
point
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Ceiling effect at 26 sessions
75% show measurable improvement at
26 sessions
Only increases to 90% at 104 sessions
Treatment Factors
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Drop Out: 23% of clients drop out of
therapy after first session
Almost 70% drop out by 10th session
Median length of treatment is only six
sessions
low-SES clients most likely to terminate
prematurely
Treatment Factors
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Other factors associated with drop out:
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Lack of anxiety (egosyntonic symptoms?)
Low levels of psychological
mindedness/insight
High need for approval
Minority group membership
Treatment Factors
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Placebo effects
Impact on medical utilization
Eclecticism
Psychiatric Hospitalization
•
•
Gender: men more likely to be
hospitalized than women
Marital Status: for both men and
women, admission rates are lowest
among the widowed, intermediate for
those who are married or
divorced/separated, and highest for
never married
Psychiatric Hospitalization
•
•
Age: For males and females, largest
proportion of admissions are in 25-44
range
For patients over 65, organic disorder is
most common diagnosis, followed by a
mood disorder
Final Exam
Personality
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States vs. traits
Cattell, Eysenck, Big Five
Evolutionary implications/theory
Sibling differences
Psychodynamic theory of personality
Freud’s defense mechanisms
Rotter - locus of control
Bandura - self-efficacy
Mental Disorders
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How do various theories explain
cause/etiology of mental disorders?
Anorexia
Anxiety Disorders
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Phobia
GAD
OCD
Panic Disorder
Mental Disorders
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Mood Disorders
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Depression
Bipolar Disorder
Beck & Seligman’s theories
Schizophrenia
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symptoms (positive, negative, types)
types of schizophrenia
culture
Mental Disorders
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Somatoform disorder
Dissociative Identity Disorder
Mental Disorders
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Assessment/Treatment
methods of assessment
Which drugs for which disorders
tenets of psychodynamic therapy (Freud)
tenets of humanistic/client-centred therapy
(Rogers)
tenets of cognitive therapy (Ellis & Beck)