Transcript Chapter 17 notes

Chapter 17 - Therapy
Reading Map
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Wednesday, April 4 – 659 - 669
Thursday, April 5 – Assembly Schedule – 669 - 673
Friday, April 6 to Friday, April 13 – Easter
Monday, April 16 – 674 - 685
Tuesday, April 17 – 685 - end
Wed, Apr 18 – Staff Mtg – Ch 17 Quiz/Cards/St Guide
Thursday, April 19 - Desk Mat due
Thursday, April 19 – PLC day – 1st AP Exam
Historical Perspective (659)
Old Methods
• Holes in head
• Warm baths
• Bleeding
• Beating the devil out
New Methods
• Philippe Pine (France) and
Dorothea Dix (USA) saw
mental disorders as
DISEASES and treatable
in HOSPITALS
Two Main Perspectives (659)
1. Psychological Therapies
2. Biomedical Therapies
The Psychological Therapies (660)
• are built on 4 main theories
– Psychoanalytic
– Humanistic
– Behavioral
– Cognitive
• Note - the Eclectic Approach - uses a blend of
therapies
Psychoanalysis (660)
Aims:
• to bring repressed
impulses and conflicts
from childhood into
consciousness where the
patient can deal with them
• gets patient to release the
energy they previously
devoted to the Id-EgoSuperego conflicts
Psychoanalysis Methods (661)
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Free Association
Resistance
Dream Analysis
Transference
Psychoanalysis Methods (661)
Free Association
• the patient retells his
past, moment by
moment, as it occurs
to him without editing
or censoring.
• Therapist mainly just
listens for what is
being said and not said
Psychoanalysis Methods (661)
Resistance
• the therapist listens for
resistance - blocks in the
free flow of the patient’s
talking
• Resistance gives the
therapist an opportunity to
interpret what repressed
ideas are causing the
resistance.
Psychoanalysis Methods (661)
Dream Analysis
• used to uncover the
latent (hidden) content
of the patient's
manifest
(remembered)
dreams.
• The latent dream
reveals repressed
ideas.
Psychoanalysis Methods (661)
Transference
• the patient will transfer
strong feelings from his
earlier relationships onto
the therapist
• The patient “blames” the
therapists - but this is a
good step in the therapy
• this is another way for
repressed ideas to be
discovered
Current Psychodynamic Therapy (662)
• try to understand a
patient's current
symptoms by
exploring childhood
experiences.
• probe for repressed
information
• face-to-face therapy
has replaced the couch
Interpersonal Therapy (662)
• an alternative to psychodynamic
therapy
• focuses on current relationships rather
than childhood and assists people to
improve their current relationship skills
Humanistic Therapies (663)
• emphasizes humans’ inherent potential for selffulfillment
• aims to boost self-fulfillment by helping people
grow in self-awareness and self-acceptance
• Focuses on:
– the present and future rather than the past (childhood)
– conscious rather than the unconscious
– taking responsibility for your feelings/actions rather
than uncovering hidden reasons
– growth rather than curing illness
Humanistic Therapies (663)
Carl Roger’s Client-Centered Therapy
• focus on client's conscious self perceptions rather
than the therapist's interpretations
• non-directive therapy where the therapist refrains
from directing the client towards certain insights
• therapist shows acceptance, genuineness and
empathy to allow client to feel unconditionally
accepted and deepening their self-understanding
and self-acceptance
• used active listening (echoing/restating/ seeking
clarification/acknowledging expressed feelings) to
give client unconditional positive regard.
Behavior Therapies (665)
• Unlike the psychoanalysts and humanists, the
behavior therapists doubt the healing power of
self-awareness.
• they assume that the problem behaviors ARE the
problem
• they apply learning principles to eliminate
unwanted behaviors (rather than look for the cause
of the behavior)
• they replace maladaptive behavior with
constructive behaviors
Behavior Therapies (665)
Classical Conditioning Techniques
• assumes that we learn
behavior and emotion and
therefore we can "unlearn"
behavior and emotion
• O.H. Mowrer - uses
classical condition to cure
bed wetters - a liquid
sensitive pad sounds an
alarm waking the child the child learns to
associate a relaxed bladder
with waking up -
Behavior Therapies (665)
Counter-Conditioning
• pair a trigger stimulus (ie small space) with a
NEW response that is incompatible with fear (ie
relaxation). The relaxation then displaces the old
response of fear to the stimulus.
2 Types of Counter-Conditioning
• 1. Systematic Desensitization
• 2. Aversive Conditioning
Counter-Conditioning
Systematic Desensitization Therapies
• replace a fear response with a response that is
incompatible with fear - the theory is that you
cannot be relaxed and fearful at the same time the relaxation will eventually displace the fear
• Mary Jones used a technique of having a child eat
close to a rat that it feared - eventually the
pleasure associated with the eating displaced the
fear response to the rat
Counter-Conditioning
Systematic Desensitization Therapies
• Joseph Wolpe used a method called Exposure
Therapy - people are over-exposed to a fearful
stimulus and eventually they become habituated to
the stimulus
• Progressive Relaxation - you relax one muscle
group at a time until you achieve a drowsy state of
relaxation and comfort - then the therapist has you
imagine a mildly anxiety-arousing situation - this
imagined scene is paired with your state of
relaxation until you no longer feel the anxiety.
Counter-Conditioning
Systematic Desensitization Therapies
• Anxiety Hierarchies - as
you are in your relaxed
state you imagine "worse"
situations and then you
eventually experience
actual anxiety causing
situation.
• Virtual-Reality Exposure
Therapy - client wears
goggles that give them a
3D image of what they
fear (ie flying)
Counter-Conditioning
Aversive Conditioning (667)
• the therapist tries to replace a positive response to
a harmful stimulus (ie alcohol) with a
negative/aversive response. (The therapist will
put a nausea drug in the alcohol)
• Note - for alcohol treatment only 33% of clients
are still booze-free after 3 years using this method
Counter-Conditioning
Systematic Desensitization
pair a stimulus
(elevator) with a new
response (relaxation)
that is incompatible
with
anxiety
Aversive Conditioning
Replace a positive
response to a harmful
stimulus (alcohol)
with a negative
response (nausea)
Behavior Therapies (668)
Operant Conditioning
• voluntary behaviors are strongly influenced
by consequences (reward and punishments)
• operant conditioning is used to deal with
specific behaviors
• token economy - used in institutions exchange tokens for concrete rewards
Critics of Behavior Modification (668)
• will the behavior stop when the reward stops?
• The behaviorists say that you can wean people off
of the rewards and move towards more intrinsic
rewards
• is it ethical to control another's behavior with
reward/punishment?
• The behaviorists say that behavior will always be
"controlled" so we may as well control it for the
"good"
Cognitive Therapies (669)
• behavior therapy is good for treating specific
fears and behaviors.
• when the client's fear/anxiety is less clearly
defined, cognitive therapy is useful
• assumes that our thinking colours our feelings
• aims to teach people new, more positive ways of
thinking
Cognitive Therapy for Depression (670)
• reverse client's catastrophic beliefs
• teach clients to view life differently and discover
their irrationalities (Aaron Beck - therapist)
• depressed people don't exhibit the self-serving bias
common in healthy people
• depressed people attribute their failures to
themselves and their successes to external
circumstances
• Adele Rabin (therapist) has clients record a day's
positive events and their contribution to each
event
Cognitive-Behavior Therapy (671)
• an integrated therapy that seeks to teach
positive thinking and also alter behaviors
• ie - OCD patients are taught to re-label their
compulsions. Instead of hand washing they
force themselves to take a walk and they
acknowledge and label the hand washing as
an irrational urge.
Stress Inoculation Training
• trains people to restructure
your thinking in stressful
situations
• self-talk - "relax - if the
exam is hard it is hard for
everyone. You studied
and will do well."
• you are trained to dispute
your negative thoughts.
Groups and Family Therapy (672)
• saves time and money
• all but traditional
psychoanalysis can be
done in a group setting
• often used for family
conflict
• group context allows
people to discover that
others share their
problems
• allows people to try out
new ways of behaving
• ex. AA 12 step program
Evaluating Psychotherapies (674)
Client’s Perspective
• 3 out of 4 are satisfied with the effectiveness
• However, the critics of psychotherapy say:
– people enter therapy in crisis and then attribute normal
improvement (that would have happened anyway) to
therapy
– client's spend time/money on therapy therefore they
"need" to believe that therapy is effective
– clients like their therapists so they find something
positive about the therapy
– selective/biased recall by clients
Joan McCord Study
• 500 boys aged 5 to 13 headed for delinquency
• half were put into counseling and the control
group was not.
• 30 years later although the counseled group
attributed their success to the counseling, there
was not a statistically significant difference
between the 2 groups - in fact - in second crime,
alcoholic tendencies, death rate and job
satisfaction, the control group actually had fewer
problems
Evaluating Psychotherapies
Clinicians’ Perceptions (675)
• Clients over-estimate problems when entering
therapy, over-emphasize their well being when
leaving therapy and stay in touch only if satisfied
• therapists are more aware of other therapists'
failures
• clients find a new therapist if their problems
reoccur
Outcome Research (676)
Hans Eysenck (1952) found that
• 2/3rds of people suffering non-psychotic
disorders improved markedly after
psychotherapy
• HOWEVER
• 2/3rds of untreated people with nonpsychotic disorders also improved
Outcome Research
• Today meta-analysis (statistically combining the results of
many different studies as if they had come from one huge
study with thousands of participants) is finding:
• the average therapy patient ends up better off than 80% of
the untreated individuals
• depression is better improved with treatment
• psychotherapy is more effective than medical therapy
• therapy is most effective for clear-cut, specific problems
(ie phobia)
• depression and anxiety therapy works in the short term but
relapses frequently occur
• chronic schizophrenia is rarely helped by psychotherapy
alone
Regression Toward the Mean (676)
• the tendency for unusual events or
emotions to return to a more
average state on their own
Placebo Effect (676)
• the belief in a treatment will cause the treatment to
succeed
• therefore what ever we doing following a "low"
will be perceived as an improvement - we are
naturally regressing to the mean (back to normal)
but in comparison to the low - normal is an
improvement
• SO, when we evaluate whether a therapy is
effective we must ask whether the improvement
that follows a therapy exceeds what we could
expect from the placebo effect and the regression
toward the mean effect.
The Relative Effectiveness of Different
Therapies p. 678
Mary Smith's meta-analysis reveals:
Disorder
Best Therapy
Depression
Cognitive, interpersonal and behavior
Anxiety
Bulimia
Cognitive, exposure and stress
inoculation
Cognitive-behavioral
Bed Wetting
Behavior modification
Phobia/OCD
Behavioral conditioning
Sex Disorders Behavioral conditioning
Therapeutic Touch (680)
• popular alternate therapy
• hands move a few inches from your body and
push energy fields into balance
• used for headaches to cancer
• Rosa (1998) - using 9 year old Emily doing
research for a science fair - therapists could not
tell whether they were close to Emily's hand more
than 47% of the time (less than chance odds)
Eye Movement Desensitization
and Reprocessing (680)
• Francine Shapiro discovered that anxious thoughts
vanished as her eyes spontaneously darted
about. She developed a technique where she treats
anxiety patients by triggering eye movement as
they recall traumatic memories.
• 40,000 health professionals now trained in this
method
• critics say this is just exposure therapy in a safe
context (in trials patients had the same results with
and without the eye movement)
Light Exposure Therapy (681)
• Seasonal Affective Disorder - a form of
wintertime depression
• treated with doses of intense light
• the light affects our circadian clock - morning
light exposure decreases the hormone melatonin.
In evening darkness increases melatonin.
• controlled trials show a difference in effectiveness
between using morning light, evening light and
placebo - morning light is best
Commonalities Among
Psychotherapies (682)
All therapies offer at least 3 benefits:
1. hope for demoralized people
2. a new perspective on yourself and the world
3. empathetic, trusting, caring relationships
These 3 things are also offered by self-help
groups, support groups, traditional healers, elders,
etc.
Culture and Values in Psychotherapy (683)
• Clients often adopt their therapist's values.
• Do the patient's and therapist's religious beliefs
affect the therapy?
•
Albert Ellis (1980) - a therapist that says "no one and
nothing is supreme. Self-gratification should be
encouraged, unequivocal love, commitment, service and
fidelity, especially marriage, leads to harmful
consequences.
• Bergin (1980) - says "because God is supreme, humility
and the acceptance of divine authority are virtues. Selfcontrol and commitment, love and self-sacrifice are to be
encouraged. Infidelity to any personal commitment,
especially marriage, leads to harmful consequences."
Cultural Differences
• North America, Europe, Australia individualism is reflected by the therapists
• Asia - more collectivist
• Training in cultural sensitivity for therapists
becomes important given the different types
of societies.
The Biomedical Therapies (685)
• Drugs
• Electroconvulsive therapy
• Surgery
Biomedical Therapy
Drug Therapy (685)
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most common biomedical therapy
introduced in the 1950's
reduced hospitalizations and surgeries
Psychopharmacology - the study of drug effects
on the mind and behavior
• Double Blind - is important technique to reduce
placebo effect and the regression to the mean
effect
Antipsychotic Drugs (686)
• accidental discovery that certain drugs used for other
medical purposes calmed psychotic patients
• antipsychotic drugs mimic dopamine and occupy its
receptor sites and block its activity
• Chlorpromazine (thorazine) - used with schizophrenic
patients with positive symptoms (thought to be caused by
too much dopamine)
• Note that thorazine can have the side effect of
tremors/twitches similar to Parkinsons (which is caused by
too little dopamine)
• Clozapine - used with schizophrenic patients with negative
symptoms
Antianxiety Drugs (687)
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ex. alcohol - valium - xanax
depress central nervous system activity
help people cope with fear and anxiety
dependency on drug and on withdrawal issues
critics say the drugs reduce symptoms without
resolving underlying problems
Antidepressant Drugs (687)
• increase norepinephrine and seratonin
which elevate mood and arousal
• ex. Prozac partially blocks the reuptake of
seratonin • Prozac takes about 4 weeks for relief of
symptoms - why - increased seratonin
promotes growth of new brain cells
Antidepressant Drugs
• drug therapy is often combined with cognitive
therapy and exercise
• placebos that mimic the real drug's side effects are
nearly as effective as the actual drug in doubleblind trials
• Prozac does not result in an elevated rate of
suicide although their are individual anecdotes of
users of Prozac committing suicide
• Lithium - used for bipolar patients
Electroconvulsive Therapy (689)
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•
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shock treatment - introduced in 1938
electricity produces convulsions and brief unconsciousness
used for severe depression that does not respond to drugs
some memory loss is a side effect
How does it work?????? We don't know!!!!!
maybe it causes release of norepinephrine???
maybe it calms brain area where over-activity would cause
depression?????
• ECT treated patients often have relapses of depression
• http://www.youtube.com/watch?v=zYl13Relzbs
Some Gentler Alternatives
• Vagus Nerve stimulation - chest implant
intermittently stimulates the vagus nerve which
sends impulses to the limbic system. Video clip
http://www.youtube.com/watch?v=G7uu1dccqo&feature=related
• Repetitive Transcranial Magnetic Stimulation magnetic coil held close to the skull above the
right eye - energizes the left frontal lobe produces no seizures or memory loss and shows
50% improvement in trials of depressed patients
Psychosurgery (690)
• least commonly used
• 1930's - Egas Moniz developed the lobotomy (won the
Nobel prize) - sever nerves connecting frontal lobe with
the emotion-controlling centres of the inner brain
• used to calm uncontrollably emotional and violent patients
• hammer an ice-pick like instrument through each eye
socket and wiggle it to sever connections to the frontal
lobe
• lobotomies - effects - permanent lethargic, immature,
impulsive personality
• today lobotomies are almost never performed
• today psychosurgery used for extreme seizures and
excessive OCD patients
Prevention (690)
• deal with poverty, work issues, racism,
sexism to prevent psychological disorders
• keep our bodies healthy
• mind body connection