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Unit 13 Treatment of Psychological Disorders/ Therapy Care as a Social Issue: The History of Psychological Treatment What to do with the severely disturbed? middle Ages to 17th century madness = in league with devil torture, hanging, burning, sent to sea 18th century mentally disordered people = degenerates keep them away from society http://youtu.be/1Izmyru5T_w The 19th Century Attempts at Reform: The History of Psychological Treatment Philippe Pinel (1745- 1826) reform in Paris mental hospital some patients got better enough to leave hospital http://youtu.be/GdxlFlA cJzw The 19th Century Attempts at Reform The History of Psychological Treatment reform of U.S. system moral-treatment movement kindly care led to large, statesupported public asylums overcrowding, loss of public attention Dorothea Dix (18021887) The 20th century: The History of Psychological Treatment Deinstitutionalization (mid-1950s) get people out of asylums and back into community effective antipsychotic medication general mood of optimism in country 1961: establishment of community mental health centers The Rosenhan Study Rosenhan (1973): "On being sane in insane places” http://youtu.be/xAsqKCQDgmA sane people got into mental hospitals as patients found very low interaction with staff dehumanizing nature of interactions normal behaviors interpreted pathologically Therapy Psychotherapy an emotionally charged, confiding interaction between a trained therapist and someone who suffers from psychological difficulties http://youtu.be/ZdTFqpItd8I THERAPY Types of Psychotherapy psychodynamic humanistic cognitive behavior group family Eclectic Approach an approach to psychotherapy that, depending on the client’s problems, uses techniques from various forms of therapy Psychotherapy Many approaches to mental problems 400 different forms of psychotherapy have appeared Most common psychodynamic humanistic behavioral cognitive Psychoanalysis 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 use has rapidly decreased in recent years Psychodynamic/Psychoanalytic Therapy Sigmund Freud Psychological problems result from inner mental conflicts Must make these conflicts conscious Unconscious wishes Repressed memories Predisposing & precipitating experiences http://youtu.be/VkWikN3fl7g Therapy- Psychoanalysis Interpretation the analyst’s noting supposed dream meanings, resistances, and other significant behaviors in order to promote insight Transference the patient’s transfer to the analyst of emotions linked with other relationships e.g. love or hatred for a parent Resistance unconscious material causes anxiety patients resist attempts to bring unconscious into conscious “forgetting” refusing to discuss certain topics Techniques in Psychoanalysis Free association patient relaxes and reports everything that comes to mind Dream analysis latent content manifest content Freudian symbols Mistakes slips of the tongue http://youtu.be/EMUPr28v_ao Psychoanalysis- Insight & Cure Analyst’s job is to make inferences about patient’s unconscious conflicts Once patient experiences them consciously, can modify or express them Patient must accept insights of therapist Analyst leads patient to insight so patient comes to insight themselves http://youtu.be/oS_L8efaJ-E Behavior Therapy Behavior Therapy therapy that applies learning principles to the elimination of unwanted behaviors Counterconditioning procedure that conditions new responses to stimuli that trigger unwanted behaviors based on classical conditioning includes systematic desensitization and aversive conditioning Behavior Therapy Concentrate on observable stimuli & responses Consider mental events as “covert” responses Most behaviorist therapists now practice cognitive-behavior therapy combination of cognitive & behavioral principles used Big Bang Theory http://youtu.be/ejjZZNGfIOM Other Behavioral Techniques Token economies an operant conditioning procedure that rewards desired behavior patient exchanges a token of some sort, earned for exhibiting the desired behavior, for various privileges or treats Contingency contracts formal written agreement Assertiveness & social skills training Modeling therapist models adaptive behaviors for client Behavior Therapy Exposure Therapy treat anxieties by exposing people (in imagination or reality) to the things they fear and avoid Behavioral Therapy:Exposure Treatments Systematic Desensitization *Joseph Wolpe http://youtu.be/LcojyGx8q9U type of counterconditioning associates a pleasant, relaxed state with gradually increasing anxiety-triggering stimuli commonly used to treat phobias Aversive Conditioning type of counterconditioning that associates an unpleasant state with an unwanted behavior nausea ---> alcohol Flooding expose person to feared stimulus and allow them to experience accompanying fear Fear gradually declines & disappears Behavior Therapy Systematic Desensitization Aversion Treatment/ Aversive Conditioning Used for bad habits drinking smoking gambling Use of operant conditioning principles painful or unpleasant stimulus follows the unwanted behavior Example Antabuse for alcohol usage Controversial treatment Limited generalizability of results Behavior Therapy Aversion therapy for alcoholics Humanistic Therapy Emphasis on inner potential for positive growth Similarity to psychodynamic help clients become more aware of inner feelings & desires Differences from psychodynamic inner feelings & desires are seen as positive & lifepromoting main goal is to help client take control of own life Humanistic Therapy Client-Centered Therapy humanistic therapy developed by Carl Rogers therapist uses techniques such as active listening within a genuine, accepting, empathic environment to facilitate clients’ growth Client- Centered Therapy focus on thoughts, abilities, cleverness of client not focused on insights of therapist therapist as a sounding board for client’s thoughts http://youtu.be/m30jsZx_Ngs Carl Rogers Humanistic Therapy Active Listening-empathic listening in which the listener echoes, restates, and clarifies Client-Centered Therapy Concepts Problems caused by denial of own feelings & distrust of ability to make decisions Empathy attempt to comprehend feelings from client’s point of view use of reflection Unconditional positive regard client is worthy & capable no matter what client does or says creates safe, nonjudgmental atmosphere Genuineness Cognitive Therapy Cognitive Therapy 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 The Cognitive Revolution Cognitive Therapy A cognitive perspective on psychological disorders Cognitive Therapy Cognitive therapy for depression Cognitive Therapy People disturb themselves with their own thoughts Goals of cognitive therapy identify maladaptive ways of thinking replace these with adaptive ways Similarity to humanistic focus on conscious mental experience Differences from humanistic problem-centered rather than client-centered relationship is more directive Beck’s Cognitive Therapy Treatment of depression Depressed people: distort experiences & maintain negative views of themselves, the world, their future minimize positive & maximize negative experiences misattribute negative experiences to own deficiencies http://youtu.be/GqW8p9WPweQ Ellis’ Rational-Emotive Therapy Albert Ellis Negative emotions arise from people’s irrational interpretations of experiences Musterbations irrational belief that you must do or have something Awfulizing mental exaggeration of setbacks Ellis’ ABC theory of emotions A = activating event in the environment B = belief triggered in client’s mind by event C = emotional consequence of the belief Loss of job I’m worthless Depression Healthy Pattern My job Loss of job sucked http://youtu.be/2xFfdshNKYk No Depression Cognitive Therapy Cognitive-Behavioral Therapy a popular integrated therapy that combines cognitive therapy (changing self-defeating thinking) with behavior therapy (changing behavior) ECLECTIC/MODERN Martin Seligman Positive Psychology Explanatory Styles: Learned Helplessness Learned Optimism http://www.ted.com/talks/martin_seligman_on_the_state_of_psychology.h tml Group Therapy Psychodynamic interactions among group members provide clues to hidden motives gain insight into how unconscious affects relations with others Humanistic members gain opportunity to express selves honestly Cognitive & Behavioral clients can practice new skills, new ways of thinking http://youtu.be/PwnfWMNbg48 Group and Family Therapies Family Therapy treats the family as a system views an individual’s unwanted behaviors as influenced by or directed at other family members attempts to guide family members toward positive relationships and improved communication Couples & Family Therapy Problem not in individual but interaction between individuals Couples: http://youtu.be/VNSrJ1qfaQQ Family therapy see whole family together, observe interactions help members gain perspective Family systems perspective each person accommodates to the family fix family problems by offering insight into how each affects others http://youtu.be/6JjcIiCJaDo Intergenerational approach considers influence of previous generations ALTERNATIVE THERAPIES http://youtu.be/zBtqWrs2-K0 Eye Movement Desensitization and Reprocessing (EMDR)1 is a comprehensive, integrative psychotherapy approach including psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies During treatment various procedures and protocols are used to address the entire clinical picture. One of the procedural elements is "dual stimulation" using either bilateral eye movements, tones or taps. During the reprocessing phases the client attends momentarily to past memories, present triggers, or anticipated future experiences while simultaneously focusing on a set of external stimulus. During that time, clients generally experience the emergence of insight, changes in memories, or new associations. The clinician assists the client to focus on appropriate material before initiation of each subsequent set. Places of treatment public or private mental hospitals general hospitals nursing homes for older patients with mental health needs halfway houses/group homes community mental health centers private offices Providers of treatment Psychiatrists medical degree (M.D.) special training/residency in psychiatry mainly hospitals & private practice can prescribe drugs Clinical psychologists doctoral degree (Ph.D.) in psychology training in research & practice universities, private practice, community mental health Providers of treatment Counseling psychologists doctoral degree in psychology sometimes more emphasis on practice than research problems of living, rather than diagnosable conditions Counselors master's degree in psychology schools & institutions school-or job-related problems Providers of treatment Psychiatric social workers master's degree in social work public agencies, home visits Psychiatric nurses bachelor's or master's in nursing hospital settings Self-help groups Alcoholics Anonymous LaLeche League Overeaters Anonymous Therapists and their Training Clinical psychologists Most are psychologists with a Ph.D. and expertise in research, assessment, and therapy, supplemented by a supervised internship About half work in agencies and institutions, half in private practice Recipients of treatment Most people who meet criteria for DSM diagnoses do not seek treatment Variability due to sex, education, race & income level women seek more treatment than men college educated seek more treatment than high school educated whites seek more treatment than nonwhites higher income seek more treatment than lower income Clinical Assessment Assessment process of gathering information to develop treatment plan for client Assessment Interview very common assessment technique range from unstructured to highly structured Objective questionnaires self-report to get information on feelings, thoughts, behaviors of clients examples: Beck Depression Inventory, Child Behavior Checklist The Intake: MMPI A psychometric personality test Used in clinical assessment 567 statements about the self Client answers true or false to items 10 clinical scales, 15 content scales, several validity scales The Intake: Projective Tests Most commonly used by psychodynamic therapists Designed to provide clues about unconscious mind Developed from free association technique The Rorschach Thematic Apperception Test Behavioral Monitoring Used to help with treatment & assessment Counting actual instances of target behaviors Hospital staff, therapist, patient Self-monitoring done by patient Assessment of the physical brain Electroencephalogram (EEG) pattern of electrical activity in brain used to scan for brain damage Computerized axial tomography (CAT scan) multiple x-rays of brain can look for anatomical abnormalities Magnetic resonance imaging (MRI) pictures of brain sections Positron emission tomography (PET scan) images that reflect the pattern of blood flow and rate of oxygen use YOU HAVE (3) MINUTES TO REVIEW YOUR NOTES… UNIT 13 QUIZ REVIEW o o o o o o o o o o o o o o Contrast two historical perspectives on treatment of mentally ill Explain Phillipe Pinel’s contribution to treatment of mentally ill Explain Dorthea Dix’ contribution to treatment of mentally ill Explain what happened in the Rosenhan study and why Describe the focus of psychodynamic therapy Describe the focus of humanistic therapy Describe the focus of cognitive therapy Describe the focus of behavior therapy Describe the focus of couples therapy Describe the focus of family systems therapy Differentiate (4) kinds of treatment providers Differentiate (3) kinds of treatment locations Identify (3) possible intake practices Explain (3) factors involved in therapy effectiveness Does Therapy Work? *With your table, design a study that evaluates the effectiveness of therapy… People report feeling better after therapy Maybe they would have gotten better anyway Need studies comparing no treatment to treatment to evaluate efficacy Does Therapy Work? Studies show that people in therapy do better than notreatment controls Connect the image here to a study on therapy’s effectiveness and explain your interpretation Therapy Effectiveness People in treatment do better than those not Some types of therapy work better for specific problems cognitive-behavioral best for fear & anxiety humanistic best for self-esteem psychodynamic best for work/school achievement Some therapists are better than others warm, understanding, motivated Nonspecific Factors in Therapy Effectiveness Nonspecific = unrelated to specific principles but critical to outcome Support acceptance, empathy, encouragement, guidance Hope sense of faith in therapy process placebo effect = improvement from belief, rather than actual effect BIOMEDICAL TREATMENT Attempts to solve the disorder by altering bodily processes History drilling holes in head blood letting Biomedical Therapies Electroconvulsive Therapy (ECT) therapy for severely depressed patients in which a brief electric current is sent through the brain of an anesthetized patient Psychosurgery surgery that removes or destroys brain tissue in an effort to change behavior lobotomy now-rare psychosurgical procedure once used to calm uncontrollably emotional or violent patients http://youtu.be/_0aNILW6ILk Electroconvulsive Therapy Electroconvulsive Shock Therapy (ECT) Used primarily in cases of severe, unrelenting depression Modern ECT is very different from early ECT safer patient given drugs to sedate beforehand painless 70% people who don’t respond to other treatments get relief with ECT Concerns with ECT Permanent brain damage? no evidence to support do find temporary disruptions in cognition (memory) Bilateral ECT can result in loss of memory for events a day or two previous to treatment usually returns in a month Unilateral ECT produces little apparent memory loss http://youtu.be/y8K37POBojs Mind-Body Interaction Biomedical Therapies Psychopharmacology study of the effects of drugs on mind and behavior Anti-psychotics Anti-depressants Anti-anxiety Antipsychotic Drugs Used for schizophrenia & other psychotic disorders Most work on neurotransmitter dopamine Problems relieve positive but not negative symptoms make person seem more normal, but don’t increase life satisfaction unpleasant & harmful side effects tardive dyskinesia may reduce chances of full recovery Biomedical Therapies The emptying of U.S. mental hospitals Lithium Used for bipolar disorder Especially effective for manic phases Unclear how it works Most dangerous side effect is dehydration Antidepressants Many work to increase availability of monoamine transmitters Tricyclics imipramine amitriptyline block reuptake of serotonin & norepinephrine Selective serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac) Biomedical Therapies Biomedical Therapies Antianxiety Drugs Historically, barbituates were prescribed Benzodiazepines are safer chlordiazepoxide (Librium) & diazepam (Valium) most effective for generalized anxiety not effective for phobias, OCD, or panic disorder work by augmenting action of GABA Types of Therapy: Summary Psychodynamic therapy unconscious motives free association, dream analysis, mistakes resistance, transference, insight best therapy for achievement problems Humanistic therapy focus on inner potential of client Carl Rogers’ client-centered therapy empathy, unconditional positive regard, genuineness best therapy for self-esteem issues Types of Therapy: Summary Cognitive therapy maladaptive thinking causes mental problems Albert Ellis’ rational-emotive therapy (ABC’s) Aaron Beck’s cognitive therapy for depression Behavior therapy observable stimulus-response patterns thoughts are private behaviors phobias systematic desensitization, flooding, aversion therapist is very directive Cognitive-behavioral therapy best for anxiety Types of Therapy: Summary Group therapy each theory has own type of group therapy family & couple therapy family systems perspective interaction of family members creates problems Evaluating Psychotherapies being in therapy better than not therapist attributes very important nonspecific factors also important support hope