Transcript Treatment - Psychology

Treatment
Approaches and Outcomes
Overview
• Brief History
• Psychological Treatments
• Biomedical Treatments
• Client-Therapist Relationship
• Is Treatment Effective?
History
• Earliest history
• Mental illness believed to be caused by evil spirits
• Treatments were harsh, ineffective
• Drill holes in skulls to create exits for spirits
• Make the body horribly uncomfortable for the spirits
• Purge demons through inducing vomiting
History
• Middle Ages
• Mental illness viewed more like a disease
• Mental institutions were created
• Purpose: confine madmen
• Included other social “undesirables”
• Inhumane treatment
• (shackles and chains)
• Spinning
• Ice-water baths
Beginning of Reform
• Early to Mid 1800s
• Philippe Pinel put in charge of Paris’ hospital system
• Removed shackles and chains
• Patients allowed to exercise, venture outside
Beginning of Reform
• Dorthea Dix
• Fought for humane treatment
of patients in U.S.
• Early 20th century
• Freud’s “talking cure”
Two Main Avenues of Approach
Psychological: Behavioral/Experiential
one viewpoint we’ve taken in course: more psychological, social
Biological: Biochemical/Neural
more mechanistic viewpoint we’ve taken in course: more brain,
cognitive mechanism oriented
Roughly correspond to diasthesis/stress idea but also more interactive
Psychological Treatment
Overview
• Treatment involves addressing three major components of the illness:
• Biological
• Psychological
• Social
• Something to keep in mind:
• These three major components are not necessarily black-and-white or eitheror
Who provides treatment?
• Clinical psychologists
• Psychiatrists
• Neurologists
• Psychiatric Nurses
• Marriage and Family Counselors
• Social workers
• School counselors
• In situ mileau “treatment”
Psychological Treatments
• Focused on changing the way the patient thinks and behaves
• Involves discussion, interpretation, instruction, or training
• Over 500 different forms of such treatment
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Psychodynamic
Humanistic
Behavioral
Cognitive
Psychodynamic Approaches
• Illness result of unconscious conflicts developed early in childhood
• Defense mechanisms shield from the inner conflict
• This can lead to symptoms of mental illness
• Treatment: Uncovering unconscious desires and conflicts, and resolving them
• Integrate thoughts and memories coherently
Psychodynamic Approaches
• “Working through” the conflict
• Transference
• Used as a therapeutic tool
• In order to be effective, therapist must remain neutral
Humanistic Approaches
• Based off of Freud’s “talking cure”
• However, less focused on basic drives
• Instead, focus on creating meaning
• Clients need to take responsibility for their lives and actions, and live in the “here
and now”
Humanistic Approaches
• Client-Centered Therapy (Carl Rogers)
• Focuses on achieving self-acceptance
• Does not pass judgment, or provide instruction
• Aim is to create an environment in which the client feels understood and valued
Humanistic Approach
• Creating the therapeutic environment
• Genuineness- sharing authentic reactions
• Unconditional positive regard
• Non-judgmental, accepting
• Empathic Understanding- putting oneself in the patients’ shoes
Behavioral Approaches
• Reaction to Freud’s psychoanalysis
• Viewed Freud’s approach as too unscientific
• Treatment directed at reducing or eliminating problematic behaviors
• Approach involves replacing old habits with more effective or adaptive behaviors
• Classical conditioning, operant conditioning, modeling
Behavioral Approaches
Classical Conditioning Techniques
• Treatment of Phobias
• Extinguish the association between the neutral stimulus and the fearful
stimulus
• Exposure Therapy
• Train clients in deep muscle relaxation, pair relaxation with the fearful stimulus
• Create a hierarchy of progressively more frightening stimuli
• Systematic desensitization: gradual exposure to the real phobic stimulus
Systematic Desensitization
Behavioral Approaches
Operant Conditioning Techniques
• Token economies
• Earn tokens for positive behaviors, which can be exchanged for prizes
• Shaping
• Contingency Management
• Strict consequences for certain behaviors
• Successful for shaping communicative behavior in children with autism
• Modeling Techniques
• Therapist perceived as role model
Cognitive-Behavioral Approaches
• Rational Emotive Behavioral Therapy (Albert
Ellis)
• People typically think that an event causes them
to behave a certain way
• But…beliefs matter
• A (acting event) B (belief)  C (consequence)
• Focused therapy on changing beliefs
• Teacher-like
Cognitive Therapy
• Aaron Beck
• Focused on changing dysfunctional thought
• Cognitive Restructuring
• Challenge a person’s unhealthy beliefs or
interpretations
• Used persuasion and confrontation
• Brief, problem-focused
• Initially treated depression
Cognitive-Behavioral Therapy
• Followers of Ellis and Beck blended the two therapies to form CBT
• Focus on addressing problems the patient wishes to solve
• Often clients are assigned homework
• Practice new ways skills or thought techniques
• Loosely based on self-perception theory—but more on that later
Eclecticism
• Modern therapy tends to
blend aspects from many of
these perspectives
• Makes sense, since there are
often many causes of mental
illness
Client-Therapist Relationship
• Therapeutic Alliance
• Support
• Trust
• Hope
• Understanding
Group Therapies
• Often groups are chosen because they share
similar problems (e.g., Alcoholics Anonymous)
• Focus on the shared problems, less on the
individuals’ emotions
• Advantages
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Social support
Share advice, information
Observe other peoples’ successes
Realize that not alone, others share
similar problems
Biological Treatments
• Pharmacological treatments (drugs)
• Not only helped treat patients, but also further understanding of the illness
Pharmacological Treatments
• Antipsychotics
• Treat positive symptoms of schizophrenia
• Not effective for treating the negative symptoms
• Most common are Thorazine, Haldol and Stelazine
• Block dopamine receptors in particular brain pathways
• Atypical Antipsychotics
• Treat negative symptoms of schizophrenia, too
• Risperdal, Clozaril, Seroquel
Antipsychotics and Deinstitutionalization
• Movement in the 1950s shortly after development of the first antipsychotics
• Aimed to provide less expensive mental health care at local community centers instead of
institutions
• Pros
• Fewer people spending their lives in institutions
• Shorter stays
• Downside
• Lack of appropriate care in community settings
• Lack of integration into the community (support services, employment)
• Many mentally ill are now homeless, or in jail
Deinstitutionalization
Antidepressants
• Monoamine Oxidase Inhibitors (MAOIs)
• Nardil
• Tricyclic antidepressants
• Tofranil
• Increase serotonin and norephinephrine for synaptic transmission
• Both very effective (significant improvement in 65% of patients)
• Many negative side effects
Antidepressants
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Prozac, Zoloft, Paxil, Celexa, Lexapro
• Minimally effect dopamine and norepinephrine, and maximally effect serotonin
• Reduced side effects
• Most commonly prescribed
• Atypical Antidepressants
• Effect serotonin, norepinephrine and dopamine in various ways
• Wellbutrin (fewer side effects)
Antidepressants
• Downside
• Takes a while before effective (a month)
• Trial-and-error
• Side effects
• Weight gain, nausea, diarrhea, insomnia, reduced sexual desire or response
Mood Stabilizers
• Treat symptoms of bipolar disorder
• Lithium carbonate
• Treats manic episodes as well as depressive episodes
• Side Effects
• Weight gain, sedation, dry mouth, tremors
• Adherence to medication
• Often patients do not wish to treat mania, only depression
• Lethal at high doses
• Effective for 60 – 70% of patients
Anxiolytic Medications
• Treat anxiety disorders
• Increase neurotransmission of GABA
• Beta Blockers
• Benzodiazepines
• Tricyclic Antidepressants and SSRIs
Anxiolytic Medications
• Beta Blockers
• Controls autonomic arousal
• Benzodiazepines
• Valium, Xanax, Klonopin
• Short term treatments
• Highly addictive
• Interact dangerously with alcohol
• New drugs are being developed to reduce these negative side effects
• Rebound effect
Medication: Costs and Benefits
• Can be highly effective
• Sometimes only treats and controls the
symptoms
• Relapse
• But, makes patient available for other
treatments!
• Requires trial-and-error for correct drug
and correct dosage
• Side effects
• Reduce adherence to medication
• Over-prescription
Emerging Biomedical Treatments
• Repetitive TMS
• Areas of the brain stimulated with
magnetic coil for 20-30 minutes over
several weeks
• Effective for medication-resistant
depression
• No cognitive side effects
• Deep Brain Stimulation
• Electrodes implanted in brain
Combined Treatments
• Most therapists use a combination of treatments
• Drug treatments for short-term effects
• Therapy for long-term effects
Evaluating the Efficacy of Treatments
• Randomized Clinical Trial (RCT)
• Treatment group
• Placebo group
• Random assignment
• Symptoms and severity similar across participants
• Follow participants over several months
Is therapy effective?
• A meta-analysis found that 80% of patients who received treatment
fared better than those without
Are all Therapies Equally Effective?
Recent Reconceptualization
• Some people are able to cognitively overcome even serious levels of
disorders
• Available to psychotherapy
• Find meaning in some symptoms
• Able to live normally or quasi-normally
• Example in Nash film + reading for today
If you feel you need help…
• Seek it! Ask for advice, or set up an appointment with a counselor. It’s not a
weakness.
• Make sure the therapist is a good match for you!
• Remember it can take time and you may face some setbacks, but also…
• Remember treatment is effective! Most people improve!
Who provides the most effective psychological
treatment?
• Number of years of practice?
• Not necessarily
• Professional credentials?
• No
• The rapport between therapist and client seems to be strongest
predictor
• Respect, trust, comfort
Who is most likely to benefit from treatment?
• Strong alliance with therapist
• Shop around!
• Motivated
• Optimistic
• More effective with more therapy
Are All Treatments Equally Effective?
• A depression meta-analysis shows…
• Drug treatment alone 55% effective
• Therapy alone 52% effective
• Drug AND therapy 85% effective!
(New England Journal of Medicine, 2000)
Are all Treatments Equally Effective?
• Treatment more effective than no treatment
• Combining treatments appears most beneficial
• Some therapies seem particularly effective for specific disorders
• Exposure therapy phobias
Moral of the Story
• Treatment is effective!
• Modern treatments are much more effective and humane than past
treatments
• The relationship between therapist and client really matters!
What’s Missed in This Account
• Interpersonal Aggression: Killings
• Inter-societal Aggression: War
Roots of Aggression
Two Theories
Some “Take-homes”
• Self Perception Theory (Bem)
• Largely unrecognized part of the basis for cognitve behavioral therapy
• Fun experiments
• Valins & Ray, Bem (similarity & contrast to Cog Dissonance Theory)
• One of many ways that we don’t know ourselves!
Over-riding Issue in a Course About Ourselves:
Do we Know Ourselves & How to Expand That Knowledge
• Unconscious motivation & repression
• Cephalization
• Top-down perception
• Automaticity of thought: retrieval & other cognitive mechanisms
(Stroop ex.)
• Selective memory
• Attentional filtering (ex. Filter theory)
• IAT
Don’t Underestimate Conformity!
• We don’t like to think of ourselves as conformists.
• But we are conformists!
• Cure?
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Ask big questions
Challenge popular beliefs—they’re almost never eternal!
Value the relevance of data and empirical science
Challenge dominant views—remember Asch!!
Schein POW study example—a cause for optimism!
Recognize that we are part of history—some day people will look back at our
“silly” views just as we do with past viewpoints!