Approaches and Outcomes 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 Ordered removal of chains, shackles

Dr. Phillippe Pinel removing chains off patients at the Selpetriere Philippe Pinel a la Selpetrierre

Beginning of Reform Dorthea Dix Early 20th century Fought for humane treatment of patients in U.S. Early 20th century Freud’s “talking cure” Talk to patients about their problems, and what may possibly have caused it

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 either- or Placement?

Who provides treatment? Clinical psychologists Psychiatrists Neurologists Psychiatric Nurses Marriage and Family Counselors Social workers School counselors In situ mileau “treatment” Placement?

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 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 T

Psychodynamic Approaches “Working through” the conflict Transference Used as a therapeutic tool In order to be effective, therapist must remain neutral : patient tends to treat the therapist as the major figures with which they have conflict

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” Instead of the “there and then” living in the past

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 Taking ownership of who you are and what you do

Humanistic Approach Creating the therapeutic environment Genuineness- sharing authentic reactions Unconditional positive regard Non-judgmental, accepting Empathic Understanding- putting oneself in the patients’ shoes Video?

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 Focused on overt behaviors

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 Token economies used in psychiatric wards Contingency Management- menu of good and bad behaviors with rewards and punishments Parents who use these operant techniques had children who were functioning well in school by first grade, and stayed Therapist thinks aloud Lack of fear response to a phobic stimulus

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 Video?

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 Changes in thinking lead to changes in emotion and behavior…short-term, problem-focuses Trained as a psychoanalyst Self, world, situation, future, all-or-none thinking, overgeneralizations Applied to other disorders (bipolar disorder, schizophrenia, obesity)

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 Advantages Social support Share advice, information Observe other peoples’ successes Realize that not alone, others share similar problems Often groups are chosen because they share similar problems (e.g., Alcoholics Anonymous) Focus on the shared problems, less on the individuals’ emotions

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 Hallucinations, delusions Flat affect, reduced feelings of pleasure

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 Before the movement 2/3 of individuals diagnosed with schizophrenia spent most of their lives in institutions 200,000 mentally ill individuals are homeless 200,000 in jail for small crimes

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 Include symptoms here

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 Generalized Anxiety Disorders, panic attacks, PTSD

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 Generalized Anxiety Disorders, panic attacks, PTSD

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 comparing results of 475 studies

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 Placement?

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? 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!