Treatment

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)

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.  19 th century Freud’s “talking cure”

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

Who provides treatment?  Clinical psychologists  Psychologists  Neurologists  Psychiatric Nurses  Marriage and Family Counselors  Social workers  School counselors

Who seeks treatment?  People with mental illness, hoping to relieve pain and dysfunction  People with subsyndromal disorders  People looking for assistance in recovering from grief, anxiety, confusion, relationship issues… Women European Americans Financially well off

Psychological Treatments  Focused on changing the way the patient thinks and behaves  Involves discussion, 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

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

Humanistic Approaches  Gestalt Therapy (Fritz Perls)  Mental illness is result of inconsistencies in one’s understanding of the self  Increase self-awareness and self-acceptance Ask how clients felt, and point out discrepancies in the way they appeared Empty chair technique

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

Eclecticism  Modern therapy tends to blend aspects from many of these perspectives  Makes sense, since there are often many causes of mental illness

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 Social support Share advice, information Observe other peoples’ successes Realize that not alone, others share similar problems

Couple and Family Therapy  Views the family or relationship as a complex system One person’s negative behavior or cognitions may reflect a larger issue for the entire family or relationship

Biomedical Treatments The Early Gruesome Years  Trephination Allowed “evil spirits” to escape the skull  Hot or Cold Baths  Spinning

Biomedical Treatments Psychosurgery  Prefrontal Lobotomy Sever connections between thalamus and frontal lobes Disrupted higher cognitive functions  Modern techniques are more precise and used as a last resort treatment

Electroconvulsive Therapy (ECT)  Brief electrical current passed through the brain causing a convulsive seizure  Originally developed to treat schizophrenia  Very effective for treating severe depression (70-90% effective)  Memory impairment  Mechanisms are not known

Pharmacological Treatments  Psychotropic 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  Only treats and controls the symptoms Relapse  Requires trial-and-error for correct drug and correct dosage  Side effects Reduce adherence to medication  Overprescription

Emerging Biomedical Treatments  Repetitive TMS Areas of the brain stimulated with magnetic coil for minutes over several weeks Effective for medication- resistant depression No cognitive side effects  Deep Brain Stimulation Electrodes implanted in brain

Client-Therapist Relationship  Therapeutic Alliance Support  Trust  Hope  Understanding

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 Symptoms and severity similar across participants Follow participants over several months Random assignment

Efficacy vs. Utility  Difficult to run RCT for psychotherapy Waitlist Manualized Therapy  Controlled studies allow researchers to come to conclusions about the efficacy of particular treatments  In most circumstances, patients have more than one illness  Also, therapists typically use more than one approach

Is therapy effective?  A meta-analysis found that 80% of patients who received treatment fared better than those without

Are all Therapies Equally Effective?

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 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!

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!

Thank you!  Thanks to Dr. Kotovsky, Jen H., Jen L., Scotty, Kim, Jordan, and Scott for a successful semester!  Good luck on the final! December 14 th from 1-3pm  See you at the review session! December 11 th 2-4pm