1. Chapter 17 : Therapy

2. History of the Treatment of Mental Illness w 16th and 17th Centuries Many of the mentally ill were considered to be “witches” and were tortured or killed. Many of the mentally ill were institutionalized where they were kept in chains. w 18th Century Philippe Pinel encourages moral treatment of the mentally ill. Patients are freed from their chains and given more humane treatment.

3. History of the Treatment of Mental Illness- Cont. w 19th Century Dorothea Dix fights for the establishment of State Mental Hospitals w 20th Century Deinstitutionalization: With new drugs available to treat mental illness, many of the mentally ill are able to live outside of institutions. Continued Drug Therapy Development: New drugs that are specific to each of the mental disorders are being developed. These new drugs have fewer side effects and greater effectiveness.

4. Different Approaches to Therapy

5. Insight Therapies- Psychoanalysis w Psychoanalysis Developed by Sigmund Freud Believed that psychological problems come from unresolved unconscious conflicts Goal is to uncover unconscious conflicts and bring them into consciousness

6. Techniques for Psychoanalysis Free Association: asking clients to say what comes to mind without filtering it or altering it in any way Dream Interpretation: determine manifest and latent content of dreams Analyzing Resistance: when a client stops free associating because critical unconscious thoughts are too close to the surface of consciousness Analyzing Transference: when a client transfers feelings about a significant person in their life onto the therapist

7. Resistance & Transference Visual

8. Relationship between # of sessions of psychotherapy & improvement

9. Neo-Freudian Psychodynamic Therapies These therapies were developed by psychologists why embraced some of Freud’s ideas, but disagreed with others. While they follow many of the same techniques, their emphasis is on the conscious, rather than the unconscious, mind. Basically they spend less time probing for hidden conflicts and repressed memories.

10. Therapy – Psychodynamic w Psychodynamic understand current symptoms by focusing on themes across important relationships w Help explore & gain perspective on defended- against thoughts/feelings w Face-to-face once a week for only a few months w Interpersonal Therapy – Brief variation of psychodynamic Help gain insight into roots of difficulties Goal – become symptom free in the present not in overall personality change Focusing on current relationships/relationship skils

11. Insight Therapies Insight therapies attempt to change people on the inside-changing the way they think and feel. think therapies distressed persons need to develop an understanding of the disordered thoughts, emotions and motives that underline their mental difficulties.

12. Cognitive Therapy w Cognitive Therapies: Analyze faulty thought processes, beliefs, and negative self-talk and change these destructive thoughts with cognitive restructuring. teaches people new, more adaptive ways of thinking and acting based on the assumption that thoughts intervene between events and our emotional reactions

13. Cognitive Therapy w The Cognitive Revolution

14. Cognitive Therapy w A cognitive perspective on psychological disorders Lost job Depression Internal beliefs: I’m worthless. It’s hopeless. Lost job Internal beliefs: My boss is a jerk. I deserve something better. No depression

15. Cognitive Therapy w Cognitive-Behavioral Therapy a popular integrated therapy that combines cognitive therapy (changing self- defeating thinking) with behavior therapy (changing behavior) Aims to alter the way patient thinks & act

16. Insight Therapies- Cognitive Therapy Cognitive-Behavior Therapy (CBT): Focuses on changing faulty thoughts and behaviors. Leader in the field: Aaron Beck w General CBT Assumptions: w The cognitive approach believes that abnormality stems from faulty cognitions about others, our world and us. This faulty thinking may be through cognitive deficiencies (lack of planning) or cognitive distortions (processing information inaccurately).abnormality w These cognitions cause distortions in the way we see things; (Ellis suggested it is through irrational thinking, while Beck proposed the cognitive triad). w We interact with the world through our mental representation of it. If our mental representations are inaccurate or our ways of reasoning are inadequate then our emotions and behavior may become disordered

17. Cognitive Therapy: Aaron Beck w The Cognitive Triad w The cognitive triad are three forms of negative (i.e helpless and critical) thinking that are typical of individuals with depression: namely negative thoughts about the self, the world and the future. These thoughts tended to be automatic in depressed people as they occurred spontaneously. As these three components interact, they interfere with normal cognitive processing, leading to impairments in perception, memory and problem solving with the person becoming obsessed with negative thoughts.

18. Beck: The Cognitive Triad

19. Cognitive-Behavioral Therapy: REBT/Ellis This approach assumes that an irrational self- statement often underlies maladaptive behavior.

20. Cognitive-Behavioral Therapy: Ellis/REBT In this form of treatment, therapist and client work together to: w modify irrational self-talk, w set attainable behavioral goals w develop realistic strategies for attaining them. In this way, people change the way they approach problems and gradually develop new skills and a sense of self-efficacy.

21. REBT: Albert Ellis Replacing irrational thoughts Rational Emotive Behavior Therapy (REBT): developed by Albert Ellis w Believed that understanding thoughts & beliefs held by the client will lead to an understanding of the psychological manifestation of those beliefs w Goal is to change distorted thoughts and thereby change maladaptive behavior w Tools used: therapist confronts client regarding distorted thoughts & teaches client to replace those thoughts with rational beliefs

22. Cognitive View of Depression

23. Insight Therapies – Humanistic Client-Centered Client-Centered Therapy: developed by Carl Rogers w Believed that psychological problems come from when a client’s ideal self differs significantly from the client’s real self w Goal is to create an unconditional environment where the client feels safe to find solutions to his/her problems. Facilitate personal growth. w Tools used: unconditional positive regard, genuineness, active listening and empathy for client.

24. Insight Therapies – Group Therapy Group Therapy w Mostly used in addition to individual therapy w Advantages: Allows clients to try out new behaviors in a safe environment (behavior rehearsal) Allows clients to not feel so isolated in their feelings and challenges (provide group support, feedback) w Marital and Family Therapy: A special form of group therapy that allow the problems that clients present with for treatment to be addressed in the larger family setting.

25. Behavior Therapies Behavior therapy, or behavior modification, is based on the assumption that undesirable behaviors have been learned, and therefore, can be unlearned. Behavior therapist focus on the problem behaviors rather than inner thoughts, motives or emotions. Their goal is to determine how these behaviors were learned and see if they can eliminate them.

26. Behavior Therapy w Behavior Therapy therapy that applies learning principles to the elimination of unwanted behaviors Derived from Pavlov’s ideas Learned behaviors/emotions cause psych issues w Counterconditioning procedure that conditions new responses to stimuli that trigger unwanted behaviors based on classical conditioning includes systematic desensitization and aversive conditioning

27. Behavior – Exposure Therapies Exposure Therapies – Exposure to stimuli that is normally avoided Progressive Relaxation – Relax 1 muscle group after another until one reaches complete relaxation Systematic Desensitization – type of counterconditioning – associates a pleasant, relaxed state with gradually increasing anxiety-triggering stimuli – commonly used to treat phobias

28. Steps of Systematic Desensitization For a fear of public speaking: 1.Seeing a picture of a person giving a speech 2.Watching another person give a speech 3.Preparing a speech to give 4.Having to introduce oneself to a large group 5.Waiting to be called upon to speak at a meeting. 6.Being introduced as a speaker to a group 7.Walking to the podium to make a speech 8.Making a speech to a large group

29. Mary Covers Jones – Desensitization, – used to cure phobias. A patient may be desensitized through the repeated introduction of a series of stimuli that approximate the phobia. Her study of the removal a fear of rabbits through conditioning, on a three-year-old named Peter. Jones treated Peter’s fear of a white rabbit by “direct conditioning,” in which a pleasant stimulus (food) was associated with the rabbit. As the rabbit was gradually brought closer to him in the presence of his favorite food, Peter grew more tolerant, and was able to touch it without fear. Systematic Desensitization

30. Systematic Desenitization John Wolpe – Hierarchical of Anxiety w Cannot be both relaxed and anxious at the same time. w Client and the therapist create a hierarchy of anxieties (i.e. list of all the things that produce anxiety in all its different forms) starting with what produces the lowest level of anxiety to what produces the most anxiety. w Client be fully relaxed while imaging the anxiety producing stimulus. w Depending on what their reaction is, whether they feel no anxiety or a great amount of anxiety, the stimulus will then be changed to a stronger or weaker one. Systematic desensitization, though successful, has flaws as well. w The patient may give misleading hierarchies, have trouble relaxing, or not be able to adequately imagine the scenarios. Despite this possible flaw, it seems to be most successful

31. Behavior Therapies- Sys. Desensitization & Flooding w Systematic Desensitization: Clients are asked to produce a hierarchy of their fear from least anxiety provoking to the most anxiety provoking. Using classical conditioning, client replaces anxiety with relaxation. w Flooding: Clients are immediately taken to a high anxiety producing situation.

32. Exposure Therapies w Virtual Reality Exposure Therapy Progressively exposure to simulations of fears w Aversive Conditioning type of counterconditioning associates an unpleasant state with an unwanted behavior nausea ---> alcohol

33. Virtual Technology Exposure Therapy

34. Aversion Therapy Aversion therapy takes on the psychological problems with a conditioning procedure designed to make tempting stimulus less provocative by pairing them with an unpleasant (aversive) stimuli. In time, the negative reaction (UCR) associated with the averse stimuli come to be associated with the conditioned stimuli. This is usually a last resort type of therapy, though it has been shown to be successful.

35. Behavior Therapies- Aversion Therapy w Aversion Therapy is frequently used to decrease unwanted behaviors  Uses the pairing of an unpleasant stimulus with the unwanted behavior in hopes that the client will associate the unpleasant stimulus with the unwanted behavior Ex: The presentation of Antabuse which causes nausea in the presence of the consumption of alcohol

36. Behavior Therapy w Aversion therapy for alcoholics

37. Operant Conditioning Therapy Behavior Modification – Reinforcing desired behaviors & withholding reinforcement for undesired behaviors Token Economy – 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 – Often used with patients with Schizophrenia in a hospital setting to encourage appropriate behavior Contingency Management: An approach to changing behavior by changing the consequences associated with a behavior.

38. Behavior Therapies- Modeling w Modeling is a technique where the therapist can demonstrate or “model” appropriate behaviors for the client in the safe setting of a therapy appointment. The client may even be asked to mirror back the behaviors and practice them within the therapy setting.

39. Leading Psychotherapies

40. Does Therapy Work? w Meta-analysis procedure for statistically combining the results of many different research studies Poor outcome Good outcome Average untreated person Average psychotherapy client Number of persons 80% of untreated people have poorer outcomes than average treated person

41. Biomedical Approach Changing the brain’s chemistry with drugs, its circuitry with surgery or its patterns of activity with pulses of electricity or magnetic fields.

42. Biomedical Therapy w Pharmaceuticals w ECT (electroconvulsive therapy) w Psychosurgery

43. Biomedical Therapies w Psychopharmacology study of the effects of drugs on mind and behavior w Lithium chemical that provides an effective drug therapy for the mood swings of bipolar (manic-depressive) disorders

44. Drug Therapy/Psychopharmacology The first psychological drugs were administered in 1953 with the antipsychotic drugs. In 1955, over ½ a million Americans were living in mental institutions, each staying an average of a few years. Then, with the introduction of tranquilizers, the number declined. By 1965, the number of patients was down to ¼ million, with most patients staying for only a few months.

45. Antipsychotic Drugs Antipsychotic drugs are used to treat the symptoms of psychosis: delusions, hallucinations, social withdrawal and agitation. (Schizophrenia) Most work by reducing the activity of the neurotransmitter dopamine. These drugs (Thorazine) often have powerful side effects

46. Pharmaceutical Treatment for M.I.- Antipsychotic Drugs Antipsychotic Drugs w Function: To decrease delusions and hallucinations. They are less effective on symptoms like apathy and depression of speech patterns. w Mechanism of Action: Block dopamine receptors w Side effect- Tardive dyskinesia w Examples: Thorazine Promazine

47. Dopamine antagonists

48. +/- of Antipsychotic Drugs While these drugs reduce the overall brain activity, they do not simply put the patient in a trance. Instead they reduce the “positive” symptoms of psychosis. Unfortunately, long-term use can cause problems like tardive dyskinesia, which produces an uncontrollable disturbance of motor control, especially in the facial muscles.

49. Positive and Negative Categories Often times, researchers now simply characterize symptoms of schizophrenia into positive and negative categories. Positive symptoms refer to active process such as delusions, and hallucinations while negative symptoms refer to passive processes like social withdrawal.

50. Antidepressant Drugs There are three major classes of antidepressant drugs, and all three work by “turning up the volume” on messages transmitted over certain brain pathways, especially those using norepinephrine and serotonin. The major downside of these drugs is that it often takes a few weeks for them to have an effect.

51. Pharmaceutical Treatment of Mental Illness- Antidepressants Antidepressant Drugs w Function: to decrease symptoms of depression w Classes of Drugs Tricyclics: Increase availability of norepinephrine and serotonin by blocking reuptake Ex: Elavil, Nortriptyline MAO Inhibitors: Increase availability of the monoamines by blocking the function of the enzyme that degrades them after their release into the synapse Ex: Phenelizine, Tranylcypromine Selective Serotonin Reuptake Inhibitors: Increase availability of serotonin by blocking reuptake Ex: Prozac, Zoloft, Paxil Mood stabilizer (bipolar)- Lithium

52. Reuptake blockers

53. Biomedical Therapies: SSRIs

54. Antianxiety Drugs Antianxiety drugs most commonly fall into two categories: barbiturates and benzodiazepines. w Barbiturates act as a central nervous system depressant, so they have a relaxing effect. w Benzodiazepines work by increasing the activity of certain neurotransmitters.

55. Pharmaceutical Treatment for Mental Illness- Antianxiety Drugs Antianxiety Drugs w Function: reduce the symptoms of anxiety. w w Mechanism of Action: Increase the effectiveness of GABA in the brain, lowering the CNS activity w Examples: Valium Librium Xanax

56. Stimulants Stimulants is a broad category that includes everything from caffeine to nicotine to amphetamines to cocaine-they are any drugs that produce excitement or hyperactivity. These drugs are prescribed for a variety of disorders including narcolepsy and ADHD.

58. Truth About Drugs w Cannot cure any mental illness w Can alter the brain to suppress some symptoms w Can have negative long term effects w Can be habit forming w Often over prescribed

59. Biomedical Therapies w The emptying of U.S. mental hospitals Introduction of antipsychotic drugs Rapid decline in the mental hospital population 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 Year 700 600 500 400 300 200 100 0 State and county mental hospital residents, in thousands

60. Biomedical Therapies Psychosurgery – surgery that removes or destroys brain tissue in an effort to change behavior – lobotomy Egas Moniz developed the lobotomy in the 1930s. Now-rare psychosurgical procedure once used to calm uncontrollably emotional or violent patients Electroconvulsive Therapy (ECT) – therapy for severely depressed patients in which a brief electric current is sent through the brain of an anesthetized patient

61. Biomedical Therapies w Electroconvulsive Therapy

62. Biomedical Treatments-ECT w Electroconvulsive Therapy: the application of electrical current to the head to induce a generalized seizure w Historical Use: ECT was first used to treat schizophrenia, today, it is used to treat severe depression that does not respond to antidepressant therapy. w Current Use: Patients are placed under general anesthesia and given muscle relaxants to prevent bodily damage due to convulsions w Mechanism of Action: While unknown, it may be that it increases the availability of a number of critical neurotransmitters

63. Biomedical Treatments- Psychosurgery w Historical Use: Prior to the 1950’s, psychosurgery was broadly used for a number of disorders without any scientific evidence of its effectiveness. w Present Use: It is currently an extremely rare procedure, used only as a last resort to treat severe depression, OCD, or severe aggressive behaviors. When it is used the lesions created in the brain are much smaller and more controlled by intricate surgical procedures.

64. Psychotherapy Effectiveness w Clients’ perceptions w Clinicians’ perceptions w Control group problems w Regression toward the mean w Meta-analysis 80% better than no treatment w NIMH 50% vs 29% w One in four psycho, one in six drug 18mon

65. The Munchel Therapy to cure all of your ills: w Stop focusing on yourself. w Do something to help someone else. w Know that the good life is about solving your own problems, not blaming someone because you have them. w Most people’s bad lives are self-induced. w Don’t revisit the past – you can’t change it. w Smile and fool your brain everyday.