1. Approaches and Outcomes
Treatment
Approaches and Outcomes

2. Overview Brief History Psychological Treatments Biomedical Treatments
Client-Therapist Relationship
Is Treatment Effective?

3. 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

4. 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

5. 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

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

7. 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

8. 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

9. 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?

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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?

17. 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

18. 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

19. Systematic Desensitization

20. 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

21. 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?

22. 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)

23. 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

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

25. Client-Therapist Relationship
Therapeutic Alliance
Support
Trust
Hope
Understanding

26. 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

27. Biological Treatments
Pharmacological treatments (drugs)
Not only helped treat patients, but also further understanding of the illness

30. 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

31. 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

32. Deinstitutionalization

33. 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

34. 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)

35. Antidepressants Downside Takes a while before effective (a month)
Trial-and-error
Side effects
Weight gain, nausea, diarrhea, insomnia, reduced sexual desire or response

36. 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

37. Anxiolytic Medications
Treat anxiety disorders
Increase neurotransmission of GABA
Beta Blockers
Benzodiazepines
Tricyclic Antidepressants and SSRIs
Generalized Anxiety Disorders, panic attacks, PTSD

38. 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

39. 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

40. 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

41. Combined Treatments Most therapists use a combination of treatments
Drug treatments for short-term effects
Therapy for long-term effects

42. 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

44. Is therapy effective?
A meta-analysis found that 80% of patients who received treatment fared better than those without
comparing results of 475 studies

45. Are all Therapies Equally Effective?

46. 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

47. 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!

48. 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?

49. Who is most likely to benefit from treatment?
Strong alliance with therapist
Shop around!
Motivated
Optimistic
More effective with more therapy

50. 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)

51. 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

52. 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!

53. What’s Missed in This Account
Interpersonal Aggression: Killings
Inter-societal Aggression: War

55. Roots of Aggression
Two Theories

56. 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!

57. 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

58. 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!