1. Treating Psychological Disorders
Chapter 15

2. Who Seeks Treatment? 15% of U.S. population in a given year
4.5 million people
Most common presenting problems
Anxiety and Depression
Demographics
Women more than men
Education level
Barriers to Treatment
Medical insurance
According to the recent U.S. Surgeon General’s report on mental health (1999), about 15% of the population uses mental health services in a given year.
The two most common presenting problems are anxiety and depression.
People vary considerably in their willingness to seek treatment, with women more likely to seek help than men, and people with higher educational levels doing so more frequently. Medical insurance is also related to treatment-seeking; having it increases the likelihood.
Many people who need help don’t seek it, and the Surgeon General reports that the biggest roadblock is the “stigma surrounding the receipt of mental health treatment."

3. Who Provides Treatment?
Clinical psychologists
Counseling psychologists
Psychiatrists
Clinical social workers
Psychiatric nurses
Counselors
There are a variety of “helping professions” available:
Psychologists who provide psychotherapy may have degrees in clinical or counseling psychology, specializing in the diagnosis and treatment of psychological disorders and everyday behavioral problems.
Both types must earn a doctoral degree (Ph.D., Psy.D., or Ed.D.), which requires 5-7 years beyond a bachelor’s degree. Admission to Ph.D. programs in clinical psychology is very competitive, about like getting into medical school.
Psychiatrists are medical doctors who specialize in the diagnosis and treatment of psychological disorders.
They are, at present, the only psychotherapy administering profession to be able to prescribe drugs, although psychologists are lobbying for prescription rights (given appropriate training).
Clinical social workers generally have a master’s degree and are increasingly providing a wide range of therapeutic services as independent practitioners.
Psychiatric nurses may hold a bachelor’s or master’s degree and often play a large role in hospital inpatient treatment.
Counselors are usually found working in schools, colleges, and assorted human service agencies. They typically have a master’s degree and often specialize in specific areas, such as vocational or marital counseling.

4. Types of Treatment Psychotherapy Insight therapies Behavior therapies
“talk therapy”
Behavior therapies
Changing overt behavior
Biomedical therapies
Biological functioning interventions
Psychotherapy is used in the text in its broadest sense, to refer to all the diverse approaches used in the treatment of mental disorder and psychological problems.
Many different treatment methods are used, and experts estimate that there may be over 400 different approaches to psychotherapy, although approaches to treatment can be classified into three major categories.
Insight therapy involves pursuing increased insight regarding the nature of the client’s difficulty and sorting through possible solutions.
Behavior therapy is based on the principles of learning, with behavior therapists working to alter maladaptive habits and change overt behaviors.
Biomedical therapies involve interventions to alter a person’s biological functioning.

5. Psychoanalysis
Focuses on uncovering unconscious conflicts resulting from fixations at early developmental stages
Uses techniques such as...
Free association
Dream analysis
Interpretation
To minimize
Resistance
and facilitate
Transference
Goal is to rebuild personality
Insight therapies involve verbal interactions intended to enhance clients’ self-knowledge and thus promote healthful changes in personality and behavior.
Psychoanalysis is an insight therapy that emphasizes the recovery of unconscious conflicts, motives, and defenses through a variety of techniques.
Freud believed that inner conflicts among the id, ego, and superego (usually over sexual and aggressive impulses) cause problems and that defense maneuvers on the part of the ego often lead to self-defeating behavior and are only partially successful.
Freud believed that the groundwork for depression was laid in the oral stage of childhood. In this stage the child depends on others for gratification of needs. Undergratification or overgratification results in fixation at the oral stage. Because of this fixation, the person supposedly grows up being overdependent on others for the maintenance of self‑esteem (Davison & Neale, 1998).
Freud noted similarities between depression and mourning. Both occur after losing a loved one, and both often combine feelings of anger (“Why did you have to leave me?”) and grief. Through the process of introjection, a depressed person first brings the image of the lost one inward (identification) and then directs the anger inward so that depression represents anger turned inward (Nevid, Rathus, & Greene, 2003).
Psychoanalytic therapy for depression is aimed at reducing the stress of the loss and developing better ways of responding for the future (Holmes, 2001). In particular, psychoanalysis seeks to uncover the ambivalent feelings about the loss. If the anger can be uncovered and directed outward, the person will exhibit more effective coping behavior in the future (Nevid et al., 2003). Classical psychoanalytic treatment for depression probed the unconscious for the basis of the fixation in the oral stage. Once this problem was identified, the patient’s dependence on others would be alleviated.
In free association, clients spontaneously express their thoughts and feelings exactly as they occur, with as little censorship as possible. The analyst looks for clues about what is going on in the unconscious.
Dream analysis involves the therapist interpreting the symbolic meaning of the client’s dreams. Freud called dreams the “royal road to the unconscious."
Interpretation refers to the therapist’s attempts to explain the inner significance of the client’s thoughts, feelings, memories, and behaviors.
Resistance refers to the largely unconscious defensive maneuvers intended to hinder the progress of therapy.
Transference occurs when the clients unconsciously start relating to their therapist in ways that mimic critical relationships in their lives.
However, the classical approach could take years. In the meantime, the depression would probably dissipate. A modern psychodynamic therapy would probably be better suited to dealing with depression, as it is designed to work more quickly. For example, the client might be encouraged to give up on the lost person or the disappointing experience and to establish new relationships or goals that the ego is more likely to deal with in a constructive manner.

6. Client-Centered Treatment
Believes disorders result from incongruence between self-concept and reality or dependence on acceptance from others.
Uses techniques such as
Unconditional positive regard
Empathy
Genuineness
Reflection
Goal is to increase client self-acceptance (minimize incongruence)
Using a humanistic perspective, Carl Rogers developed Client-centered therapy in the 40s and 50s.
Client-centered therapy is an insight therapy that emphasizes providing a supportive emotional climate for clients, who play a major role in determining the pace and direction of their therapy.
Rogers maintained that most personal distress is due to incongruence between a person’s self-concept and reality. The goal of therapy involves helping people restructure their self-concept to correspond better to reality.
Rogers held that there are 3 main elements to creating this atmosphere: genuineness, or the therapist being completely honest and spontaneous with the client; unconditional positive regard, or a complete nonjudgmental acceptance of the client as a person; and empathy, an understanding of the client’s point of view.

7. Behavioral Therapies
Believe disorders are maladaptive patterns of behavior that have been learned.
Use techniques such as
Conditioning (Classical & Operant)
Aversion
Systematic Desensitization
Social Skills Training
Biofeedback
To eliminate maladaptive behavior and replace with adaptive behavior.

8. Behavior Therapies B.F. Skinner and colleagues
Goal: unlearning maladaptive behavior and learning adaptive ones
Systematic Desensitization – Joseph Wolpe
Classical conditioning
Anxiety hierarchy
Aversion therapy
Alcoholism, sexual deviance, smoking, etc.
Behavior therapies involve the application of learning principles to direct efforts to change clients’ maladaptive behaviors.
Behavior therapies are based on the work of B.F. Skinner, assuming that behavior is a product of learning, and that what is learned can be unlearned.
Joseph Wolpe (1958) developed a therapy called systematic desensitization to reduce phobic clients’ anxiety responses through counterconditioning. Systematic desensitization involves 3 steps: the therapist first helps the client build an anxiety hierarchy (a ranked list of anxiety-arousing stimuli); next, the client is trained in deep muscle relaxation; finally, the client tries to work through the hierarchy, learning to remain relaxed while imagining each stimulus. The basic idea is that you cannot be anxious and relaxed at the same time. Research shows that this technique is very effective in treating phobias.
Aversion therapy is the most controversial of the behavior therapies, where an aversive stimulus is paired with a stimulus that elicits an undesirable response. Alcoholics, for example, have had emetic drugs paired with their favorite drinks, with the subsequent vomiting creating a conditioned aversion to alcohol. This technique has been used with alcohol and drug abuse, sexual deviance, smoking, shoplifting, gambling, stuttering, and overeating.

9. Figure 15.7 The logic underlying systematic desensitization

10. Behavior Therapy B.F. Skinner and colleagues Social skills training
Modeling
Behavioral rehearsal
Social skills training is a behavior therapy, designed to improve interpersonal skills, that emphasizes modeling, behavioral rehearsal, and shaping.
In biofeedback, a bodily function is monitored, and information about the function is fed back to the person so that they can develop more control over the physiological process.

11. Cognitive-Behavioral Therapy
Aaron Beck
Cognitive therapy
Believe disorders result from irrational assumptions and negative, self-defeating thoughts.
Use techniques such as
Thought stopping
Recording automatic thoughts
Refuting negative thinking
Reality testing
Homework
Goal is to detect negative, irrational thinking and replace with realistic thinking
Cognitive theory applied to abnormal behavior is probably best known for its use in treating depression.
Aaron Beck, the leading proponent of cognitive therapy, believes that depression is the result of negative thinking.
As specific examples of cognitive errors, Davison and Neale (1998) listed arbitrary inference and minimization.
Arbitrary inference refers to drawing an inference when there is insufficient evidence or no evidence to do so. For example, you conclude that you are worthless because it is raining on a day that you had planned to have a picnic.
Minimization refers to discounting oneself in performance evaluation. For example, despite numerous accomplishments that attract praise and commendation, you continue to believe that you are worthless.
Hamilton and Abramson (1983) did demonstrate that depressed individuals have more negative cognitions than nondepressed patients or normal people. Holmes (2001) cited research that has also shown depressives are more likely to recall negative information from their past (failures, being left out, being criticized).
The basic goal of cognitive therapy is to change the negative cognitions of the depressed individual. Holmes (2001) identified three steps in this process:
The therapist identifies the negative beliefs that are influencing the person’s behavior and mood. The therapist challenges the person to test those cognitions.
The cognitions are actually tested. For example, if the patient says “No one likes me,” the therapist collects data on this statement.
The negative thoughts are replaced with more accurate cognitions. For example, the patient should think such thoughts as “I am not perfect, but others are not either. Other people will still like me even if I am not perfect.”
The third step is not easy, and it may take some time to get the client to preempt the negative thoughts from automatically coming to mind. The therapist and patient often work together to plan activities that are congruent with these new thoughts in order to provide confirmation of the new belief system. Eventually, patients become self‑sufficient in monitoring their cognitions and ensuring that they are realistic. Many studies have demonstrated that cognitive therapy for depression is as effective as other approaches (Holmes, 2001).

12. Cognitive-Behavioral Therapy
Martin Seligman
Learned helplessness and depression
Difficult to establish helplessness-depression link
A second cognitive theory of depression revolves around learned helplessness.
Seligman’s research shows that animals that learn they cannot control their consequences seem to give up and fail to learn in a later situation in which they can control the consequences. Seligman (1975) hypothesized that people who believe that they cannot control the consequences in their lives become depressed. Rather than blaming themselves, as in the first cognitive theory described here, they feel that events are uncontrollable.
In one of the studies that established the learned helplessness paradigm, Seligman and Maier (1967) divided dogs into three groups. The first two groups consisted of "yoked pairs." That is, one dog of each pair received an electric shock that it could terminate, and the other dog in each pair received the same shock. To this second dog, the shock seemed to stop at random, because it was the first dog that was ending the shock. The dogs with no control over the shocks were said to receive "inescapable shock." The third group of dogs were control subjects who received no shock in this phase of the experiment.
Next, all three groups were tested in a shuttle-box apparatus, in which the dogs could escape electric shock by jumping over a partition. The only dogs that tended to perform poorly in the shuttle-box were those that had received inescapable shock in the pre-treatment phase of the experiment. They did not try to escape, but rather passively accepted the painful shocks. Dogs in the control group, as well as dogs that had been pre-treated with controllable shock, tended to jump over the partition and escape the shocks. Since the dogs which had experienced escapable shock behaved in the same manner as the control dogs, Seligman and Maier claimed to have demonstrated that it was the perceived inescapability of the shocks, and not the shocks alone, which explained the passive behavior.
Learned helplessness can easily be demonstrated in humans, but its hypothesized link to depression has been difficult to demonstrate (Holmes, 2001). Such problems forced Seligman to rethink his ideas about helplessness and depression.

13. Cognitive-Behavioral Therapy
Martin Seligman
Explanatory style
a person’s habitual way of explaining events, typically assessed along three dimensions: internal/external, stable/unstable, and global/specific
Abramson, Seligman, and Teasdale (1978) reformulated the theory to focus on attributions for failure rather than merely on the failure itself because some research had shown that helplessness actually resulted in facilitated performance (Davison & Neale, 1998).
A global, stable, internal attributional style is thought to be more likely to lead to depression. Some evidence does support the idea that this attributional style leads to depression, but the verdict is not unanimous.
Explanations for behavior typically focus on 3 dimensions:
Internal/External – our tendency to explain behavior as resulting from dispositional (personality) or situational factors
Stable/Unstable – our tendency to see the cause of behavior as constant or fluctuating (e.g., performing poorly on a test)
Stable attribution – “I’m too stupid to understand the material.”
Unstable attribution – “That particular test was extremely difficult.”
Global/Specific – “I’m no good” vs. “I’m no good at math”
When it comes to attributions about negative events:
Pessimistic style – global, internal, stable
Optimistic style – specific, external, unstable
Looked at life insurance sales persons (Correlational study)
Difficult job
Nearly 80% of people do not make it through 1 year
Developed Attribution Style Questionnaire (ASQ)
Researchers coded responses as either pessimistic (scoring low) or optimistic (scoring high)
Results showed optimistic employees more likely than pessimistic employees to remain at MetLife
Practical application – use personality characteristic of optimism for hiring
Looked at the relationship between attributional style and health/longevity.
Followed soldiers who returned from WWII
Upon return soldiers given full physical and psychiatric exam
Repeated every 5 years
Couldn’t use ASQ – it didn’t exist
Used answers from psych exam to determine optimism/pessimism
People who were deceased when Seligman did the study tended to have global, stable, internal attributions for negative events (pessimism)
People who were alive and healthy had specific, unstable, external attributions for negative events (optimism)
Examined correlations between explanatory styles and health, controlling for initial health (See table)
Not correlation when young (not much variability in health)
Relationships appears later when variations in health start to appear (optimism positively related to health)
Variations were related to explanatory style
At this time, it is not clear whether the helplessness/attribution model of depression is viable or not. Should it prove to be predictive of depression, the therapeutic approach should be modeled closely after Beck’s approach, in which negative attributions are identified, tested, and replaced.
Of the two cognitive models of depression, the one that is currently more viable revolves around the individual’s typical negative bias in processing information. However, therapy aimed at changing the cognitive patterns of the individual is effective in either case.

14. Biomedical Therapies

15. Biomedical Therapies Psychopharmacotherapy
Antianxiety - Valium, Xanax, Buspar
Antipsychotic - Thorazine, Mellaril, Haldol
Tardive dyskinesia
Clozapine
Antidepressant:
Tricyclics – Elavil, Tofranil
Mao inhibitors (MAOIs) - Nardil
Selective serotonin reuptake inhibitors (SSRIs) – Prozac, Paxil, Zoloft
Biomedical therapies are physiological interventions intended to reduce symptoms associated with psychological disorders. They assume that these disorders are caused, at least in part, by biological malfunctions.
Psychopharmacotherapy is the treatment of mental disorders with medication…drug therapy.
Drugs used to treat psychological disorders fall into 3 major categories, antianxiety, antipsychotic, and antidepressant. Mood stabilizers do not fit well into any of these categories, but they are very important drugs in the treatment of bipolar disorder.
Antianxiety drugs relieve tension, apprehension, and nervousness.
Antipsychotic drugs are used to gradually reduce psychotic symptoms, including hyperactivity, mental confusion, hallucinations, and delusions. Antipsychotic drugs appear to decrease activity at dopamine synapses, sometimes producing unfortunate side-effects such as symptoms of Parkinson’s disease and tardive dyskinesia, an incurable neurological disorder marked by involuntary writhing and ticklike movements of the mouth, tongue, face, hands, or feet.
Newer drugs, which have a different mechanism of action, such as clozapine, have fewer motor side effects but are not risk free.

16. Figure 15.12 Antidepressant drugs’ mechanisms of action

17. Biomedical Therapies Psychopharmacotherapy
Mood stabilizers
Lithium
Valproic acid
Electroconvulsive therapy (ECT)
Biomedical therapies are physiological interventions intended to reduce symptoms associated with psychological disorders. They assume that these disorders are caused, at least in part, by biological malfunctions.
Psychopharmacotherapy is the treatment of mental disorders with medication…drug therapy.
Drugs used to treat psychological disorders fall into 3 major categories, antianxiety, antipsychotic, and antidepressant. Mood stabilizers do not fit well into any of these categories, but they are very important drugs in the treatment of bipolar disorder.
Antianxiety drugs relieve tension, apprehension, and nervousness.
Antipsychotic drugs are used to gradually reduce psychotic symptoms, including hyperactivity, mental confusion, hallucinations, and delusions. Antipsychotic drugs appear to decrease activity at dopamine synapses, sometimes producing unfortunate side-effects such as symptoms of Parkinson’s disease and tardive dyskinesia, an incurable neurological disorder marked by involuntary writhing and ticklike movements of the mouth, tongue, face, hands, or feet.
Newer drugs, which have a different mechanism of action, such as clozapine, have fewer motor side effects but are not risk free.
Antidepressants gradually elevate mood and help bring people out of a depression. The 3 major classes of antidepressant drugs are listed on the slide. Today, the SSRIs are the most frequently prescribed.
Lithium is a chemical used to control mood swings in patients with bipolar mood disorders; it is very successful at preventing future episodes of mania and depression, but it can be toxic and requires careful monitoring.
Electroconvulsive therapy (ECT) is a biomedical treatment in which electric shock is used to produce a cortical seizure accompanied by convulsions. While the use of ECT peaked in the 40s and 50s, there has been a recent resurgence in this therapy.

18. Current Trends and Issues in Treatment
Managed care
Empirically validated treatments
Blending Approaches to treatment
Multicultural sensitivity
Deinstitutionalization
Revolving door problem
Homelessness
Many clinicians and their clients believe that managed care, or health-care systems that involve pre-paid plans with small copayments that are run by health maintenance organizations (HMOs), is negatively impacting psychological care. Managed care involves a tradeoff: consumers pay lower prices but give up freedom to choose providers and obtain whatever treatments they believe necessary. Further, in the mental health domain, the question of what is “medically necessary” is more ambiguous.
One response to the demands of managed care has been to increase research efforts to validate the efficacy of specific treatments for specific problems. While this seems to be a step in the right direction, there are concerns in some quarters primarily regarding the inability of empirical studies to capture the complexity of the real world or the flexibility with which therapists must practice their craft. Some argue that the movement toward empirically supported treatment runs counter to the eclectic blending of therapeutic approaches, which current studies suggest has merit.
Combinations of insight, behavioral, and biomedical therapies are often used today in the treatment of psychological disorders, as many modern therapists are eclectic.
The highly-culture bound origins of Western therapies have raised doubts about their applicability to other cultures and even ethnic groups in Western society.
Deinstitutionalization refers to the movement away from inpatient treatment in mental hospitals to more community based treatment. The negative effects of mental hospitals have fueled this movement, as has the ability to treat serious mental problems with effective drug therapy, and long-term hospitalization for mental disorders is largely a thing of the past.
Unfortunately, many people with serious mental problems receive short-term inpatient treatment, are sent back to communities that aren’t prepared to provide adequate outpatient care, and end up back in inpatient treatment; the revolving door problem. Some researchers argue that this has significantly increased homelessness, while others see the homelessness problem as primarily an economic one.