History of Therapy

  • People with mental illnesses had few treatment options - most of the time placed in hospital.
  • Early ‘insane asylums’ were similar to prisons, little treatment (ship of fools - literally placed on a ship and sent out).
  • Blood letting, spinning chairs, etc. were used to control behavior
  • Sometimes would see trephining - drilling holes in peoples heads to promote the release of evil spirits.
  • Pioneers in humane care of patients: Pinel, Dorothea Dix
  • 20th century - psychological and physiological breakthroughs.
    • Hysteria (today, conversion disorder) - symptoms could be treated with hypnosis - Psychological breakthrough
    • General Paresis (today, syphilis) - bacteria that could be treated with medications - physiological breakthrough

Whom people seek help from

Family, friends, clergy 34.6%, family doctors 16.1%, self-help and support groups 13.6%, mental health professionals 35.8% (marriage counselors 9%, social workers 14%, psychiatrists 22%, psychologists 37%, others 18%)

 

Types of therapists

•         Psychiatrist – MD, 3 yr. residency, write meds.

•         Psychologist – PsyD, PhD, EdD, training and internship, licensed

–        Clinical, counseling, school

Other licensed therapists in GA – LCSW, LPC, MFT (master’s degree)

Others may call themselves a therapist, but not necessarily have any training

 

Psychoanalysis

  • Freud’s Psychoanalysis - ‘talking cure’
  • Childhood conflicts repressed in unconscious lead to psychological symptoms., Insight leads to catharsis (emotional release) and change.
  • Free Associations - Patient says whatever comes to mind, regardless of how trivial or irrelevant it seems, Clues about the content of unconscious will be revealed (Dreams - manifest vs. latent).

Techniques of Psychoanalysis

  • Interpretation - Therapist clarifies the importance of patient’s experience, pieces together the free associations, explains meaning, helps gain insight into thoughts and behaviors
  • Resistance - Patient’s reluctance to focus on certain experiences or emotions
  • Transference - The patient reacts to the therapist in the same way that he/she reacts to other important people.

Classical Conditioning Therapies

  • Behavior therapies – eliminate maladaptive behavior and replace with more adaptive response (not looking for underlying cause)
  • Systematic Desensitization - Client learns to relax in presence of phobic object
  • relaxation technique, use through gradual series of anxiety producing situations
  • Aversion Therapy - Pair an unpleasant stimulus (UCS) with a stimulus (CS) that leads to an inappropriate, socially unacceptable or unpleasant response.
  • Aversion therapy for alcoholics, UC Antabuse, CS alcoholic beverage, UR nausea to Antabuse, CR nausea to beverage

Operant Conditioning Therapies

  • Positive Reinforcement - Reward desirable behavior
  • Token Economy Good behavior earns tokens that individuals use to ‘purchase’ things they want.
  • Behavior modification – identify target behavior, count number of times occur, find out what works to help change behavior
  • Extinction- Remove reinforcer and behavior stops.
  • Using extinction and reinforcement to reduce delusional speech in schizophrenics

Participant modeling- appropriate response modeled in graduated steps and client attempts each step, encouraged and supported by the therapist

Cognitive Therapies

  • Rational-Emotive Behavior Therapy (Ellis)
  • Challenge irrational beliefs.
  • Replace negative or maladaptive thoughts with less harsh thoughts.
    • "I never do anything right!" to "Just like everyone else, I do some things well."

ABCs of rational-emotive therapy - Activating event (letter of rejection from graduate school), beliefs (I must succeed at everything I do), consequences (Depression and feelings of incompetence)

Beck’s cognitive behavior therapy – is designed to change cognitive tendencies (e.g. distorted thinking) that contributes to depression, such patterns of thought often produce negative affect (mood), which then increases the likelihood of further negative thoughts. Cognitive behavior therapy attempts to break this cycle

·        illogical ideas – tendency to over generalize setbacks, explain away positive outcomes or experiences, magnify the importance of negative events

·        Negative affect

·        negative thoughts, memories, and ideas

·        depression

·        Beck’s therapy focuses on this kind of thinking

Humanistic Therapies

  • Assume people have ability and freedom to lead rational lives and make rational choices
  • Person-centered Therapy (Rogers)
  • Promote self understanding and acceptance.
  • Nondirective – facilitate growth rather than actively directing course of therapy
  • People are innately good and will grow toward self-actualization (realization of inner, fullest potential)
  • Promote self understanding and acceptance.
  • Empathy, Genuineness, Unconditional Positive Regard
  • Show warmth and caring for the client.
  • Accept the client no matter how they behave.

Types of therapists – Humanistic 12.5%, Cognitive-behavioral 12.1%, Behavioral 6.8%, psychoanalytical 14.7%, other 12.8%, eclectic (use a variety of therapies) 41.2%

Social-Relations Orientation: Group Therapies

  • Several clients meet together
  • Why? –
  • usually cheaper
  • interact with others
  • gain social support (more information and life experiences, hope for future)
  • Behavioral Group Therapies - Practice new behavior with other group members, Social Skills, Assertiveness Training
  • Self help groups – usually not led by a therapist, just share common problem and meet to receive support
  • Encounter Groups Open expression of intense emotions. - focus on self-awareness, promote personal growth

Marriage and Family Therapy

  • Family Therapy - Family learn to express emotion and provide feedback to each other. Family unit is treated as a client
  • Marriage Therapy
  • communication - how to listen to one another and express feeling
  • conflict management - how to handle problems
  • how to handle feelings - depression, anger

Combination of treatments for schizophrenia

Family training plus social skills training, better than just family treatment or social skills alone, better than control

 

How long before see improvement?
8 weeks 50%, 26 weeks 75%, 52 weeks 80%

Takes a while, but then problem has been around for a while 
 

Biopsychological Treatments: Psychosurgery

  • Destroy brain tissue to alter behavior, Used with violent or agitated patients.
  • Prefrontal lobotomy - Separate parts of frontal lobes from rest of brain.
  • Side effects:
  • Apathy, withdrawal
  • Lack of goal directed behavior
  • Difficulty learning new material.

Biopsychological Treatments: Electroconvulsive Therapy (ECT)

  • Current use of ECT
  • Brief, electrical current - 30 second seizure.
  • Electrodes attached to non-dominant hemisphere (right)
  • Loss of consciousness 30 - 60 minutes
  • Side effects - confused & disoriented, headache, memory loss.
  • Used mostly for depression treatment failures.
  • Works faster than anti-depressants.
  • Why improvement unknown.

Introduction of antipsychotic drugs – mid 1950s, sharp decrease in resident patients

 

Biopsychological Treatments:
Anti-anxiety Drugs

  • Minor tranquilizers – most prescribed psychoactive drugs
  • anxiety disorders, sleeping pills
  • decreases activity of CNS
  • Benzodiazepines - Xanax, Valium, Librium
  • Side effects:
  • Sleepiness, depression, dependence
  • Potential withdrawal symptoms: Anxiety, agitation, irritability, insomnia, relapse


Antidepressant Drugs

  • Depression, eating disorders, panic, OCD, generalized anxiety, social phobia.
  • Must build up to therapeutic level – can take weeks
  • MAO Inhibitors - Nardil, Parnate
  • Block enzyme that breaks down Norepinephrine & Serotonin.
  • Side effects: Potentially dangerous high blood pressure when eating foods containing tyramine.
  • Tricyclics -Tofranil, Elavil
  • Prevent reuptake of norepinephrine & serotonin.
  • Side effects - Constipation, dry mouth, weight gain, nervousness
  • Selective Serotonin Reuptake Inhibitors (SSRIs) -Prozac, Zoloft
  • Prevent reuptake of serotonin.
  • Side effects:Loss of sexual desire, hypomania, nausea, insomnia.

Antimania Drugs

  • Lithium Carbonate
  • Evens out the highs/lows of Bipolar Disorder
  • Affects dopamine, achetocholine, serotonin, norepinephrine
  • Side effects: hand tremors, memory impairment, thirst
  • Toxic in high doses - Seizures, brain damage, irregular heartbeat
  • May need to use indefinitely
  • Some anticonvulsive drugs may work as well


Antipsychotic Drugs

  • Major tranquilizers - schizophrenia
  • Phenothiazines - Thorazine, Haldol, Mellaril
  • Reduce psychotic symptoms (both positive and negative)
  • Hallucinations, delusions, agitation, thought disorder.
  • Believed to block dopamine receptors.
  • Not a cure - maintained on medication long term.

Side Effects of Antipsychotic Drugs

  • Minor - Dry mouth, sleepiness, problems with coordination.
  • Major - Tardive dyskinesia - Severe neurological disorder, Facial tics, tongue protrudes, hand wringing
    • No cure but can be treated with other drugs
  • Clozapine
  • Newer Antipsychotic
  • Fewer side effects but higher cost.

Problem with drugs

  • Placebo effect
  • Dropout rates
  • Dosage problems
  • Long term risks

Is psychotherapy effective?

  • Psychotherapy leads to more improvement than no therapy but no particular therapy is more effective than any other.
  • NIMH Depression Treatment Study
    • Compared cognitive therapy, short term psychodynamic therapy, and drug therapy.
    • All treatments effective for more patients than placebo.
      • Drug therapy worked more quickly than psychotherapy.

Why go to therapy:

•         Is your distress level intense enough that you want to do something about it

•         Do you feel unable to handle your problems

•         Is your distress affecting your personal life, family and/or work?

 

•         Confidentiality – unless client suicidal, goes to court & uses mental condition as part of defense, therapist defends against patient in malpractice lawsuit, sexual or physical abuse of child or elder, client suggest will commit violent act

•         Can’t have sex with client (unlike movies) or others close to client

•         No prejudice or cultural ignorance on part of therapist