Treatment - a summary of chapter 17 of Psychology by Gray and Bjorklund (7th edition)

Psychology
Chapter 17
Treatment

Care as a social issue

What to do with individuals with severe mental disorders? A brief history

A major chance in the treatment of people with severe mental disorders occurred in the 1950s, inspired by several factors;

• Increase in the number of Ph.D. programs in clinical psychology to train psychologist to treat the mental health problems of World War II veterans.
• Disenchantment with large state institutions
• The development of antipsychotic drugs

A positive development: assertive community treatment

Since the 1970s, an increasing number of communities have developed outreach programs, often referred to as assertive community treatment (ACT) programs, and aimed at helping individuals with severe mental illness wherever they are in the community.
Each person with mental illness in need is assigned to a multidisciplinary treatment team. Someone on the team is available at any time of the day to respond to crises.
Each patient is visited at least twice a week by a team member, who checks on his or her health, sees if any services are needed, and offers counseling when that seems appropriate.
The team meets frequently with family members who are involved with the patient, to support them in their care for the patient.

Structure of the mental health system

Mental health professionals

Mental health professionals are those who have received special training and certification to work with people who have psychological problems or mental disorders.
The primary categories;

• Psychiatrists
• Clinical psychologists
• Counseling psychologists
• Counselors
• Psychiatric social workers
• Psychiatric nurses

Biological treatments

Relieve the disorder by directly altering bodily processes.

Drugs

Drugs for mental disorders are far from unmixed blessings.
They nearly always produce undesirable side effects.

Antipsychotic drugs

Used to treat schizophrenia and other disorders in which psychotic symptoms predominate.
Such drug reduce and in some cases abolish the hallucinations, delusions, and bizarre actions that characterize the active phase of schizophrenia and they reduce the need for hospitalization.
All antipsychotic drugs in use today decrease the activity of the neurotransmitter dopamine at certain synapses in the brain, which is believed to be responsible for the reduction in psychotic symptoms.

Two classes:

• Typical antipsychotics
  The first developed
• Atypical antipsychotics
  Newer. Also effect receptors for other neurotransmitters such as serotonin.

All antipsychotic drugs have unpleasant and damaging side effects.

• Dizziness, confusion, nausea, dry mouth, blurred vision, heart rate irregularities, constipation, weight gain, heightened risk for diabetes, sexual impotence in man, disrupted menstrual cycles in women.
  They also interfere with motor-control processes in the brain.

Antianxiety drugs

Used primarily to treat anxiety. Commonly referred to as tranquilizers.
Produce effect by augmenting the action of the neurotransmitter GABA in the brain.
GABA is the brain’s main inhibitory neurotransmitter. So its increased action decreases the excitability of neurons almost everywhere in the brain.

Side effects at high doses:

• Drowsiness, a decline in motor coordination, a consequent increase in accidents.
  It enhance the action of alcohol.
  They are moderately addictive.

Questionable effectiveness.

Antidepressant drugs

Tricyclics
Block the normal reuptake of the neurotransmitters serotonin and norepinephrine into presynaptic neurons after their release. Thereby prolonging the action of the transmitter molecules on postsynaptic neurons.

Selective serotonin reuptake inhibitors (SSRI)
Block the reuptake of serotonin but not that of other monoamine transmitters.

Tricyclics and SSRIs are about equally effective in treating depression.

Antidepressants are less effective for people with mild or moderate depression.
SSRIs are preferred because of their milder side effects.
Tricyclics are much more likely to be fatal if taken in overdose and are more likely to produce disruptive side effects:

• Fatigue, dry mouth, blurred vision.
  In some people, the SSRIs do produce side effects:
• Like reduced sexual drive, headache, nausea and diarrhea.

The effects of antidepressant drugs on neurotransmitters occur immediately, but the antidepressant effects take several weeks to develop.
Some gradual process underlies the therapeutic effect.

Placebo effects

A placebo: an inactive substance that is indistinguishable in appearance from the drug.

Three different categories of effects through which people improve:

• Spontaneous remission effect
• Placebo effect
• Drug effect

Other biologically based treatments

Electroconvulsive therapy

Electroconvulsive therapy, or ECT, is used primarily in cases of severe depression that does not respond to psychotherapy or antidepressant drugs.

Today, ECT is administered in a way that is painless and quite safe.
Before receiving the shock, the patient is put under general anesthesia, and given a muscle-blocking drug so that no pain will be felt and no damaging muscle contradictions will occur.
Then an electric current is passed through the patient’s skull, triggering a seizure in the brain that lasts approximately 1 minute.
Usually such treatments are given in series, one every 2 or 3 days for about 2 weeks.

In some cases, the remission is permanent; in others, depression recurs after several months or more, and then another series of treatments may be given.

• The shock because immediate release of all varieties of neurotransmitters, followed by longer-lasting changes in transmitter production and in the sensitivity of postsynaptic receptors.
• The shocks also stimulate the growth of new neurons in the brain.

The most frequent side effect of ECT is memory loss, both retrograde amnesia and anterograde amnesia.
In most cases, the memory loss clears up within a few months of the treatment.

Psychosurgery, deep brain stimulation, and transcranial magnetic stimulation

A treatment of last resort.
Involves surgically cutting or producing lesions in portions of the brain to relieve a mental disorder.

Refined versions of psychosurgery where developed in 1960s and continue to be used in rare cases today.
They knew procedures involve destruction of very small areas of the brain by applying radiofrequency current through fine wire electrodes implanted temporarily into the brain.
This procedure is used primarily for treatment of highly incapacitating cases of obsessive-compulsive disorder that have proven, over many years, to be untreatable by any other means.
Obsessive-compulsive disorder is often associated with abnormal amounts of activity in a neural circuit that is involved in converting conscious thought into action. This circuit includes a portion of the prefrontal cortex, a portion of the limbic system called cingulum, and parts of the basis ganglia.
Surgical destruction either of a portion of the cingulum or of a specific neural pathway that enters the basal ganglia reduces or abolishes obsessive-compulsive symptoms in 50 percent of people who could not be successfully treated in any other way.

BUT

The procedure produce quite serious side effects in some patients

• Confusion, weight gain, depression, and in rare cases epilepsy

Deep brain stimulation
A hair-thin wire electrode is implanted permanently into the brain. This electrode can be activated in order to electrically stimulate the neurons lying near it.
Low-frequently stimulation through the electrode is believed to desynchronize and disrupt ongoing neural activity and in a way to have an effect comparable to producing a lesion.
This effect can be reversed just by turning off the electrical current.
Tries suggest it is as effective as psychosurgery, without the negative side effects.

Transcranial magnetic stimulation
A technician sends a pulse of electricity through a small copper coil, held just above a person’s head.
The magnetic field passes through the scalp and skull and induces an electric current in the neurons immediately below the coil.
When focused on the prefrontal cortex, changes in the activity of neurons reduces depression in some patients when it is administered daily over 2 to 4 weeks.

Psychotherapy I: psychodynamic and humanistic therapies

Psychotherapy: any theory-based, systematic procedure, conducted by a trained therapist, for helping people to overcome or cope with mental problems through psychological rather than directly physiological means.
Psychotherapy usually involves dialogue between the person in need and the therapist, and its aim is usually to restructure some aspect of the person’s way of feeling, thinking or behaving.

• The psychodynamic approach focuses on the idea that unconscious memories and emotions influence our conscious thoughts and actions.
• The humanistic approach focuses on the value of self-esteem and self-direction, and the idea that people often need psychological support from others in order to pursue freely their own chosen goals
• The cognitive approach focuses on the idea that people’s ingrained, habitual ways of thinking affect their moods and behavior.
• The behavioral approach focuses on the roles of basic learning processes in the development and maintenance of adaptive and maladaptive ways of responding to the environment.

Principles of psychodynamic therapies

The idea that unconscious conflicts, often deriving from early childhood experiences, underlie mental disorders.

Mental problems arise from unresolved mental conflicts, which themselves arise from the holding of contradictory motives and beliefs.
The motives, beliefs, and conflicts may be unconscious, or partly so, but they nevertheless influence conscious thoughts and actions.

Sexual and aggressive drives are particularly important, as these drives often conflict with learned beliefs and societal constraints.
Childhood is a particularly vulnerable period during which frightening or confusing experiences can produce lasting marks on a person’s ways of feeling, thinking and behaving.

The idea that patients’ observable speech and behavior provide clues to their unconscious conflicts

The disorder is buried in the person’s mind and must be unearthed before it can be treated.
To learn about the content of a patient’s unconscious mind, the psychodynamic therapist must analyze clues found in the patient’s speech and other forms of observable behavior.

The elements of thought and behavior that are least logical provide the most useful clues.
They represent elements of the unconscious mind that leaked out relatively unmodified by consciousness.
Sources:

• Free associations
• Dreams (but partly disguised)
  Latent content: they underlying unconscious meaning of the dream
  Manifest content: the dream as it is consciously experienced
• Mistakes and slips of the tongue

The roles of resistance and transference in the therapeutic process

Patients often resist the therapist’s attempt to bring their unconscious memories or wishes into consciousness.
The resistance may manifest itself

• Refusing to talk about certain topics
• Forgetting to come to therapy sessions
• Persistently arguing in a way that subverts the therapeutic process

Resistance stems from the general defensive processes by which people protect themselves from becoming conscious of anxiety provoking thoughts.
Resistance provides clues that therapy is going in the right direction.
To avoid triggering too much resistance, the therapist must present interpretations gradually, when the patient is ready to accept them.

Transference: the phenomenon by which the patient’s unconscious feelings about a significant person in his or her life are experienced consciously as feelings about the therapist.
With help from the analyst, the patient can gradually become aware of the origin of those feelings and their true target.

The relationship between insight and cure

Once conscious, the conflicting beliefs and wishes can be experienced directly and acted upon. Or, if they are unrealistic, modified by the conscious mind into healthier, more appropriate beliefs and pursuits.
At the same time, the patient is freed of the defenses that had kept that material repressed and has more psychic energy for other activities.
For all this to happen, the patient must truly accept the insights, viscerally as well as intellectually.

Principles of humanistic therapy

Each person must decide for him- or herself what is true and worthwhile in order to live a full, meaningful life. Meaning and purpose cannot be thrust upon a person from the outside.

Two fundamental ideas:

• People have the capacity to make adaptive choices regarding their own behavior, choices that promote their survival and well-being
• In order to feel good about themselves and to feel motivated to move forward in life, people need to feel accepted and approved of by others.

The humanistic view of the person emphasizes the inner potential for positive growth. The actualizing potential.
Of the self-actualizing potential to exert its effects, people must be conscious of their feelings and desires, not deny of distort them.
Denial and distortion occur when people perceive that others who are important to them consistently disapprove of their feelings and desires.

Client-centered therapy focuses on the abilities and insights of the client rather than those of the therapist.
The therapists must attend to his or her own thoughts and feelings, as well as to those of the client, in order to respond in a supportive yet honest way to the client.

The therapist lets the client take the lead in therapy, strives to understand and empathize with the client, and endeavors to think positively and genuinely of the client as a competent, valuable person.
Through this means, the therapist tries to help the client regain the self-understanding and confidence necessary to control his or her own life.

Allowing the client to take the lead

Humanistic therapists more often just paraphrase what the clients said, as a way of checking to be sure what they understood correctly.

Listening carefully and empathetically

Providing unconditional but genuine positive regard

Implies a belief on the therapist’s part that the client is worthy and capable even when the client may not feel or act that way.
By expressing positive feelings about the client regardless of what the client says or does, the therapist creates a safe, nonjudgmental environment for the client to explore and express all of his or her thoughts and
feelings.
Though experiencing the therapist’s positive regard, clients begin to feel more positive about themselves, an essential step if they are going to take charge of their lives.
It does not imply agreement with everything the client says or approval of everything the client does, but it does imply faith in the client’s underlying capacity to make appropriate decisions.

Psychotherapy II: cognitive and behavioral therapies

Cognitive and behavioral therapies typically focus more directly and narrowly on the specific symptoms and problems that the client presents.
They are also very concerned with data. They use objective measures to assess whether or not the treatment given is helping the client to overcome the problem.

Principles of cognitive therapy

People’s beliefs and ingrained, habitual ways of thinking affect their behavior and emotions.
Cognitive therapy begins with the assumption that people disturb themselves through their own, often illogical beliefs and thoughts.
The goal is to identify maladaptive ways of thinking and replace them with adaptive ways they provide a base for more effective coping with the real world.
Cognitive therapy generally centers on conscious thoughts, though such thoughts may be so ingrained and automatic that they occur with little conscious effort.

Three general principles:

Identifying and correcting maladaptive beliefs and habits of thought

Masturbation: the irrational belief that one must have some particular thing or must act in some particular way in order to be happy or worthwhile.

Establishing clear-cut goals and steps for achieving them

Clients can be given homework.

Moving from a teaching role to a consulting role with the client

Principles of behavior therapy

A behavior therapist is a trainer.
Behavioral therapy deals directly with maladaptive behaviors. It is not fundamentally talk therapy. Clients are exposed by the therapist to new environmental conditions that are designed to retrain them so that maladaptive habitual or reflexive ways of responding become extinguished and new, healthier habits and reflexes are conditioned.
Symptom oriented and concerned with measurable results.

Contingency management: altering the relationship between actions and rewards.

What reward is this person getting for his behavior, which leads him or her to continue it?
The next step, once the reward is understood, is to modify the behavior-reward contingency so that desired actions are rewarded and undesired are not.
This is: Contingency management.

Exposure treatment for unwanted fear

• Imaginal exposure
• In vivo exposure
• Virtual reality exposure

Evaluating psychotherapies

Is psychotherapy helpful, and are some types of it more helpful than others?

Psychotherapy works, but not one variety of therapy is regularly better than any other standard variety.

Evidence that psychotherapy helps

Psychotherapy is at least as effective as drug therapy in treating depression and generalized anxiety disorder and is more effective than drug therapy in treating panic disorder.

Evidence that no type of therapy is clearly better, overall, that other standard types

The role of common factors in therapy outcome

These factors are important to the effectiveness of therapy than the specific, theory-derived, factors that differentiate therapies.
Three fundamental categories

• Support
• Hope
• Motivation

We are social animals who need positive regard from other people in order to function well, but sometimes regard is lacking.
We are thinking animals, but sometimes our emotions and disappointments get in the way of our thinking.
We are self-motivated and self-directed creatures, but sometimes we lose our motivation and direction.
In these cases, a supportive, hope-inspiring, and motivating psychotherapist can help. The therapists helps not by solving our problems for us, but by providing a context in which we can solve them ourselves.