Chapter 16

Barriers to Treatment

• Uncertainty whether one qualifies for help

• Stigma about mental illness

• Gender roles

• Expense and availability of treatment

Gender roles

Men under-report mental health problems

Mental Health Providers

• Counseling psychologists:

• Clinical psychologists:

• Psychiatrists:

Counseling Psychologists

Address common problems such as stress, coping, and mild forms of anxiety and depression

Clinical psychologists:

mental health professionals with doctoral degrees who diagnose and treat problems ranging from the everyday to the chronic and severe

Psychiatrists:

physicians who specialize in mental health, and who diagnose and treat mental disorders primarily through prescribing medications that influence brain chemistry

• Work with psychologists to provide biopsychosocial interventions

Residential Treatment Centers

Provide psychotherapy and life skills training so that the residents can reintegrate into society to the greatest extent possible

• Range from low to high level centers with varying restrictions

Community Psychology

Focuses on how mental health is influenced by the neighborhood, economics, social groups, and other community-based variables

• Public awareness campaigns

• Educational programs

• Subsidized therapy

Community psychology (types)

• Public awareness campaigns

• Educational programs

• Subsidized therapy

EVIDENCE BASED THERAPIES

• Empirically Supported Treatments

• Bibliotherapy

Empirically Supported Treatments

Most psychological interventions have been tested and evaluated using sound research designs

Limitations (EST)

• No double-blind procedures

• Ethical considerations for control groups

• Cannot standardize therapeutic alliance

Bibliotherapy

The use of self-help books and other reading materials as a form of therapy

• Minor effects

• Questionable source material

Historical Insight Therapies

Dialogue between client and therapist for the purposes of gaining awareness and understanding of psychological problems

Types (Historical Insight Therapies)

• Psychodynamic therapies

• Humanistic-existential psychotherapy

Psychodynamic therapies

forms of insight therapy that emphasize the need to discover and resolve unconscious conflicts

Humanistic-existential psychotherapy

Phenomenological approach:

Phenomenological approach:

therapist listens empathetically and addresses the clients’ subjective feelings and thoughts as they unfold in the present moment

• Unconditional positive regard

Modern Insight Therapies

• Object relations therapy:

• Emotion-focused therapy:

• Therapeutic Alliance

• Group and Family Therapies

Object relations therapy: (Mod.T)

a variation of psychodynamic therapy that focuses on how childhood experiences and emotional attachments influence later psychology

Emotion-focused therapy: (Mod.T)

a variation of humanistic-existential psychotherapy based on the belief that it is better to face and accept difficult emotions and thoughts rather than to ignore them

Therapeutic Alliance

Relationship between therapist and client is the best predictor of therapy success regardless of the type of insight therapy used

Group and Family Therapies (Mod.T)

• Less expensive

• Organized to fit needs

• Provides social support and practice

• Gives therapist a more realistic account of patient’s behaviour

Systems approach (G & FT)

an orientation toward family therapy that involves identifying and understanding what each individual family member contributed to the entire family dynamic

Behavioural Therapies

Address problem behaviours and thoughts, and the environmental factors that trigger them, through conditioning

• Aversive conditioning

Aversive conditioning: (Be.T)

involves replacing a positive response to a stimulus with a negative response, typically by using punishment

Exposure Therapies

• Systematic desensitization:

• Flooding:

Systematic desensitization: (Exp.T)

gradually exposing an individual to stressful stimuli such that the aversive response extinguishes

Flooding: (Exp.T)

individual is immersed in stress-inducing situations

Virtual Reality Exposure

Virtual reality technology can enhance exposure therapies by generating immersive environments that would not otherwise be possible to reproduce

• PTSD treatment for soldiers

COGNITIVE- BEHAVIOURAL THERAPIES

• Cognitive-Behavioural Therapy (CBT)

• Mindfulness-Based Cognitive Therapy

Cognitive-Behavioural Therapy (CBT)

Not only addresses problematic behaviours, but also the distorted cognitions underlying them

Types (CB.T)

• Cognitive restructuring:

• Stress inoculation training:

Requires commitment from therapist and client

Cognitive restructuring: (CB.T)

changing negative cognition into more realistic and rational thought patterns

Stress inoculation training: (CB.T)

helps client put traumatic memories into perspective

Mindfulness-Based Cognitive Therapy

Combines mindfulness meditation with standard cognitive-behavioural therapy

• Decentering

Decentering:

occurs when one is able to ‘step back’ from one’s normal consciousness and observe one’s thoughts more objectively

Drug Treatments

Psychopharmacotherapy:

Psychopharmacotherapy:

the process of treating psychological disorders with drugs

• Psychotropic drugs

What do drugs have to pass through to get to the brain?

Blood-Brain barrier

Blood-brain barrier:

a network of tightly packed cells that only allow specific types of substances to move from the bloodstream to the brain

Mood Stabilizers

Drugs that prevent or reduce the manic side of bipolar disorder

• Lithium

Lithium: (Mood.S)

reduces severity/frequency of manic phases

What was lithium replaced by?(Mood.s)

Replaced by anticonvulsant medications

anticonvulsant medications

drugs used to stabilize mood, often prescribed for bipolar disorder.

When does mood stabilizers become difficult

Treatment compliance often a problem during mania

Antianxiety Drugs

Alleviate nervousness and tension, and to prevent and reduce panic attacks

What does antianxiety drugs do?

Promote activity of GABA, an inhibitory neurotransmitter, thereby reducing neural activity

Problem with antianxiety drugs

Short-term effects and high potential for abuse

MDMA-Assisted Therapy

Early evidence that MDMA (ecstasy) may facilitate therapy for individuals with PTSD

What does MDMA increase?

Increases norepinephrine, serotonin, and dopamine

What does MDMA facilitate?

Facilitates concentration and trust during therapy so as to better contextualize traumatic memories

Antipsychotic Drugs

Prescribed for disorders such as schizophrenia and severe mood disorders

Antipsychotic Drugs

• First Generation

• Tardive Dyskinesia

• Atypical antipsychotics (second-generation)

First-generation: Antipsychotics

blocked dopamine receptors

Tardive Dyskinesia: Antipsychotics

Parkinsonian-like symptoms marked by involuntary movements and facial tics

• long-term use of first-generation antipsychotics.

Atypical antipsychotics (second-generation):

reduces dopamine and serotonin

Depression and Neurotransmitters

• Monoamine theory of depression:

Monoamine theory of depression:

underactivity at serotonin and norepinephrine synapses

• Upregulation of serotonin/ norepinephrine receptors in autopsies studies

• Most effective drugs target monoamines

Antidepressants

• Monoamine oxidase inhibitors (MAOIs)

• Tricyclic antidepressants:

• selective serotonin reuptake inhibitors (SSRIs)

Monoamine oxidase inhibitors (MAOIs):

deactivates monoamine oxidase, an enzyme that breaks down serotonin, dopamine, norepinephrine

Tricyclic antidepressants:

block reuptake of serotonin/norepinephrine

Tricyclic antidepressants replaced by

selective serotonin reuptake inhibitors (SSRIs)

selective serotonin reuptake inhibitors (SSRIs)

which primarily increase serotonin levels.

Mechanisms of Action (Antidepressants)

Antidepressant drugs take weeks to months before producing a clinical effect

• Down-regulation of serotonin receptors (5HT1A)

Down Regulation: An Update

Action of antidepressants (SSRIs)

• stimulate release of BDNF which promotes neurogenesis in the hippocampus

• Hippocampus helps regulate HPA axis and reward circuitry, involved in contextualizing fear memories, and supports new learning and memories

Hippocampus and depression

helps regulate HPA axis and reward circuitry, involved in contextualizing fear memories, and supports new learning and memories

ARE DRUGS A CURE ALL?

No

Evaluating Drug Therapies

• Response vs remission

• Similar efficacy between CBT and antidepressants

• Lower relapse rate with CBT

• Exercise

Response vs remission

Response refers to any improvement in symptoms, while remission indicates the absence of significant symptoms.

results of comparing CBT and antidepressants

• Similar efficacy between CBT and antidepressants

• Lower relapse rate with CBT

Exercise vs medication

• can be as effective as SSRIs for some

• Stimulates release of endorphins and BDNF

• Positive side effects

Combining Therapies

• Drugs most effective when combined with other therapies

• Therapeutic approach needs to be tailored to each person

Early Surgical Methods

Neurologists in 1800s and 1900s experimented with removing regions

• Leucotonomy

• Prefrontal lobotomy with “ice pick”

Leucotomy:

Wire loop to destroy frontal lobe

Prefrontal lobotomy with ‘ice pick’

A surgical procedure involving inserting an ice pick-like instrument through the eye socket to sever connections in the prefrontal cortex.

When were these early surgical methods eliminated?

Eliminated in U.S. by 1970s

Modern Surgical Methods

Focal lesions:

Focal lesions:

small, specific damage applied to a cluster of nerve cells

When are modern surgical methods used?

For severe psychiatric problems when all other methods failed

Electroconvulsive Therapy (ECT)

Treatment in which an electrical current is passed through the brain to induce a temporary seizure

• Used in severe cases unresponsive to other treatments

• Mild side effects such as temporary confusions and amnesia for events around time of treatment

Side effects (ECT)

Mild side effects such as temporary confusions and amnesia for events around time of treatment

Repetitive Transcranial Magnetic Stimulation (rTMS)

A technique in which a powerful magnetic field is used to either stimulate or inhibit brain activity

• No anesthesia or seizure

• Reduces symptoms in treatment resistant depression

Benefits of (rTMS)

No anesthesia or seizure

Deep Brain Stimulation (DBS)

A technique that involves electrically stimulating highly specific regions of the brain

• Thin electrode-tipped wires inserted into brain

• Instantaneous results

Benefits of (DBS)

Instantaneous results