Psyc 101 Final Exam Loeb (Chapter 15)

3 Major Treatments:

1. Insight therapies

2. Behavior therapies

3. Biomedical therapies

Insight therapies

Insight therapy is talk therapy in the tradition of Freud's psychoanalysis. In insight therapies, clients engage in complex, often lengthy verbal interactions with their therapist

Behavior therapies

Behavior therapies are based on the principles of learning. Instead of emphasizing personal insights, behavior therapists make direct efforts to alter problematic responses (phobias, for instance) and maladaptive habits (drug use, for instance).

Biomedical therapies

- Biomedical approaches to therapy involve interventions into a person's biological functioning.

- The most widely used procedures are drug therapy and electroconvulsive (shock) therapy. In recent decades, drug therapy has become the dominant mode of treatment for psychological disorders.

- As the name biomedical therapies suggest, these treatments have traditionally been provided only by physicians with a medical degree (usually psychiatrists).

Clinical psychologists and counseling psychologists

specialize in the diagnosis and treatment of psychological disorders and everyday behavioral problems.

Psychiatrists

are physicians who specialize in the diagnosis and treatment of psychological disorders.

Insight therapies

involve verbal interactions intended to enhance clients' self-knowledge and thus promote healthful changes in personality and behavior

Psychoanalysis

an insight therapy that emphasizes the recovery of unconscious conflicts, motives, and defenses through techniques such as free association and transference.

Free association

clients spontaneously express their thoughts and feelings exactly as they occur, with as little censorship as possible.

Dream analysis

the therapist interprets the symbolic meaning of the client's dreams.

Resistance

refers to largely unconscious defensive maneuvers intended to hinder the progress of therapy.

Transference

occurs when clients start relating to their therapists in ways that mimic critical relationships in their lives.

Ex: you see your father's demanding quality in the therapist and begin to dislike or even despise the therapist because you now relate them to your father.

Client-centered therapy

is 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.

Group therapy

is the simultaneous treatment of several clients in a group.

Couples or marital therapy

involves the treatment of both partners in a committed, intimate relationship, in which the main focus is on relationship issues.

Family therapy

involves the treatment of a family unit as a whole, in which the main focus is on family dynamics and communication. Family therapy often emerges out of efforts to treat children or adolescents with individual therapy.

Behavior therapies

involve the application of the principles of learning and conditioning to direct efforts to change clients' maladaptive behaviors.

Systematic desensitization

a behavior therapy used to reduce clients' phobic responses.

Exposure therapies

clients are confronted with situations they fear so they learn that these situations are really harmless.

Social skills training

a behavior therapy designed to improve interpersonal skills that emphasizes modeling, behavioral rehearsal, and shaping.

Cognitive-behavioral treatments (CBT)

use combinations of verbal interventions and behavior modification techniques to help clients change maladaptive patterns of thinking

Cognitive therapy

uses specific strategies to correct habitual thinking errors that underlie various types of disorders.

Biomedical therapies

physiological interventions intended to reduce symptoms associated with psychological disorders.

4 Major Drug Treatments

1. Antianxiety drugs

2. Antipsychotic drugs

3. Antidepressant drugs

4. Mood stabilizers.

Antianxiety drugs

reduce tension, apprehension, and nervousness

Antipsychotic drugs

used to gradually reduce psychotic symptoms, including hyperactivity, mental confusion, hallucinations, and delusions.

Antidepressant drugs

gradually elevate mood and help bring people out of depression.

Mood stabilizers

drugs used to control mood swings in patients with bipolar mood disorders.

Electroconvulsive therapy (ECT)

a biomedical treatment in which electric shock is used to produce a cortical seizure accompanied by convulsions.

Mental hospital

a medical institution specializing in providing inpatient care for psychological disorders.

Deinstitutionalization

transferring the treatment of mental illness from inpatient institutions to community-based facilities that emphasize outpatient care.

Types of treatments

Insight therapies

Behavior therapies, Cognitive therapies and Cognitive Behavioral therapies (aka CBT)

Biomedical therapies

Clients: Who seeks therapy?

Range of issues, from serious to everyday issues

Most common issues: depression and anxiety

Barriers to seeking therapy: stigma, lack of insurance/cost

Many who need therapy do not receive it; often long delay in seeking treatment, even if treatment is sought

Whites > Blacks, Hispanic

Females > Males

Greater education > less education

Not married, divorced/separated > married

Public health insurance > private insurance > no insurance

Therapists: Who provide professional treatment?

Clinical Psychologist - PhD or PsyD

Psychiatrists - MD

Counseling Psychologist - PhD, PsyD, or EdD

Other mental health professionals (psychiatric social workers, psychiatric nurses, marriage and family therapists, clergy)

What matters when choosing a therapist?

Degree?

Good relationship

Insight Therapies

1. Psychoanalysis (Freud)

2. Psychodynamic therapies: also considers drives and forces inside a person, but the treatments tend to be less intense and shorter in duration than Psychoanalysis

3. Client-centered therapy (humanist perspective)

Psychoanalysis (Freud) (Insight Therapy)

How might psychopathology develop? Unconscious, unresolved conflicts; person may not have successfully gone through the psychosexual stages of development

What would treatment (TX) goal be? Uncover & resolve these conflicts (also motives and defenses)...to achieve insight and catharsis

What tools would you use to achieve TX goals?

- Free association

- Dream analysis

- Analyzing resistance

- Analyzing transference

Psychodynamic therapies (Insight Therapy)

also considers drives and forces inside a person, but the treatments tend to be less intense and shorter in duration than Psychoanalysis

Core features of psychodynamic therapies:

- Focus on emotional experience

- Exploration of efforts to avoid distressing thoughts and feelings (resistance)

- Identification of recurring patterns in patients' lives

- Discussion of past experience

- Analysis of interpersonal relationships

- Focus on therapeutic relationship (e.g. transference)

- Exploration of fantasy life

Client-centered therapy (humanist perspective) (Insight Therapy)

How might psychopathology develop? Rogers suggests that it is when there is incongruence (when the real self does not align well with the ideal self) of the self-concept vs. reality; generally due to "conditional love" environments; the assumption is that people have an innate drive/ability to become who they need to be if they have a supportive environment

What would TX goal be? Rogers: decrease incongruency (when the real self does not align well with the ideal self)

What tools would you use to achieve TX goals?

- Create positive emotional climate (genuineness, unconditional positive regard, accurate empathy) so clients can discover themselves and not worry so much about pleasing others

+ Genuineness

+ Unconditional positive regard

+ Accurate empathy

> Mirroring (for clarification)

- Research suggests that the components of Roger's therapy (esp. empathy) are critical for good outcomes for other therapies as well.

Are insight therapies effective?

Difficult question to answer because of spontaneous remission; different theoretical backgrounds leading to different techniques; and different severity of issues being treated. (In other words, because insight therapies can be so varied, it's hard to assess them as a whole.)

Still, in general, yes, the therapies are effective

- Roughly as effective as drug therapies (but without side effects)

- First 10-20 weeks of treatment = greatest effects

- Durable effects

- Insight therapies do not work for everyone (many studies show that about 1/3 have spontaneous remission, treatment is particularly effective for 1/3 and treatment is not as effective for the last third). Insight therapies an also be combined with biomedical therapies (e.g. medication)

How do insight therapies work?

Debatable

- Do different approaches accomplish the same thing in different ways or do all therapies share common factors which lead to improvement? Could be both but the benefit of common factors has gained a lot of research support, in particular.

Common factors which may be at play

- Relationship with therapist

- Emotional support and empathy

- Cultivation of hope and positive expectations in client

- Explanation of the issues and plausible solution(s)

- "Opportunity to express feelings, confront problems and gain new insights"

Format? Therapies are often done individually, however, they can be done as "couples" therapy or as "group" therapy as well.

Group therapy

- Therapist screens potential group members, sets goals for group, initiates and maintains the therapeutic process, prevents harmful interactions between groups members

- 4-12 people (6-8 ideal)

- Costs less

- Other benefits: people who can relate/normalization, practical tips Couples and family therapy

- Some are an outgrowth of individual therapy; others are a new "complex systems" approach

- Goals

+ To understand the system

To facilitate communication

Behavior therapies:

• How might psychopathology develop? B/c the person has learned maladaptive behaviors in response to stimuli

• What would TX goal be? To "unlearn" or suppress maladaptive behavioral responses and replace with adaptive behavioral responses

• What tools would you use to achieve TX goals? Specific examples include:

o Systematic Desensitization Therapy

▪ Build anxiety hierarchy

▪ Teach relaxation techniques

▪ (Imagined) incremental exposure to anxiety-provoking stimuli

▪ Exposure therapy: instead of imagining, exposing the person to the feared-stimulus (systematic desensitization therapy can be combined with exposure therapy)

▪ Virtual-reality presentations

o Social Skills Training

▪ Modeling (purposely changing a behavior in order to improve your mindset and achieve your goals)

▪ Behavioral rehearsal (imagination)

▪ Shaping (the process of training a learned behavior that would not normally occur)

o Aversion Therapy (this is actually a combination of biomedical + learning principles)

▪ e.g. Disulfiram & alcoholism: patients would take disulfiram (aka Antabuse) in the morning. If they drank alcohol later during the day, they would get extremely sick. In this example, what type of consequence is being followed by the behavior of drinking alcohol? It would be operant conditioning

Effectiveness of behavior therapies

o Effective for a wide variety of issues, though some treatments are appropriate for some issues and not others

Cognitive therapies:

• How might psychopathology develop? Maladaptive thinking such as having unreasonable global assumptions

• What would TX goal be? To change maladaptive thinking

• What tools would you use to achieve TX goals? Examples (e.g. Beck's cognitive therapy):

o Help person to: 1) identify maladaptive thoughts and 2) challenge the unreasonable negative thoughts

o Homework assignments to work on changing behavior

o Behavioral activation (identify which activities make clients feel pleasure and accomplishment)

o Cognitive bias modification (computerized cognitive training programs)

Cognitive Behavior Therapies (CBT):

• Often cognitive and behavioral therapies are used together

o There is a great amount of evidence that CBT is quite effective.

o Effects are durable (though booster sessions may be good for some to have)

o There are no side effects (vs. medications which all have various side effects)

o Ellis' rational-emotive behavior therapy focuses on how "you think the way you feel" so his therapy is a combination of cognitive therapy and behavioral therapy.

o Dialectical Behavior Therapy (DBT) is another type of CBT which specifically targets managing intense emotions.

o UNC's Psychology & Neuroscience clinicians generally practice some form of CBT due to the great amount of evidence of its effectiveness

Dialectical Behavior Therapy (DBT)

o A type of CBT which emphasizes emotion-regulation and tolerance of distressful emotional situations. Recommended for everyone:

Biomedical Therapies

1. Drugs

2. ECT

Antianxiety drugs (aka anxiolytics aka sedatives aka tranquilizers)

▪ Technical drug name vs. brand name/trade name

• e.g. Valium = diazepam, Xanax = alprazolam

▪ short-lived effects (e.g. hours)

▪ side effects (drowsiness, lightheadedness, cottonmouth, depression, nausea, constipation)

▪ abuse, drug dependence, overdose, synergistic effects

▪ withdrawal effects

Antipsychotic drugs (aka psychotropic drugs aka neuroleptics)

▪ Traditionally, DA antagonist

▪ 70% of patients respond, in varying degrees

▪ 2 days to 1 week to take effect, improvement may continue for several months

▪ Side effects (drowsiness, cottonmouth, tremors, rigidity, etc.)

• Tardive dyskinesia (15-25% on traditional antipsychotics)

• 2nd generation antipsychotic drugs (aka atypical antipsychotics)

o Can have milder side effects (but can ↑ risk of diabetes and cardiovascular disease)

o Less risk of tardive dyskinesia

o Partial agonists can help both positive and negative symptoms.

▪ Affinity (how strongly they bind to receptors) (strength)

▪ vs.

▪ Efficacy (how much they activate the receptors) (efficiency)

▪ Relapse

▪ Has been used to treat other conditions, including bipolar disorder.

Antidepressant drugs

▪ Tricyclics (e.g. Tofranil), MAO Inhibitors (e.g. Iprozid, cheese effect), SNRIs (e.g. Strattera), buproprion (e.g. Wellbutrin), esp. SSRIs which are the most widely prescribed (e.g. Prozac [fluoxetine], Paxil [paroxetine], Zoloft [sertraline])

▪ Side effects, possibly including increased suicidal thinking in adolescents and young adults (though they are at risk when untreated as well) - research results are mixed

▪ 60% = effects in the first 2 weeks...but effects are generally over a period of more weeks

▪ Most effective for the severely depressed

▪ Antianxiety drugs have been found to be very effective for treatment of depression as well

Mood stabilizers

▪ Lithium, valproate

▪ To prevent future episodes as well as to bring someone out of a current episode

▪ Side effects (e.g. small therapeutic index for lithium)

Effectiveness of medications

▪ Effective for many

▪ Can treat some cases where talk therapy does not seem to be effective

▪ Issues: short-lived, treating symptoms not the cause (leading to relapse when medication is stopped), overprescribed/overmedicated, severity of side effects may be underestimated

▪ Research difficulties: conflict of interest (e.g. drug companies doing the research on drug effectiveness), studies are not long-term enough, research is biased towards publishing positive results (vs. no effect).

Electroconvulsive Therapy (ECT)

o Electrical current (~1 sec) which triggers a seizure

o Patient awakens in 1-2 hours

o 2-3x per week for about 2-7 weeks/6 to 12 sessions

o Use has been declining

o Effectiveness

▪ Controversial

• Mild, short-term cognitive impairments or more severe, permanent cognitive impairments? (e.g. retrograde amnesia for autobiographical information)

▪ Effective for cases which do not respond to other forms of treatment. Depression has been cited as the most debilitating, even above other physical illnesses.

▪ Relapse is high but may be so because this is used for the most severely depressed who do not respond to medication

Trends in treatment

• Increasing multicultural sensitivity in treatment

1. Minorities underutilize treatments

2. Technology

3. Blending treatment approaches

Minorities underutilize treatments

▪ Previous negative experience with institutions/services, language barrier, may be a financial barrier as well

▪ Outcomes tend to be better when clients' ethnicity and therapists' ethnicity match

▪ Efforts to improve may include:

• Recruiting more minority therapists

• Fostering cultural competence

• Fostering cultural humility

• Note: "culture" is more broad than ethnicities/race, e.g. sexual orientation

Technology

▪ Not enough clinicians/treatment centers for everyone, esp. among ethnic minorities

▪ Technology can increase the reach: phone (e.g. elderly clients with anxiety), videoconferencing, internet (CBT adaptations) modules which educate and take people through exercises/homework. Some are partially automatized (with access to a therapist) while others are fully automatized. Use of apps.

▪ Pandemic facilitated changes...a surprising consequence was decreased missed appointments.

Blending treatment approaches

▪ Can increase effectiveness of treatments in general, though not for all types of disorders

▪ Eclectic approach

Mental institutions

• The mentally ill used to be housed (hidden) with family and/or caring villagers. Then they were housed in mental hospitals.

Problems of mental institutions:

o underfunded

▪ untrained and overworked personnel

o isolation from social support networks

(1960s) Community mental health movement

o push for local care

o less dependent on hospitalization

o prevention

(1960s) Deinstitutionalization

o mixed success

▪ alternative, less costly option, can be near loved ones

▪ however, "revolving door" for many of the most seriously ill and increased homeless mentally ill

o mental illness, revolving door, homelessness

▪ worldwide, 1 in 7 readmitted within 30 days; 40-50% re-hospitalized within a year

▪ elevated rates of mental illness among the homeless

• 1/3 mentally ill (e.g. schizophrenia or mood disorder)

• 1/3 drug/alcohol dependence

• co-morbidities

• homeless shelters and prisons (3x more than psychiatric hospitals)

▪ lack of funding: overall health care spending has increased but funding for mental health care has diminished