16.1 Mental Health Treatment: Past and Present

Treatment in the Past

• For much of history, the mentally ill have been treated very poorly.

• It was believed that mental illness was caused by demonic possession, witchcraft, or an angry god .

• If someone was considered to be possessed, there were several forms of treatment to release spirits from the individual: exorcism, trephining, execution, imprisonment, or left to be homeless beggars.

• The prevailing theory of psychopathology in earlier history was the idea that mental illness was the result of demonic possession by either an evil spirit or an evil god because early beliefs incorrectly attributed all unexplainable phenomena to deities deemed either good or evil.

• By the 18th century, people who were considered odd and unusual were placed in asylums.

  • Asylums: the first institutions created for the specific purpose of housing people with psychological disorders, but the focus was ostracizing them from society rather than treating their disorders.

• In the late 1700s, a French physician, Philippe Pinel, argued for more humane treatment of the mentally ill.

• In the 19th century, Dorothea Dix led reform efforts for mental health care in the United States, which led to the creation of the first mental asylums in the United States.

• A typical asylum was filthy, offered very little treatment, and often kept people for decades.

• Antipsychotic medications were introduced in 1954 and helped to control the symptoms of certain psychological disorders, such as psychosis.

• Psychosis was a common diagnosis of individuals in mental hospitals, and it was often evidenced by symptoms like hallucinations and delusions, indicating a loss of contact with reality.

• In 1963, Congress passed and John F. Kennedy signed the Mental Retardation Facilities and Community Mental Health Centers Construction Act, which provided federal support and funding for community mental health centers.

  • This legislation started the process of deinstitutionalization

Mental Health Treatment Today

• Today, there are community mental health centers across the nation.

• Part of what occurred with deinstitutionalization was that those released from institutions were supposed to go to newly created centers, but the centers were underfunded, staff was not trained to handle severe illnesses, there was high staff burnout, and no provision was made for the other services people needed.

• Without these supports, those people released under deinstitutionalization often ended up homeless.

• Today, instead of asylums, there are psychiatric hospitals run by state governments and local community hospitals focused on short-term care.

• In all types of hospitals, the emphasis is on short-term stays, with the average length of stay being less than two weeks and often only several days.

  • This is partly due to the very high cost of psychiatric hospitalization. Therefore, insurance coverage often limits the length of time a person can be hospitalized for treatment.

  • Usually individuals are hospitalized only if they are an imminent threat to themselves or others.

• Most people suffering from mental illnesses are not hospitalized.

• Some people seek treatment because their children have been removed from their care due to abuse or neglect.

• Some people seek therapy because the criminal justice system referred them or required them to go.

• Involuntary treatment: therapy that is not the individual’s choice.

• Voluntary treatment: the person chooses to attend therapy to obtain relief from symptoms.

• There are many different types of treatment providers, and licensing requirements vary from state to state.

  • Besides psychologists and psychiatrists, there are clinical social workers, marriage and family therapists, and trained religious personnel who also perform counseling and therapy.

• A range of funding sources pay for mental health treatment: health insurance, government, and private pay because of the Mental Health Parity and Addiction Equity Act of 2008, which requires group health plans and insurers to make sure there is parity of mental health services

• Finding treatment sources is also not always easy: there may be limited options, especially in rural areas and low-income urban areas; waiting lists; poor quality of care available for indigent patients; and financial obstacles such as co-pays, deductibles, and time off from work.

16.2 Types of Treatment

• Two types of therapy are psychotherapy and biomedical therapy.

• Psychotherapy: a psychological treatment that employs various methods to help someone overcome personal problems, or to attain personal growth.

• Biomedical therapy: involves medication and/or medical procedures to treat psychological disorders.

Psychotherapy Techniques: Psychoanalysis

• Psychoanalysis was developed by Sigmund Freud and was the first form of psychotherapy.

• Freud believed most of our psychological problems are the result of repressed impulses and trauma experienced in childhood, and he believed psychoanalysis would help uncover long-buried feelings.

• Free association: the patient relaxes and then says whatever comes to mind at the moment.

• Freud felt that the ego would at times try to block, or repress, unacceptable urges or painful conflicts during free association, causing the patient to demonstrate resistance to recalling these thoughts or situations.

• Dream analysis: a therapist interprets the underlying meaning of dreams.

• Transference: the patient transfers all the positive or negative emotions associated with the patient’s other relationships to the psychoanalyst.

Psychotherapy: Play Therapy

• Play therapy: the therapist observes how the child interacts with toys in an effort to understand the roots of the child’s disturbed behavior; can be nondirective or directive.

  • Nondirective play therapy: children are encouraged to work through their problems by playing freely while the therapist observes.

  • Directive play therapy: the therapist provides more structure and guidance in the play session by suggesting topics, asking questions, and even playing with the child.

Psychotherapy: Behavior Therapy

• Psychoanalysis: therapists help their patients look into their past to uncover repressed feelings.

• Behavior therapy: a therapist employs principles of learning to help clients change undesirable behaviors.

  • Behavior therapy employs both classical and operant conditioning techniques to change behavior.

    • Therapists using classical conditioning techniques believe that dysfunctional behaviors are conditioned responses.

      • Counterconditioning: a client learns a new response to a stimulus that has previously elicited an undesirable behavior; two counterconditioning techniques are aversive conditioning and exposure therapy.

        • Aversive conditioning: uses an unpleasant stimulus to stop an undesirable behavior; therapists apply this technique to eliminate addictive behaviors

        • Exposure therapy: a therapist seeks to treat clients’ fears or anxiety by presenting them with the object or situation that causes their problem, with the idea that they will eventually get used to it; can be done via reality, imagination, or virtual reality.

          • Systematic desensitization: a calm and pleasant state is gradually associated with increasing levels of anxiety-inducing stimuli.

          • Virtual reality exposure therapy: uses a simulation to help conquer fears.

    • Therapists using operant conditioning believe they can reinforce positive behaviors and punish unwanted behaviors

      • Applied Behavior Analysis (ABA): child-specific reinforcers are used to reward and motivate autistic children when they demonstrate desired behaviors, and punishment from the therapist or parent might be used to discourage undesirable behaviors.

      • Token economy: involves a controlled setting where individuals are reinforced for desirable behaviors with tokens that can be exchanged for items or privileges.

Psychotherapy: Cognitive Therapy

• Cognitive therapy: a form of psychotherapy that focuses on how a person’s thoughts lead to feelings of distress.

• The idea behind cognitive therapy is that how you think determines how you feel and act.

• Cognitive therapists help their clients change dysfunctional thoughts in order to relieve distress.

• Cognitive therapy was developed by psychiatrist Aaron Beck in the 1960s.

Psychotherapy: Cognitive-Behavioral Therapy

• Cognitive-behavioral therapists focus much more on present issues than on a patient’s childhood or past, as in other forms of psychotherapy.

• Rational emotive therapy (RET): founded by Albert Ellis; gets clients to recognize and overcome irrational beliefs

• Cognitive-behavioral therapy (CBT): helps clients examine how their thoughts affect their behavior; designed to change the way people think as well as how they act.

• Similarities to cognitive therapy

  • Attempts to make individuals aware of their irrational and negative thoughts and helps people replace them with new, more positive ways of thinking.

  • Teaches people how to practice and engage in more positive and healthy approaches to daily situations.

• ABC model: there is an Action, the Belief about the event, and the Consequences of this belief.

• Cognitive-behavioral therapy examines specific maladaptive and automatic thoughts and cognitive distortions.

• Examples of cognitive distortions: all-or-nothing thinking, overgeneralization, and jumping to conclusions.

  • Overgeneralization: someone takes a small situation and makes it huge

  • All or nothing thinking: reflects extremes.

  • Jumping to conclusions: assuming that people are thinking negatively about you or reacting negatively to you, even though there is no evidence.

Psychotherapy: Humanistic Therapy

• Humanistic therapy: attempts to help people become more self-aware and accepting of themselves.

• Humanistic therapists focus on conscious rather than unconscious thoughts, and emphasize the patient’s present and future.

• Client-centered therapy: developed by Carl Rogers; a form of nondirective therapy in which the therapist uses the techniques active listening and unconditional positive regard

  • Active listening: the therapist acknowledges, restates, and clarifies what the client expresses

  • Unconditional positive regard: involves not judging clients and simply accepting them for who they are.

• Nondirective therapy: a therapeutic approach in which the therapist does not give advice or provide interpretations but helps the person to identify conflicts and understand feelings.

Evaluating Various Forms of Psychotherapy

• According to the American Psychological Association, three factors work together to produce successful treatment: the use of evidence-based treatment that is deemed appropriate for your particular issue, the clinical expertise of the psychologist or therapist, and your own characteristics, values, preferences, and culture.

• Through psychotherapy, individuals can learn to engage in healthy behaviors designed to help them better express emotions, improve relationships, think more positively, and perform more effectively at work or school.

Biomedical Therapies

• Biomedical therapy: when individuals are prescribed biologically based treatments or psychotropic medications to treat mental disorders.

• Psychotropic medications: medications used to treat psychological disorders

• Different types and classes of medications are prescribed for different disorders.

• Electroconvulsive therapy (ECT): involves using an electrical current to induce seizures to help alleviate the effects of severe depression.

16.3 Treatment Modalities

• Intake: the therapist’s first meeting with the client; the therapist gathers specific information to address the client’s immediate needs; the therapist and client will work together to discuss treatment goals and create a treatment plan

• Confidentiality: the therapist cannot disclose confidential communications to any third party unless mandated or permitted by law to do so.

Individual Therapy

• Individual therapy: the client and clinician meet one-on-one.

• These meetings typically occur weekly or every other week, and sessions are conducted in a confidential and caring environment.

• The clinician will work with clients to help them explore their feelings, work through life challenges, identify aspects of themselves and their lives that they wish to change, and set goals to help them work towards these changes.

• The amount of time spent in therapy depends on the needs of the client as well as her personal goals.

Group Therapy

• Group therapy: a clinician meets together with several clients with similar problems.

• Benefits of group therapy:

  • It can help decrease a client’s shame and isolation about a problem while offering needed support, both from the therapist and other members of the group

  • Members can confront each other about their patterns

• Group therapy limitations:

  • Members of the group may be afraid to speak in front of other people because sharing secrets and problems with complete strangers can be stressful and overwhelming.

  • Personality clashes and arguments among group members.

  • Concerns about confidentiality

• Psycho-educational groups: groups that have a strong educational component are called psycho-educational groups.

• The focus is always on making sure that everyone benefits and participates in the group and that no one person is the focus of the entire session.

• Groups can be organized in various ways

Couples Therapy

• Couples therapy: involves two people in an intimate relationship who are having difficulties and are trying to resolve them.

• The primary therapeutic orientation used in couples counseling is cognitive-behavioral therapy.

• Couples meet with a therapist to discuss conflicts and/or aspects of their relationship that they want to change.

• The therapist helps them see how their individual backgrounds, beliefs, and actions are affecting their relationship.

• Often, a therapist tries to help the couple resolve these problems, as well as implement strategies that will lead to a healthier and happier relationship.

• Sometimes after working with a therapist, a couple will decide to separate.

Family Therapy

• Family therapy: a special form of group therapy, consisting of one or more families.

• The systems approach: the family is viewed as an organized system, and each individual within the family is a contributing member who creates and maintains processes within the system that shape behavior

  • The goal of this approach is to enhance the growth of each family member as well as that of the family as a whole.

• Structural family therapy: the therapist examines and discusses the boundaries and structure of the family; the therapist helps them resolve these issues and learn to communicate more effectively.

• Strategic family therapy: the goal is to address specific problems within the family that can be dealt with in a relatively short amount of time.

16.4 Substance-Related and Addictive Disorders: A Special Case

• Addiction is often viewed as a chronic disease

• Chronic substance use can permanently alter the neural structure in the prefrontal cortex, an area of the brain associated with decision-making and judgment, a person becomes driven to use drugs and/or alcohol

• Relapse: an individual return to abusing drugs and/or alcohol after a period of improvement.

• The goal of substance-related treatment is to help a person with an addiction stop compulsive drug-seeking behaviors

• Treatment usually includes behavioral therapy and/or medication, depending on the individual

What Makes Treatment Effective?

• An addict needs to be in treatment for at least three months to achieve a positive outcome, due to the psychological, physiological, behavioral, and social aspects of abuse

• The treatment needs to be holistic and address multiple needs, not just the drug addiction.

• Group therapy is the most widespread treatment modality.

• The rationale behind using group therapy for addiction treatment is that people with addiction are much more likely to maintain sobriety in a group format.

• Treatment usually involves medications to detox a person with addiction safely after an overdose, to prevent seizures and agitation that often occur in detox, to prevent reuse of the drug, and to manage withdrawal symptoms.

Comorbid Disorders

• Frequently, a person with an addiction to drugs and/or alcohol has an additional psychological disorder.

• These individuals fall into the category of mentally ill and chemically addicted (MICA)—their problems are often chronic and expensive to treat, with limited success.

• Compared with the overall population, substance abusers are twice as likely to have a mood or anxiety disorder.

• Drug abuse can cause symptoms of mood and anxiety disorders and the reverse is also true—people with debilitating symptoms of a psychiatric disorder may self-medicate and abuse substances.

• In cases of comorbidity, the best treatment is thought to address both disorders simultaneously.

• Behavior therapies are used to treat comorbid conditions, and in many cases, psychotropic medications are used along with psychotherapy.

16.5 The Sociocultural Model and Therapy Utilization

• Sociocultural perspective: looks at you, your behaviors, and your symptoms in the context of your culture and background.

• Cultural competence: to understand and address issues of race, culture, and ethnicity.

• Multicultural counseling and therapy aims to offer both a helping role and process that uses modalities and defines goals consistent with the life experiences and cultural values of clients.

• This therapeutic perspective integrates the impact of cultural and social norms, starting at the beginning of treatment.

• Therapists who use this perspective work with clients to obtain and integrate information about their cultural patterns into a unique treatment approach based on their particular situation

Barriers to Treatment

• Ethnic minorities and individuals of low socioeconomic status report that barriers to services include lack of insurance, transportation, and time.

• Reasons why people do not seek treatment: self-sufficiency and not seeing the need for help, not seeing therapy as effective, concerns about confidentiality, and the many effects of stigma and shame

• People belonging to ethnic groups often have concerns about prejudice and discrimination and view mental illness services as an additional stigma

• Language differences are a further barrier to treatment.