Mental Health treatment: History, Modalities, and Modern Practice

Prevalence and Statistics of Mental Illness and Treatment

• According to the U.S. Department of Health and Human Services ($2017$), approximately $18.9\%$ of U.S. adults experienced some form of mental illness in the year $2017$.

• Among teenagers (ages $13$ to $18$), the prevalence rate is similar to that of adults.

• For children aged $8$ to $15$, estimates indicate that about $13\%$ experience mental illness in a given year.

• Regarding the receipt of treatment, the Substance Abuse and Mental Health Services Administration (SAMHSA) reported that in $2017$, only $14.8\%$ of adults received mental health care.

• The percentage of adults seeking treatment showed a slight increase between $2004$ and $2008$.

• Statistics from the Centers for Disease Control and Prevention's National Health and Nutrition Examination Survey (NHANES) show that approximately $50.6\%$ of children with mental disorders received treatment within the past year.

• Treatment rates vary significantly by the type of disorder in children: those with ADHD or conduct disorders are more likely to receive treatment, while children with anxiety disorders are the least likely to have received care.

Historical Perspectives on Mental Health Treatment

• Throughout much of history, mental illness was attributed to supernatural causes such as demonic possession, witchcraft, or the wrath of an angry god.

• In medieval times, abnormal behaviors were viewed as signs of possession, leading to specific religious and physical interventions:

  • Exorcism: Conducted by priests or religious figures, this involved saying incantations and prayers over the individual's body and sometimes administering medicinal drinks.

  • Trephining: Used in extreme cases, this involved drilling a small hole in the individual's skull to allow spirits to exit the body. This procedure was usually fatal.

• Other historical responses included the execution or imprisonment of the mentally ill, while many others were left as homeless beggars.

• Witchcraft and the Devil: From the late $1400\text{s}$ to the late $1600\text{s}$, a common belief held that individuals made pacts with the devil. Accused individuals, frequently the mentally ill, were labeled as witches, tried in courts, and often burned at the stake. It is estimated that tens of thousands were killed worldwide due to these accusations.

The Rise of Asylums and Early Reform Efforts

• The Inception of Asylums: By the $18^{\text{th}}$ century, asylums were created as the first institutions specifically for housing those with psychological disorders. However, the primary goal was social ostracization rather than therapy. Inhabitants were often kept in windowless dungeons, chained to furniture, beaten, and denied contact with caregivers.

• Philippe Pinel: In the late $1700\text{s}$, the French physician Philippe Pinel advocated for humane treatment. In $1795$, at La Salpêtrière in Paris, he ordered that patients be unchained and engaged in conversation. This change allowed many patients to improve and eventually leave the institution.

• Dorothea Dix: In the $19^{\text{th}}$ century, Dix led reform in the United States after discovering an unregulated, underfunded system that abused the mentally ill and the poor. Her lobbying of state legislatures and the U.S. Congress led to the creation of the first American mental asylums.

• The Reality of $20^{\text{th}}$-Century Asylum Life: Despite reforms, many asylums remained filthy and offered minimal treatment. For example, the Willard Psychiatric Center in New York submerged patients in cold baths and administered frequently harmful electroshock treatments. In $1943$, Willard doctors administered $1,443$ shock treatments, sometimes resulting in broken backs. Some facilities, including Willard, did not close until as late as $1995$.

Deinstitutionalization and Modern Mental Health Services

• Introduction of Antipsychotics: In $1954$, and gaining momentum in the $1960\text{s}$, the introduction of antipsychotic medications allowed for better control of psychosis symptoms, such as hallucinations and delusions.

• Legislative Action: In $1963$, President John F. Kennedy signed the Mental Retardation Facilities and Community Mental Health Centers Construction Act, providing federal funding for local community centers.

• Deinstitutionalization: This policy involved closing large asylums so that people could stay in their communities. In $1955$, there were $558,239$ severely mentally ill patients in public hospitals; by $1994$, the hospitalized population had decreased by $92\%$.

• Challenges of Deinstitutionalization: The transition was often poorly managed. Community centers were underfunded, staff lacked training for severe conditions like schizophrenia, and there were no provisions for housing, food, or job training. Consequently, many released individuals became homeless. Today, approximately $26\%$ of homeless adults in shelters experience mental illness.

• Correctional Involvement: Individuals with mental illness are overrepresented in the criminal justice system at rates $2$ to $4$ times that of the general population. In $2006$, roughly $705,600$ adults with mental health issues were in state prisons, $78,800$ in federal prisons, and $479,000$ in local jails. Incarceration often triggers or worsens conditions such as PTSD and depression due to exposure to violence and isolation.

Current Delivery of Care and Treatment Access

• Psychiatric Hospitals: Modern hospitals focus on short-term care, with the average stay lasting less than $2$ weeks—often only a few days—due to high costs ranging from $\$800$ to $\$1000$ per night. Hospitalization is generally reserved for those who are an imminent threat to themselves or others.

• Voluntary vs. Involuntary Treatment:

  • Voluntary Treatment: The individual chooses to attend therapy to seek relief from symptoms.

  • Involuntary Treatment (Mandated): Therapy that is not the individual's choice, often referred by the criminal justice system or child protective services.

• Treatment Providers: Care is provided by psychiatrists, psychologists, clinical social workers, marriage and family therapists, and trained religious personnel.

• Legal Protections: The Mental Health Parity and Addiction Equity Act of $2008$ requires health insurers to ensure parity between mental health services and physical medical/surgical services regarding co-pays and visit limits.

• Rural Deficits: Over $85\%$ of federally designated mental health professional shortage areas are rural. Primary care physicians often serve as the first line of care despite lacking specialized training.

Primary Modalities of Therapy

• Psychotherapy: A psychological treatment employing various methods to help a person overcome personal problems or achieve growth.

• Biomedical Therapy: Involves medication and/or medical procedures to treat psychological disorders.

• Autobiography in Five Short Chapters (by Portia Nelson): A poem illustrating the process of therapy as a journey of recognizing and avoiding destructive patterns, eventually leading to choosing a different path entirely.

Psychoanalysis and the Psychodynamic Perspective

• Psychoanalysis: Developed by Sigmund Freud, it focuses on repressed impulses and childhood trauma. Techniques include:

  • Free Association: The patient relaxes and says whatever comes to mind; the therapist watches for resistance, where the ego blocks painful thoughts.

  • Dream Analysis: The therapist interprets the underlying meaning of the patient's dreams.

  • Transference: The patient transfers emotions from other relationships (e.g., feelings about a parent) onto the therapist.

• Psychodynamic Perspective: A modern evolution of Freud's work that still considers internal drives and the unconscious but is less intensive.

Play Therapy

• Used primarily for children who cannot engage in traditional talk therapy. Children act out fantasies or traumas using dolls, sandbox figurines, or stuffed animals.

• Nondirective Play Therapy: Children play freely while the therapist observes.

• Directive Play Therapy: The therapist provides structure, asks questions, and participates in the play sessions.

Behavior Therapy

• Focuses on learning principles to change undesirable behaviors rather than uncovering the unconscious.

• Classical Conditioning Techniques:

  • Counterconditioning: Learning a new response to a stimulus that previously caused an undesirable behavior.

  • Aversive Conditioning: Uses unpleasant stimuli (e.g., mild shock or Antabuse for alcoholism) to stop behaviors. Antabuse causes nausea and vomiting when paired with alcohol consumption.

  • Exposure Therapy: Developed by Mary Cover Jones (e.g., the case of Peter and the rabbit), this involves presenting the feared object until the patient habituates.

  • Systematic Desensitization: Refined by Joseph Wolpe, a person creates a hierarchy of anxiety and pairs these scenarios with relaxation techniques until they can face the feared object without anxiety.

  • Virtual Reality Exposure Therapy: Uses simulations to treat conditions like PTSD in combat veterans, with an effective reduction in symptoms for about $80\%$ of participants.

• Operant Conditioning Techniques:

  • Token Economy: A system in controlled settings (like psychiatric hospitals) where desirable behaviors are reinforced with tokens that can be exchanged for privileges like TV time or canteen visits.

Cognitive and Cognitive-Behavioral Therapy (CBT)

• Cognitive Therapy: Developed by Aaron Beck in the $1960\text{s}$, it focuses on how thoughts lead to distress. It aims to eliminate cognitive distortions, such as overgeneralization or blowing things out of proportion.

• Cognitive-Behavioral Therapy (CBT): Focuses on present issues and aims to change both cognitive distortions and self-defeating behaviors. It draws from Albert Ellis's Rational Emotive Therapy (RET).

• The ABC Model:

  • A (Action/Activating Event): Something occurs (e.g., a social rejection).

  • B (Belief): The interpretation of the event.

  • C (Consequences): The emotional or behavioral result of that interpretation.

• Types of Cognitive Distortions:

  • All-or-Nothing Thinking: Seeing things in black or white (e.g., "No one will ever go out with me").

  • Overgeneralization: Taking a specific situation and applying it broadly (e.g., failing one test means one is a "loser").

  • Jumping to Conclusions: Assuming negative reactions from others without evidence.

Humanistic Therapy

• Developed by Carl Rogers, this client-centered (or Rogerian) approach focuses on conscious thoughts and the future.

• Nondirective Therapy: The therapist does not give advice but helps the person identify their own feelings.

• Techniques:

  • Active Listening: The therapist acknowledges, restates, and clarifies the client's statements.

  • Unconditional Positive Regard: Not judging and simply accepting the client.

  • Genuineness, Empathy, and Acceptance: Essential qualities that help foster personal growth.

Evaluating Therapy Effectiveness

• The American Psychological Association identifies three factors for success: use of evidence-based treatment, clinical expertise of the therapist, and the characteristics/preferences of the client.

• Studies show that CBT is as effective or more effective than other therapies for PTSD, general anxiety, and social phobia. CBT success rates for depression ($43\%$) are comparable to medication ($50\%$).

• No single psychotherapeutic approach has been proven significantly more effective than others; the most critical factor is the quality of the relationship between the therapist and the client.

Biomedical Therapies and Medications

• Psychotropic Medications: Prescribed to treat symptoms by altering neurotransmitter levels. They are most effective when paired with psychotherapy.

• Specific Classes of Medication:

  • Antipsychotics (e.g., Haldol, Thorazine): Block dopamine; used for schizophrenia. Side effects include tardive dyskinesia.

  • Atypical Antipsychotics (e.g., Abilify, Risperdal): Target dopamine and serotonin; used for negative symptoms of schizophrenia. Side effects include obesity and diabetes risk.

  • Anti-depressants (e.g., Prozac, Zoloft [SSRIs]; Tofranil [Tricyclics]): Alter serotonin and norepinephrine levels.

  • Anti-anxiety Agents (e.g., Xanax [Benzodiazepines]; Buspar): Depress central nervous system activity.

  • Mood Stabilizers (e.g., Lithium, Depakote): Treat mania and depression in bipolar disorder.

  • Stimulants (e.g., Adderall, Ritalin): Improve focus for ADHD.

• Other Biological Procedures:

  • Electroconvulsive Therapy (ECT): Induces seizures to treat severe depression; effective for $85\%$ of patients who do not respond to drugs, though it may cause memory loss.

  • Transcranial Magnetic Stimulation (TMS): Approved in $2008$, uses magnetic fields to stimulate nerve cells to alleviate depression symptoms.