Chapter 15: Healing the Troubled Mind: Therapy

• Psychological treatments (psychotherapies) - conversation between the professional and the person seeking help - often combined with biological treatments

• Biological treatment - have roots in our understanding of the biological factors that contribute to psychological disorders

• John Case - 1949 - discovered lithium salts could produce remarkable improvements in the behaviour of patients with bipolar disorder - later used for schizophrenia

• Franz Anton Mesmer - First to treat Hysteria through the use of hypnosis - in many cases permanently cured it

• Behaviourist perspective - observable behaviour and approached the treatment of abnormal behaviour

• Humanistic psychologists - rebelled against psychodynamic thinking and the practice of psychoanalysis

• Carl Rogers - Humanistic therapist who started counselling

• Evidence-based practice (EBP) - combines research evidence, clinical expertise, and individual values to provide the best outcome for a patient or client

• EBP - Five steps

  • Construct an answerable question

  • Clinicians conduct a search of the most current scientific literature related to the question

  • Clinicians critically evaluate the relevant literature

  • Information is then integrated with data regarding particular cases

  • Clinicians evaluate their performance based on the patients' outcomes and make any necessary adjustments

• Clinical Assessment - Therapists need to understand the problems presented by the client before providing treatment - Interviews, observations, standardized tests

• Who provides psychotherapy - General medical practitioners, psychiatrists, psychologists, social workers, nurses, and religious leaders

Psychiatrists

• Training - MD degree, followed by 3-4 years specializing in psychiatry

• Prescribe medication, perform medical procedures - likely to focus on biological causes of disorders

• Licensed by the Canadian Psychiatric Association

Psychologists

• Training - PhD or PsyD in psychology

• Clinical psychology focuses on assessment, diagnosis, and treatment of psychological disorders

• Clinical psychology students typically complete supervised internships

Counselors

• Certified by Canadian Counselling and Psychotherapy Association (CCPA)

• Often provide therapy for non-severe issues

Hypnotherapists

• Not frequently regulated but may be certified by organizations like the Canadian Federation of Clinical Hypnosis

• Hypnosis is used for legitimate therapeutic purposes - practitioners should be verified

Life Coaching

• Unregulated in Canada - no specific licensing requirements

• Overlaps with psychotherapy - lacks the formal structure of regulated therapy

• Life coaches can still help clients improve coping skills and self-regulation

• Psychoanalysis - Frequent (4-5 times/week) and long-term (years)

• Cognitive Behavioural Therapy (CBT) - Shorter duration (weekly for ~6 weeks)

• Group Therapy - Can be homogeneous (same issue) or heterogeneous (varied diagnoses) - group size typically 6-12 individuals

• Leaderless Self-Help Groups - Non-licensed members lead these groups - Ex. Alcoholics Anonymous (AA), Weight Watchers

• Family Therapy - Involves multiple family members to address problems within the family dynamic - couples therapy is a subset of family therapy

• Online Therapy - Offers privacy, convenience, and therapist flexibility - typically done through email, and video chat

• PhD - programs emphasize research

• PsyD - programs focus more on practical therapy skills - concerns about lack of emphasis on scientific methods

• Psychological Clinical Science Accreditation System (PCSAS) - aims to increase scientific rigor in clinical psychology training

• Psychoanalysis - Developed by Freud, focuses on uncovering unconscious conflicts affecting behaviour

• Insight therapy - Assumes people improve once they understand the root of their problems

• Disorders caused by - Unconscious conflicts between the ego, id, and superego

• Free association - Patient speaks freely without self-censorship, allowing unconscious thoughts to surface

• Dream analysis - Dreams are seen as reflections of unconscious wishes

• Transference - Patient projects past relationships onto the therapist

• Resistance - Patient resists uncovering unconscious material, often reflecting avoidance of painful truths

• Humanistic Approaches - Humans are inherently good, with natural drives to grow and improve

• Person-Centered Therapy (Carl Rogers) - Focuses on achieving congruence (alignment between ideal and real selves)

• Behaviour Therapy - Based on classical and operant conditioning to change behaviours - effective for disorders like autism, schizophrenia, and habit modification

• Desensitization - Gradual exposure to feared stimuli to reduce fear (e.g., phobias)

• Counterconditioning - Pairing a negative behaviour with an incompatible response (e.g., smoking cessation)

• Token economies - Using rewards (tokens) to reinforce positive behaviour

• Cognitive Therapy - Focus on irrational beliefs that cause distress aim to replace them with rational thoughts

• Cognitive Behavioural Therapy (CBT) - Combines cognitive restructuring with behavioural methods

• Rational Emotive Behavioural Therapy (REBT) - More confrontational than CBT - focusing on challenging irrational thoughts directly

• CBT - highly effective, especially for depression, anxiety, and stress management

• Biopsychosocial Approach - Integrative approach considering biological, psychological, and social factors affecting the client - personalized treatment

• Major types of biological treatments for psychological disorders - medication, electroconvulsive therapy (ECT), psychosurgery, brain stimulation, and neurofeedback

• Medication - Medications have dramatically improved outcomes for many psychological disorders - most commonly used therapy

Electroconvulsive Therapy (ECT)

• Patient is anesthetized, given a muscle relaxant, and general seizures are induced by electricity

• Increases responsiveness to dopamine and norepinephrine

• Initially used for schizophrenia - now primarily for major depressive disorder and bipolar disorder

• One-third of patients experience persistent memory loss

Psychosurgery

• Trepanation - (drilling holes in the skull) was one of the first attempts at psychosurgery

• Frontal Lobotomy - Popularized in the 1930s-1950s to treat psychotic disorders but often resulted in severe cognitive and personality changes

• Causes impaired judgment, personality, initiative, social behaviour, and self-awareness

• Modern Psychosurgery - Radiation and precise lesions used to treat conditions like MDD and OCD - focuses on specific brain areas

Deep Brain Stimulation (DBS)

• Electrodes surgically implanted in the brain to treat OCD and MDD - 50% success rate in severe depression cases

• Nucleus accumbens stimulation improves mood and increases engagement in pleasurable activities

• Repetitive Transcranial Magnetic Stimulation (rTMS) - Non-invasive technique using low-frequency magnetic pulses to alter brain activity - treats MDD and schizophrenia

Biofeedback & Neurofeedback

• Biofeedback - Trains individuals to control physiological functions (e.g., blood pressure) that are usually unconscious

• Neurofeedback - Focuses on brain activity using EEG or fMRI to train individuals to maintain certain brain activity patterns - not proven to be very effective

Treating Autism Spectrum Disorder (ASD)

• Antipsychotic drugs - help with aggression, tantrums, and self-injury - have negative side effects (weight gain)

• Off-label use - Antidepressants and other drugs are commonly prescribed without FDA approval for ASD symptoms

• Alternative Treatments - Dietary interventions, chelation (removing heavy metals), hyperbaric oxygen therapy, sensory integration treatment - lack research

Applied Behaviour Analysis (ABA)

• Focuses on observable behaviours using operant conditioning and intensive therapy

• Results in strong positive effects on language acquisition - moderate effects on social skills and daily functioning

• Some adults with ASD treated with ABA as children argue that it emphasizes "normal" behaviours instead of respecting neurodiversity

Treating Attention-Deficit/Hyperactivity Disorder (ADHD)

• Stimulants like methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and Adderall are used

• They increase dopamine and norepinephrine activity - help improve focus and behaviour - side effects weight loss, sleep disturbance, increased heart rate etc

• Non-stimulants are used when stimulants don't work or cause side effects

• Hyperactivity and impulsivity are believed to result from insufficient activity in the brain's basal ganglia and frontal lobes

• Behavioural Parent Training - Teaches parents operant conditioning methods to manage ADHD behaviour

• Behavioural Classroom Management - Applies learning principles in school to help children with ADHD

Treating Conduct Disorder

• Medication is rarely used for conduct disorder

• Use Cognitive Behavioural Therapy (CBT), Family Therapy, Peer Group Therapy etc - especially effective for younger kids

• Multimodal Treatment (MMT) - Tailored approach using multiple treatment forms (child, family, peers, school, community)

Treating Schizophrenia

• Phenothiazines (First-Generation Antipsychotics) - Block dopamine receptors, reducing psychotic symptoms (hallucinations, delusions)

• Clozapine (Clozaril) (Second-Generation Antipsychotics) - Treat both positive and negative symptoms by affecting serotonin and dopamine

• Deinstitutionalization - While medication helped patients leave institutions, many lacked adequate community support

• Psychosocial Rehabilitation - Improved outcomes observed in developing countries, focusing on home care, meaningful work, and social skills

Treating Bipolar Disorder

• Lithium Carbonate - Prevents mania recurrences, reduces suicidal behaviour, increases grey matter in the brain

• Side Effects of Lithium Carbonate - Toxicity can cause nausea, vomiting, tremors, seizures, and coma

• Antipsychotics may be used but are less effective than lithium in preventing hospital admissions

• Psychotherapy - isn’t used as a primary treatment but can help with coping and adherence to medication

Treating Depression (MDD)

• Antidepressant Medications - SSRIs (ex. Prozac, Zoloft) increase serotonin availability in the brain

• SSRIs - can cause increased risk of suicidal thoughts, nausea, headaches, sexual dysfunction, weight gain, sleep disturbances etc

• If SSRIs don’t work - CBT, ECT, deep brain stimulation, rTMS

• Mindfulness-Based Cognitive Therapy (MBCT) - Combines CBT and mindfulness-based stress reduction

• Aerobic exercise has effects comparable to medication and CBT in mild to moderate depression

Treating Anxiety Disorders

• Benzodiazepines (ex. Valium, Xanax) - Commonly prescribed for anxiety, but overuse and addiction are concerns

• SSRIs (Selective Serotonin Reuptake Inhibitors) and other antidepressants - often used -anxiety and depression may share common underlying causes

• GABA-related medications (ex. alcohol, benzodiazepines) - aim to reduce brain activity and produce a calming effect but can be dangerous in combination

• CBT - Often used for Generalized Anxiety Disorder (GAD), phobias, and panic disorder

Treating Obsessive-Compulsive Disorder (OCD)

• Antidepressants (ex. SSRIs) can help reduce OCD symptoms

• CBT - Highly effective, involving exposure and response prevention

• CBT combined with medication is often effective

Treating Body Dysmorphic Disorder

• CBT - Helps individuals restructure unrealistic thoughts about perceived physical flaws

• Cosmetic surgery treatments are also common

Treating Post-Traumatic Stress Disorder (PTSD)

• Exposure Therapy - most common treatment, with or without SSRIs

• Addressing substance use disorders - crucial for full recovery since many with PTSD also struggle with addiction

Treating Dissociative Identity Disorder (DID)

• Hypnosis is commonly used - unsupported by scientific evidence and for potentially creating false memories

• Critics advocate for treating underlying stress, anxiety, and depression instead of focusing on DID

Somatic Symptom Disorders

• Antidepressants and increased physical activity may help manage symptoms

• CBT is the most common approach

• 50-80% of patients referred for therapy by physicians do not pursue it

Antisocial Personality Disorder (ASPD)

• Tranquilizers, antipsychotics, and anticonvulsants may be used in institutions to manage aggression

• Anger control, social skills training, character formation, and moral reasoning approaches are modestly effective in children and youth

• Treatment is often limited due to patients' lack of guilt and empathy

Narcissistic Personality Disorder (NPD)

• CBT is commonly used - an emphasis on building an alliance with the client

• Therapy - Addressing defensiveness and help differentiate between pathological and protective behaviours

Borderline Personality Disorder (BPD)

• Medications prescribed - antidepressants, antipsychotics, mood stabilizers, antianxiety medications, and anticonvulsants

• CBT is widely used, focusing on stress management, emotions, and relationships

• DBT shows superior outcomes compared to CBT

• Dialectical Behaviour Therapy (DBT) - designed for BPD - addressing symptoms in order: reducing suicidal thoughts, preventing behaviours that interfere with therapy, and improving life quality