Therapy and Treatment of Abnormal Behavior

What I'm Working For Token Economy

• Therapy utilizes the concepts of:
  • STOP
  • THINK
  • 5 SECOND DELAY
  • GO
• These concepts allow an individual to have free time for what they are working for.

AP Exam: Treatment of Abnormal Behavior (5-7%)

• This section focuses on empirically based treatments for psychological disorders.
• It emphasizes treatment modalities based on different orientations in psychology.
• AP students should be able to:
  • Describe the characteristics of psychotherapeutic intervention.
  • Describe major treatment orientations (behavioral, cognitive, humanistic) and their influence on therapeutic planning.
  • Compare and contrast different treatment formats (individual, group).
  • Summarize the effectiveness of specific treatments for specific problems.
  • Discuss how cultural and ethnic context influence treatment choice and success, including factors leading to premature termination.
  • Describe prevention strategies that build resilience and promote competence.
  • Identify major figures in psychological treatment (Aaron Beck, Albert Ellis, Sigmund Freud, Mary Cover Jones, Carl Rogers, B. F. Skinner, Joseph Wolpe).

What are Therapists?

• Professionals who:
  • Know the art of establishing a helping relationship.
  • Apply psychological knowledge to individuals struggling with problems and choices.

Therapy

• Therapy is a treatment process used to deal with mental disorders or cope with problems of living.
• Reasons for seeking therapy include:
  • Making difficult decisions.
  • Dealing with academic problems.
  • Coping with loss.
  • Dealing with relationship issues.

History of Therapy

• Therapy has a history of misguided theories, similar to the history of psychology and psychological disorders.
• In medieval Europe, mental disorders were often attributed to the devil and demons, leading to exorcisms.

Bedlam and its Origins

• Bethlehem Hospital in London was a well-known asylum.
• People could pay to watch the inmates, which led to the term "Bedlam" being used to describe any noisy, chaotic place.

Medieval Asylums

• Patients received:
  • Custodial care at best.
  • Neglect.
  • Cruel restraints such as cages and straightjackets.
  • Torture, including beatings and cold showers.

Modern Therapy

• Modern therapy focuses on developing a strong, supportive relationship with the patient.
• The end goal is to change a person’s functioning.
• Psychologists may use an eclectic approach, selecting various techniques to help individuals.

Components of Therapy

• The therapeutic process generally involves:
  • Identifying the problem.
  • Identifying the cause or maintaining conditions.
  • Deciding on and carrying out treatment

7 Main Types of Professional Help

• Counseling Psychologist
  • Deals with common problems.
  • Works in schools, clinics, or institutions.
  • Requires a master’s degree or PhD in counseling.
• Clinical Psychologist
  • Works with severe disorders.
  • Usually in private practice.
  • Requires a PhD and state certificate.
• Psychiatrist
  • Deals with severe mental problems and prescribes drugs.
  • May be in private practice or employed by hospitals.
  • Requires an MD and medical board license.
• Psychoanalyst
  • Practitioners of Freudian therapy.
  • Usually in private practice
  • MD degree
• Psychiatric Nurse Practitioner
  • Prescribes drugs for mental disorders.
  • May work in private practice or in clinics and hospitals.
  • Requires an RN credential plus specialty training.
• Clinical or Psychiatric Social Worker
  • Deals with mental disorders from a social and environmental context.
  • MSW (Masters of Social Work) required.
• Pastoral Counselor
  • A member of a religious order specializing in psychological disorders.
  • Varies in qualification

Who Does Therapy?

• Physicians: 41.6% (drug therapy)
• Other professionals: 19.8% (e.g., clergy)
• Mental health specialists: 38.6%

Therapy: Gentler Treatment

• Brought about by:
  • Philipe Pinel (France)
  • Dorothea Dix (US, Canada, Scotland)
• Creation of mental hospitals.
• Mid-1950s: creation of psychotropic drugs led to emptying hospitals.
• Psychotherapy:
  • An emotionally charged, confiding interaction between a trained therapist and someone who suffers from psychological difficulties.
  • Examples: psychoanalysis, CBT, insight therapy.
• Biomedical Approach:
  • Medication or medical procedures to act on the nervous system.
• Eclectic Approach:
  • Uses techniques from various forms of therapy depending on the client’s problems.

Freudian Psychoanalysis

• Problems arise from tension in the unconscious mind caused by forbidden impulses and threatening memories.
• Psychoanalysis:
  • Probes the unconscious to bring issues into consciousness.
• Major goal:
  • Reveal and interpret the contents of the unconscious mind.

Therapy - Psychoanalysis

• Involves psychological techniques.
• First therapy available.
• Aims to address disorders fueled by childhood residue or repressed impulses and conflicts.
• Patients work through buried feelings and take responsibility for growth.

Therapy - Psychoanalysis: Methods

• Historical reconstruction:
  • Uses the past to unmask the present.
• Free Association
• Resistance:
  • Blocking from consciousness of anxiety-laden material.
• Interpretation:
  • The analyst noting supposed dream meanings, resistances, and other significant behaviors in order to promote insight.

Therapy - Psychoanalysis

• Latent content:
  • Important to underlying censored meaning.
• Transference:
  • The patient’s transfer to the analyst of emotions linked with other relationships (e.g., love or hatred for a parent).
• Traditional Psychoanalysis:
  • Takes time (several sessions a week for years).
  • Can be expensive (usually 100/HR).
  • In USA, most take insurance.

Psychoanalysis Theory

• People recover when released from repressive mental restraints established in early childhood relationships with their parents.

Neo-Freudian Psychodynamic Therapies

• Developed by psychologists who embraced some of Freud’s ideas but disagreed with others.
• Emphasis is on the conscious mind, not the unconscious mind.
• Spend less time probing for hidden conflicts and repressed memories.

Therapy – Psychodynamic

• Understand current symptoms by focusing on themes across important relationships.
• Help explore and gain perspective on defended-against thoughts/feelings.
• Face-to-face, once a week for a few months.
• Interpersonal Therapy:
  • Brief variation of psychodynamic therapy.
  • Help gain insight into roots of difficulties.
  • Goal: become symptom-free in the present, not in overall personality change.
  • Focusing on current relationships/relationship skills.

Insight Therapies

• Attempts to change people on the inside by changing the way they think and feel.
• Distressed persons need to develop an understanding of the disordered thoughts, emotions, and motives that underline their mental difficulties.

Humanistic Therapies

• Motivated by healthy needs for growth and psychological well-being.
• Problems occur when conditions interfere with normal development and produce low self-esteem.
• Help clients confront their problems by recognizing their own freedom, enhancing their self-esteem, and realizing their fullest potential.

Humanistic Therapy

• Aims to boost self-fulfillment by growing self-awareness and self-acceptance.
• Referred to as Insight Therapies.
• Aim to improve psychological functioning and awareness of underlying motives & defenses.
• Different than psychoanalytic:
  • Present & future focus.
  • Consciousness.
  • Immediate responsibility for own feelings.
  • Promoting growth instead of cure.
  • Clients rather than patients.

Humanistic Therapy: Client-Centered Therapy

• Developed by Carl Rogers.
• Uses techniques such as active listening within a genuine, accepting, empathic environment to facilitate clients’ growth.
• Nondirective therapy:
  • Therapist listens without judgment.
  • Refrains from directing towards insights.

Humanistic Therapy: Active Listening

• Empathic listening in which the listener echoes, restates, and clarifies.
• Unconditional positive regard:
  • Accepts worst traits & feel valued & whole.
• Psychological problems decrease as self-awareness grows.

Behavior Therapies

• Based on the assumption that undesirable behaviors have been learned and can be unlearned.
• Focus on problem behaviors rather than inner thoughts, motives, or emotions.
• Goal: determine how behaviors were learned and eliminate them.

Behavior Therapy

• Therapy that applies learning principles to the elimination of unwanted behaviors.
• Derived from Pavlov’s ideas.
• Learned behaviors/emotions cause psychological issues.
• Counterconditioning:
  • Procedure that conditions new responses to stimuli that trigger unwanted behaviors.
  • Based on classical conditioning.
  • Includes systematic desensitization and aversive conditioning.

Behavior – Exposure Therapies

• Exposure Therapies:
  • Exposure to stimuli that are normally avoided.
• Progressive Relaxation:
  • Relax one muscle group after another until one reaches complete relaxation.
• Systematic Desensitization:
  • Type of counterconditioning.
  • Associates a pleasant, relaxed state with gradually increasing anxiety-triggering stimuli.
  • Commonly used to treat phobias.

Steps of Systematic Desensitization

• For a fear of public speaking:
  • Seeing a picture of a person giving a speech.
  • Watching another person give a speech.
  • Preparing a speech to give.
  • Having to introduce oneself to a large group.
  • Waiting to be called upon to speak at a meeting.
  • Being introduced as a speaker to a group.
  • Walking to the podium to make a speech.
  • Making a speech to a large group.

Systematic Desensitization: Mary Cover Jones

• Used desensitization to cure phobias.
• A patient may be desensitized through the repeated introduction of a series of stimuli that approximate the phobia.
• Her study of the removal of a fear of rabbits through conditioning, on a three-year-old named Peter.
• Jones treated Peter’s fear of a white rabbit by “direct conditioning,” in which a pleasant stimulus (food) was associated with the rabbit. As the rabbit was gradually brought closer to him in the presence of his favorite food, Peter grew more tolerant and was able to touch it without fear.

Systematic Desensitization: John Wolpe

• Hierarchical of Anxiety:
  • Cannot be both relaxed and anxious at the same time.
  • Client and the therapist create a hierarchy of anxieties.
    • (i.e. list of all the things that produce anxiety in all its different forms) starting with what produces the lowest level of anxiety to what produces the most anxiety.
  • Client needs to be fully relaxed while imaging the anxiety producing stimulus.
  • Depending on what their reaction is, whether they feel no anxiety or a great amount of anxiety, the stimulus will then be changed to a stronger or weaker one.
• NOTE: Systematic desensitization, though successful, has flaws as well.
  • The patient may give misleading hierarchies, have trouble relaxing, or not be able to adequately imagine the scenarios. Despite this possible flaw, it seems to be most successful

Behavior Therapy: Systematic Desensitization

{Pulse Rate}

Exposure Therapies: Virtual Reality Exposure Therapy

• Progressive exposure to simulations of fears
• Aversive Conditioning
• Type of counterconditioning
• Associates an unpleasant state with an unwanted behavior
  • nausea ---> alcohol

Aversion Therapy

• Takes on psychological problems with a conditioning procedure designed to make tempting stimuli less provocative by pairing them with unpleasant (aversive) stimuli.

• In time, the negative reaction (UCR) associated with the averse stimuli comes to be associated with the conditioned stimuli.

• This is usually a last resort type of therapy, though it has been shown to be successful.

• Clockwork Orange

Aversion therapy for alcoholics

• Unconditioned Stimulus (UCS) (drug) leads to an Unconditioned Response (UCR) (nausea)
• Conditioned Stimulus (CS) (alcohol) + UCS (drug)
• CS (alcohol) then leads to Conditioned Response (nausea)
• UCR (nausea)

Aversion Therapy & Smoking

• Sequence:
  • Put cigarette in mouth.
  • Rapid Smoking.
  • Nauseating Feeling.
  • Desire to smoke reduced.

Operant Conditioning Therapy: Behavior Modification

• Reinforcing desired behaviors & withholding reinforcement for undesired behaviors.
• Token Economy:
  • An operant conditioning procedure that rewards desired behavior.
  • Patient exchanges tokens earned for desired behavior for various privileges or treats.
• Contingency Management:
  • An approach to changing behavior by changing the consequences associated with a behavior.

Cognitive Therapy

• Teaches people new, more adaptive ways of thinking and acting.
• Based on the assumption that thoughts intervene between events and our emotional reactions.

Cognitive Therapy: Statistics

• Cognitive: 49%
• Psychoanalytic/psychodynamic: 28%
• Family/systems: 19%
• Humanistic: 11%
• Behavioral: 9%

Cognitive Therapy: Cognitive Perspective

• Lost job leading to depression
  • Internal beliefs: I’m worthless. It’s hopeless.
• Lost job with no depression
  • Internal beliefs: My boss is a jerk. I deserve something better.

Cognitive Therapy: Cognitive-Behavioral Therapy

• A popular integrated therapy that combines cognitive therapy (changing self-defeating thinking) with behavior therapy (changing behavior).
• Aims to alter the way patients think & act.

The Cognitive-Behavioral Therapy

• This approach assumes that an irrational self-statement often underlies maladaptive behavior.
• Physical Sensations, Thoughts, behavior and Emotions affect each other.

Cognitive-Behavioral Therapy

• Therapist and client work together to:
  • Modify irrational self-talk.
  • Set attainable behavioral goals.
  • Develop realistic strategies for attaining goals.
• People change the way they approach problems and develop new skills and a sense of self-efficacy.

Group/Family Therapies: Group Therapy

• Benefit:
  • Social context allows people to discover others have similar problems & give feedback to each other.
• Family Therapy:
  • Treats the family as a system.
  • Views an individual’s unwanted behaviors as influenced by or directed at other family members.
  • Attempts to guide family members toward positive relationships and improved communication.

Group/Family Therapies

• Most focus on hard-to-discuss or stigmatized illness
  • AIDS patients high amongst group therapy
  • The worse the illness, the more people actually attend groups

Does Therapy Work? Meta-analysis

• Procedure for statistically combining the results of many different research studies
• 80% of untreated people have poorer outcomes than average treated person

Does Therapy Actually Work?

• In 1952, Hans Eysenck suggested that 2/3 of all people with non-psychotic problems recovered within two years whether they received therapy or not arguing that therapy was worthless

Response to Eysenck

• Overall research supports two major conclusions:
  • Therapy is more effective than non-therapy.
  • Eysenck overestimated the improvement rate in no-therapy control groups.

Biomedical Approach

• Changing the brain’s:
  • Chemistry with drugs.
  • Circuitry with surgery.
  • Patterns of activity with pulses of electricity or magnetic fields.

Biomedical Therapies: Psychopharmacology

• Study of the effects of drugs on mind and behavior.
• Lithium:
  • Chemical that provides an effective drug therapy for the mood swings of bipolar (manic-depressive) disorders.

Drug Therapy/Psychopharmacology

• First psychological drugs were administered in 1953 (antipsychotic drugs).
• In 1955, over 1/2 million Americans were living in mental institutions, each staying an average of a few years.
• With the introduction of tranquilizers, the number declined.
• By 1965, the number of patients was down to 1/4 million, with most patients staying for only a few months.

Antipsychotic Drugs

• Treat the symptoms of psychosis: delusions, hallucinations, social withdrawal, and agitation.
• Most work by reducing the activity of the neurotransmitter dopamine.
• Drugs (Thorazine) often have powerful side effects.

+/- of Antipsychotic Drugs

• These drugs reduce the overall brain activity.
  • They do not simply put the patient in a trance.
  • Instead, they simply reduce the “positive” symptoms of psychosis.
• Long-term use can cause problems like tardive dyskinesia
  • (Tardive: delayed, Dyskinesia: abnormal movements)
  • Produces an uncontrollable disturbance of motor control, especially in the facial muscles.

Positive and Negative Categories

• Symptoms of schizophrenia are categorized into positive and negative.
• Positive symptoms:
  • Refer to active processes such as delusions and hallucinations.
• Negative symptoms:
  • Refer to passive processes like social withdrawal.

Antidepressant Drugs

• Three major classes of antidepressant drugs.
• All three work by increasing messages transmitted over certain brain pathways, especially those using norepinephrine and serotonin.
• Major downside:
  • Takes a few weeks for them to have an effect.

Antianxiety Drugs

• Most commonly fall into two categories:
  • Barbiturates
  • Benzodiazepines
• Barbiturates:
  • Act as a central nervous system depressant, so they have a relaxing effect.
• Benzodiazepines:
  • Work by increasing the activity of certain neurotransmitters.

Stimulants

• A broad category that includes everything from caffeine to nicotine to amphetamines to cocaine.
• Drugs that produce excitement or hyperactivity.
• Prescribed for a variety of disorders including narcolepsy and ADHD.

Truth About Drugs

• Cannot cure any mental illness.
• Can alter the brain to suppress some symptoms.
• Can have negative long-term effects.
• Can be habit-forming.
• Often over-prescribed.

Biomedical Therapies; History Of Hospital Usage

• The emptying of U.S. mental hospitals
• Introduction of antipsychotic drugs
• Rapid decline in the mental hospital population

Action of Antidepressants

• Message is sent across synaptic gap.
• Sending neuron sends neurotransmitters and the message is received.
• Excess neurotransmitter molecules are reabsorbed by the sending neuron.
• Prozac blocks normal reuptake of the neurotransmitter serotonin as excess serotonin in synapse enhances its mood-lifting effect.

Biomedical Therapies: Psychosurgery

• Surgery that removes or destroys brain tissue in an effort to change behavior.
• Lobotomy:
  • Egas Moniz developed the lobotomy in the 1930s.
  • Now-rare psychosurgical procedure once used to calm uncontrollably emotional or violent patients.
• Electroconvulsive Therapy (ECT):
  • Therapy for severely depressed patients in which a brief electric current is sent through the brain of an anesthetized patient.

Disorders & Therapies in Cultural Settings

• The way a disorder is treated relies on the way it is viewed.
  • Heavily dependent on the culture in which it is being treated.
• Individualistic:
  • Western views generally regard psychological disorders to be a result of:
    • disease process
    • abnormal genetics
    • disordered thinking
    • unhealthy environments or stressors.
• Collectivist:
  • Cultures often think of mental disorders as a disconnect between the person and the group.
  • In such cultures, treating mentally disturbed people by removing them from society is unthinkable.

Indigenous Treatments

• Rooted in religion and spirituality.
• They rely heavily on:
  • family
  • community networks
  • spiritual healers

Consider when treat ethnic minorities

• Understanding different culturally-based ways of thinking and expressing thoughts about illness.
• Correct interpretation of nonverbal communication.
• Taking into account how cultures vary on importance of hierarchy in interpersonal relationships.
• Establishing treatment expectations.
• Recognizing role of extended families in treatment for many cultures

Cultural Competency

• Providing clinicians who are sensitive to the client's cultural background.
• Take the time and effort to understand the client within his or her cultural context can be more beneficial that simply matching ethnicities.
• Culture-sensitive counselors have been rated as being more credible and competent to conduct treatment across cultures by African Americans and Mexican Americans

Limitations in applying traditional psychotherapy to other cultures

• 1)The assessment of clients
  • Expressions of abnormality, and their underlying psychological causes, are at least partly bound to culture.
• 2) How functionality is defined by culture
  • If the goal of psychotherapy is to help people to become more functional within their society, then functionality itself is culturally determined; different cultures and societies would necessitate different outcomes.
• 3) Understanding is culture bound-syndromes
  • The ability of the therapist or clinician to assess and deal with such behaviors is intimately related to his or her knowledge, understanding, and appreciation of the cultural context within which the behaviors occur.