Therapy for Psychological Problems Notes

Mental Health Treatment: Introduction

• Therapy for psychological problems can involve:
  • Psychological interventions.
  • Biological interventions, aiming to alleviate distress.
• Psychological problems stem from:
  • Biology.
  • Genetics.
  • Childhood experiences.
  • Conditioning.
  • Sociocultural influences.
• Therapeutic techniques vary:
  • Some emphasize therapist-client relationships.
  • Others prioritize behavior change.
    *Figure 1 depicts the Ocean Therapy program, which employs multiple approaches to support veterans' mental health.

Historical Treatment of Psychological Disorders

• Past beliefs:
  • Psychological disorders were attributed to demonic possession.
  • Treatment involved exorcisms, imprisonment, or execution.
• Asylums:
  • Built to house the mentally ill, but offered little to no treatment.
  • Methods were often cruel.
• Reformers:
  • Philippe Pinel and Dorothea Dix advocated for humane treatment.
• Deinstitutionalization movement (mid-1960s):
  • Aimed to close asylums and enable community-based treatment.
  • Lack of resources led to homelessness for many.
• Modern approach:
  • Psychiatric hospitals offer short-term stays.
  • Emphasis on outpatient mental health services.
  • Services are provided by psychologists, psychiatrists, therapists, counselors, social workers, and religious personnel.
  • Covered by insurance, government funds, or self-pay.

Mental Health Treatment in the Past

• Historically, mental illness was attributed to:
  • Demonic possession.
  • Witchcraft.
  • Angry gods (Szasz, 1960).
• Medieval treatments:
  • Exorcism: Conducted by religious figures with incantations and medicinal drinks.
  • Trephining: Drilling a hole in the skull to release spirits, often resulting in death.
  • Execution or imprisonment.
  • Homelessness.
• Prevailing theory: Mental illness as demonic possession.
• Late 1400s to late 1600s:
  • Belief in pacts with the devil.
  • Accusations of witchcraft led to the deaths of mentally ill people (Hemphill, 1966).
• 18th century: Asylums were created to house people with psychological disorders but focused on isolating them rather than treating them.
  • Conditions: Windowless dungeons, beatings, chains, and minimal care.
• Late 1700s: Philippe Pinel advocated for humane treatment.
  • Unchained patients and engaged in conversation at La Salpêtrière in Paris (1795).
  • Improved patient outcomes.
    *Figure 3: Depicts Dr. Philippe Pinel ordering removal of chains from patients.
• 19th century: Dorothea Dix led reform efforts in the United States.
  • Advocated for the mentally ill and poor.
  • Lobbied for the creation of mental asylums.
    *Figure 4: Dorothea Dix advocating for the indigent insane.
• Asylum conditions:
  • Filthy, lacking treatment, and often long-term.
  • Electroshock treatment was used without safeguards.
  • At Willard Psychiatric Center Doctors administered 1,443 shock treatments in 1943.
  • Cold conditions.
  • Willard Psychiatric Center closed in 1995.
• 1954: Antipsychotic medications were introduced to control symptoms of psychosis.
  • Psychosis: Hallucinations and delusions indicating a loss of contact with reality.
• 1963: Mental Retardation Facilities and Community Mental Health Centers Construction Act.
  • Signed by John F. Kennedy.
  • Provided federal support for community mental health centers (National Institutes of Health, 2013).
  • Started deinstitutionalization: Closing large asylums and providing community-based treatment. Mental Health Treatment Today
• 1955: 558,239 severely mentally ill patients were institutionalized at public hospitals (Torrey, 1997).
• 1994: There were 92% fewer hospitalized individuals (Torrey, 1997).

Mental Health Treatment Today

• Prevalence of mental illness (U.S. Department of Health and Human Services, 2013):
  • 19% of U.S. adults in 2012.
  • Similar rate for teens (13–18).
  • 13% of children ages 8–15 (National Institute of Mental Health [NIMH], n.d.-a).
  • In 2016, 18.53% of adults reported suffering from a mental illness.
• Treatment rates:
  • In 2008, 13.4% of adults received treatment (NIMH, n.d.-b).
  • “2016 State of Mental Health in America” report: 57% of adults with mental illnesses do not receive treatment.
  • Contributing factors: Stigma, cost, insurance, awareness, and accessibility.

Community Mental Health Centers

• Locations:
  • Neighborhood-based.
  • Provide various mental health services.
• Deinstitutionalization problems:
  • Underfunding.
  • Untrained staff.
  • High staff burnout.
  • Lack of support services: Housing, food, and job training, led to homelessness.
• Homeless population:
  • 26% of homeless adults in shelters experience mental illness (U.S. Department of Housing and Urban Development [HUD], 2011).
    Figure 7 shows that One quarter of individuals in U.S. shelters have a mental illness and high number of people living with a mental illness are in correctional institutions
• Corrections system:
  • Approximately 705,600 mentally ill adults incarcerated in state prisons.
  • 78,800 in federal prisons.
  • 479,000 in local jails.
  • Mentally ill individuals are overrepresented in probation and parole populations (Prins & Draper, 2009).
  • The Treatment Advocacy Center reported that the growing number of mentally ill inmates has placed a burden on the correctional system (Torrey et al., 2014).

Modern Mental Health Treatment

• Psychiatric hospitals:
  • Emphasis on short-term care, averaging less than two weeks, often several days.
  • High cost: $800 to $1000 per night (Stensland, Watson, & Grazier, 2012).
  • Hospitalization limited to those who are an imminent threat to themselves or others.
• Seeking treatment:
  • Referred by primary care physicians or other sources.
  • Involved with child protective services: Parental treatment and child trauma treatment.
  • Criminal justice system.
  • Voluntary vs. involuntary treatment.
    *Figure 8. shows a therapy session for children where play may be involved.
• Treatment settings:
  • Community mental health centers.
  • Private or community practices.
  • School counselors or social workers.
  • Prisons.
• Treatment providers: Psychologists, psychiatrists, clinical social workers, marriage and family therapists, and religious personnel.
• Funding sources: Health insurance, government, and private pay.
• Mental Health Parity and Addiction Equity Act of 2008:
  • Requires parity of mental health services in group health plans (U.S. Department of Labor, n.d.).
  • Equal co-pays, visits, and deductibles for mental health and physical illnesses.
  • Rural areas face challenges in mental health services: Limited options, waiting lists, poor quality of care, and financial obstacles.
  • Primary care physicians and law enforcement often serve as first-line providers.
  • Availability, accessibility, and acceptability issues exist.
  • Approximately two-thirds of those with symptoms receive no care (U.S. Department of Health and Human Services, 2005; Wagenfeld, Murray, Mohatt, & DeBruiynb, 1994).

Psychotherapy

• Common treatment methods: psychotherapy or medicine, or a combination of both.

• Psychotherapy encompasses various therapy methods used by psychologists, psychiatrists, and counselors.

• Types of psychotherapy:

  • Psychoanalysis: Developed by Sigmund Freud to uncover repressed impulses or childhood trauma through techniques like free association and dream analysis.
  • Play therapy: A psychodynamic technique for children using dolls, stuffed animals, and sandbox figurines to play out hopes, fantasies, and traumas.
  • Behavior therapy: Employs principles of learning from classical and operant conditioning to change undesirable behaviors; uses counterconditioning and token economy.
  • Cognitive therapy: Focuses on how thoughts lead to feelings of distress, helping clients change dysfunctional thoughts.
  • Cognitive-behavioral therapy: Aims to change cognitive distortions and self-defeating behaviors.
  • Humanistic therapy: Focuses on helping people achieve their potential, using techniques like active listening, unconditional positive regard, genuineness, and empathy.

Autobiography in Five Short Chapters by Portia Nelson (1993)

• This poem reflects the goal of therapy, which is to help a person stop repeating destructive patterns and start looking for better solutions to difficult situations.
  • The poem consists of five short chapters where the character falls into a hole in the sidewalk, but eventually realizes it's their fault and learns to walk down another street.

Psychotherapy vs. Biomedical Therapy

• Psychotherapy: A psychological treatment that employs various methods to help someone overcome personal problems or attain personal growth.
• Biomedical therapy: Involves medication and/or medical procedures to treat psychological disorders.
• Social approach: Focuses on family or group therapies.

Psychodynamic Psychotherapy

• Talk therapy based on the belief that the unconscious and childhood conflicts impact behavior
• The patient talks about his/her past.

Play Therapy

• Psychoanalytical therapy wherein interaction with toys is used instead of talk; used in child therapy
• The child patient acts out family scenes with dolls.

Behavior Therapy

• Principles of learning applied to change undesirable behaviors
• The patient learns to overcome fear of elevators through several stages of relaxation techniques

Cognitive Therapy

• Awareness of cognitive process helps patients eliminate thought patterns that lead to distress.
• The patient learns not to overgeneralize failure based on a single failure.

Cognitive-Behavioral Therapy

• Work to change cognitive distortions and self-defeating behaviors
• The patient learns to identify self-defeating behaviors to overcome an eating disorder.

Humanistic Therapy

• Increase self-awareness and acceptance through focus on conscious thoughts.
• The patient learns to articulate thoughts that keep her from achieving her goals.

Psychoanalysis

• Developed by Sigmund Freud and was the first form of psychotherapy.
• Beliefs:
  • Most psychological problems result from repressed impulses and childhood trauma.
  • Psychoanalysis would help uncover long-buried feelings.
• Techniques:
  • Free association: The patient relaxes and says whatever comes to mind.
  • Dream analysis: Interpreting the underlying meaning of dreams.
• Resistance: Freud felt that the ego would at times try to block, or repress, unacceptable urges or painful conflicts during free association. Consequently, a patient would demonstrate resistance to recalling these thoughts or situations.
  *Figure 9. shows the famous couch in Freud’s consulting room. Today, a psychotherapy patient is not likely to lie on a couch; instead he is more likely to sit facing the therapist.
• Transference: The patient develops strong feelings (positive or negative) for the therapist, transferring emotions from other relationships.
• Modern perspective: The psychodynamic perspective expands on Freud’s ideas with less intensive treatment, remaining centered on internal drives and forces affecting one's behavior.

Cognitive Therapy

• Cognitive therapy is 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 distortion: A client may overgeneralize (e.g., failing one test leads to feeling stupid and worthless).
• Therapists also help clients recognize when they blow things out of proportion.
• Developed by psychiatrist Aaron Beck in the 1960s, focusing on how self-defeating attitudes maintain depression.
• Through questioning, a cognitive therapist can help a client recognize dysfunctional ideas, challenge catastrophizing thoughts about themselves and their situations, and find a more positive way to view things.
  *Figure 10. shows that your emotional reactions are the result of your thoughts about the situation rather than the situation itself.

Cognitive-Behavioral Therapy (CBT)

• One of the first forms of cognitive-behavior therapy was rational emotive therapy (RET), which was founded by Albert Ellis and grew out of his dislike of Freudian psychoanalysis

• During the 1980s and 1990s, cognitive and behavioral techniques were merged into cognitive-behavioral therapy.

  • CBT helps clients examine how their thoughts affect their behavior; it aims to change cognitive distortions and self-defeating behaviors.

• Reappraisal: a technique of reappraisal, or cognitive restructuring, is a fundamental aspect of CBT.

• The therapist helps point out inaccurate or maladaptive thoughts and help replace them with accurate, adaptive thoughts.

• Effective in the treatment of numerous psychological disorders such as depression, PTSD, anxiety disorders, eating disorders, bipolar disorder, and substance abuse.

• Cognitive-behavioral therapy aims to change cognitive distortions and self-defeating behaviors using techniques like the ABC model.

  • With this model, there is an Action (sometimes called an activating event), the Belief about the event, and the Consequences of this belief.
    • Jon’s belief about what happened results in a consequence of further depression, whereas Joe’s belief does not. Jon is internalizing the attribution or reason for the rebuffs, which triggers his depression. On the other hand, Joe is externalizing the cause, so his thinking does not contribute to feelings of depression.
  • Cognitive-behavioral therapy examines specific maladaptive and automatic thoughts and cognitive distortions. Some examples of cognitive distortions are all-or-nothing thinking, overgeneralization, and jumping to conclusions.

Behavior Therapy Example

Example: Miriam is terrified of speaking in front of people who are not her close friends. She wants to conquer them. Systematic desensitization works by gradually—step-by-step—exposing the person to situations that are increasingly more anxiety-producing

• The first steps in systematic desensitization is the development of a “hierarchy of fears. ”
• This simply means that you must help your Miriam create a list of situations related to her fear of public speaking.
  *The early ones are not threatening or are only mildly threatening. However, as soon as your client learns to cope with each situation, you start working on the next most frightening situation.
• Behavioral therapy teaches the client to cope with an anxiety-producing situation by replacing fear with an alternative response.
• A common alternative response is relaxation (slow breathing and focus on positive thoughts).

Miriam's Systematic Desensitization Therapy Treatment

• Preparation: Miriam creates a hierarchy of fears and practices relaxation techniques.
• Exposure Session 1:
  • Chatting with friends: Fear level 1 (no fear).
  • Thinking about a talk to a friendly audience: Anxiety starts at 3, drops to 1 with relaxation.
• Exposure Session 2:
  • Thinking about talking to a small, friendly group: Anxiety drops from 2 to 1.
  • Imagining telling company executives about a technical problem: Anxiety starts at 5, drops to 2.
• Exposure Session 3:
  • Practicing new scenarios: Anxiety quickly drops to 1.
  • Watching a video of someone similar giving a talk: Anxiety starts at 6, drops to 2.
• Exposure Session 4:
  • Preparing to give a talk to coworkers:
  • Giving the talk to a small group: Anxiety starts at 9, drops to 5.
• Exposure Session 5:
  • Giving the talk to the small group (20-minute presentation): Anxiety starts at 10, drops to 4.
• Exposure Session 6:
  • Being the introductory speaker at a literacy tutoring volunteer organization (45 people): Anxiety starts at 8, drops to 2. Miriam reports it was almost fun.
    *Flooding has the potential to be more traumatic so it must be carefully planned.
    In flooding therapy, you would skip the earliest situations described in systematic desensitization and you would move directly to highly threatening situations.
    *Homework and repeated practice reinforce the new positive response to situations that once produced fear.*.

Humanistic Therapy

• In contrast to psychoanalysis, humanistic therapists focus on conscious rather than unconscious thoughts.
• They also emphasize the patient’s present and future, as opposed to exploring the patient’s past.
• Psychologist Carl Rogers developed a therapeutic orientation known as Rogerian, or client-centered therapy (also sometimes called person-centered therapy or PCT).
  *Rogers felt that the term patient suggested the person seeking help was sick and looking for a cure. Since this is a form of nondirective therapy, Rogers emphasized the importance of the person taking control of his own life to overcome life’s challenges.
• In client-centered therapy, the therapist uses the technique of active listening.
  *In active listening, the therapist acknowledges, restates, and clarifies what the client expresses.
  *Therapists also practice what Rogers called unconditional positive regard, which involves not judging clients and simply accepting them for who they are.
  *Rogers also felt that therapists should demonstrate genuineness, empathy, and acceptance toward their clients because this helps people become more accepting of themselves, which results in personal growth.
  *Figure 11. shows that the quality of the relationship between therapist and patient is of great importance in person-centered therapy.

Mindfulness

• Mindfulness: tries to cultivate a nonjudgmental, yet attentive, mental state.
  *Mindfulness focuses on one’s awareness of bodily sensations, thoughts, and the outside environment.
  *Rather than modifying or eliminating sensations and thoughts, mindfulness focuses on non-judgmentally accepting them.
  *There are two important components of mindfulness:

  • Self-regulation of attention
  • Orientation toward the present moment.
    *Mindfulness improves mental health because it draws attention away from past and future stressors, encourages acceptance of troubling thoughts and feelings, and promotes physical relaxation.
    *Psychologists have adapted the practice of mindfulness as a form of psychotherapy, generally called mindfulness-based therapy (MBT).
    Mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) are several popular types of MBT.

• MBSR: meditation, yoga, and attention to physical experiences to reduce stress.
  *In MBCT, rather than reducing one’s general stress to address a specific problem, attention is focused on one’s thoughts and their associated emotions.
  *MBCT helps prevent relapses in depression by encouraging patients to evaluate their own thoughts objectively and without value judgment.
  *CBT focuses on “pushing out” the maladaptive thought, whereas mindfulness-based cognitive therapy focuses on “not getting caught up” in it.

Emerging Treatments

*Emerging Treatments includes Internet- and mobile-delivered therapies and cognitive bias modification.
*Cognitive bias modification (via video games) helps change problematic thought processes.
*CBT-enhancing pharmaceutical agents are drugs used to improve the effects of therapeutic interventions.
*The antibiotic d-cycloserine improves treatment for anxiety disorders by facilitating the learning processes that occur during exposure therapy.

Evaluating Various Forms of Psychotherapy

*This section discusses clinical expertise, evidence-based practice, and integrative or eclectic psychotherapy.
*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.
*   Your own characteristics, values, preferences, and culture.

Advantages and Disadvantages of Different Treatments

Psychoanalysis

• Advantages: Some patients and therapists find the prolonged and detailed analysis very rewarding.

• Disadvantages:

  • Not appropriate for some types of patients (e.g., those with severe psychopathology or mental retardation).
  • Treatment usually lasts many years, and it can be expensive.

Cognitive-Behavioral Therapy (CBT)

• Advantages:

  • CBT interventions tend to be relatively brief, making them cost-effective.
  • CBT is an intuitive treatment that makes logical sense to patients.
  • It can also be adapted to suit the needs of many different populations.
  • The greatest strength of CBT is the abundance of empirical support for its effectiveness.

• Disadvantages:

  • CBT involves significant effort on the patient’s part, because the patient is an active participant in treatment.
  • Therapists often assign “homework” to maintain the cognitive and behavioral habits the patient is working on.

Humanistic Therapy

• Advantages: It is highly acceptable to patients by offering a supportive and flexible environment.

• Disadvantages:

  • Humanistic Therapy is difficult to do experiments on, and not as well researched.
    Several studies have explored the effectiveness of psychotherapy with no studies finding that one psychotherapeutic approach more effective than another.
    *Figure 12. shows that therapy comes in many different forms and settings, but one critical factor in its success is the relationship between the therapist and client.

Biological Therapy

*Ancient and medieval times made use of trepanation wherein a drilling or cracking of a hole in the skull to expose the brain, was sometimes used to free evil spirits or demons from within a person’s head.
*In the 20th century, lobotomy gained use.

• Lobotomy: destruction of parts of the frontal lobe of the brain.*The goal of lobotomy was usually to calm symptoms in people with serious psychological disorders, such as schizophrenia.
  *One of the reasons lobotomy fell out of favor was the development in the 1950s and 1960s of new medications for the treatment of psychological disorders; these are now the most widely used forms of biological treatment.
  While these are often used in combination with psychotherapy, they also are taken by individuals not in therapy. This is known as biomedical therapy.
  Medications used to treat psychological disorders are called psychotropic medications and are prescribed by medical doctors, including psychiatristsThe types of medications and how they are used are shown in table 3.

Electroconvulsive Therapy (ECT) vs. Transcranial Magnetic Stimulation (TMS)

• Another biologically based treatment that continues to be used, although infrequently, is electroconvulsive therapy (ECT) which involves using an electrical current to induce seizures to help alleviate the effects of severe depression.
  *About 85% of people treated with ECT improve.
• A more recent alternative is transcranial magnetic stimulation (TMS), a procedure approved by the FDA in 2008 that uses magnetic fields to stimulate nerve cells in the brain to improve depression symptoms

Evidence-Based Practice

• Evidence-based practice is used to reduce errors in treatment selection by making clinical decisions based on researchEvidence-based treatment can reduce variability between therapists to ensure that a specific approach is delivered with integrityClients then have a higher chance of receiving therapeutic interventions that are effective at treating their specific disorder

Treatment Modalities

• There are several modalities, or methods, of treatment: individual therapy, group therapy, couples therapy, and family therapy are the most common.
  In an individual therapy session, a client works one-on-one with a trained therapist.*
• In group therapy, usually 5–10 people meet with a trained group therapist to discuss a common issue (e.g., divorce, grief, eating disorders, substance abuse, or anger management).
• Couples therapy involves two people in an intimate relationship who are having difficulties and are trying to resolve them.
  The therapist helps them resolve their problems as well as implement strategies that will lead to a healthier and happier relationship.
  *Family therapy is a special form of group therapy. The therapy group is made up of one or more familiesThe goal of this approach is to enhance the growth of each individual family member and the family as a whole.

Individual Therapy

• In individual therapy, also known as individual psychotherapy or individual counseling, the client and clinician meet one-on-one.
  ** During the intake, the therapist and client will work together to discuss treatment goals. Then a treatment plan will be formulated, usually with specific measurable objectives.
  Figure 13. Therapy may occur (a) one-on-one between a therapist and client, or (b) in a group setting.

Group Therapy

*In group therapy, a clinician meets together with several clients with similar problems.
*Match clients for age and problems.

• One benefit of group therapy is that 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. It is also more economical
  Group treatment is more economical than individual, couples, or family therapySexual abusers often feel more comfortable admitting and discussing their offenses in a treatment group where others are modeling openness.Clients often accept feedback about their behavior more willingly from other group members than from therapists. Finally, clients can practice social skills in group treatment settings.
  Figure 14. shows an example of group therapy

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.
  The therapist helps them see how their individual backgrounds, beliefs, and actions are affecting their relationship.
  *Some couples seek therapy to work out their problems, while others attend therapy to determine whether staying together is the best solutionCounseling couples in a high-conflict and volatile relationship can be difficult.

Family Therapy

*Family therapy is a special form of group therapy, consisting of one or more families.

• A family with this dynamic might wish to attend therapy together rather than individually.
  Family therapists work with the whole family unit to heal the family.
  **In structural family therapy, the therapist examines and discusses the boundaries and structure of the familyIn 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.

Cultural Factors and Therapy

*As our society becomes increasingly multiethnic and multiracial, mental health professionals must develop cultural competence.
*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.
Figure 16. shows that cultural and religious beliefs affect your attitude toward mental health treatment

Barriers to Treatment

*Statistically, ethnic minorities tend to utilize mental health services less frequently than White, middle-class Americans (Alegría et al., 2008; Richman, Kohn-Wood, & Williams, 2007).
*Perhaps the reason has to do with access and availability of mental health services. Ethnic minorities and individuals of low socioeconomic status (SES) report that barriers to services include lack of insurance, transportation, and time.
The public has a negative perception of children and teens with mental health disordersand stigmatization of psychological disorders is one of the main reasons why young people do not get the help they need when they are having difficulties.
Fortunately, we are starting to see campaigns related to the destigmatization of mental illness and an increase in public education and awareness.

Psychotherapies List

1. Dynamic Therapy: Reveal the unconscious content of a client’s psyche to alleviate psychic tension.
2. Behavioral Therapy: Focus on behaviors and how the environment impacts those behaviors (operant & classical conditioning).
3. Cognitive and Cognitive Behavioral Therapy (CBT): Identify maladaptive thoughts and reactions to influence destructive negative emotions. Combine cognitive & behavioral therapy to address maladaptive thoughts and dsyfunctional behaviors.
4. Humanistic Therapy: Emphasize subjective meaning, a rejection of determinism, and a concern for positive growth rather than pathology. Posit an inherent human capacity to maximize potential.
5. Group Therapy: One or more therapists treat a small group of clients together as a group.
6. Eclectic Therapy: Combine aspects of multiple types of therapies based on teh patient's specific scenario.

Biomedical Therapies

• Pharmacotherapy: Medications exist in four classes: antipsychotics, antidepressants, anti-cycling agents, and hypnoanxiolytics.
  *