Psychopathology Chapter 16 : Therapy

Family Thearpy

Began with the finding that many people who had shown marked clinical improvement after individual treatment ( often in institutional settings) had a relapse when they returned home. Designed to reduce high levels of criticism and family tension have been successful in reducing relapse rates with patients that have schizophrenia and mood disorders.

Why do people seek therapy ?

a) Stressful current life circumstances b) People with longstanding problems (chronic unhappiness) c) Reluctant clients (men less willing than women) d) People who seek personal growth

Gestalt Therapy

"Gestalt means whole" and this therapy emphasizes the unity of mind and body -- placing strong emphais on the need to integrate thought, feeling and action. Developed by Fritz Perls as a means of blocking off awareness. Commonly used in a group setting, Indv. may be asked to act out fantasies/conflicts in an "empty chair technique". Attention to dreams but very different than psychoanalysis. In gestalt all elements of dream are unacknolwedged aspects of the dreamers self rather than unconscious. Goal is to integrate in present "be"

Eclecticism and Integration

"Multimodal therapy"; ecelectic = therapists try to borrow and combine concepts/techniques from various school of theory, depending on what seems best for the indv.

Object relations, Attachement-beased approaches and self psychology

"objects"are other people. Focus on interpersonal relationship issues, searching for balance of past issues with current relational issues.

Medication or Psychotherapy?

*Advances in psychopharmacology have allowed many people who would otherwise need hospitatliztion to remain with families in their community while reducing the time patients need to spen in the hosital. Meds favorable for getting away from hospital climate * There is a greater trend to use meds now than psychotherapy. May be problematic alleviate symptoms but not undestand the change / invidv/ behaviors. Relapse as well * Combining meds and psychotherapy is common for schizophrenia and bipolar / depression the most * Not all comibned treatments are superior to single treatments. Gotta figure out based on client/disorder/history/etc.

Boundary Violations

A special case of therapeutic harm when the therapist behaves in ways that exploit the trust of the patient or engages in behavior that is highly inappropriate. (sexual, buying gifts . etc)

Lithium

mood stabilizing drug most commonly used for Mania.

Would change occur anyway, with no treatment?

*Improvement often occurs without professional intervention. Psychotherapy can accelerate improvement. * Most researchers today would agree that psychotherapy is more effective than no treatment (chances are impressive) But why do patients improve? - Not too sure, cognitive/dynamic changes.. how skillful the therapist administers therapy, and its delivery type.

Becks Cognitive Therapy

*Orginally developed for depression and later on anxiety disorders* Clients made aware of connection between their patterns of thinking and their emotional responses. First to identify negative automatic thoughts/dysfunctional schemas allowing them to perceive the world selectively with harmful thoughtsm, to overgeneralize on the basis of limited examples (ex. I am worthless bc I got laid off from work) , to magnify significance of undesirable events and to engage in absolutist thinking

Can therapy by harmful?

*Some clients are actually harmed by their encounters with psychotherapists . (5% of clients, those with OCD and Borderline are the most ) Problems in the thearapeutic alliance account for instances of treatment failture. It is ethically required of all therapists to (1) monitor their work with various typse of clients to discover and differences (2) to refer to other therapists those clients that may be ill equipped to work with *Clinicians are quite bad to recognizing when their clients are not doing well

Freudian Psychoanlysis four basic techniques

1) free association 2) analysis of dreams 3) analysis of resistance 4) analysis of transference

Measuring Success in Psychotherapy

1) therapists impression of changes that have occurred 2) a clients report of change 3) reports from the clients family or friends 4) comparison of pretreatment and postreatment scores on personality tests and other instruments measuring psychological functioning 5) measures in change in selected overt behaviors *are limitations when measuring (ex. therapist bias in success) *regression to the mean

Motivational Interviewing ( Humanistic-Experiential Therapy)

A brief form of therapy that can be delivered in one or two sessions. Developed as a way to help people resolve their ambivalence about change and a commitment to treatment. Supporitve, empathic style like Carl Rogers. Differs because it employs a more firect apporach tha explores the clients own reason for wanting the change. Therapist encurages motivational statements and "change talk". MI is used most often in the areas of substance abuse and addiction.

Transference Neurosis

A person's reliving of pathogenic past relationship in asense recreates the neurosis in rel life.

What role do social values an culture play in psychotherapy?

Although psychotherapy is a set of tools to be used in pursuit of a clients welfare, not an ethics system, therapists are often faced with moral dilemmas in the course of treatment. Racial and ethnic minoritesar currently underserved by the mental health system

Exposure Therapy - Systematic Densistization

Anxiety-provoking stimuli administered in a very controlled, slow and gradual way. Find a behavior that is imcompatible with being anxious (such as being relaxed or pleasure ) and repeatedly pair it with stimulus that provokes anxiety.

Classical psychoanalyis

At least three sessions per week / intensive, long term procedure for unwanted repressed memoreis, thoughts fears stemming from psychosexual development and helping individuals come to terms with them in a light of the realities of adult life. Client sits on the couch. Therapist as "blank slate"

Rational Emotive Behavior Therapy (REBT) (Cognitive- Behavioral Therapy)

Attempts to change a clients maladaptive thought processes, on which the maladaptive emotional responses, and thus behavior, are presumed to depend. A well functioning indv. behaves rationally and in tune with empirical reality. ex. a client may think " I should be able to win everyone's love and approval" Task of REBT is to restructure indv belief system and self-evaluation esepcially with respect to irrational "shoulds", "oughts" and "musts". REBT usese behaviorally oriented techniques such as client hw assignments aiming to increse an individuals feelings of self-worth and clear the way for self-acutalization by removing the false beliefs that have been stumbling blocks to personal growth.

Traditional Behavioral Couple Therapy (Couple Therapy)

Based on social-learning model and views marital satisfaction and marital distress in terms of reinforcement. Usually 10-26 sessions, guided by a manual. Resolve communication and adaptive problem solving. Shows success, 2/3 of couples ten do show relationship improvement. Doesn't work for all couples and improvement is not usually over time.

Structural Family Thearpy

Based on systems theory, holds that if the family context can be changed, then the indv. members will have altered experiences in the family and will behave differently in accordance with the changed requirements o the new family context. *Important goal of this therapy is changing the organization of the family in such a way that the family members will beave more supportively. Therapsist analyzes INTERACTION amongst family in a more active way that could alter.

Humanistic- Experiential Therapies

Based on the assumption that people have both the freedom and the responsibility to control their own behavior- that they can reflect on their problem, make choices and take positive action. Central focus is expanding a clients awareness

Psycotherapy

Belief that people with psychological problems can change -- can learn more adaptive ways of perceiving, evaluating and behaving. Change can be hard

Psychodynamic Therpies

Board treatment approach that focuses on the indv. personality dynamics, usually from a psychoanyltic derived perspective. Freud. Classical psychoanalysis and psychoanalytically oriented psychotherapy.

SSRIs treating more than just depressive disorder

Can treat panic disorder, social phobia and generalized anxiety disorder as well as OCD and Bulimia nervosa, some binge eating

Client-Centered Therapy (Humanistic-Experiential Therapy)

Carl Rogers; focuses on the natural power of the organism to heal itself. Primary objective is to resovlve incgrounence (to help clients be able to accept themselves). Unconditional positive regard and empathy. Therapist does not give answers, does not interpret , does not probe for unconscious material. Therapist listens attentively and always reaffirms empahty and uncoditional positive regard.

Evaluating Psychodynamic Therapies

Classical psychoanalysis is routinely criticized for being time consuming and expensive. More research done on newer psychodynamically oriented approaches. Good for depresession, panic disorder, PTSD, substance abuse. "insight" ^ as a key construct and involves cognitive /emotional understanding of inner conflicts.

Behavior Therapy (Psychosocial Therapy)

Direct and active treatment that recognizes the importance of behavior, acknowledges the role of learning and includes assessment/evaluation. Instead of exploring past events, the focus is on the presenting problem that is presumed to be acquired by learning . Goal is to unlearn these maladaptive behaviors *Behavior therapy usually achieves results in a short period of time because it is generally directed to specific symptoms, leading to a faster releif of a clients current distress

Analysis of Resistance

During process of free association or dreams, an indivdiual may show an unwillingness or inability to talk about certain thoughts, motives or experiences. Must be sought to have indv. face this repressing resistance.

The Therapeutic Relationship

Evolves out of what both client and therapist bring to the relationship. The clients major contribution is motivation and expectation. Therapeutic alliance : 1) a sense of working collaboratively on the problem 2) agreement between patient and therapist about goals /tasks of therapy 3) an affective bond between patient and therapist. *Clear communication.

Interpersonal Therapy

Ex. of Eclectism ; IPT focuses on current relationships in the patients life and has the goals of reducing symptoms and impriving functioning.

Cognitive/ Cognitive Behavioral Therapy

Focus on "private events" (thoughts, perceptions, evaluation and self-statements) Stem from both cognitive psychology (with emphasis on the effects of thoughts on behavior) and with behaviorism ( with its rigorous methodology and performance-oriented focus) two main themes 1) the conviction that cognitive processes influence emotion, motivation and behavior 2) the use of cognitive and behavior-change techniques in a pragmatic (hypothesis-testing) manner

Behavioral Activation

Form of behavior therapy in which the client and the threapist work together to help the client find ways to become more active and engaged with life activities

Evaluating Humanistic - Experiential Thearpies

Have made a major impact on meaning, human capacity for choice/diretion but also cricized for their vaugness. Unique appraoch so we should expect differnt techniques to be approatpraite for different cases.

Analysis of Dreams (Classical Freudian)

Importantfor related unconscious material in the anaylsis of dreams, repressed defensives. Manifest Content : Which is the dream as it appears to the dreamer Latent Content : Consists of actual otives that are seeking expression but are so painful or unacceptable that they are disguised.

Exposure Therapy - In vivo exposure / Imaginal Exposure

In vivo = real exposure Imaginal = imaginary, thinking of the anxiety-provoking stimuli * In vivo is preferable whenever practically possible

Free association

Indv. must say whatever comes into his or her mind regardless of how personal, painful or seemingly irrevlant it may be. Usually client is in relaxed position (on couch). Freud didnt consider any associations to be "random" but as maladaptive unconscious thoughts.

Integrative Behavorial Couple Therapy

Instead of emphasizing change (which sometimes has a paradoxical effect of making people not want to change) IBCT focuses on acceptance and includes strategies that help each member of thecouple come to terms with an accept some of the limitations of his or her partner. Acceptance strategies are than combined with change strategies.

Aversion Therapy (Behavior- Psychosocial Therapy)

Involves modifying undesirable behavior by the old-fashioned method of punishment. Ex. Drugs like Antabuse which induces nausea when a person takes alcohol. In the past painful electric shock was adminsiterd . Aversion therapy used for smoking, drinking, overeating, druges, gambling, sexual deviance, bizarre psychotic behavior

Trycyclic Antidepressants

Operate to inhibit the ruptake of nonpinephrine and some serotonin weight gain side effect , 1970's med for antidepressant?

Manualized therapies

Originated to standardize psycohoscial treatments to fit the RCT paradigm. ( Efforts to manualize therapy represent one way that researchers have tried to minimize the variability in patients clinical outcomes that might result from characteristics of the threapist themselves

Who provides psychotherapeutic services?

Physicians, psychological specialists, psychiatrists, *Clergy for emotional crisis* Psychologists, psychiatrists and psychiatric special workers provide psychotherapy in mental health professions * In some states supervised psychologists can provide meds. Psychiatrists differ from psychologists by treating with biological means (ex. Meds) , whereas psychologists treat patients problems by examining and in some cases changing behaviors / thoughts

Response Shaping

Positive reinforcement is used to establish, by gradual approximation, a response that is atviely resisted or is not initially in an idv. behavioral repetoire. Ex. A child who refuses to speak in front of others ( selective mutism) may be first rewarded (with praise or a more tangible treat) for making any sound. Later, only complete words and later again only strings of words, would be rewarded

Evaluating Cognitive-Behavioral Therapies

REBT less assimilated into mainstream than CBT. REBT basically used for healthy people to cope better with everyday stress and perhaps in preventing them from developing full-blown anxiety/depressive disorders. CBT treatment methods have been well documented and apporahces are extremely beneficail in allevating major types of disorders. In all but psychotic dpression, CBT is at least comparable to drug treatment. CBT also offers long-term advantages with possible prevention of relapse. Used for panic, generalized anxiety disorders. Treatment choice for bulimia.

Systematic Use of Reinforcement

Reinforment to suppress unwanted material or to elicit/ maintain desired behavior to achieve notable success. (called contingent management programs)

Modeling (Behavior- Psychosocial Therapy)

The client learns new skills by imitating another person (such as parent or therapist) who performs the behavior to be acquired.

Benzodiazepines

The most important and widely used calss of antianxiety drugs . Another class of barbituates are seldm used today unless to control seizures. Benzodiazepines work rapidly in digestive track. ex. Xanax, Valium.

Psychoanalytically oriented psychothearapy

The treatment and the ideas guiding it may depart from the principles and procedures laid out by orthodox Freudian theory, yet the therapy is till loosley based on psychoanalytic concepts. Less frequent sessions (once a week) , sit face to face with client and not on the couch. Relatively passive stance of therapist (ex. free association and interpretations) is replaced with a more active conversationaly style. * Widely believed that tis more direct approach significantly shortens total treatment time

Electrode Placement for ECT

Unilateral ECT = limited to one side of the brain Bilateral ECT= electrodes placed on each side of the head. * Bilateral ECT is moer effective but also associated with more cogitve/memory side effects.

Antidepressent Meds- MAOI's

These werer the first anti-depresants used. Inhibit monoamine oxidase . Must avoid foods such as salami/cheese (amino acid tyramine)

Regression to the mean

This reflects the statistical tendency for extreme scores (ex. very high or very low) on a given measure to look less extreme a the second assesment. Those who scored far from the group mean to begin with, will score closer to the group mean on the second assesment, even if no real clinical change has occurred

Objectifying and Quantifying change

Today the emphasis is more quantative methods of measuring change. Beck Depression Inventory, Hamilton Rating Scales both yield summary scores that have been the standard. MRI to help study OCD patients in one study.

Token Economies

Token economy resembles the outside world, where an individual is paid for his or her work in tokens (money) that can later be exchanged for desired object and activities.

Analysis of Transference/ Countertransference

Transference : People carry over (unconsciously) feelings/ attitudes that they had in their relations with a parent or other close person to there therapist. Countertransference : Wherin the therapist reacts in accord with the clients transferred attributions rather than objectively. This must be recognized by the therapist.

Anti-anxiety drugs

Used for conditions in which tension and anxiety are significant components . They do not provide a cure. Ex. Benzodiazipines *Anti-anxiety drugs are widely presribed causing concern because these drugs have addivtive potetnial and sedative effects.

Deep brain stimulation

Used for severe and chronic health problems/depression. Electrodes are implanted into the brain and stimulated by pulse generators implanted into the chest region.

Neurosurgery

Used occasionally in the 19th century to treat mental disorders by relieving pressure in the brain. Frontal lobes of the brain wer severed from the deeper centers underlying them. This became a technique known as "frontal lobotomy" which stands * as dubious tribute to the extremes to which profesionals have sometimes been driven in their serch for effective treatment of psychoses (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality)

Electroconvulsive Therapy (ECT)

Used of electricity to produce convulsions and unconsciousness. A treatment used primarily to alleviate depressive and manic episodes. * Patient who receives ECT is given sedative and muscle relaxants prior to the procedure to prevent violent contractions. In the time before this, the violent contractions were so bad that a patient could fracture vertabrae.

Antipsychotic Drugs (Neuroleptics)

Used to treat psychotic disorders such as schizophrenia and psychotic mood disorders. Alleviate hallucinations and delusions by blocking dopamine receptors. First Generation meds (conventional) ( ex. thorazine (cholorpromazine) have horrible side effects such as tardive dyskinesia = movement abnormality of lips. Second Generation meds (atypical) less side effects

Exposure Thearpy ( Behavior- Psychosocial Therapy)

Used widely in anxiety disorders. Get rid of anxiety from anxiety provoking stimuli.

Transference-focused psychotherapy

Uses techniques like clarification, confrontation to help the patient undersnd and correct the distortions that occur in his or her perception of people , especially the therapist.

Evidence - Based Treatment

When a pharm. co. develops a new drug, it must be approved by the FDA. This demonstrates its efficacy (the drug does what it is supposed to do in curing or relieving condition). To test for this they use randomized clinical trials (RCT's) or simply efficacy trials. These trials have half people using the drug and other half using placebo. Double blind procedure : neither the patient nor the prescriber is informed which drug is to be admisntered to which group

Exposure Therapy - Flooding

Which the patient administers anxiety-provoking stimuli at full strength

Antidepressant Meds - SSRI's

classical antidepressents were Monoamine Oxidase Inhibitors and Trycyclics have been replaced with SSRI's. Ex . of SSRI = Prozac / Zoloft. Older antidepressents increased serotonin by SSRI's block it.