Chapter 17 - TherapyReading Map

• Wednesday, April 4 – 659 - 669

• Thursday, April 5 – Assembly Schedule – 669 - 673

• Friday, April 6 to Friday, April 13 – Easter

• Monday, April 16 – 674 - 685

• Tuesday, April 17 – 685 - end

• Wed, Apr 18 – Staff Mtg – Ch 17 Quiz/Cards/St Guide

• Thursday, April 19 - Desk Mat due

• Thursday, April 19 – PLC day – 1st AP Exam

Historical Perspective (659)

Old Methods• Holes in head• Warm baths• Bleeding• Beating the devil out

New Methods

• Philippe Pine (France) and Dorothea Dix (USA) saw mental disorders as DISEASES and treatable in HOSPITALS

Two Main Perspectives (659)

1. Psychological Therapies

2. Biomedical Therapies

The Psychological Therapies (660)

•  are built on 4 main theories     

– Psychoanalytic

– Humanistic

– Behavioral

– Cognitive

• Note - the Eclectic Approach - uses a blend of therapies

Psychoanalysis (660)

Aims:

• to bring repressed impulses and conflicts from childhood into consciousness where the patient can deal with them

• gets patient to release the energy they previously devoted to the Id-Ego-Superego conflicts

Psychoanalysis Methods (661)

• Free Association

• Resistance

• Dream Analysis

• Transference

Psychoanalysis Methods (661)Free Association

• the patient retells his past, moment by moment, as it occurs to him without editing or censoring.

• Therapist mainly just listens for what is being said and not said

Psychoanalysis Methods (661)Resistance

• the therapist listens for resistance - blocks in the free flow of the patient’s talking

• Resistance gives the therapist an opportunity to interpret what repressed ideas are causing the resistance. 

Psychoanalysis Methods (661)Dream Analysis

• used to uncover the latent (hidden) content of the patient's manifest (remembered) dreams. 

• The latent dream reveals repressed ideas.

Psychoanalysis Methods (661)Transference

• the patient will transfer strong feelings from his earlier relationships onto the therapist

• The patient “blames” the therapists - but this is a good step in the therapy

• this is another way for repressed ideas to be discovered

Current Psychodynamic Therapy (662)

• try to understand a patient's current symptoms by exploring childhood experiences.

• probe for repressed information

• face-to-face therapy has replaced the couch

Interpersonal Therapy (662)

• an alternative to psychodynamic therapy

• focuses on current relationships rather than childhood and assists people to improve their current relationship skills

Humanistic Therapies (663)

• emphasizes humans’ inherent potential for self-fulfillment

• aims to boost self-fulfillment by helping people grow in self-awareness and self-acceptance

•  Focuses on:– the present and future rather than the past (childhood)– conscious rather than the unconscious– taking responsibility for your feelings/actions rather

than uncovering hidden reasons– growth rather than curing illness

Humanistic Therapies (663)Carl Roger’s Client-Centered Therapy

• focus on client's conscious self perceptions rather than the therapist's interpretations

• non-directive therapy where the therapist refrains from directing the client towards certain insights

• therapist shows acceptance, genuineness and empathy to allow client to feel unconditionally accepted and deepening their self-understanding and self-acceptance

•  used active listening (echoing/restating/  seeking clarification/acknowledging expressed feelings) to give client unconditional positive regard.

Behavior Therapies (665)

• Unlike the psychoanalysts and humanists, the behavior therapists doubt the healing power of self-awareness.

• they assume that the problem behaviors ARE the problem

• they apply learning principles to eliminate unwanted behaviors (rather than look for the cause of the behavior)

• they replace maladaptive behavior with constructive behaviors

Behavior Therapies (665)Classical Conditioning Techniques

• assumes that we learn behavior and emotion and therefore we can "unlearn" behavior and emotion

• O.H. Mowrer - uses classical condition to cure bed wetters - a liquid sensitive pad sounds an alarm waking the child - the child learns to associate a relaxed bladder with waking up -

Behavior Therapies (665)Counter-Conditioning

• pair a trigger stimulus (ie small space) with a NEW response that is incompatible with fear (ie relaxation).  The relaxation then displaces the old response of fear to the stimulus.

2 Types of Counter-Conditioning• 1.    Systematic Desensitization• 2.    Aversive Conditioning

Counter-ConditioningSystematic Desensitization Therapies

• replace a fear response with a response that is incompatible with fear - the theory is that you cannot be relaxed and fearful at the same time - the relaxation will eventually displace the fear

• Mary Jones used a technique of having a child eat close to a rat that it feared - eventually the pleasure associated with the eating displaced the fear response to the rat

Counter-ConditioningSystematic Desensitization Therapies

• Joseph Wolpe used a method called Exposure Therapy - people are over-exposed to a fearful stimulus and eventually they become habituated to the stimulus

• Progressive Relaxation - you relax one muscle group at a time until you achieve a drowsy state of relaxation and comfort - then the therapist has you imagine a mildly anxiety-arousing situation - this imagined scene is paired with your state of relaxation until you no longer feel the anxiety.

Counter-ConditioningSystematic Desensitization Therapies

• Anxiety Hierarchies - as you are in your relaxed state you imagine "worse" situations and then you eventually experience actual anxiety causing situation.

• Virtual-Reality Exposure Therapy - client wears goggles that give them a 3D image of what they fear (ie flying)

Counter-ConditioningAversive Conditioning (667)

• the therapist tries to replace a positive response to a harmful stimulus (ie alcohol) with a negative/aversive response.  (The therapist will put a nausea drug in the alcohol)

• Note - for alcohol treatment only 33% of clients are still booze-free after 3 years using this method

Counter-Conditioning

Systematic Desensitization

pair a stimulus (elevator) with a new response (relaxation) that is incompatible with anxiety                                                                                               

Aversive Conditioning

Replace a positive response to a harmful stimulus (alcohol) with a negative response (nausea)

Behavior Therapies (668)Operant Conditioning

• voluntary behaviors are strongly influenced by consequences (reward and punishments)

• operant conditioning is used to deal with specific behaviors

• token economy - used in institutions - exchange tokens for concrete rewards

Critics of Behavior Modification (668)

• will the behavior stop when the reward stops?• The behaviorists say that you can wean people off

of the rewards and move towards more intrinsic rewards

• is it ethical to control another's behavior with reward/punishment?

• The behaviorists say that behavior will always be "controlled" so we may as well control it for the "good"

Cognitive Therapies (669)

•  behavior therapy is good for treating specific fears and behaviors.

• when the client's fear/anxiety is less clearly defined, cognitive therapy is useful

• assumes that our thinking colours our feelings• aims to teach people new, more positive ways of

thinking

Cognitive Therapy for Depression (670)

• reverse client's catastrophic beliefs• teach clients to view life differently and discover

their irrationalities  (Aaron Beck - therapist)• depressed people don't exhibit the self-serving bias

common in healthy people• depressed people attribute their failures to

themselves and their successes to external circumstances

• Adele Rabin (therapist) has clients record a day's positive events and their contribution to each event

Cognitive-Behavior Therapy (671)

• an integrated therapy that seeks to teach positive thinking and also alter behaviors

• ie - OCD patients are taught to re-label their compulsions.  Instead of hand washing they force themselves to take a walk and they acknowledge and label the hand washing as an irrational urge.

Stress Inoculation Training

• trains people to restructure your thinking in stressful situations

• self-talk - "relax - if the exam is hard it is hard for everyone.  You studied and will do well."

• you are trained to dispute your negative thoughts.

Groups and Family Therapy (672)

• saves time and money• all but traditional

psychoanalysis can be done in a group setting

• often used for family conflict

• group context allows people to discover that others share their problems

• allows people to try out new ways of behaving

• ex. AA 12 step program

Evaluating Psychotherapies (674)Client’s Perspective

• 3 out of 4 are satisfied with the effectiveness• However, the critics of psychotherapy say:

– people enter therapy in crisis and then attribute normal improvement (that would have happened anyway) to therapy

– client's spend time/money on therapy therefore they "need" to believe that therapy is effective

– clients like their therapists so they find something positive about the therapy

– selective/biased recall by clients

Joan McCord Study

• 500 boys aged 5 to 13 headed for delinquency• half were put into counseling and the control

group was not.  • 30 years later although the counseled group

attributed their success to the counseling, there was not a statistically significant difference between the 2 groups - in fact - in second crime, alcoholic tendencies, death rate and job satisfaction, the control group actually had fewer problems

Evaluating PsychotherapiesClinicians’ Perceptions (675)

• Clients over-estimate problems when entering therapy, over-emphasize their well being when leaving therapy and stay in touch only if satisfied

• therapists are more aware of other therapists' failures

• clients find a new therapist if their problems reoccur

Outcome Research (676)

Hans Eysenck (1952) found that • 2/3rds of people suffering non-psychotic

disorders improved markedly after psychotherapy

• HOWEVER • 2/3rds of untreated people with non-

psychotic disorders also improved

Outcome Research

• Today meta-analysis (statistically combining the results of many different studies as if they had come from one huge study with thousands of participants) is finding:

• the average therapy patient ends up better off than 80% of the untreated individuals

• depression is better improved with treatment• psychotherapy is more effective than medical therapy• therapy is most effective for clear-cut, specific problems (ie

phobia)• depression and anxiety therapy works in the short term but

relapses frequently occur• chronic schizophrenia is rarely helped by psychotherapy alone

Regression Toward the Mean (676)

• the tendency for unusual events or emotions to return to a more average state on their own

Placebo Effect (676)

• the belief in a treatment will cause the treatment to succeed

• therefore what ever we doing following a "low" will be perceived as an improvement - we are naturally regressing to the mean (back to normal) but in comparison to the low  - normal is an improvement

• SO, when we evaluate whether a therapy is effective we must ask whether the improvement that follows a therapy exceeds what we could expect from the placebo effect and the regression toward the mean effect.

The Relative Effectiveness of Different Therapies   p. 678

Mary Smith's meta-analysis reveals:

Disorder Best Therapy

Depression Cognitive, interpersonal and behavior

Anxiety Cognitive, exposure and stress inoculation

Bulimia Cognitive-behavioral

Bed Wetting Behavior modification

Phobia/OCD Behavioral conditioning

Sex Disorders Behavioral conditioning

Therapeutic Touch (680)

• popular alternate therapy• hands move a few inches from your body and

push energy fields into balance• used for headaches to cancer• Rosa (1998) - using 9 year old Emily doing

research for a science fair - therapists could not tell whether they were close to Emily's hand more than 47% of the time (less than chance odds)

Eye Movement Desensitization and Reprocessing (680)

• Francine Shapiro discovered that anxious thoughts vanished as her eyes spontaneously darted about.  She developed a technique where she treats anxiety patients by triggering eye movement as they recall traumatic memories.

• 40,000 health professionals now trained in this method

• critics say this is just exposure therapy in a safe context (in trials patients had the same results with and without the eye movement)

Light Exposure Therapy (681)

• Seasonal Affective Disorder - a form of wintertime depression

• treated with doses of intense light• the light affects our circadian clock - morning

light exposure decreases the hormone melatonin. In evening darkness increases melatonin.

• controlled trials show a difference in effectiveness between using morning light, evening light and placebo - morning light is best

Commonalities Among Psychotherapies (682)

All therapies offer at least 3 benefits:

1.    hope for demoralized people

2.    a new perspective on yourself and the world

3.    empathetic, trusting, caring relationships

These 3 things are also offered by self-help groups, support groups, traditional healers, elders, etc.

Culture and Values in Psychotherapy (683)

• Clients often adopt their therapist's values.• Do the patient's and therapist's religious beliefs affect

the therapy?•  Albert Ellis (1980) - a therapist that says "no one and nothing is

supreme.  Self-gratification should be encouraged, unequivocal love, commitment, service and fidelity, especially marriage, leads to harmful consequences.

•  Bergin (1980) - says "because God is supreme, humility and the acceptance of divine authority are virtues.  Self-control and commitment, love and self-sacrifice are to be encouraged.  Infidelity to any personal commitment, especially marriage, leads to harmful consequences."

Cultural Differences

• North America, Europe, Australia - individualism is reflected by the therapists

• Asia - more collectivist

• Training in cultural sensitivity for therapists becomes important given the different types of societies.

The Biomedical Therapies (685)

• Drugs

• Electroconvulsive therapy

• Surgery

Biomedical TherapyDrug Therapy (685)

• most common biomedical therapy• introduced in the 1950's• reduced hospitalizations and surgeries• Psychopharmacology - the study of drug effects

on the mind and behavior• Double Blind - is important technique to reduce

placebo effect and the regression to the mean effect

Antipsychotic Drugs (686)

• accidental discovery that certain drugs used for other medical purposes calmed psychotic patients

• antipsychotic drugs mimic dopamine and occupy its receptor sites and block its activity

• Chlorpromazine (thorazine) - used with schizophrenic patients with positive symptoms (thought to be caused by too much dopamine)

• Note that thorazine can have the side effect of tremors/twitches similar to Parkinsons (which is caused by too little dopamine)

• Clozapine - used with schizophrenic patients with negative symptoms

Antianxiety Drugs (687)

• ex.  alcohol - valium  - xanax• depress central nervous system activity• help people cope with fear and anxiety• dependency on drug and on withdrawal issues• critics say the drugs reduce symptoms without

resolving underlying problems

Antidepressant Drugs (687)

• increase norepinephrine and seratonin which elevate mood and arousal

• ex. Prozac partially blocks the reuptake of seratonin -

• Prozac takes about 4 weeks for relief of symptoms - why - increased seratonin promotes growth of new brain cells

Antidepressant Drugs

• drug therapy is often combined with cognitive therapy and exercise

• placebos that mimic the real drug's side effects are nearly as effective as the actual drug in double-blind trials

• Prozac does not result in an elevated rate of suicide although their are individual anecdotes of users of Prozac committing suicide

• Lithium - used for bipolar patients

Electroconvulsive Therapy (689)

• shock treatment - introduced in 1938• electricity produces convulsions and brief unconsciousness• used for severe depression that does not respond to drugs• some memory loss is a side effect• How does it work??????   We don't know!!!!!• maybe it causes release of norepinephrine???• maybe it calms brain area where over-activity would cause

depression?????• ECT treated patients often have relapses of depression

• http://www.youtube.com/watch?v=zYl13Relzbs

Some Gentler Alternatives

• Vagus Nerve stimulation - chest implant intermittently stimulates the vagus nerve which sends impulses to the limbic system. Video clip http://www.youtube.com/watch?v=G7uu1dcc-qo&feature=related

• Repetitive Transcranial Magnetic Stimulation - magnetic coil held close to the skull above the right eye - energizes the left frontal lobe - produces no seizures or memory loss and shows 50% improvement in trials of depressed patients

Psychosurgery (690)

• least commonly used• 1930's - Egas Moniz developed the lobotomy (won the Nobel

prize) - sever nerves connecting frontal lobe with the emotion-controlling centres of the inner brain

• used to calm uncontrollably emotional and violent patients• hammer an ice-pick like instrument through each eye socket and

wiggle it to sever connections to the frontal lobe• lobotomies - effects - permanent lethargic, immature, impulsive

personality• today lobotomies are almost never performed• today psychosurgery used for extreme seizures and excessive

OCD patients

Prevention (690)

• deal with poverty, work issues, racism, sexism to prevent psychological disorders

• keep our bodies healthy

• mind body connection