Copyright © 2007 Pearson Education Canada 1 Approaches to Treatment and Therapy Chapter 17

Copyright © 2007 Pearson Education Canada

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Approaches to Treatment Approaches to Treatment and Therapyand Therapy

Chapter 17Chapter 17


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Chapter OutlineChapter Outline

• Biological treatments for mental Biological treatments for mental disordersdisorders

• Kinds of psychotherapyKinds of psychotherapy

• Evaluating psychotherapyEvaluating psychotherapy


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Biological TreatmentsBiological Treatments

• The question of drugsThe question of drugs

• Surgery and electroshockSurgery and electroshock


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The Question of DrugsThe Question of Drugs


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Antipsychotic DrugsAntipsychotic Drugs

• Many block or reduce sensitivity of brain Many block or reduce sensitivity of brain receptors that respond to dopaminereceptors that respond to dopamine

• Some increase levels of serotonin, a Some increase levels of serotonin, a neurotransmitter that inhibits dopamine neurotransmitter that inhibits dopamine activityactivity

• Can relieve positive symptoms of Can relieve positive symptoms of schizophrenia but are ineffective for or even schizophrenia but are ineffective for or even worsen negative symptomsworsen negative symptoms


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Antidepressant DrugsAntidepressant Drugs• Monoamine oxidase inhibitors (MAOIs)Monoamine oxidase inhibitors (MAOIs)

– Elevate norepinephrine and serotonin in brain by Elevate norepinephrine and serotonin in brain by blocking an enzyme that deactivates these blocking an enzyme that deactivates these neurotransmittersneurotransmitters

• Tricyclic antidepressantsTricyclic antidepressants– Boost norepinephrine and serotonin in brain by Boost norepinephrine and serotonin in brain by

preventing normal reuptake of these substances.preventing normal reuptake of these substances.

• Selective serotonin reuptake inhibitors (SSRIs)Selective serotonin reuptake inhibitors (SSRIs)– Work same way as tricyclic antidepressants but target Work same way as tricyclic antidepressants but target

serotoninserotonin

• Herbal methods such as St. John’s wort have Herbal methods such as St. John’s wort have also been usedalso been used


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TranquilizersTranquilizers

• Increase the activity of the Increase the activity of the neurotransmitter gamma-aminobutyric neurotransmitter gamma-aminobutyric acid (GABA)acid (GABA)

• Developed for treatment of mild anxiety Developed for treatment of mild anxiety and often inappropriately prescribed by and often inappropriately prescribed by general physicians for patients who general physicians for patients who complain of any mood disordercomplain of any mood disorder


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Lithium CarbonateLithium Carbonate

• Used to treat bipolar disorderUsed to treat bipolar disorder• Moderates levels of norepinephrine or by Moderates levels of norepinephrine or by

protecting cells from being overstimulated by protecting cells from being overstimulated by the neurotransmitter, glutamatethe neurotransmitter, glutamate

• Must be given in right dose and bloodstream Must be given in right dose and bloodstream levels need to be monitoredlevels need to be monitored

• Newer drug treatments for bipolar disorder Newer drug treatments for bipolar disorder include Tegetrol and Depakoteinclude Tegetrol and Depakote


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Cautions About Drug Cautions About Drug TreatmentTreatment

• Placebo effectPlacebo effect

• High relapse and dropout ratesHigh relapse and dropout rates

• Dosage problemsDosage problems

• Long-term risksLong-term risks


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Placebo effectPlacebo effect

• The apparent success of a treatment that is The apparent success of a treatment that is due to the patient’s expectation of the drug’s due to the patient’s expectation of the drug’s effectiveness rather than to the drug or effectiveness rather than to the drug or treatment itselftreatment itself

• Meta-analyses indicate that clinicians Meta-analyses indicate that clinicians considered medication helpful yet patient considered medication helpful yet patient ratings in treatment groups were no greater ratings in treatment groups were no greater than patient ratings in placebo groupsthan patient ratings in placebo groups


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High Relapse and Dropout RateHigh Relapse and Dropout Rate

• There may be short-term success but There may be short-term success but many patients (50% to 66%) stop taking many patients (50% to 66%) stop taking medication due to side effectsmedication due to side effects

• Individuals who take antidepressants Individuals who take antidepressants without learning to cope with problems without learning to cope with problems are more likely to relapseare more likely to relapse


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Dosage ProblemsDosage Problems• Finding the therapeutic window or the Finding the therapeutic window or the

amount of medication that is enough but not amount of medication that is enough but not too muchtoo much

• Drugs may be metabolized differently in:Drugs may be metabolized differently in:– men and women, old and young, and in different men and women, old and young, and in different

ethnic groupsethnic groups– groups may differ in dosages due to variations in groups may differ in dosages due to variations in

metabolic rates, amount of body fat, number or metabolic rates, amount of body fat, number or type of drug receptors in the brain, smoking and type of drug receptors in the brain, smoking and eating habitseating habits


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Long-term risksLong-term risks

• Antipsychotic drugs can be dangerous, Antipsychotic drugs can be dangerous, even fatal if taken for many yearseven fatal if taken for many years– Tardive dyskinesiaTardive dyskinesia

• Antidepressants are assumed to be Antidepressants are assumed to be same but no long-term studies have same but no long-term studies have been conductedbeen conducted


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Direct Brain InterventionDirect Brain Intervention

• PsychosurgeryPsychosurgery– Any surgical procedure that destroys Any surgical procedure that destroys

selected areas of the brain believed to be selected areas of the brain believed to be involved in emotional disorders or violent, involved in emotional disorders or violent, impulsive behaviourimpulsive behaviour

• Electroconvulsive Therapy (ECT) Electroconvulsive Therapy (ECT) – A procedure used in cases of prolonged A procedure used in cases of prolonged

and severe major depression, in which a and severe major depression, in which a brief brain seizure is inducedbrief brain seizure is induced


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Transcranial Magnetic StimulationTranscranial Magnetic Stimulation

• Involves use of pulsing magnetic coil Involves use of pulsing magnetic coil held to a person’s skull over the left held to a person’s skull over the left prefrontal cortexprefrontal cortex

• This area is less active in those with This area is less active in those with depressiondepression

• Treatment does not result in pain or Treatment does not result in pain or memory problems and controlled memory problems and controlled studies have suggested positive resultsstudies have suggested positive results


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Kinds of PsychotherapyKinds of Psychotherapy

• Psychodynamic therapyPsychodynamic therapy

• Behavioural and cognitive therapyBehavioural and cognitive therapy

• Humanist and existential therapyHumanist and existential therapy

• Family and couples therapyFamily and couples therapy


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Psychodynamic TherapyPsychodynamic Therapy

• PsychoanalysisPsychoanalysis– A method of psychotherapy developed by A method of psychotherapy developed by

Freud that emphasizes the exploration of Freud that emphasizes the exploration of unconscious motives and conflictsunconscious motives and conflicts

– Free Association Free Association • In psychoanalysis, a method of uncovering In psychoanalysis, a method of uncovering

unconscious conflicts by saying freely whatever unconscious conflicts by saying freely whatever comes to mindcomes to mind


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Psychodynamic TherapyPsychodynamic Therapy

• Other psychodynamic therapies also Other psychodynamic therapies also explore the unconscious dynamics of explore the unconscious dynamics of personality, although they differ from personality, although they differ from Freudian analysisFreudian analysis– TransferenceTransference

• In psychodynamic therapies, a critical step in In psychodynamic therapies, a critical step in which the client transfers unconscious emotions which the client transfers unconscious emotions or reactions, such as conflicts about his or her or reactions, such as conflicts about his or her parents, onto the therapistparents, onto the therapist


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Behaviour and Cognitive Behaviour and Cognitive TherapyTherapy

• Behaviour therapyBehaviour therapy– Systematic desensitizationSystematic desensitization– Exposure treatmentsExposure treatments– Behavioural recordsBehavioural records– Skills trainingSkills training

• Cognitive therapyCognitive therapy


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Behaviour TherapyBehaviour Therapy

• A form of therapy that applies principles A form of therapy that applies principles and techniques of classical and operant and techniques of classical and operant conditioning to help people change self-conditioning to help people change self-defeating or problematic behavioursdefeating or problematic behaviours


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Graduated ExposureGraduated Exposure

• In behaviour therapy, a method in which In behaviour therapy, a method in which a person suffering from an anxiety a person suffering from an anxiety disorder, such as phobia or panic disorder, such as phobia or panic attacks, is gradually taken into the attacks, is gradually taken into the feared situation or exposed to the feared situation or exposed to the traumatic memory until the anxiety traumatic memory until the anxiety subsidessubsides


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FloodingFlooding

• A technique whereby a person suffering A technique whereby a person suffering from an anxiety disorder such as a from an anxiety disorder such as a phobia or panic attack is taken directly phobia or panic attack is taken directly into the feared situation until the anxiety into the feared situation until the anxiety subsidessubsides


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Systematic DesensitizationSystematic Desensitization

• A step-by-step process of desensitizing A step-by-step process of desensitizing a client to a feared object or experiencea client to a feared object or experience

• Based on counterconditioningBased on counterconditioning


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Behavioural RecordsBehavioural Records

• A method of keeping careful data on the A method of keeping careful data on the frequency and consequences of the frequency and consequences of the behaviour to be changedbehaviour to be changed


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Skills TrainingSkills Training

• An effort to teach a client skills he or An effort to teach a client skills he or she may lack as well as new, more she may lack as well as new, more constructive behaviours to replace self-constructive behaviours to replace self-defeating onesdefeating ones


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Cognitive TechniquesCognitive Techniques

• Examine the evidence for beliefsExamine the evidence for beliefs

• Consider other explanations for the Consider other explanations for the behaviour of othersbehaviour of others

• Identify assumptions and biasesIdentify assumptions and biases– Rational emotive behaviour therapyRational emotive behaviour therapy

• A form of cognitive therapy devised by Albert A form of cognitive therapy devised by Albert Ellis, designed to challenge the client’s Ellis, designed to challenge the client’s unrealistic or irrational thoughtsunrealistic or irrational thoughts


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Cognitive TechniquesCognitive Techniques

• Meichenbaum developed a form of Meichenbaum developed a form of cognitive therapy to treat excessive cognitive therapy to treat excessive anxiety called “stress inoculation”anxiety called “stress inoculation”– Involves 3 phases:Involves 3 phases:

• Education phaseEducation phase• Rehearsal phaseRehearsal phase• Implementation phase Implementation phase


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Humanist TherapyHumanist Therapy

• Humanist therapyHumanist therapy– Based on the assumption that people seek self-Based on the assumption that people seek self-

actualization and self-fulfillmentactualization and self-fulfillment– Emphasized people’s free will to change, not past Emphasized people’s free will to change, not past

conflictsconflicts

• Client-Centred (Nondirective) Therapy Client-Centred (Nondirective) Therapy • Developed by Carl Rogers; emphasizes the Developed by Carl Rogers; emphasizes the

therapist’s empathy with the client, seeing the therapist’s empathy with the client, seeing the world as client does, and creating climate of world as client does, and creating climate of Unconditional Positive RegardUnconditional Positive Regard


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Existential TherapyExistential Therapy

• Helps clients explore the meaning of Helps clients explore the meaning of existence and face with courage the great existence and face with courage the great issues of life such as death, freedom, free issues of life such as death, freedom, free will, alienation and lonelinesswill, alienation and loneliness


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Family and Couples TherapyFamily and Couples Therapy

• Problems develop in the context of family and Problems develop in the context of family and are sustained by the dynamics of the family; any are sustained by the dynamics of the family; any changes made will affect all members of the changes made will affect all members of the familyfamily

• Can look for patterns of behaviour across Can look for patterns of behaviour across generations and create a family tree of generations and create a family tree of psychologically significant eventspsychologically significant events


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Family-Systems PerspectiveFamily-Systems Perspective

• Therapy with individuals or families Therapy with individuals or families that focuses on how each member that focuses on how each member forms part of a larger interacting forms part of a larger interacting systemsystem


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One Family’s GenogramOne Family’s Genogram


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Primary Goals of TherapiesPrimary Goals of Therapies• PsychodynamicPsychodynamic

– Insight into unconscious motives and feelingsInsight into unconscious motives and feelings• Cognitive-BehaviouralCognitive-Behavioural

– Modification of behaviour and irrational beliefsModification of behaviour and irrational beliefs• HumanistHumanist

– Insight; self-acceptance and self-fulfillmentInsight; self-acceptance and self-fulfillment• FamilyFamily

– Modification of individual habits and family Modification of individual habits and family patternspatterns


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Primary Methods of TherapiesPrimary Methods of Therapies• PsychodynamicPsychodynamic

– Probing the unconscious through dream analysis, free Probing the unconscious through dream analysis, free association, transferenceassociation, transference

• Cognitive-behaviouralCognitive-behavioural– Behavioural techniques such as systematic desensitization, Behavioural techniques such as systematic desensitization,

flooding; cognitive exercises to identify and change faulty flooding; cognitive exercises to identify and change faulty beliefsbeliefs

• HumanistHumanist– Providing a safe, non-judgmental setting in which to discuss Providing a safe, non-judgmental setting in which to discuss

life issueslife issues• FamilyFamily

– Working with couples, families, and sometimes individuals to Working with couples, families, and sometimes individuals to identify and change patterns that perpetuate problemsidentify and change patterns that perpetuate problems


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Evaluating PsychotherapyEvaluating Psychotherapy

• The scientist-practitioner gapThe scientist-practitioner gap

• The therapeutic allianceThe therapeutic alliance

• When therapy helpsWhen therapy helps

• When therapy harmsWhen therapy harms


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The Scientist-Practitioner GapThe Scientist-Practitioner Gap

• Some psychotherapists believe that Some psychotherapists believe that evaluating therapy using research evaluating therapy using research methods is futilemethods is futile

• Scientists find that therapists who do Scientists find that therapists who do not keep up with empirical findings are not keep up with empirical findings are less effective and can do harm to clientsless effective and can do harm to clients

• Economic pressures require empirical Economic pressures require empirical assessment of therapiesassessment of therapies


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Is More Psychotherapy Is More Psychotherapy Better?Better?

• With additional therapy With additional therapy sessions, the percentage sessions, the percentage of people improved of people improved increased up to 26 increased up to 26 sessionssessions

• Rate of improvement Rate of improvement then levels offthen levels off– Based on a summary of Based on a summary of

15 studies, 2400 clients 15 studies, 2400 clients (Howard, et al., 1996)(Howard, et al., 1996)

• Patients’ sense of Patients’ sense of improvement slower but improvement slower but more steadymore steady


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The Therapeutic AllianceThe Therapeutic Alliance

• Qualities of the ParticipantsQualities of the Participants– Motivation to improve and solve Motivation to improve and solve

problemsproblems– Support from families and actively deal Support from families and actively deal

with problemswith problems– Empathic, warm, and genuine therapistsEmpathic, warm, and genuine therapists


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Therapeutic AllianceTherapeutic Alliance

• Culture and the Therapeutic ConnectionCulture and the Therapeutic Connection– In Canada, group therapy is popular with In Canada, group therapy is popular with

Indigenous clients, in part because it bears Indigenous clients, in part because it bears more similarity to traditional healing more similarity to traditional healing practices in these groupspractices in these groups


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Psychotherapy Research QuestionsPsychotherapy Research Questions

• What are the common ingredients in What are the common ingredients in successful therapies?successful therapies?

• What kinds of therapy are best suited What kinds of therapy are best suited for which problems?for which problems?

• Under what conditions can therapy be Under what conditions can therapy be harmful?harmful?


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Common Ingredients in Common Ingredients in Successful TherapiesSuccessful Therapies

• When there is a bond between therapist When there is a bond between therapist and client (a.k.a. Therapeutic Alliance) and client (a.k.a. Therapeutic Alliance)

• When participants want to be helpedWhen participants want to be helped

• When therapists distinguish normal When therapists distinguish normal cultural patterns from individual cultural patterns from individual psychological problemspsychological problems


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Which Therapy for Which Problem?Which Therapy for Which Problem?

• DepressionDepression– Cognitive therapy’s greatest success has Cognitive therapy’s greatest success has

come in treatment of mood disorderscome in treatment of mood disorders

• Anxiety DisordersAnxiety Disorders– Exposure techniques are more effective Exposure techniques are more effective

than othersthan others

• Anger and Impulsive ViolenceAnger and Impulsive Violence– Cognitive therapy is extremely successfulCognitive therapy is extremely successful


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Which Therapy for Which Problem?Which Therapy for Which Problem?

• Health ProblemsHealth Problems– Cognitive and behaviour therapies are Cognitive and behaviour therapies are

effective for a wide range of health problemseffective for a wide range of health problems

• Childhood and Adolescent Behaviour Childhood and Adolescent Behaviour ProblemsProblems– Behaviour therapy is the most effective Behaviour therapy is the most effective

treatmenttreatment– Relapse preventionRelapse prevention


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When Therapy HelpsWhen Therapy Helps• Problems of assessing therapyProblems of assessing therapy

– Justification of effort effectJustification of effort effect– Clinical researchers conduct randomized Clinical researchers conduct randomized

controlled trials designed to determine the controlled trials designed to determine the effectiveness of a new medication or form of effectiveness of a new medication or form of therapy, in which people with a given therapy, in which people with a given problem are randomly assigned to one or problem are randomly assigned to one or more treatment groups or to a control groupmore treatment groups or to a control group


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Successful TherapySuccessful Therapy

• Psychotherapy outcome depends not only on Psychotherapy outcome depends not only on method of therapymethod of therapy

• Qualities of client and therapist, and their Qualities of client and therapist, and their alliance, also determine successalliance, also determine success


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When Therapy HarmsWhen Therapy Harms

• Sexual intimacy or other unethical behaviour Sexual intimacy or other unethical behaviour on the part of the therapiston the part of the therapist

• Prejudice or cultural ignorance on the part of Prejudice or cultural ignorance on the part of the therapistthe therapist

• Inappropriate or coercive influence, which Inappropriate or coercive influence, which can create new problems for the clientcan create new problems for the client

• The use of empirically unsupported, The use of empirically unsupported, potentially dangerous techniquespotentially dangerous techniques

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Copyright © 2007 Pearson Education Canada 1 Approaches to Treatment and Therapy Chapter 17