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Chapter 16: Treatment of Psychological Disorders

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Psychotherapy
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Df: Therapeutic interventions based on psychological principles Goal: Help people improve their QOL. Don’t need to have a diagnosis of mental disorders to benefit from psychotherapy. Not born with all the tools to resolve all challenges in our lives
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Who practice therapy?
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1) Clinical psychologists > Receive the most training, usually need a PhD in Canada 2) Psychiatrist > Have a medical degree and prescribe medications > Focus mainly on biomedical treatment > Tend to see people who suffer from more mental disorders. > Not rare for someone suffering from schizophrenia to see both psychiatrist and clinical psychologists 3) Counselling psychologists > Training focused on less severe mental disorders, more day to day problems > Not typically people who haven’t received diagnosis of a disorder 4) Clinical social workers – psychiatric nurse > Work in hospital settings. Offer some sort of therapy and it is from a multi-discipline team 5) Paraprofessionals > Term ‘therapists’ not legally protected in Canada. > Don’t have adequate training to practice.
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Therapeutic Alliance
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Df: Relationship between client and therapists > Best predictors of outcome of therapy. > Difficult to open up to the therapist as don’t feel comfortable with them. Or don’t trust or like them. Critical element is the trust you develop for the therapist. > Need to trust that the therapist has the best interest at heart for you. Establishing expectations during therapy (should happen early on) > Guided by ethical prinicples > Respect for dignity of persons, includes informed consent (what they can expect in therapy so there are no surprises). > Discussion of confidentiality. Everything siao is confidential except for certain occasions.
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Therapist-Client Confidentiality
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3 limits to confidentiality: A) Info about vulnerable person being harmed > Have to ensure that person is safe and might have to share information to law enforcement officers B) Info that client intends on hurting self or others > Must share to others C) Records are subpoenaed by court of law *** Purpose is to ensure that individuals that could be harmed are safe
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What to look for in a therapist
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> I can talk freely and openly > My therapist listens carefully to what I say and understands my feelings > My therapist is warm, direct, and provides useful guidance > My therapist explains up front what they will be doing and why, and is willing to answer questions about qualifications and training, diagnosis, and treatment plan > My therapist encourages me to confront challenges and solve problems > My therapist uses scientifically-based approaches and discuss the pros and cons of other approaches > My therapist monitors how I am doing regularly and is willing to change course when treatment isn’t going well
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Psychoanalysis
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Rationale why client is facing away from therapists is so that it’s easier for clients to come up with free-association Sigmund Freud – abnormal behaviour caused by unconscious conflicts Largest part of our mind is unconscious and drives our behaviours.
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Goal of Psychoanalysis
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Goal: Insight > Enhance the knowledge of themselves. Pursue our insights that will promote healthy changes in our personality and behaviours. > A better understanding of ourselves and will be sufficient for positive changes in our lives. Bring awareness the unconscious conflict and by being aware of these conflicts will be enough to resolve them.
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5 primary processes for Psychoanalysis
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A) Free Association > The idea is that is allows people to express themselves without censorship. If you don’t think about what you are saying, you are less likely to use the defense mechanisms. B) Interpretation > were the therapist is necessary. > Will suggest explanations to the clients about their behavior or the thoughts. The timing and the nature of the thought is important. > The interpretation needs to be slightly out of reach for the client. If it is within the reach of the client, they probably would have come to that conclusion by themselves at home. If it is too far out of reach, client might not accept the interpretation C) Dream Analysis > dreams express unconscious themes that influences the client’s conscious life. > Trying to understand the relation between the dream and the client’s life. D) Resistance > – happens regardless of the form therapy (avoid discussing certain aspects, hinder the progress in therapy). E.g.: If specific topic is being discussed and client starts to skip therapy. Or if they say have trouble remembering things, avoid question. How this is addressed in therapy Resistance is addressed directly, e.g.: therapist will say you seem to be resisting the therapy, it happens around this topic, etc. E) Transference > Clients are believed to project feelings or expectation of the past onto therapists. > Have feelings of anger on parents and projects feelings to therapists. Also considered to be important in other areas in psychotherapy. Repeating the same patterns in relationships
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Neo-Freudian Psychodynamic
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> More emphasis on conscious, cultural and interpersonal influences Interpersonal therapy Df: focuses almost exclusively on client’s current relationships with important people in their lives > Typically requires 12-16 sessions. Goal: strengthen people’s social skills and help them cope with different interpersonal problems 4 problem areas: 1) Grief 2) Role dispute 3) Role transition 4) Interpersonal deficits Very useful for depression and bulimia nervosa. Issues and personal relaitonships are very central to depression and bulimia nervosa. Reduction in symptoms and improvement in social relationships.
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Critical Analysis of Psychodynamic Therapies
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Many treatments not scientifically sound. > Poor external validity > Small sample size and biased sample > Not clear if what have been studied can be generalised to the rest of the population Another criticism is that is relies on unfalsifiable constructs. > Makes it difficult to measure trials > Difficult to assess changes in people when these changes can’t be measured easily Based on the idea that it is the insight of the cause and the nature of the problem that will lead to a change in behaviour. > Assumes that when people understand where the problems come from, will solve problem. NOT TRUE! Lack of evidence on the effectiveness of psychodynamic therapies. HOWEVER, IPT have shown to be more effective.
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Humanistic Psychotherapies
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Another type of narrative therapy. Puts emphasis on self-actualisation (also emphasises insight) and takes for granted that human nature is positive (natural tendency to work towards positivism) Maladaptive behaviour due to lack of awareness of oneself. Could be due to -ve self-image, and an incongruity of perception of oneself and doesn’t fit with what you want to be. Treatment Focus: > Development of human potential > Phenomenological approach – encounter subjective thoughts, feelings experiences in the present.
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Differences between Psychodynamic and Humanist
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> Focus on the present thought and experience as opposed to past experiences (psychodynamic theories) > Therapists don’t believe in the interpretation of the therapists as being useful as the client is believed to be the expert of his own life. Try to understand the clients world thought empathy so the client has an even better understanding of themselves.
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Person-centered therapy (Carl Rogers)
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> Main humanistic approach > Non-directed (client uses the time as they choose to). Clients talk about what they want to Major focus on the therapeutic alliance. Specific features is believed to lead to changes in behaviour and personality 1) Unconditional postiive regard from the therapists. Non-judgmental acceptance of all the feelings that is expressed by the clients during therapy. Critical as experience will make clients more easier for them to accept themselves and to explore the experience a bit more 2) Empathy – encouraged therapists to try to understand their client’s world as much as possible but to not forget that they are therapists 3) Genuineness – therapists has to be authentic and genuine as possible. Should share their own reaction to what client is communicating.
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Bad Empathy VS Good Empathy
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Bad > A complete misunderstanding or inability to put yourself into other’s shoes, Complete reverse to a person-cantered therapists. Good > The therapist is validating the client by telling him that many people have felt uneasy when discussing things with strangers, being very non-judgmental about the client’s feelings. > The therapist checks with the client > She does a lot of reflective listening or mirroring. This is actively listening to what the client is saying and sharing the information back to client, ideally using different words. Very good to provide an enhanced understanding of the situation not just for the therapist, but also the client. Give the client the opportunity to clarify his thoughts, add more or explain more.
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Critical Evaluation of Humanistic Therapies
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Strengths > Focuses on therapeutic alliance. One of the strongest predictors for treatment outcome. > Research has found that 2 features, positive regard and empathy is correlated moderately to success. The higher both features are present, the higher the likelihood for success. It is possible that empathy and positive regard are important ingredients to make people change but not sufficient to do so. Cons > Lack of research on effectiveness to treat mental disorders. Was done on anecdotes and have little external validity. Also have inconsistent findings > What is unique about this? Couldn’t these elements be integrated into other approaches?
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Behaviour Therapies
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Df: Maladaptive behaviours are the problem, not a symptom. > If change behaviour, solve the problem Functional analysis: examine variables that maintain problem behaviours. > Identify all variables. Use learning principles to change them: > Classical conditioning > Operant conditioning > Modelling
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Behavioural Approaches for Anxiety Disorders
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What we know from research is that anxiety disorders can be developed through classical conditioning. Many anxiety disorders are maintained by operant conditioning. People avoid the stimuli that triggers their fear and they feel better and so re-enforces their phobia. Exposure therapy used. > Confront patients with their fears/anxiety to reduce it as avoidance behaviour is prevented. 2 main types: 1) Flooding 2) Systematic Desensitisation
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Flooding
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Df: Sudden exposure to feared stimuli. > Tends to be drastic. > Not used as much Provokes anxiety in absence of -ve consequences, so that extinction can proceed. > Response prevention – prevent patient form performing typical avoidance behaviours > when you peak in anxiety levels, the body can’t sustain it for long periods of time and if you don’t avoid the phobia, at some point (usually takes a few minutes), the anxiety will decline and the person will learn that there is nothing to fear as nothing bad happened. Shows that avoidance is bad. > A lot of VR software is being developed for it and veterans who are suffering from PTSD can use it.
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Systematic Desensitisation
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> Graduated exposure therapy > Counterconditioning: Anxiety & relaxation cannot co-exist together Steps: Clients will get some training on any relaxation technique. Most common is progression muscle relaxation techniques Then the client will create a stimulus hierarchy from the least anxiety to the most anxiety. Typically around 10 steps. Very subjective thing, CLIENT must do this Relaxation paired while exposed to the stimuli. Once the person is completely relaxed, go onto the next step. Over a number of sessions. Important that the client must be fully relaxed
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Difference between flooding and systematic desensitisation
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1) Gradual exposure compared to a flood of the stimulus 2) Based on principles of counterconditioning were anxiety and relaxation cannot co-exist. (systematic desensitization)
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Behavioural Therapies for Behaviour Modification
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Based on Operant Conditioning: > Positive reinforcement (rewards) > Negative reinforcement (removing negative stimuli) > Extinction (removing rewarding stimuli) > Punishment (introducing negative stimuli) Often used when traditional therapies are difficult to implement (e.g. insight needed) > Used to help change maladaptive behaviour and mostly used on kids or those with lower level of intellect.
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Different Behaviour Therapies
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1) Token Economies 2) Behavioural Modelling
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Token Economies
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Tends to be used in residential/institutional settings. > Can be used by teachers or parents as well Certain good behaviours are constantly rewarded with tokens and clients can later exchange these token for tangible rewards > Positive reinforcement > Behaviours we trying to extinguish will be punished or ignored. Can help with people who have schizophrenia
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Behavioural Modelling
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Df: Observing someone performing a behaviour will make you more likely to perform the behaviour later E.g.: Social skills training. Teach specific social skills to someone diagnosed on the autism spectrum disorder. More so a technique than a therapy. Very rare for it to be used on it’s own.
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Critical Evaluation of Behavioural Therapies
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MOST effective type of treatment for variety of anxiety disorder. Ton of research here and can be operationalised outcome here (easy to measure).
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Cognitive Therapies
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Key Figures: Aaron Beck & Albert Ellis Focus: Role of irrational and self-defeating thought patterns Goal: Help clients discover maladaptive thoughts & replace with more adaptive, rational ones. General principle: Thoughts influence feelings and behaviours > If have -ve thought, will feel bad and have more maladaptive behaviours. First goal is to id the maladaptive belief and learn to dispute own -ve thoughts by looking at evidence for and against these thoughts and using this info to replace irrational belief with more realistic and adaptive belief.
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Rational Emotive Behaviour Therapy
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The ABCs of emotions and behaviour Antecedent Event -> Belief -> Consequence (emotional & behavioural) Albert Ellis suggested that we respond to unpleasant events (internal or external) by activating certain beliefs. Activating these beliefs will have different emotional and behavioral consequences (The ABC model) The relationship between the events and the emotions are mediated by the beliefs. By understanding this relationship and disputing the irrational beliefs, will have more positive consequence
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Example of Rational Emotive Behaviour Therapy
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He is the one disputing her maladptive thought pattern. Then he tries to explain the relationship between the thinking patterns and her feelings. Typically what is done in cognitive therapy. Very difficult for people to dispute our own thoughts in the beginning and we have to learn how to dispute them. In cognitive therapy, the therapist does this at first until the person learns how to.
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Critical Evaluation of Cognitive Therapies
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Relatively direct and cost-efficient (brief) Most effective type of treatment for mood disorders (along with interpersonal therapy) Difficult to implement with lower functioning clients as need quite a bit of insight. Not techniques that can be used with everyone.
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Effectiveness of Psychotherapy
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1995 Consumer Reports Study (Seligman) 7000 responses, 60% used mental health professionals > In context of this study MHPs were equally effective > Found that treatment outcomes were same across different therapies > One finding is that there was no specific modality of therapy that did any better. It is known as the “dodo bird” hypothesis. Refers to the fact that all forms of psychotherapies do equally well and was a controversial finding.
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What does this result tells us?
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Common factors central to effectiveness of any therapeutic intervention > Plausible explanation for problems > Empathic listening > Instilling hope > Supportive relationship > Opportunity to practice new behaviours > Increased optimism & self-efficacy Up to 70% of theory outcome due to common factors HOWEVER, research suggests that these common factors are necessary but not always sufficient. The remaining 30% is explained by the technique used in each situation. > WE now know that specific disorders are treated more effectively with certain therapies. This was not done in the study above. It’s not because we have 2 therapies that work equally well, they use the same mechanism. They could be effective but use different mechanism
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Psychopharmacotherapy
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Medications to treat psychological problems > Due to imbalance of neurotransmitters E.g.: Selective serotonin re uptake inhibitors (SSRIs) – for depression
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Upsides and Downsides of Psychopharmacotherapy
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Downside > Side effects > Don’t “cure” the disorder. > Don’t teach client coping and problem solving skills to deal with stress. Explains why there is a high level of relapse Upside > When symptoms are severe, it is very difficult to benefit from psychotherapy. It is important to have medication in the beginning for them to start and benefit from psychotherapy. In the future, they could lower or even stop the medications