Treatment of Psychological Disorders
UNIT PREVIEW
Mental health therapies include psychological therapies and biomedical therapies. Therapists using an eclectic approach draw from a variety of techniques. In fact, half of all psychotherapists describe themselves as taking an eclectic approach. Psychotherapy integration attempts to combine a selection of assorted techniques into a single, coherent system.
Psychoanalysts use free association and the interpretation of dreams, resistances, and transference to help their patients gain insight into the unconscious origins of their disorders and to work through the accompanying feelings.
Humanistic therapy focuses on clients’ conscious feelings and on their taking responsibility for their own growth. Client-centered therapists use active listening to express genuineness, acceptance, and empathy.
Behavior therapists emphasize the direct modification of problem behaviors. They use exposure therapies, such as systematic desensitization and aversive conditioning, and they may also apply operant conditioning principles with techniques such as token economies.
Cognitive therapies aim to change self-defeating thinking by training people to view themselves in new, more positive ways. Cognitive-behavioral therapists aim to change the way people act as well as alter the way they think.
Except for traditional psychoanalysis, these various types of therapies may also occur in therapist-led small groups. One special type of group therapy, family therapy, assumes that no person is an island. Research on the effectiveness of therapy indicates that people who receive therapy are more likely to improve than the untreated. No one therapy is generally more effective, but some are better
than others for treating certain problems.
Administration of antipsychotic, antianxiety, and antidepressant drugs and mood-stabilizing medications constitutes the most widely used biomedical therapy. Electroconvulsive therapy (ECT), although controversial, continues to be an effective treatment for many severely depressed people who do not respond to drug therapy. Gentler alternatives to ECT are now being used. Psychosurgery is rarely used to alleviate specific problems largely because the effects are irreversible and potentially drastic.
The biopsychosocial approach acknowledges that effective treatment of psychological disorders must consider biological, psychological, and social-cultural factors. Therapeutic life-style change recognizes these factors in a training program that treats depression through aerobic
exercise, adequate sleep, light exposure, social connections, anti-rumination, and nutritional supplements. Preventive mental health experts aim to change oppressive, esteem-destroying environments into more benevolent, nurturing environments that foster individual growth and self-confidence.
The Psychological Therapies
Psychoanalysis is Sigmund Freud’s therapeutic approach of using the patient’s free associations, resistances, dreams, and transference, and the therapist’s interpretations of them, to help the person release repressed feelings and gain self-insight. The goal of psychoanalysis is to help people gain insight into the unconscious origins of their disorders, to work through the accompanying feelings, and to take responsibility for their own growth.
Psychoanalysts draw on techniques such as free association (saying aloud anything that comes to mind), resistances (the defensive blocking from awareness of anxiety-laden material) and their interpretation, and other behaviors such as transference (transferring to the therapist of long repressed feelings). Freud also believed that the latent content of dreams was another clue to unconscious conflicts. Like the psychoanalytic perspective on personality, psychoanalysis is criticized because its interpretations are hard to prove or disprove and because it is time-consuming and costly.
Influenced by Freud, psychodynamic therapists try to understand patients’ current symptoms by exploring their childhood experiences and the therapist-patient relationship. They may also help the person explore and gain perspective on defended-against thoughts and feelings. However, they talk with the patient face-to-face, once a week, and for only a few weeks or months. Interpersonal psychotherapy, a brief variation of psychodynamic therapy, emphasizes symptom relief in the present, not overall personality change. The therapist also focuses on current relationships and the mastery of relationship skills. It has been found effective with depressed patients.
Both psychoanalytic and humanistic therapies are referred to as insight therapies, which attempt to improve psychological functioning by increasing the client’s awareness of underlying motives and defenses. However, in contrast to psychoanalysis, humanistic therapists focus on the present and the future more than the past, on clients’ conscious feelings, and taking immediate responsibility for their feelings and actions. In emphasizing people’s inherent potential for self-fulfillment, they aim to promote growth rather than to cure illness. In his non directive client-centered therapy, Rogers used active listening to express genuineness, acceptance, and empathy. This technique, he believed, would help clients to increase their self-awareness and self-acceptance. The therapist interrupts only to restate and confirm the client’s feelings, to accept what the client is expressing, or to seek clarification. The client-centered counselor seeks to provide a psychological mirror that helps clients see themselves more clearly. In a therapeutic environment that provides unconditional positive regard, clients may come to accept even their worst traits and feel valued and whole.
Traditional psychoanalysts attempt to help people gain insight into their unresolved and unconscious conflicts. Humanistic therapists help clients to get in touch with their feelings. In contrast, behavior therapists question the therapeutic power of increased self-awareness. They assume problem behaviors are the problems and thus do not look for inner causes. Instead, they apply learning principles to eliminate a troubling behavior.
Counterconditioning is a behavior therapy procedure, based on classical conditioning, that conditions new responses to stimuli that trigger unwanted behaviors. Exposure therapies treat anxieties by exposing people to the things they fear and avoid. In systematic desensitization, a prime example of exposure therapy, a pleasant, relaxed state is associated with gradually increasing anxiety triggering stimuli. This procedure is commonly used to treat phobias. Virtual reality exposure therapy equips patients with a head-mounted display unit that provides vivid simulations of feared stimuli, such as a plane’s takeoff. In aversive conditioning, an unpleasant state (such as nausea) is associated with an unwanted behavior (such as drinking alcohol). This method works in the short run, but for long-term effectiveness it is combined with other methods.
Operant conditioning therapies are based on the premise that voluntary behaviors are strongly influenced by their consequences. Behavior therapists apply operant conditioning principles in behavior modification. They reinforce desired behaviors and withhold reinforcement for undesired behaviors or punish them. The rewards used to modify behavior vary from attention or praise to more concrete rewards such as food. In institutional settings, therapists may create a token economy in which a patient exchanges a token of some sort, earned for exhibiting the desired behavior, for various privileges or treats.
Critics express two concerns: First, what happens when the reinforcers stop? Might the person have become so dependent upon the extrinsic rewards that the appropriate behaviors quickly disappear? Second, is it ethical for one person to control another’s behavior?
Cognitive therapists assume that our thinking colors our feelings, and so they try to teach people who suffer psychological disorders new, more constructive ways of thinking. Cognitive-behavioral therapists combine the reversal of self-defeating thinking with efforts to modify behavior. They aim to make people aware of their irrational negative thinking, to replace it with new ways of thinking and talking, and to practice the more positive approach in everyday settings.
In treating depression, Aaron Beck seeks to reverse clients’ catastrophizing beliefs about themselves, their situations, and their futures. His technique is a gentle questioning that aims to help people discover their irrationalities. In stress inoculation training, people suffering from depression learn to dispute their negative thoughts and to restructure their thinking in stressful situations.
The social context provided by group therapy allows people to discover that others have problems similar to their own and to try out new ways of behaving. Receiving honest feedback can be very helpful, and it can be reassuring to find that you are not alone. Family therapy assumes that we live and grow in relation to others, especially our families. It views an individual’s unwanted behaviors as influenced by or directed at other family members. In an effort to heal relationships, therapists attempt to guide family members toward positive relationships and improved communication.
Evaluating Psychotherapies
Clients tend to overestimate the effectiveness of psychotherapy because they enter therapy in crisis. With the normal ebb and flow of events, the crisis passes and people attribute their improvement to the therapy. Clients may also need to believe that the investment of time and money has been worth it. Finally, clients generally speak positively of therapists who have been very understanding
and who have helped them gain a new perspective. Research has generally not supported clients’ estimates of therapy’s effectiveness.
Clients enter therapy when they are extremely unhappy, usually leave when they are less extremely unhappy, and stay in touch only if satisfied. Thus, therapists, like most clients, testify to therapy’s success. Clinicians are mostly aware of other therapists’ failures as clients seek new therapists for their recurring problems.
Clients’ and therapists’ views of therapy’s effectiveness are vulnerable to inflation from the placebo effect—the power of belief in a treatment. If one anticipates that therapy will be effective, it just may be so because of the healing power of positive expectations. In addition, regression toward the mean—the tendency for unusual events (including emotions) to return to their average state—may lead people to overestimate the effectiveness of therapy. When things hit bottom, going to a therapist is more likely to be followed by improvement than by further descent.
Randomized clinical trials assign people on a waiting list to therapy or no therapy. The results of many such studies are then digested by meta-analysis, a statistical procedure that combines the conclusions of a large number of different studies. The results reveal that (1) people who remain untreated often improve; (2) those who receive psychotherapy are more likely to improve; and (3) when people seek psychological treatment, their search for other medical treatment declines.
No one therapy has been shown to be best in all cases, nor is there any relationship between clinicians’ experience, training, supervision, and licensing and their clients’ outcomes. Some therapies are, however, well suited to particular disorders, such as behavioral conditioning therapies for treating specific problems such as phobias, compulsions, and marital problems and cognitive therapy for treating depression and reducing suicide risk.
Therapy is most effective when the problem is clear-cut. However, some therapies—such as energy therapies, recovered-memory therapies,
rebirthing therapies, facilitated communication, and crisis debriefing—have no scientific support. Evidence-based practice involves clinical decision making that integrates the best available research with clinical expertise and patient characteristics and preferences. In short, available therapies are rigorously evaluated and then applied by clinicians who are mindful of their skills and of
each patient’s unique situation.
In EMDR (eye movement desensitization and reprocessing) therapy, the therapist waves a finger in front of the eyes of the client to unlock and reprocess previously frozen trauma memories. Controlled studies have not supported the effectiveness of EMDR; belief in its effectiveness may be explained in terms of the combination of exposure therapy—repeatedly reliving traumatic memories in a reassuring environment—and a robust placebo effect. In contrast, light exposure therapy (exposure to daily doses of light that mimics outdoor light) has proven effective in treating people with seasonal affective disorder, a form of depression linked to periods of decreased sunlight.
Despite their differences, all therapies offer at least three benefits. First, they all offer the expectation that, with commitment from the patient, things can and will get better. Second, every therapy offers people a plausible explanation of their symptoms and an alternative way of looking at themselves or responding to their worlds. Third, regardless of their therapeutic technique, effective therapists are empathic people who seek to understand another’s experience, whose care and concern the client feels, and whose respectful listening, reassurance, and advice earn the client’s trust and respect. In short, all therapies offer hope for demoralized people, a new perspective on oneself and
the world, and an empathic, trusting, caring relationship.
Psychotherapists’ personal beliefs and values influence their therapy. While nearly all agree on the importance of encouraging clients’ sensitivity, openness, and personal responsibility, they differ sharply on the pursuit of self-gratification, self-sacrifice, and interpersonal commitment. Value differences also become important when a client from one culture meets a therapist from another.
For example, clients from a culture where people are mindful of others’ expectations may have difficulty with a therapist who gives priority to personal desires and identity. Such differences may help explain the reluctance of some minorities to use mental health services. Some psychologists believe that therapists should divulge their values more openly.
Another area of potential value conflict is religion. Highly religious people may prefer and benefit from religiously similar therapists. They may have trouble establishing an emotional bond with a therapist who does not share their values.
In choosing a therapist, a potential client may wish to have a consultation with two or three. After describing the problem, you can learn the therapist’s specific treatment approach. Moreover, you can ask questions about the therapist’s values, credentials, and fees. Finally, recognizing the significance of the emotional bond between therapist and client, you can sense the appropriateness of the match.
The Biomedical Therapies
With a few exceptions, only psychiatrists (as medical doctors) offer biomedical therapies. Psychopharmacology, the study of the effects of drugs on mind and behavior, has revolutionized the treatment of people with severe disorders. To evaluate the effects of any new drug, researchers use the double-blind technique, in which half the patients receive the drug while the other half receive a placebo. Because neither staff nor patients know who gets which, this research strategy eliminates bias that results from therapists’ and patients’ expectations of improvement. Using this approach, several types of drugs have proven effective in treating psychological disorders.
Antipsychotic drugs, such as chlorpromazine (sold as Thorazine), provide help to people experiencing the positive symptoms of auditory hallucinations and paranoia by dampening their responsiveness to irrelevant stimuli. Newer atypical antipsychotics, such as clozapine (sold as Clozaril), help reanimate schizophrenia patients with the negative symptoms of apathy and withdrawal. Long-term use of some of these drugs block dopamine receptors and can produce tardive dyskinesia, which is marked by involuntary movements of facial muscles, tongue, and limbs. Many of the newer antipsychotics have fewer such side effects, but they may increase the risk of obesity and diabetes.
Antianxiety drugs, such as Xanax and Ativan, depress central nervous system activity. A new antianxiety drug, the antibiotic D-cycloserine, acts upon a receptor that facilitates the extinction of learned fears. Used in combination with other therapy, antianxiety drugs can help people learn to cope with frightening stimuli. However, they can produce both psychological and physiological
dependence.
Antidepressant drugs aim to lift people up, typically by increasing the availability of the neurotransmitters norepinephrine and serotonin. For example, fluoxetine (Prozac) partially blocks the reabsorption and removal of serotonin from the synapses, and so Prozac and its cousins Zoloft and Paxil are called selective-serotonin-reuptake-inhibitors (SSRIs). They also are increasingly being used to treat anxiety disorders such as obsessive-compulsive disorder. Other dual-action antidepressants work by blocking the reabsorption or breakdown of both norepinephrine and serotonin. Although no less effective, these dual-action drugs have more potential side effects, such as dry mouth, weight gain, hypertension, or dizzy spells. Administering them by means of a patch helps reduce such side effects. Although antidepressants influence neurotransmitter systems almost immediately, their full psychological effects may take weeks. The delay may occur because increased serotonin seems to promote neurogenesis. The risk of suicide for those taking these drugs has probably been overestimated.
The simple salt lithium is often an effective mood stabilizer for those suffering the emotional highs and lows of bipolar disorder. Although lithium significantly lowers the risk of suicide, we do not fully understand how it works.
Electroconvulsive therapy (ECT), or shock treatment, is used for severely depressed patients. A brief electric current is sent through the brain of an anesthetized patient. Although ECT is credited with saving many from suicide, no one knows for sure how it works. Some patients with chronic depression have found relief through a chest implant that intermittently stimulates the vagus nerve, which sends signals to the brain’s mood-related limbic system. Repetitive transcranial magnetic stimulation (rTMS) is performed on wide-awake patients. Magnetic energy penetrates only to the brain’s surface (although tests are under way with a higher energy field that penetrates more deeply). Unlike ECT, the rTMS procedure produces no seizures, memory loss, or other side effects. Several recent studies have confirmed its therapeutic effect. Deep brain stimulation has shown potential in calming a brain area that appears active in people who are depressed or sad.
Psychosurgery removes or destroys brain tissue in an effort to change behavior. For example, the lobotomy was once used to calm uncontrollably emotional or violent patients. The nerves that connect the frontal lobes to the emotion-controlling centers of the inner brain are cut. The lobotomy usually produced a permanently lethargic, immature, impulsive personality. Because of these effects and the introduction of drug treatments in the 1950s, the procedure has been abandoned. Other psychosurgery is used only in extreme cases. For example, for patients who suffer uncontrollable seizures, surgeons may deactivate the specific nerve clusters that cause or transmit the
convulsions. MRI-guided precision surgery may also be used to cut the circuits involved in severe obsessive-compulsive disorder.
Preventing Psychological Disorders
One way to prevent some disorders is to build individuals’ resilience—an ability to cope with stress and recover from adversity. Preventive mental health experts view many psychological disorders as an understandable response to a disturbing and stressful society. It is not only the person who needs treatment but also the person’s social context. Thus, the aim of preventive mental health programs is to change oppressive, esteem-destroying environments into more benevolent, nurturing environments that foster individual growth and self-confidence. Preventing psychological disorders means empowering those who feel helpless, changing environments that breed loneliness,
strengthening the disintegrating family, and fostering parents’ and teachers’ skills at encouraging children’s achievements and resulting self-esteem.
*Work Cited: All summary notes come from *Myers Pyschology for AP, Lecture Guides (2011 Worth Publishers)