Myers PSYCHOLOGY C17:1 History of Treatment Treatment of mental illness originally cruel and ineffective, based on naïve beliefs about causes Efforts of Dix, Pinel, C17:2 Chapter 17 Therapy Psychological Therapies Psychoanalysis Humanistic Therapies Behavior Therapies Cognitive Therapies Group and Family Therapies Evaluating Psychotherapies Is psychotherapy effective? Thinking critically: Regressing from Unusual to Usual Relative Effectiveness Alternative Therapies Commonalities Culture and Values Outline C17:3 Biomedical Therapies Drug Therapies Brain Stimulation Psychosurgery Preventing Psychological Disorders Psychological Therapies C17:4 Psychotherapy An emotionally charged, confiding interaction between trained therapist and someone who suffers from psychological difficulties Eclectic Approach Approach to psychotherapy that, depending on the client s problems, uses techniques from various forms of therapy Dominant approach of many therapists C17:5 Psychoanalysis Freud believed patient s Free Associations, Resistances, Dreams, and Transferences, and therapist s Interpretations of them, released previously repressed feelings, allowing patient to gain self-insight Resistance: Blocking from consciousness of anxiety-laden material Interpretation: Analysts note supposed dream meanings, resistances, and other significant behaviors to promote insight Transference: Patient s transfer to analyst of emotions linked with other relationships; e.g. love or hatred for parent Use has rapidly decreased in recent years Steps in Psychoanalysis Confrontation Clarification Interpretation Working through Psychodynamic Therapy Number of Freudian assumptions still prevalent in some approaches Exploring childhood, Unconscious Roots, Repression, Interpersonal Therapy Brief alternative to Psychoanalysis designed to elicit insight Focus on current relationships and relationship skills C17:6 1
Humanistic Therapies C17:7 Client-Centered Therapy Humanistic therapy developed by Carl Rogers Unconditional Positive Regard Therapist uses techniques such as active listening within genuine, accepting, empathic environment to facilitate client growth Active Listening Empathic listening in which listener echoes, restates, and clarifies Paraphrase: summarize speaker s words Invite clarification: example of that? Reflect feelings: It sounds as though Behavior Therapies Apply learning principles to eliminate unwanted behaviors Counterconditioning Condition new responses to stimuli that trigger unwanted behaviors Based on classical conditioning Aversive Conditioning: pair undesirable positive stimulus (e.g., alcohol) with aversive stimulus (e.g., nausea-inducing chemical) Systematic Desensitization: type of Exposure Therapy (+1 +2) C17:8 C17:9 Exposure Therapy - Expose people in imagination (Systematic Desensitization), virtual reality, or reality to things they fear and avoid Behavior Therapy C17:10 Systematic Desensitization Associates pleasant, relaxed state with gradually increasing anxiety-triggering stimuli Trained in Progressive Relaxation: alternately tense and relax muscles in systematic way; imagine relaxing scenes Create hierarchy of anxiety-provoking events Imagine events at low levels of hierarchy while relaxing, gradually moving up hierarchy Commonly used to treat phobias (+1) C17:11 Systematic Desensitization of Spider Phobia C17:12 Aversive Conditioning Type of counterconditioning that associates unpleasant state with unwanted behavior Aversion therapy for alcoholics (left) Alcohol Nausea 2
C17:13 Operant Conditioning Therapies based on operant conditioning Control consequences of behavior Positive reinforcement, Extinction, Punishment, Shaping, Token Economy Patient exchanges token, earned by exhibiting desired behavior, for various privileges or treats Often Institutional and Class settings (+1) Criticisms Generalization and Maintenance: wean client/patient Ethical: Moral to control people this way? C17:14 Cognitive Therapies Cognitive (or Cognitive-Behavioral) Therapies Popular integrated therapy that uses cognitive therapy to change self-defeating thinking Often combined with behavior therapy Currently, dominant approach, hence label Cognitive Revolution (+1) C17:15 Cognitive Therapy Teaches new, more adaptive ways of thinking and acting Based on assumption that thoughts intervene between events and emotional reactions (+2) The Cognitive Revolution C17:16 C17:17 C17:18 Treatment for OCD Replace compulsive urge with alternative, enjoyable behavior Meichenbaum s Stress Inoculation Training Learn more appropriate self-talk: Relax. Test may be hard, but hard for everyone. I studied hard. Besides, I don t need perfect score to get a good grade. Cognitive Therapy for Depression Rabin taught 235 depressed people to interpret events as non-depressed people do Home-work assignments to remember positive events and how they contributed to them Depression dropped dramatically (+1) 3
Cognitive Therapy for Depression C17:19 C17:20 Group and Family Therapies Group Therapies Clients meet as group with therapist Can be as effective as individual therapy Social context provides learning environment AA perhaps largest of self-help groups 12 Steps: admit powerlessness (?), seek help from higher power and others, take message to others in need Perhaps as effective as Cognitive Behavioral or Motivational Therapy, but difficult to evaluate (e.g., anonymity) Family Therapies Treat family as system View individual s unwanted behaviors as influenced by or directed at other family members Attempt to guide family members toward positive relationships and improved communication Psychological Therapies Psychoanalysis Humanistic Therapies Behavior Therapies Cognitive Therapies Group and Family Therapies Evaluating Psychotherapies Is psychotherapy effective? Thinking critically: Regressing from Unusual to Usual Relative Effectiveness Alternative Therapies Commonalities Culture and Values Outline C17:21 Biomedical Therapies Drug Therapies Brain Stimulation Psychosurgery Preventing Psychological Disorders Is Psychotherapy Effective? C17:22 Client Perceptions Testimonials generally positive about effectiveness of psychotherapy Consumer Reports Study of 4,100 users of therapy: 87% of very poor improved, 44% to good level; dose effect; Problems with testimonials Clients like therapists and speak kindly of them Need to believe therapy worth effort, expense, Lack of control / comparison groups: In some striking cases (e.g., Scared Straight program) Treatment Group (i.e., testimonial group) actually fared worse than Comparison Group Enter therapy in crisis, and crisis passes: Regression Toward the Mean (+1) C17:23 Thinking Critically: Regressing from Unusual to Usual (Regression to Mean) Unusual states tend to regress (return or fall back) towards mean (average) High or Low score on exam High scorers on ESP task subsequently decline Crime wave followed by decline (irrespective of stop crime drive) Athletic performance: 80% with high batting average or few earned runs did poorer in following season Simulation (+1) Confounds evaluating impact of treatments, such as psychotherapy Regression to Mean C17:24 r =.69 between 500 Z1 and Z2 scores. Below, NZ1 = 9 ordered categories based on Z1 (1=Low). Columns below are means for categories. Z2 means closer to 0 (Mean of all scores) than Z1 means, hence Regression to Mean. NZ1 Z1 Z2 1-1.580489-1.028989 2 -.897257 -.660730 3 -.519583 -.372009 4 -.238593 -.089035 5.003058.050961 Expected Mean = 0 6.240254.161535 7.566243.368435 8.944551.557094 9 1.770553 1.254580 4
C17:25 Clinician Perceptions Many of same problems as testimonials; based largely on same evidence (i.e., client reports) Also more likely to remember successes than failures, other cognitive biases Outcome Research Controlled research studies, such as those that revealed negative effects of bleeding in 1800s Eysenck: 2/3 improved markedly after therapy, but similar improvement in untreated Meta-analysis: Smith (198) aggregated results of 475 studies (+1) Meta-analysis Procedure for statistically combining results of many different research studies C17:26 C17:27 Relative Effectiveness of Therapies Smith meta-analysis failed to identify any specific treatment modality as superior Consumer Report study similar result Other studies generally favour cognitive-behavioral approaches May result from common elements in different treatments (later) But some evidence for disorder-specific effectiveness (+1) Relative Effectiveness Disorder Therapy Depression Behaviour, Cognitive, Interpersonal Anxiety Cognitive, Exposure, Stress Inoculation Bulimia Cognitive-behavioural Phobia Behaviour C17:28 Bed Wetting Behaviour Modification Alternative Therapies Many people turning to alternative (i.e., untested) approaches, such as spiritual, herbal, Lillienfield compared hits for various valid and questionable treatments in PsychInfo and WWW (+1) Therapeutic Touch Without touching, push energy fields into balance But fail to even detect presence of other person s field (+2) Eye Movement Desensitization and Reprocessing EMDR of Shapiro based on casual observation No benefit over comparison groups Perhaps Exposure and Placebo Effect Light Exposure Therapy Appears to be real benefit Subliminal Tapes (+3 to +6) No valid evidence for benefits C17:29 C17:30 5
C17:31 C17:32 Therapeutic practitioners attempted to detect presence of human hand No better than chance Initial Warning C17:33 HYPNOVISION TAPES CAN ONLY HELP PEOPLE WHO ARE OPEN MINDED, HAVE FAITH, TRUST, BELIEF, HOPE AND ARE WILLING TO TAKE A CHANCE IN LIFE WITHOUT ASKING FOOLISH & STUPID HOLLYWOOD / TV TYPE QUESTIONS! FOR THOSE of YOU WHO BELIEVE IN The POWER of the MIND, IN MAGICK, IN METAPHYSICS OR SPIRITUALITY... No Explanation of How These Tapes Work Is Necessary! For those of you who DO NOT BELIEVE...NO EXPLANATION IS POSSIBLE! Close minded people, agnostics & skeptics listen... Our tapes are not for you! Testimonials Studied for exams while listening to Deep Relaxation. Found I could study for longer periods of time and experienced less anxiety during exams. I have been using the tapes for a relatively short time and I can notice clear positive shifts in my attitudes towards life and my problems. Stop Smoking, it s worked! Prosperity, I now have sufficient income to support our needs. It was very tight before hand. L Wood I bought Weight Control because over winter I had added a couple of kilos. I have since lost that weight and I have also lost the desire to eat much of the sweet food I was before. I also bought Attracting Infinite Riches. Since then my job has gone from 2 days a week casual labour to joint supervisor! Keep up the good work. E Little Greenwald study Participants listened to Self- Esteem or Memory enhancing tapes (horizontal axis) Measured change in Self-Esteem (upper graph) or Memory (lower graph) No evidence for expected effects or even reverse in upper graph 0.45 0.4 0.35 0.3 0.25 0.2 0.15 0.1 0.05 0 0.3 0.25 0.2 0.15 0.1 0.05 0 memory memory self-esteem self-esteem C17:34 C17:35 Commonalities in Psychotherapies Compassion, Sensitivity, Empathy Hope for Demoralized People May account for placebo effects New Perspective on Self Plausible explanation for symptoms and alternative view Empathic, Trusting, Caring Relationship Most effective therapists: seen as most empathic and caring, established closest bond with clients, help clients evaluate self, link different aspects of clients lives, provide insight into clients relationship with others Paraprofessionals trained in these components as effective as Professionals Various factors examined as correlates of effective psychotherapy (+1 +2 +3) C17:36 Client Variables: Who benefits More intelligent clients Cooperative more than defensive or hostile clients Age and Gender no consistent relationship (but more women seek therapy) Motivation to change at start less important than motivation developed during therapy Client (and Therapist) being clear on goals Early studies suggested low SES poor candidates, but poor outcome more function of therapist variables (low expectations), or low SES being referred to less-experienced therapists Such personality traits as ego-strength, suggestibility, and anxiety tolerance may be related to positive outcome Moderate expectations better than high or low 6
Therapist Variables: Who is effective C17:37 Therapist Gender or Ethnicity does not affect outcome. Similarity on demographic factors (Age, Sex, Background) Slight effect for young clients with mild disorders Ethnic similarity Sometimes lowers early termination, but no clear outcome effects African-Americans may be more self-disclosing to AA therapists Client self-exploration may be higher with therapist-client similarity Therapist emotional stability and well-being Clear, modest relation to therapy success. Effect of Self-Disclosure inconsistent Clear Therapist (and Client) expectations Address client expectations and make conform to therapist s expectations (e.g., Educate about therapy) Professional experience and competence When experienced therapists compared to inexperienced therapists When clients are difficult and intractable, when complex treatments are investigated, and when outcome is assessed early in process. Therapist competence is most important predictor of outcome C17:38 Treatment Variables Therapeutic Alliance Best predictor of treatment outcome, more important than specific therapeutic approach (see common elements) Ability of client to establish therapeutic alliance depends on ability to establish trusting relationships at all Duration Any differences found tend to favor time-limited treatments over longer treatments. Relationship between length of therapy and outcome is ambiguous (confounded with severity?) But persistence in treatment beyond initial sessions important for success (+1) No type of treatment is viewed as significantly better than any other C17:39 C17:40 Culture and Values in Psychotherapy Values can differ between Client and Therapist Clients tend to be more Religious than Therapists % Atheist / Agnostic 4% General population 20-50% Psychiatrists / Clinical Psychologists 66% Psychiatrists in Britain Religious people prefer religious therapist Culture Individualist vs. Collectivist cultures C17:41 Consumer s Guide: Who Does Therapy? C17:42 To whom do people turn for help for psychological difficulties? Mental health specialists include Training (+1) 7
Psychological Therapies Psychoanalysis Humanistic Therapies Behavior Therapies Cognitive Therapies Group and Family Therapies Evaluating Psychotherapies Is psychotherapy effective? Thinking critically: Regressing from Unusual to Usual Relative Effectiveness Alternative Therapies Commonalities Culture and Values Outline C17:43 Biomedical Therapies Drug Therapies Brain Stimulation Psychosurgery Preventing Psychological Disorders Biomedical Therapies Assume mind and body function as integrated unit, each affects other Drug Therapies Psychopharmacology: study effects of drugs on mind and behavior C17:44 Freed many from mental hospitals (+1), although some undesirable consequences (e.g., homelessness) Different drugs target different disorders The emptying of U.S. mental hospitals C17:45 C17:46 Antipsychotic Drugs Dampen effects of irrelevant stimuli Block activity of Dopamine Antianxiety Drugs Depress CNS activity Can become addicted Antidepressant Drugs (widely used, +1) Increase Norepinephrine or Serotonin activity Prozac and related drugs are Selective Serotonin Reuptake Inhibitor Drugs (SSRI) (+2 +3) Other antidepressant drugs work differently (+3) Modest gains over placebo effects Lithium: chemical that provides an effective drug therapy for the mood swings of bipolar (manic-depressive) disorders C17:47 C17:48 Synaptic Effects of Prozac 8
C17:49 Issues in Drug Use C17:50 Direct advertising permitted in US Marked increase in advertising spending (right & below) associated with increased use Direct advertising does influence prescription writing (+1) Three types of antidepressant drugs all increase activity at serotonin synapses but in different ways Tricyclics and MAO inhibitors have effects at greater variety of synapses, which explains greater side effects More recent SSRIs more specific in targeting serotonin synapses C17:51 Effect of patient request for specific drug (Kravitz et al.) Standardized patients with either depression or adjustment disorder visited Doctors. Patients either 1. described their symptoms and made no specific request for medication, 2. said they had seen program on television and wondered about drug treatment, or 3. said they had seen a DTC advertisement for Paxil For patients with adjustment disorder, a condition not generally requiring drug treatment 10% of group 1 received prescription, 0% for Paxil, 39% of group 2, 26% for Paxil 55% of group 3, 67% for Paxil C17:52 Brain Stimulation (Electroconvulsive Therapy or ECT) Therapy for severely depressed patients Brief electric current sent through brain of anesthetized patient (+1) Memory loss, but improvement in depression for majority of patients; changes in brain functioning (+1) Negative attitudes toward ECT, but not in patients (+2) Electroconvulsive Therapy C17:53 C17:54 9
Search for less intense brain stimulation treatment: Repetitive Transcranial Magnetic Stimulation (rtms) C17:55 Psychosurgery Surgery removes or destroys brain tissue to change behavior Lobotomy Sever nerves from Frontal Lobes Once used to calm uncontrollably emotional or violent patients Many thousands done (40,000 to 50,000 in USA?) C17:56 Psychosurgery Contemporary work More refined: MRI guided, Gamma knife (right), Limbic system OCD, Depression, Anxiety C17:57 Psychological Therapies Psychoanalysis Humanistic Therapies Behavior Therapies Cognitive Therapies Group and Family Therapies Evaluating Psychotherapies Is psychotherapy effective? Thinking critically: Regressing from Unusual to Usual Relative Effectiveness Alternative Therapies Commonalities Culture and Values Outline C17:58 Biomedical Therapies Drug Therapies Brain Stimulation Psychosurgery Preventing Psychological Disorders Prevention Demoralizing aspects of environment Stressors: Poverty, Unemployment, Meaningless Work, Racism, Constant Criticism Change environments: Education of managers, workers, and relevant agencies Identification of at-risk individuals In many cases can predict adult dysfunction in childhood: bullying, unusual behaviors and schizophrenia Prevention programs: e.g., teach coping skills to children at risk for depression Greenberg et al (2001) (+1) C17:59 Greenberg et al (2001) C17:60 Reviewed primary prevention programs Programs that had undergone randomized or quasiexperimental trials and reduced symptoms (aggression, depression, anxiety) or factors associated with increased risk for mental disorders 34 universal and targeted interventions with positive outcomes under rigorous evaluation Characteristics of successful prevention programs Multi-Component Programs: Focus on Children, Parents, and Teachers; Systematic evaluation of effectiveness (efficacy) Community and School-Based Interventions: Integration of Early Education and Mental Health Promotion Strategic Diffusion of Effective Methods: High-fidelity implementation; Effective education and training of practitioners; On-going technical assistance; Sustainability 10