Treatment

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Treatment

• 11.21.2007
• (NO CLASS)

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Why do people seek treatment?

• Distress
• Acute Stressful current life circumstances
• Chronic People with long-standing problems
• Reluctant clients
• Physician referred
• Martial problems (therapy or divorce)
• Legal issues
• Children brought by angry parents
• Males tend to be more reluctant than females
• Personal Growth

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Who provides psychotherapeutic services?

• People Team approach is often used
• Clinical/Counseling Psychologists
• Psychiatrists
• Psychiatric Social Workers
• Physicians
• Psychiatric nurses
• Clergy
• School Psychologists
• Places
• Private clinics
• Community clinics
• Hospitals
• ER
• Churches, temples, mosques, etc.
• Schools

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Therapeutic Relationship

• Factors Important for the Client
• Motivation to change is the most crucial factor
  for success
• Expectation the you are receiving help (placebo
  effect)
• Factors Important for the Therapist
• Personal characteristics (e.g. empathy,
  trustworthiness, etc.)
• Level of expertise
• Experience
• Key Elements of the Relationship
• Sense of working collaboratively on a problem
• Agreement between patient and therapist about
  goals and tasks
• Affective bond between patient and therapist

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Measuring Success

• Assessing Change
• Therapists impression
• Clients self-report
• Report from family and friends
• Objectifying and Quantifying Change
• General terms like recovery, marked
  improvement, and moderate improvement are open
  to interpretation
• Comparison of pretreatment and posttreatment
  scores on structured assessments and
  questionnaires
• Measures of change in certain selected overt
  behaviors
• In research settings perhaps using fMRI to
  compare brain activity before and after treatment

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Measuring Success

• Would change occur anyway?
• Improvement often takes place without
  professional help
• Some disorders have a specific brief course
• Treatment attempts to accelerate change and/or
  provide change where none would likely occur
• 50 of patients show clinical improvement after
  21 sessions 75 after 40 sessions
• Can therapy be harmful?
• Often it feels worse before it gets better
• 5-10 of patients deteriorate during treatment
  highest rates among borderline personality
  disorder and OCD
• Sex between therapist and client is unethical and
  almost always destructive

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What Treatments Should Be Used?

• Good Question.
• Empirically Supported Treatments
• In order to compare psychological therapies, need
  to conduct randomized clinical trials
• Treatment manuals need to be created
• Used to study efficacy as well as cost
• Becoming more common and more similar to natural
  settings
• Medication or Psychotherapy
• Has led to decreases in hospitalization,
  restraints, and locked wards
• Unwanted side effects
• Difficult to match drug and dosage to needs of
  specific client
• High rates of relapse

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What Treatments Should Be Used?

• Combined Treatments
• Using both medication and psychotherapy
• Medication can often help get a client to a
  place where therapy will be effective
• Integration is now common (55 of clients receive
  both)
• Patients appear to prefer combined approaches
• Evidence suggests that especially for serious
  cases, combined approach is more successful

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Antipsychotics

• Alleviate or reduce the intensity of delusions
  and hallucinations in 60 of patients (block
  dopamine receptors)
• Typical antipsychotics dont treat negative
  symptoms well
• Problematic side effects (tardive dyskinesia)
• Newer atypical antipsychotics reduce the
  incidence of movement-related side effects and
  may effectively treat both the positive and
  negative symptoms

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Antidepressants

• Tricyclics
• Inhibits the reuptake of serotonin and
  norepiphrin
• Alter the way neurons function, how cells respond
  to activation of receptors, and the synthesis of
  neurotransmitters
• Selective serotonin re-uptake inhibitors (SSRIs)
• Increases serotonin by blocking re-uptake process
• Often produces dramatic results within 3-5 weeks
  (at least 50 improvement)
• Better tolerance and fewer side effects than
  tricyclics, but not more effective
• SSRIs also used for panic disorder, social
  phobia, GAD, OCD, bulimia, and Cluster B
  personality disorders

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Antidepressants

• Monoamine oxidase inhibitors (MAOIs)
• Used infrequently today
• Inhibit the activity of monoamine oxidase
• Patients must avoid foods high in the amino acid
  tyramine
• Other antidepressants
• Trazodone first antidepressant not lethal on
  overdose
• Wellbutrin increases noradrenergic function but
  does not inhibit sexual functioning (like most of
  the SSRIs do)
• Serzone/Nefazodone does not inhibit sexual
  functioning or produce insomnia

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Antianxiety Drugs

• Benzodiazapines
• Widely prescribed by physicians
• Believed to enhance the activity of GABA
  receptors (primary inhibitory neurotransmitters
  in the brain)
• Used as sleeping pills and to diminish
  generalized fear
• Significant potential for abuse, serious
  withdrawal symptoms
• Relapse rates are extremely high
• Buspirone
• Unrelated to benzos thought to work on serotonin
  rather than GABA
• Those who have previously taken benzos dont
  respond as well to Buspirone
• No sedative or muscle-relaxing properties
• Low potential for abuse
• Takes 2-4 weeks to show symptom relief

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Mood-Stabalizers

• Lithium
• Biochemical mechanism unknown thought to act on
  neurotransmitter systems
• 70-80 effective in resolving manic states
  maintenance treatment may be less reliable at
  preventing future episodes
• Side effects include increased thirst, GI
  problems, weight gain, tremor, and fatigue, can
  be toxic on overdose
• Discontinuation is very risky relapse rates 28
  times higher after withdrawal

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Mood-Stabalizers

• Other mood-stabilizing drugs
• Other bipolar drugs include Depakote and Tegretol
• Depakote - fewest and mildest side effects
  nausea, diarrhea, sedation, tremor, and weight
  gain
• Tegretol significant side effects blood
  problems, hepatitis, serious skin conditions,
  careful blood monitoring required
• Some antipsychotics are also used off-label to
  treat bipolar disorder, research is being done to
  substantiate anecdotal evidence, Abilify already
  being marketed for bipolar disorder

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Electroconvulsive Therapy

• Results indicate ECT can be safe and effective
  especially for
• Severely depressed pregnant women
• Elderly depressed patients
• Severely depressed and suicidal patients who have
  failed to respond to other treatments
• Patients with manic disorders who have not
  responded to treatments
• How ECT works is still not fully understood but
  virtually every neurotransmitter system is
  impacted

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Psychological Approaches to Treatment

• Behavior therapy
• Cognitive and Cognitive-Behavior Therapy
• Humanistic-Experiential Therapy
• Psychodynamic Therapy
• Marital and Family Therapy

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Behavior Therapy

• Self-monitoring
• Exposure therapy
• Aversion therapy
• Modeling
• Systematic use of reinforcement
• Token economies

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Behavior Therapy

• Self-monitoring
• Increases awareness
• Reactive
• Activity
• 1. Select a behavior that you would like to
  change (e.g. smoking, biting nails, saying um,
  etc.)
• 2. Record the occurrence of the behavior
  immediately after is occurs for one week
• 3. Plot the data by day (i.e. x-axis day,
  y-axis frequency of behavior)
• 4. Observe whether or not the reactivity of
  self-monitoring produces a decrease in the
  behavior

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Behavior Therapy Self-Monitoring
Behavior chewing on fingernails
Amount of time spent
Day/ Time
Mood
Place
Thoughts
5/1 1245 pm
Class
15 minutes
Anxious 70
The final is coming up in a few days and I have
to get an A. If I dont get an A, my GPA is going
to plummet and Ill never get into med school.
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Behavior Therapy Self-Monitoring
FREQUENCY OF BEHAVIOR
1
2
5
6
7
3
4
DAY
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Behavior Therapy

• Exposure therapy (Classical Conditioning)
• Widely used in the treatment of anxiety
  disorders, especially social/specific phobias,
  panic disorder, and OCD
• Involves guided exposure to anxiety provoking
  stimuli can be accomplished slowly (systematic
  desensitization) or quickly (flooding)
• Research as well as anecdotal evidence has shown
  significant success
• Relaxation is paired with exposures because
  relaxation is an incompatible response to anxiety

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Behavior Therapy

• Aversion Therapy (Operant Conditioning)
• Punishment is used to modify behavior
• Used successfully with smoking, drinking,
  overeating, drug dependence, gambling, sexual
  deviance, etc.
• Use of this technique is on the decline
• Modeling (Observational Learning)
• Behavior is learned by imitating others
• Modeling is combined with instruction

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Behavior Therapy

• Systematic Use of Reinforcement (Operant
  Conditioning)
• Often referred to as contingency management
• Must first identify and remove contingencies that
  reinforce/maintain maladaptive behavior
• Then Replace and reinforce more adaptive behavior
• Token Economies (Operant Conditioning)
• Originally developed for use with hospitalized
  schizophrenia patients
• Patients earn tokens that can later be exchanged
  for rewards or privileges
• Now being used to effectively treat other
  disorders in inpatient settings as well

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Evaluating Behavior Therapy

• Distinct advantages over other treatments
• Achieves results quickly
• Low costs
• Methods clear and can be readily evaluated
• Proven effective
• Works better with some types of problems than
  others

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Cognitive Cognitive-Behavior Therapy

• Becks cognitive therapies
• Orignially developed for depression, but later
  expanded to anxiety disorders, eating disorders,
  conduct disorder, personality disorders, and
  substance abuse
• Problems result from biased processing of
  external events or internal stimuli leading to
  cognitive errors
• Teach clients the relationship between thinking
  and emotional responses identify automatic
  thoughts and logical errors
• Clients gather information about themselves and
  then are assigned tasks to test their hypotheses
• The precise underlying automatic thoughts and
  accompanying dysfunctional schemas vary from one
  disorder to another

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Cognitive Cognitive-Behavior Therapy
Consequence
Belief
Activating Event
New Consequence
New Belief
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Evaluating Cognitive Cognitive-Behavior Therapy

• Becks type of therapy is extremely effective for
  many disorders
• Comparable to medication for depression in
  reducing symptoms better at preventing relapse
  than medication
• Neurological exams show actual functional changes
  in the brain following cognitive and
  cognitive-behavior therapies
• Research has shown efficacy in treating panic
  disorder, bulimia, personality disorders, conduct
  disorders, substance abuse, and GAD

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Humanistic-Experiential Therapies

• Client-centered therapy (Carl Rogers)
• The primary objective is to resolve incongruence
  help clients accept and be themselves
• Nondirective techniques such as empathic
  reflecting or restatement of the clients
  description of life difficulties are used
• Psychological climate of acceptance is created
• Self-concept becomes congruent with actual
  experiences
• Pure client-centered therapy is rarely used today
  in NorthAmerica, although it is popular in Europe

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Humanistic-Experiential Therapies

• Gestalt therapy (Fritz Perls)
• Gestalt means whole therapy emphasizes the
  unity of mind and body integrating thought,
  feeling, and action
• Goal is to increase awareness and acceptance of
  self
• Commonly used in group setting
• Dreams are thought to be representations of the
  dreamers self
• Process-Experiential Therapy
• Combines client-centered and Gestalt therapies
• Emphasizes the experiencing of emotions during
  therapy clients also reflect on their emotions
  and are encouraged to create meaning from them

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Evaluating Humanistic-Experiential Therapies

• Have influenced contemporary views of human
  nature and good psychotherapy
• Criticized for lack of agreed-upon therapeutic
  procedures and vagueness
• Research in past lacking newer research suggests
  these approaches may be helpful for depression,
  anxiety, trauma, and marital difficulties

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Psychodynamic Therapies

• Freudian psychoanalysis
• Free association
• Dream analysis
• Analysis of resistance
• Prevents talking about painful experiences
• Forgetting
• Analysis of transference
• React as to another person in ones life
• Counter-transference therapists reactions that
  are evoked by client

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Psychodynamic Therapies

• Interpersonal therapy (IPT)
• Transferential and counter-transferential
  phenomena in all aspects of the persons life
• All of us involuntarily invoke schemas acquired
  from our earliest interactions with others, such
  as our parents, in interpreting what is going on
  in our relationships
• Introjected characteristics of early rejection or
  abuse may distort the individuals ability to
  process accurately and objectively the
  information contained in current interpersonal
  transactions

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Evaluating Psychodynamic Therapies

• Classical psychoanalysis is time-consuming,
  expensive, based on questionable approach,
  neglects a persons immediate problems, and lacks
  proof of effectiveness
• Proponents still argue that the approach may be
  of benefit even if efficacy studies do not
  support it
• Newer brief versions of psychodynamic-interpersona
  l therapies show some efficacy

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Marital and Family Therapy

• Marital therapy
• Growing field
• Gold standard Traditional Behavioral Couple
  therapy based on a social learning model,
  empirically effective
• Integrative Behavioral Couple Therapy (IBCT)
  focuses on acceptance rather than change
  preliminary findings are quite positive
• Family therapy
• Developed from fact that many patients relapse
  when returned to their families
• Based on systems theory and focuses on changing
  the organization of the family