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					          Understanding
          Abnormal Behavior
          Chapter Seventeen



Therapeutic Interventions
Therapeutic Interventions
 Biology-based approaches
 Individual psychotherapy:
     Insight approaches
     Action approaches
 Group approaches:
     Group therapy
     Family therapy
     Couples therapy
Biology-Based Treatment
 Biological/somatic techniques use physical means to
  alter the patient’s physiological and psychological
  state
 Goes back to ancient times (trephining [boring a hole
  in the heads of mentally ill patients to allow demons
  to escape], bleeding and purging)
 Modern techniques:
      Electroconvulsive therapy
      Psychosurgery
      Psychopharmacology
Biology-Based Treatment (cont’d)
 Electroconvulsive therapy (ECT): The application of
    electric voltage to the brain to induce convulsions
   Application of electric voltage to the brain to induce
    convulsions
   Particularly useful for severe depression
   Patient is first given a muscle relaxant, then 65-140
    volts of electricity are applied causing convulsions
    and coma.
   Confusion and memory loss occurs for events
    immediately before and after the ECT
Biology-Based Treatment (cont’d)
 Use of ECT declined in 1960’s-1970’s
  because:
     Concerns about permanent brain damage
     Fracture/dislocation of bones
     Beneficial effects not long-term
     Abuses and side effects
     Advances in medication diminished the need
      for ECT
 Not sure why it works.
Biology-Based Treatment (cont’d)
 Psychosurgery: Brain surgery performed to
  correct severe mental disorders
     Prefrontal lobotomy
     Transorbital lobotomy
     Lobectomy
     Cauterization
Biology-Based Treatment (cont’d)
 Criticisms of psychosurgery:
     Patient improvement/lack of improvement is
      independent of psychosurgical treatment
     Serious negative and irreversible side effects,
      e.g., impaired cognitive and intellectual
      functioning, listlessness, uninhibited impulsive
      behavior, death
     Continuing seizures for some
     Humanitarian grounds: Psychosurgery always
      produces permanent brain damage
Biology-Based Treatment (cont’d)
 Psychopharmacology: Study of the effects of
  drugs on the mind and on behavior
     Advantages (reducing institutionalization) and
      disadvantages (e.g., addiction and abuse;
      gender bias, side effects)
     Four major categories:
          Antianxiety (minor tranquilizers)
          Antipsychotic (major tranquilizers)
          Antidepressant (MAOIs, tricyclics, SSRIs)
          Antimanic (lithium)
Table 17.1: Drugs Most Commonly Used in Drug Therapy
Barbiturates
 Barbiturates: highly addictive sedatives that have a
  calming effect and were used before the 1950s.
      Result in tolerance
      Overdose can be deadly
      Withdrawal occurs with abrupt discontinuance
      Even appropriate doses can cause muscular
       incoordination and mental confusion
      Were replaced by
Antianxiety Drugs (minor
tranquilizers)
 During the 1940s and 50s, the propanediols
  and benzodiazepines became preferred
 Can be addictive and can cause withdrawal
  symptoms, but are safer than the barbiturates
 Must be carefully monitored to prevent
  overuse and overreliance
Antipsychotic Drugs (Major
Tranquilizers)
 Thorazine was developed as a sedative in the 1950 and had the
  side effect of reducing psychotic symptoms.
 Drugs such as Thorazine, Stelazine, Prolixin and others
  increase social interaction and self-management, and decrease
  agitation for psychotic patients.
    Do not always reduce anxiety
    May lead to psychomotor symptoms (including tardive
      dyskinesia), sensitivity to light, dry mouth, drowsiness or liver
      disease.
    Do not lead to social recovery and patients must keep taking
      them to prevent resurgence of symptoms
Antidepressant Drugs
 Discovered accidentally in the 1950s.
    Iponiazid (antitubercolosis medication) made people happier
     and more optimistic
 Three classes of antidepressants
    MAOIs: Monoamineoxiydase Inhibitors – work by inhibiting
     monoamineoxydase (an enzyme that breaks down
     dopamine, norepinephrine and serotonin). Short-acting but
     can produce toxic effects.
    Tricyclics: work like MAOIs but with fewer side effects
    SSRIs: work by inhibiting reuptake of serotonin (Prozac,
     Zoloft). Fewer side effects and less likely to lead to
     overdose than tricyclics. Associated with jitteriness and
     stomach irritation.
Antimanic Drugs
 Lithium: mood-controlling (anti-manic) drug that controls about
    70-80% of bipolar disorders
   Little is known about how it works.
   May limit availability of serotonin and norepinephrine…
    however, it also decreases depression, which is inconsistent
    with this effect
   Lithium is administered as a salt and appears to have no known
    physiological function.
   Lithium is largely preventive and must be taken before
    symptoms begin.
   It is extremely difficult to determine an effective yet non-toxic
    dose.
Biology-Based Treatment (cont’d)
 Psychopharmacological considerations:
    Which medication to use with which kind of patient
     under which circumstances
    Increases effectiveness of other types of treatment
    Medications reduce active symptoms and
     hospitalizations, but do not cure mental disorders
    Women receive twice as many anti-anxiety
     prescriptions, and 73% of all psychiatric prescriptions,
     although they make up half of all clients seen by
     psychiatrists.
    Not effective with passive symptoms and do not
     improve living skills
    Lack of compliance is a problem
Psychotherapy
 Psychotherapy: Systematic application, by a
  professional therapist, of techniques derived
  from psychological principles, for the purpose
  of helping psychologically troubled people
 Common therapeutic factors:
     Development of a therapeutic alliance
     Opportunity for catharsis
     Acquisition and practice of new behaviors
     Clients’ positive expectancies
Psychotherapy (cont’d)
 Korchin’s characteristics of psychotherapy:
     A chance for the client to relearn
     Help generating the development of new,
      emotionally important experiences
     Therapeutic relationship
     Clients in psychotherapy have certain
      motivations and expectations
Psychotherapy’s Goals:
    Change maladaptive behavior
    Minimize or eliminate environmental
     conditions that may be causing or maintaining
     such behavior
    Improveinterpersonal (and other) skills
    Resolve disabling conflicts among motives
    Modify dysfunctional beliefs
    Reduce or remove distress
    Foster a clear sense of identity
Why do people seek therapy?
 Sudden and highly stressful situations
 Referred by a physician for “physical” symptoms
 Referred by a spouse or attorney
 Chronic unhappiness and an inability to feel confident
  and secure
 Vague dissatisfaction with self/life
 Intolerable mental states
Psychodynamic Therapies
 2 basic forms:
     Classical psychoanalysis
     Psychoanalytically oriented therapy
 Five basic techniques:
     Free association
     Dream analysis
     Analysis of resistance
     Analysis of transference
     Interpretation
Insight-Oriented Approaches to
Individual Psychotherapy
 Psychoanalysis: Freud: People are born with
  instinctual drives that constantly seek to
  discharge/express themselves
     As personality structure develops, conflicts
      occur among the id, ego, and superego
     Unresolved conflicts resurface in adulthood
     Psychoanalysis seeks to overcome defenses
      (repressed unacceptable thoughts/impulses)
Insight-Oriented Approaches to Individual
Psychotherapy (cont’d) Psychodynamic Therapy since
Freud
 Interpersonal Therapy
      Harry Stack Sullivan
      Examine all of a client’s relationships
      We are likely to react in stereotypical ways
       with others, reflecting early learning
       experiences
 Object Relations Therapy
      Focus is on interactions with (real and
       imagined) other people
Insight-Oriented Approaches to
Individual Psychotherapy (cont’d)
 Modern psychodynamic therapy          (cont’d):
     Therapists are more active in the sessions,
      restrict the number of sessions with a client,
      put more emphasis on current than past
      factors, and use client-centered techniques
Insight-Oriented Approaches to
Individual Psychotherapy (cont’d)
 Effectiveness of psychoanalysis:
     Criticisms:
          Limited selection of clients (young, white, highly
           educated)
          Difficulty with operational definitions (e.g.,
           unconscious, libido) makes it difficult to test the
           theory
          Symptom substitution
Humanistic-Existential Therapies
 See psychological problems as stemming from
    alienation, depersonalization, loneliness, lack of
    meaning and unfulfillment.
   Stress freedom of choice and personal responsibility,
    as well as expanding the client’s awareness
   Client (person)-centered therapy
   Existential therapy
   Gestalt therapy
Insight-Oriented Approaches to
Individual Psychotherapy (cont’d)
 Existential analysis: One’s experience/
  involvement in the world as a consciousness/
  self-consciousness being
     The inability to accept death/nonbeing restricts
      self-actualization
     Existential crisis
     Philosophical and difficult to test
Insight-Oriented Approaches to
Individual Psychotherapy (cont’d)
 Gestalt therapy: Person’s total experience is
  important and should not be fragmented or
  separated
     Here and now
     Dream analysis
     Statements to act out emotions, exaggerate
      feelings to gain greater awareness, role-play
Table 17.2: A Systematic Desensitization Fear Hierarchy
for a Client with a Fear of Flying
Action-Oriented (Behavioral) Approaches
to Individual Psychotherapy
 Classical conditioning techniques:
     Systematic desensitization is used for anxiety.
          Relaxation, fear hierarchy, and combination of
           relaxation and imagined scenes from fear
           hierarchy
     Flooding and implosion to extinguish fear:
          Client is placed in real-life anxiety-provoking
           situation at full intensity (flooding)
          Client imagines the anxiety-provoking situation at
           full intensity (implosion)
Action-Oriented (Behavioral) Approaches
to Individual Psychotherapy (cont’d)
 Classical conditioning techniques:
     Aversive conditioning pairs undesirable
      behavior with an unpleasant stimulus to
      suppress the undesirable behavior.
Action-Oriented (Behavioral)
Approaches to Individual
Psychotherapy (cont’d)
 Operant conditioning techniques:
     Token economy: Treatment program that
      rewards patients with tokens for appropriate
      behaviors; tokens may be exchanged for such
      things as hospital privileges, food, etc.
     Punishment: Used to treat children with autism
      and schizophrenia when less drastic methods
      don’t work
     Observational learning techniques (modeling):
      Acquisition of new behaviors by watching
      them being performed
Action-Oriented (Behavioral) Approaches
to Individual Psychotherapy (cont’d)
 Cognitive-behavioral therapy: Based on the belief
  that psychopathology stems from irrational, faulty,
  negative, and distorted thinking or self-statements
      Common elements: Cognitive restructuring, skills
       training, problem solving
 No exclusive set of techniques exists
 Therapy often includes “experiments” which involve
  changing thoughts and behaviors and evaluating
  results.
      Rational-emotive therapy (RET)/Albert Ellis
      Cognitive triad (Aaron Beck)
      Stress inoculation therapy
Rational Emotive Behavior
Therapy
 Albert Ellis (beginning in 1958)
 Attempts to change a client’s maladaptive thought
  process, which determine emotions and behavior
 Unrealistic beliefs and perfectionistic values cause
  people to behavior irrationally and undervalue
  themselves
 Task of therapy is to restructure the person’s belief
  system and self-evaluation.
Stress Inoculation Therapy
 Self-instructional training focused on altering self-
  statements an individual normally makes in stress-
  producing situations.
 Three stages:
      Explore beliefs and attitudes about problem situations
       (cognitive preparation)
      Learning and practicing adaptive self-statements (skill
       acquisition and rehearsal)
      Applying principles in actual situations (application and
       practice)
Beck’s Cognitive Therapies
 Psychological problems result from illogical thinking
  about self, world and future.
 Therapy consists of identifying connections between
  thoughts and emotions, and learning to challenge
  automatic thoughts.
 Therapy DOES NOT involve a debate about the
  client’s irrational beliefs, but rather, teaching the
  client to identify and test false beliefs.
Action-Oriented Approaches to
Individual Psychotherapy (cont’d)
 Health psychology: Integration of behavioral
  and biomedical sciences acknowledging that
  psychological factors are often related to the
  cause and treatment of physical illnesses
     Biofeedback: Patient receives information
      (feedback) regarding autonomic functions and
      is rewarded for influencing those functions in a
      desired direction
     Type-A behavior (Meyer Friedman)
Evaluating Individual
Psychotherapy
 Hans Eysenck: There is no evidence that
  psychotherapy facilitates recovery.
      100s of studies prove that Eysenck was wrong; the
       more psychotherapy people receive, the more they
       improve and the fewer symptoms they report.
 Persons: Contemporary outcome studies did not
  accurately represent psychotherapy, which is difficult
  to measure
 Efficacy studies: Brief, well-controlled, well-designed
  research investigations into the outcome of a
  treatment
Evaluating Individual
Psychotherapy (cont’d)
 Effectiveness studies: Examine the outcome
  of treatment as it is delivered in real life
     Effectiveness studies demonstrate greater
      patient improvement than efficacy studies and
      improvements across different kinds of
      therapies
Figure 17.1: Predictions of the Theoretical
Orientations of the Future
Evaluating Individual
Psychotherapy (cont’d)
 Meta-analysis and effect size:
   Meta-analyses analyze a large number of
    different studies at one time by looking at
    effect size, or treatment-produced change
   Meta-analyses support a conclusion that
    psychotherapy is effective
 Meta-analyses:
   Empirically supported treatments (ESTs):
    Clearly specified psychological treatments
    shown to be efficacious in controlled research
    with a delineated population
Figure 17.2: Effect Sizes for
Psychotherapy, Placebo, and No-
Treatment Groups
Group, Family, and Couples
Therapy
 Simultaneous treatment of 2 or more clients and may
  involve more than one therapist
 Members may be related or may be strangers, but
  they share various characteristics
      Therapists can provide more mental health service to
       the community
      The cost to each person is reduced
      Many psychological difficulties involve relationships
       with others and are best treated in a group rather than
       individually
Group, Family, and Couples
Therapy (cont’d)
 Features of successful groups:
    Clients are involved in social situations and
     see how their behavior affects others
    Therapist see how clients respond in real-life
     social and interpersonal contexts
    Clients develop communication skills, social
     skills, and insights
    Less isolated and fearful about problems
    Groups can provide members with social/
     emotional support
Group, Family, and Couples
Therapy (cont’d)
 Disadvantages of group therapy:
   Little attention to individual problems
   Clients may not want to share problems with a
    group
   Loss of intimacy with therapist
   Group pressures may be too strong or group
    values too deviant
   Leaderless groups may not be able to
    recognize or treat people with psychotic or
    suicidal impulses
Group, Family, and Couples
Therapy (cont’d)
 Family therapy: Group therapy that seeks to modify
  relationships within a family to achieve harmony
 Based on three assumptions:
    It is logical and economical to treat people together who
      exist and operate in a system of relationships
    The problems of the “identified patient” are only symptoms;
      the family itself is the client.
    The task of the therapist is to modify relationships within the
      family system.
 Two Aprroaches:
    Communications approach: Assumes that family problems
      arise from communication difficulties
    Systems approach: Emphasizes the interlocking roles of
      family members, assuming it is the family system that
      contributes to pathological behavior in the family
Group, Family, and Couples
Therapy (cont’d)
 Family therapy:
     Couples therapy: Treatment aimed at helping
      couples understand and clarify their
      communications, role relationships, unfulfilled
      needs, and unrealistic/unmet expectations
Systematic Integration and
Eclecticism
 Therapeutic eclecticism: The “process of
  selecting concept, methods, and strategies
  from a variety of current theories which work”
     Integrative approach: No one theory/approach
      is sufficient to explain and treat the complex
      human organism
     Goal: Integrate the therapies that work best
      with specific clients who show specific
      problems under specific conditions
Culturally Diverse Populations and
Psychotherapy
 Western psychology and mental health concepts are
  based on an assumption that they are universal and
  the human condition is governed by universal
  principles.
 Surgeon General’s Report on Mental Health:
      It is dangerous to use European American standards to
       judge normality and abnormality and may result in
       denying appropriate treatment to minority groups.
Culturally Diverse Populations and
Psychotherapy (cont’d)
 African Americans:
     Prevalence of mental disorders is higher than
      that of the general population
     Underrepresented in privately financed care,
      overrepresented in public care
     Poverty rate is 3 times that of whites
     Many barriers to effective treatment: Historical
      hostility, therapists’ bias and lack of
      knowledge of African American cultural
      values
Culturally Diverse Populations and
Psychotherapy (cont’d)
 Asian Americans/Pacific Islanders:
    Underutilize mental health facilities possibly because of
     low rates of mental disorders, discriminatory mental
     health practices, and/or cultural values
    Many problems are hidden but there are problems
     associated with past traumas and current resettlement
     problems and racism
    High levels of PTSD and depression
    Barriers to effective therapy: Process and goals of
     therapy may be antagonistic to cultural values
Culturally Diverse Populations and
Psychotherapy (cont’d)
 Latino/Hispanic Americans:
     Value family unity and loyalty to entire
      “extended” family
     Subject to poverty and prejudice
     Therapists need to understand the
      psychosocial, economic, and political needs of
      Hispanic clients and should be bilingual/
      bicultural.
     Understand issues of patriarchal system
Culturally Diverse Populations and
Psychotherapy (cont’d)
 Native Americans:
   Heterogeneous group: 550 tribes
   High poverty, high rates of death among
    children, less education, high unemployment
   Value cooperation rather than independence,
    present rather than future, harmony with
    nature
   High rates of suicide and substance abuse
   U.S. oppression has caused disrupted
    families, poverty, prejudice, and discrimination
Community Psychology
 Community psychology:
     Takes into account the influence of
      environmental factors
     Encourages the use of community resources
      and agencies to eliminate conditions that
      produce psychological problems
     Promotes well-being and prevention of mental
      disturbance
Figure 17.3: Use of Mental Health Services
Among Individuals with Mental or
Addictive Disorders
   Community Psychology (cont’d)
 Managed health care: Changes are needed in the
  mental health system to make services accessible,
  available, and affordable
      HMOs: Turn to managed-care companies to
       administer benefit plans
      Emphasize short-term treatment
      Use of MAs and MSs instead of MDs, PhDs, and
       PsyDs
      Emphasize accountability and quality assurance
Community Psychology (cont’d)
 Concerns about managed care:
     Quality/extent of services sacrificed for cost
     APA endorses training clinical psychologists to
      prescribe medications
     “Manualized” treatment
     Computer-generated psychotherapy
Community Psychology (cont’d)
 Prevention of psychopathology:
     Primary prevention: Effort to lower the
      incidence of new cases of behavioral
      disorders by strengthening or adding to
      resources that promote mental health and
      eliminating community characteristics that
      threaten mental health
Community Psychology (cont’d)
 Prevention of psychopathology:
     Secondary prevention: Attempt to shorten the
      duration of mental disorders and reduce their
      impact
     Tertiary prevention: Facilitates the
      readjustment of individuals to community life
      after hospital treatment for mental disorders

				
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