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Therapeutic Interventions

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					Therapeutic Interventions
                    Therapy


There are two types of therapies for the
 treatment of psychological disorders.
  Some feel as though many psychological
    illnesses are learned and may therefore
    advocate more psychological therapies in an
    attempt to get patients to ―unlearn‖ certain
    behaviors.
  Some feel as though psychological illnesses
    are biologically rooted and may therefore
    implement more medical treatment.
          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,
 bleeding and purging)
Modern techniques:
  Electroconvulsive therapy
  Psychosurgery
  Psychopharmacology
Biology-Based Treatment


 Electroconvulsive Therapy
  (ECT): The application of
  electric voltage to the brain
  to induce convulsions
   Effective for severe
      depression, especially
      those with internal
      (endogenous) etiology
   First therapeutic use of
      shock: Insulin shock
      treatment; later metrazol
      injections—these were
      not terribly effective
             Biology-Based Treatment


 Electroconvulsive therapy (ECT): Use declined in
  1960’s-1970’s:
   Concerns about permanent brain damage
   Fracture/dislocation of bones
   Beneficial effects but none long-term
   Abuses and side effects
     Loss of memory
   Advances in medication diminished the need for
    ECT
             Biology-Based Treatment


 Psychosurgery: Brain surgery performed to correct
  severe mental disorders.
   Prefrontal lobotomy
   Transorbital lobotomy
   Lobectomy
   Cauterization
   Severing of Corpus callosum
           Biology-Based Treatment

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


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
           Biology Based Treatment



 How Prozac
  reduces
  depression
           Biology-Based Treatment

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.
 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


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
 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)
    Freud believed the patients’ free-associations, resistances, dreams, and
     transferences- and the therapists interpretations of them- released
     previously repressed feelings, allowing the patient to gain self-insight.
   Most appropriate for people that are verbal and intelligent.
  Insight-Oriented Approaches to Individual
                Psychotherapy

Resistance: The blocking from consciousness
 of anxiety-laden material.
Interpretation: The analyst’s noting supposed
 dream meanings, resistances, and other
 significant behaviors in order to promote insight.
Transference: The patient’s transfer to the
 analyst of emotions linked with other
 relationships (such as love or hatred for a
 parent).
Dream Analysis
    Insight-Oriented Approaches to Individual
                 Psychotherapy

Modern psychodynamic therapy:
 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

Modern psychodynamic therapy:
 Ego Autonomy Theorists: Cognitive
  processes of the ego can be constructive,
  creative, and productive (independent from
  the id).
 Object Relations Theorists: Interpersonal
  relationships and the child’s separation from
  the mother are important to psychological
  growth.
    Insight-Oriented Approaches to Individual
                 Psychotherapy

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
    Insight-Oriented Approaches to Individual
                 Psychotherapy

Humanistic-Existential Therapies: Stress self-
 actualization, self-concept, free will, personal
 responsibility, and understanding the client’s
 phenomenological world
Person-Centered Therapy: In the therapeutic
 relationship the therapist should use:
  The client’s innate tendencies to grow,
   actively negotiate with environment, and
   realize potential
  Empathy, respect, and unconditional positive
   regard
    Insight-Oriented Approaches to Individual
                  Psychotherapy
                Humanistic Therapy
Humanistic therapists aim to boost self-
 fulfillment by helping people grow in self-
 awareness and self-acceptance.
Humanistic therapists tend to focus on:
  The present and future instead of the past.
  Conscious rather than unconscious thoughts.
  Taking responsibility for ones actions instead
    of seeking to place blame for them.
  Promoting growth instead of curing illness,
    those in therapy are ―clients‖ rather than
    patients.
    Insight-Oriented Approaches to Individual
                 Psychotherapy
               Humanistic Therapy

Client-Centered Therapy: A humanistic therapy
 developed by Carl Rogers in which the therapist
 uses techniques such as actively listening
 within a genuine, accepting, empathic
 environment to facilitate clients’ growth.
Active Listening: Empathic listening in which
 the listener echoes, restates, and clarifies.
    Insight-Oriented Approaches to Individual
                 Psychotherapy

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

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
    Action-Oriented 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 Approaches to Individual
             Psychotherapy
       Systematic Desensitization
    Action-Oriented Approaches to Individual
                 Psychotherapy

Classical conditioning
 techniques:
  Aversive Conditioning
   pairs undesirable
   behavior with an
   unpleasant stimulus to
   suppress the
   undesirable behavior.
Action-Oriented Approaches to Individual
             Psychotherapy

    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 Approaches to Individual
                   Psychotherapy

 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
   Rational-emotive therapy
      (RET)/Albert Ellis
        Attack on illogical beliefs
   Cognitive triad (Aaron Beck)
   Stress inoculation therapy
Action-Oriented Approaches to Individual
             Psychotherapy
           Cognitive Therapy
    Action-Oriented Approaches to Individual
                 Psychotherapy

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


Efficacy Studies: Brief, well-controlled, well-
 designed research investigations into the
 outcome of a treatment.
Effectiveness Studies: Examine the outcome of
 treatment as it is delivered in real life.
Figure 17.2: Effect Sizes for Psychotherapy,
    Placebo, and No-Treatment Groups
        Evaluating Individual Psychotherapy

 Client’s perceptions
   3 out of 4 patients report satisfaction with results of
     therapy.
   9 of 10 patients report feeling better after therapy
 Outcomes
   On average persons in treatment improve faster
     and have a better outcome than those not in
     treatment.
   Beware of regression to mean and placebo effect
 Best outcomes occur when treatments are combined –
  e.g. drug with talk therapy.
      Evaluating Individual Psychotherapy



Clinicians perceptions
 Clinicians have LOTS of success stories
 Clinicians often only hear from successful
   clients who express gratitude
 Unsuccessful therapy clients usually switch
   to other therapists.
      Evaluating Individual Psychotherapy


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.
Figure 17.1: Predictions of the Theoretical
        Orientations of the Future
       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


 Features of successful groups:
   Clients are involved in social situations and see
    how their behavior affects others.
   Therapists 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


 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

Family Therapy: Group therapy that seeks to
 modify relationships within a family to achieve
 harmony.
  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


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

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

 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

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
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

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


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


 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.
  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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