this class… treatment. care as a social issue what to do with the severely disturbed? throughout...
TRANSCRIPT
This class…
Treatment
Care as a Social Issue
What to do with the Severely Disturbed?
throughout history, people with mental disorders were often considered evil or otherwise degenerate and were treated accordingly
Attempts at Reform: In and Out of Asylums
Movement from religious (demonic possession) towards secular (degenerates)
at the beginning of the 19th Century, humanitarian reform of mental institutions really began
Attempts at Reform: In and Out of Asylums
at the beginning of the 19th Century, humanitarian reform of mental institutions really began Philippe Pinel's treatment of people in
mental hospitals, different from anything tried before, had huge effects on their mental health
Attempts at Reform: In and Out of Asylums
Dorothea Dix campaigned profusely as a leader of the moral-treatment movement in the US
Unfortunately, funding seldom held up for long
Titicut Follies
Attempts at Reform: In and Out of Asylums
In the absence of long-term good institutions, the deinstituionalization movement began This was also partly inspired by the
development of effective drug treatments for some disorders
In the early 70s, transition homes started cropping up
Attempts at Reform: In and Out of Asylums
This wasn't necessarily working out too well, either--just because you're out of the hospital doesn't necessarily mean you're cured
Hospital "Treatment" from a Patient's-Eye View: Rosenhan's
Study
Rosenhan and some of his collaborators went into hospital emergency rooms, complaining of hearing voices saying "empty, hollow, thud"
They were honest in every other respect, acted normally while in hospital, and when asked about the voices, claimed not to hear them anymore
Hospital "Treatment" from a Patient's-Eye View: Rosenhan's
Study
Other patients often detected them as imposters, but hospital staff never did, and sometimes even interpreted their normal behaviours in the context of a disorder
Hospital "Treatment" from a Patient's-Eye View: Rosenhan's
Study
Their average time with psychiatrists and psychologists, including group meetings, was less than 7 minutes per day
They noticed that staff tended not to take patients seriously as thinking individuals
Bright Spots social-learning wards have developed residents (not "patients") here tend to:
be treated with respect interact closely with staff receive and accept responsibilities take part in decision-making engage in a lot of skill learning activities
Bright Spots there's evidence of a high level of
success in these programmes there are also some community-
based programmes out there now which reduce the need for hospitalization
Structure of the Mental Health System
Places of Treatment mental hospitals - provide
custodial care for people who can't care for themselves or be cared for by family members at home
general hospitals - often used for patients whose stay will be short
Places of Treatment nursing homes - usually for older
patients; these usually don't employ specialized personnel for treating people with mental disorders
Places of Treatment halfway houses - people go to
these during transition from hospital back into the community; they often provide help in finding employment as well as a more homey-type experience
Places of Treatment private office - run-of-the-mill
psychologist visits; outpatient care community mental health centres -
cheaper versions of outpatient care
Providers of Treatment psychiatrists clinical psychologists counseling psychologists counselors psychiatric social workers psychiatric nurses
Recipients of Treatment the number of people who’ve
received treatment for mental disorders is much smaller (approx 1/4) than the number who’ve had a mental disorder
this is particularly the case for men the number's a little better for
college graduates, white people, and people with incomes over $35,000
Clinical Assessment Assessment: the process by which
a mental health professional gather and compiles information about a patient or client for the purposes of developing a plan of treatment
Diagnosis: the classifying and labeling of a disorder according to some standard set of guidelines
Assessment Interviews and Objective Questionnaires
assessment interview: basically a dialogue through which the clinician tries to learn about the client; by far, this is the most common assessment procedure
these range from quite structured to rather unstructured
Verbal and non-verbal information
Assessment Interviews and Objective Questionnaires
objective questionnaire: these vary widely in what they ask; some are multiple choice or checklists
in some ways they can be considered less biased than an assessment interview, but they require a client who is literate, reflective, and motivated to answer honestly
A Psychometric Personality Test:
the MMPI
true-false questions that have been tested on inpatient and "normal" samples to determine what question distinguish between the two groups
This inventory also contains validity scales to help pick out people who may be trying to cover a disorder or maybe even trying to fake one
Projective Tests Projective tests: designed to provide
clues about the unconscious mind Free association: Freudian technique
that many projective tests stem from--he'd often have his patients clear their heads, free their minds of "shoulds", and say the first thing, give the first image, that came to their minds in response to words that he'd say to them
Projective Tests Rorschach:
classic ink-blot test; people are shown symmetrical ink blots and are asked what they see
Projective Tests Thematic
Apperception Test: here, people see a picture and are asked to make up a story to go with the scene
Behavioural Monitoring this refers to any system for
counting or recording actual instances of desired or undesired behaviors
self-monitoring: this is behavioural monitoring when it's the client who's keeping count
Assessment of Brain Damage and Neuropsychological
Functioning
EEG - electroencephalogram - measures the pattern of electrical activity in the brain
CAT scan - computerized axial tomography - a series of x-rays are taken of the brain
Assessment of Brain Damage and Neuropsychological
Functioning
MRI - magnetic resonance imaging - pictures of brain sections are taken using electromagnetic radiation given off by specific molecules in the brain when the brain is subjected to a strong magnetic field
Assessment of Brain Damage and Neuropsychological
Functioning
PET scan - positron emission topography - measures the pattern of blood flow and rate of oxygen use across sections of the brain
There are also psychological tests, including things like perception and motor control, that can help identify brain damage
Biological Treatments
Drugs the right drug, matched with the
right person, can be pretty much a miracle worker, but there are potential problems with overuse (i.e., unwarranted prescription), dependency, and side effects
Antipsychotic Drugs most antipsychotics are aimed at
reducing dopamine a problem is that drugs often fail to
relieve negative symptoms, and in some cases make them worse
also, possible side effects include dizziness
Antipsychotic Drugs nausea dry mouth blurred vision constipation sexual impotence (in males) shaking difficulty in controlling voluntary
movements
Antipsychotic Drugs in long-term users, tardive
dyskinesia there have also been suggestions
that they might, in some people, reduce the chance of eventual full recovery possible rebound effect
Antipsychotic Drugs new drugs are constantly being
developed and tested in efforts to find something that'll work without the treatment being as bad as the disease
Antidepressant Drugs most are believed to work by
increasing the availability of monoamines, especially serotonin and norepinephrine
Good effectiveness in treating depression
Antidepressant Drugs there are, however (of course) side
effects, including: fatigue dry mouth blurred vision
Lithium for Bipolar Disorder
Mood Stabilizer: helps control both the manic and depressive phases of bipolar, especially mania
it's not really known how this drug works--most people believe it stabilizes either the level of or the sensitivity to monoamines
Lithium for Bipolar Disorder
side effects - serious dehydration, at high doses--an overdose of lithium can be lethal
Antianxiety Drugs there are various types of these;
barbiturates used to be common, but they've been replaced with safer drugs
drugs that are effective for GAD tend to not be very effective for phobias, OCD, or panic disorder
most antianxiety drugs augment GABA, which is an inhibitor
Antianxiety Drugs side effects (yes, more) include:
drowsiness decline in motor coordination increases in the effects of alcohol--it's
very dangerous to combine the two
Antianxiety Drugs just in case that wasn't enough,
these are also addictive; withdrawal symptoms include: sleeplessness shakiness anxiety headaches nausea
Other Biologically Based Treatments
non-drug biological therapies aren't used that much for mental disorders anymore--we're not big on drilling holes in people's heads or scooping out parts of their brains
biological therapies typically as last resorts
Electroconvulsive Shock Therapy
usually used only in cases of severe depression when psychotherapy and antidepressant drugs are unsuccessful
this has changed over the years - now the patients are given drugs that block nerve and muscle activity so it doesn't hurt and they don't get injured by convulsions
Electroconvulsive Shock Therapy
an electric current passed through the brain touches off a seizure that lasts about a minute; this is usually administered every 2-3 days for about 2 weeks
there's remission, sometimes permanent, and sometimes lasting several months, in about 70% of cases
Electroconvulsive Shock Therapy
why it works is not understood there are some temporary
disruptions in cognition, especially memory
Electroconvulsive Shock Therapy
movement from bilateral to unilateral (the right hemisphere) shock has resulted in a treatment that causes little apparent memory loss, but there's some controversy about whether it's as effective that way
Psychosurgery “I’d rather have a bottle in front of
me than a frontal lobotamy”
Psychosurgery
this refers to the surgical cutting or production of lesions in portions of the brain to relieve a mental disorder; typically (now) the destruction of a very small area of the brain
prefrontal lobotomy is probably the best-known, but these are generally not done anymore
Psychosurgery any sort of psychosurgery is rare and
tends to be a last-ditch effort to help someone for whom all other treatment efforts have failed and who is suffering and desperate, often suicidal
psychosurgery is sometimes successful in reducing symptoms of major depression and OCD
Varieties of Psychotherapy Psychotherapy: any formal,
theory-based, systematic treatment for mental problems or disorders that uses psychological rather than physiological means and is conducted by a trained therapist
Varieties of Psychotherapy there are many different forms,
most of which fit (to a greater or lesser extent), into one of several categories we'll discuss in this section
most psychotherapists are eclectic in orientation
Psychoanalysis and Other Psychodynamic Therapies
Psychoanalysis: Freud's term for both his theory of personality and his approach to psychotherapy
Psychodynamic therapy: any therapy approach that's based on the premise that psychological problems are manifestations of inner mental conflicts and that conscious awareness of those conflicts is a key to recovery
Unconscious Wishes and Repressed Memories
emotional disorders as arising from an interaction between a predisposing experience and precipitating experiences a predisposing experience, in Freud's
theory, would typically relate to infantile sexual wishes and conflicts; this would occur in the first 5-6 years of life
Unconscious Wishes and Repressed Memories
precipitating experiences occur later and tend to immediately bring on the emotional breakdown; typically, they're things that activate repressed memories
Routes to the Unconcious: Free Associations, Dreams, and
Mistakes
remember Freud's psychoanalysis--analysis of speech and behaviour for clues to the unconscious
free association dreams
Routes to the Unconcious: Free Associations, Dreams, and
Mistakes
Freudian symbols king and queen as parents prince or princess as the dreamer elongated objects and long, sharp
weapons as "the male organ" empty spaces, rooms, vessels of all
kinds as the uterus slips of the tongue
Roles of Resistance and Transference in Psychoanalysis
resistance may take the form of refusing to talk about certain topics, "forgetting" to come to therapy sessions, arguing incessantly in a way that diverts the therapeutic process
this is a clue that therapy is going in the right direction
Roles of Resistance and Transference in Psychoanalysis
transference is the phenomenon by which the patient's unconscious feelings about a significant person in his or her life are experienced consciously as a feeling about the therapist
Relationship Between Insight and Cure
the patient must see, acknowledge, and accept insights in order to be freed of defenses
once this happens, the person's feelings can be expressed or channeled into healthier pursuits
Post-Freudian Psychodynamic Psychotherapies
many psychodynamic therapies are designed to get to unconscious material quicker and to thus take fewer sessions often 10-40 sessions as opposed to the
hundreds of sessions Freud's patients would attend
there's often less focus on early childhood and repressed memories
Non-Freudian Psychodynamic Therapies
in many cases, this refers to a shift of focus from the conflicts Freud thought were important (like sex) to other potential conflicts
Humanistic Therapy unlike Freud, humanistic therapists
generally share the belief that people are basically good and that our inner desires are generally positive things that we need the freedom to express and to try to achieve
Rogers's Client-Centred Therapy
this sort of thing focuses on the thoughts, abilities, and innate potential of the client rather than those of the therapist
the therapist often acts more as a sounding-board
Rogers's Client-Centred Therapy
from Rogers's perspective, psychological problems originate when people learn from their parents or other authorities to deny their own feelings and to distrust their own ability to make decisions
incongruence
Rogers's Client-Centred Therapy
in order to be an effective therapist, you need: empathy: the therapist's attempt to
comprehend what the client is saying or feeling at any given moment from the client's point of view rather than as an outside observer
Rogers's Client-Centred Therapy
unconditional positive regard: a belief on the therapist's part that the client is worthy and capable even when the client may not feel or act that way
Rogers's Client-Centred Therapy
unconditional positive regard: a belief on the therapist's part that the client is worthy and capable even when the client may not feel or act that way
genuineness: this reflects the belief that it's impossible to fake empathy and positive regard, so the therapist must really feel them
Cognitive Therapy this is the therapeutic perspective that
begins with the assumption that people disturb themselves through their own thoughts - the goal is to identify maladaptive ways of thinking and replace them with adaptive ways that provide a base for more effective coping with the real world
the focus tends to be on the problem at hand
Ellis's Rational-Emotive Therapy
RET has the basic premise that negative emotions arise from people's irrational interpretations of their experiences rather than from the objective experiences themselves
Ellis's Rational-Emotive Therapy
Musturbation: the irrational belief that one must have some particular thing or must act in some particular way in order to be happy or worthwhile
Awfulizing: the mental exaggeration of setbacks or inconveniences
Ellis's Rational-Emotive Therapy
Ellis saw the generation of problems as generally a 3-part process:
activating event belief consequent emotion his job was to show people that A
doesn't directly cause C--by seeing and acknowledging B, clients had the opportunity to change it, thus changing C
Beck's Cognitive Therapy Beck found that depressed clients
tended to minimize positive experiences, maximize negative experiences, and misattribute negative experiences to their own deficiencies when they weren't really at fault
Beck's Cognitive Therapy Beck's therapy differs from Ellis's
in that it involves trying to lead people to discover and correct their own irrational thoughts instead of just pointing out to them that they're being irrational
Behaviour Therapy this type of therapy focuses less on
mental phenomena and more on direct relationships between observable aspects of the environment and observable behaviors
Behaviour Therapy sometimes is blended with cognitive
therapy to have a joint focus (thus the term "cognitive-behavioural therapy")
like cognitive therapy, this is very problem-centred--you work on the immediate problems with the assumption that what has been learned can be unlearned
Exposure Treatments to Eliminate Unwanted Fears
this is based on the idea of habituation; it basically aims at extinguishing a response, like with classical conditioning
systematic desensitization involves gradual, escalating, imagined exposure to the feared object or event, combined with relaxation techniques
Exposure Treatments to Eliminate Unwanted Fears
flooding involves exposing a person (in large amounts) to the stimulus and the fear until the fear declines and disappears
there are techniques in between that involve controlled exposure
Aversion Treatment to Eliminate Bad Habits
Habit: a learned action that has become so ingrained that the person performs it unconsciously and may even feel compelled to perform it
Aversion Treatment to Eliminate Bad Habits
Aversion treatment: application of an aversive stimulus immediately after the person has made the unwanted habitual response or immediately after the person has experienced cues that would normally elicit the response--basically, you're changing the reinforcement contingencies
Aversion Treatment to Eliminate Bad Habits
there are some ethical problems with this treatment, and it also has mixed results in terms of effectiveness, so it's pretty controversial
Treatment of sexual deviance Clockwork Orange
Some Other Behavioural Techniques
Token economies--direct rewards for "good" behaviour in institutions
Contingency contracts--contracts clearly spelling out a behavioural agreement between two people
Some Other Behavioural Techniques
Assertiveness and social skills training Assertiveness: the ability to express
one's own desires and feelings and to maintain one's rights in interactions with others, while at the same time respecting the others' rights
Can involve multiple techniques, including role-playing
Some Other Behavioural Techniques
Modeling: teaching people to do something by having them watch someone else do it
Therapies Involving More Than One Client
Group Therapies this has the advantages of being
less costly in therapist's time and of the therapeutic benefits of interactions among group members
pretty much any kind of therapy that's out there is also out there in group format
Social Nature of Man “We are not only gregarious animals liking
to be in sight of our fellows, but we have an innate propensity to get ourselves noticed, and noticed favorably, by our kind. No more fiendish punishment could be devised, were such a thing physically possible, than that one should be turned loose in society and remain absolutely unnoticed by all the members thereof”. William James
Yalom’s Therapeutic Factors
Instillation of hope Universality (inadequacy, inability
to love, sexual secrets) Imparting information Altruism Corrective recapitulation of family Socialization
Yalom’s Therapeutic Factors
Imitative behaviour Interpersonal learning (social
microcosm) Group cohesiveness Catharsis Existential factors
Couple and Family Therapies
by observing interactions between or among the couple or family members, the therapist can gain insights about their habitual ways of relating to one another
interactions may also be videotapes so they can observe themselves from each other's perspective
Couple and Family Therapies
the family systems perspective views each person's behavioural style and problems as in part an accommodation to the needs of the family as a whole
an intergenerational approach focuses on ways by which family members' behaviours may be affected by events in previous generations
Psychotherapy Research Does it work? Eysenck (1952) summarized results
of 24 outcome studies (1920-1950) Concluded that effects of
psychotherapy are “small or nonexistent”
Any positive effects attributable to spontaneous remission
Psychotherapy Research 72% of neurotic adults in no-therapy
group showed improvement within 2 years of onset
66% of patients receiving eclectic therapy showed substantial decrease
44% of patients in psychoanalytic therapy
Psychotherapy Research Smith, Glass & Miller (1980) Meta-analysis of 475 studies Mean effect size of .85 Similar results from numerous
other studies
Consumer Reports Survey (1995) 4,100 respondents 90% who felt “very poorly” at
beginning of therapy said therapy “helped somewhat” or “helped a lot”.
Long-term treatment (> 6 months) better than short term therapy
No particular therapeutic modality is better than others
Consumer Reports Survey (1995)
Psychologists, psychiatrists, social workers are about equally effective and more effective than marriage counselors and family doctors
Patients whose treatment was limited by insurance/managed care reported fewer gains
Psychotherapy with children & adolescents
1. The average treated child is better off than 70-75% of those with similar problems who do not receive treatment
2. Behavioral techniques generally produce greater effects than non-behavioral techniques, regardless of type of problem, therapist training, or child age/gender
Psychotherapy with children & adolescents
Therapy is equally effective for undercontrolled and overcontrolled problems
Therapy outcome is better for adolescents (especially girls) than for children
Client Factors Intelligence: higher IQ predicts
better therapy outcome Disturbance: more seriously
disturbed have poorer outcomes Clients suffering from depression or
anxiety, especially during initial therapy sessions, tend to improve most
Client Factors Participation: Greater client
participation in therapy = more positive effects
Age: unrelated to therapy outcome Gender: Women more likely to
seek therapy, but no consistent relationship between gender and therapy outcome
Client Factors Sexual Orientation: Gays and
lesbians more likely to seek therapy than heterosexuals
Stay in therapy longer Express more positive attitudes
towards seeking therapy
Therapist Factors Experience: Some evidence that
greater therapist experience related to lower dropout rates and better outcomes
Competence: more important than specific treatment modality
Client-Therapist Factors Therapeutic Alliance Attraction Expectations Similarity
Treatment Factors Duration of Treatment: longer
associated with better outcome to a point
Ceiling effect at 26 sessions 75% show measurable
improvement at 26 sessions Only increases to 90% at 104
sessions
Treatment Factors Drop Out: 23% of clients drop out
of therapy after first session Almost 70% drop out by 10th
session Median length of treatment is only
six sessions low-SES clients most likely to
terminate prematurely
Treatment Factors Other factors associated with drop
out: Lack of anxiety (egosyntonic
symptoms?) Low levels of psychological
mindedness/insight High need for approval Minority group membership
Treatment Factors Placebo effects Impact on medical utilization Eclecticism
Psychiatric Hospitalization• Gender: men more likely to be
hospitalized than women• Marital Status: for both men and
women, admission rates are lowest among the widowed, intermediate for those who are married or divorced/separated, and highest for never married
Psychiatric Hospitalization• Age: For males and females,
largest proportion of admissions are in 25-44 range
• For patients over 65, organic disorder is most common diagnosis, followed by a mood disorder
Final Exam
Personality States vs. traits Cattell, Eysenck, Big Five Evolutionary implications/theory Sibling differences Psychodynamic theory of personality Freud’s defense mechanisms Rotter - locus of control Bandura - self-efficacy
Mental Disorders How do various theories explain
cause/etiology of mental disorders? Anorexia Anxiety Disorders
Phobia GAD OCD Panic Disorder
Mental Disorders Mood Disorders
Depression Bipolar Disorder Beck & Seligman’s theories
Schizophrenia symptoms (positive, negative, types) types of schizophrenia culture
Mental Disorders Somatoform disorder Dissociative Identity Disorder
Mental Disorders Assessment/Treatment methods of assessment Which drugs for which disorders tenets of psychodynamic therapy (Freud) tenets of humanistic/client-centred
therapy (Rogers) tenets of cognitive therapy (Ellis & Beck)