Chapter 17 - Therapy Reading Map

1
Chapter 17 - TherapyReading Map

• Monday, April 13- AP Exam 1 in-class (No
  pre-test copy)
• Tuesday, April 14- 659-669 Students have
  tonight to examine AP Exam 1
• Wednesday, April 15- 669-674
• Thursday, April 16- Parent/Teacher Conferences-
  No Class
• Friday, April 17- 2 Essays in-class (No advance
  notice) and peer marking with rubrics on the
  weekend.

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Chapter 17 - TherapyReading Map

• Monday, April 20- 674-685 (peer-marked essays
  due)
• Tuesday, April 21- 685-695
• Wednesday, April 22- Quiz/Cards/Study Guides

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Historical Perspective (659)

• Old Methods
• Holes in head
• Warm baths
• Bleeding
• Beating the devil out

• New Methods
• Philippe Pinel (France) and Dorothea Dix (USA)
  saw mental disorders as DISEASES and treatable in
  HOSPITALS

4
Two Main Perspectives (659)

• Psychological Therapies
• 2. Biomedical Therapies

5
The Psychological Therapies (660)

•  are built on 4 main theories     
• Psychoanalytic
• Humanistic
• Behavioral
• Cognitive
• Note - the Eclectic Approach - uses a blend of
  therapies

6
Psychoanalysis (660)

• Aims
• to bring repressed impulses and conflicts from
  childhood into consciousness where the patient
  can deal with them
• gets patient to release the energy they
  previously devoted to the Id-Ego-Superego
  conflicts

7
Psychoanalysis Methods (661)

• Free Association
• Resistance
• Dream Analysis
• Transference

8
Psychoanalysis Methods (661)Free Association

• the patient retells his past, moment by moment,
  as it occurs to him without editing or censoring.
• Therapist mainly just listens for what is being
  said and not said

9
Psychoanalysis Methods (661)Resistance

• the therapist listens for resistance - blocks in
  the free flow of the patients talking
• Resistance gives the therapist an opportunity to
  interpret what repressed ideas are causing the
  resistance. 

10
Psychoanalysis Methods (661)Dream Analysis

• used to uncover the latent (hidden) content of
  the patient's manifest (remembered) dreams. 
• The latent dream reveals repressed ideas.

11
Psychoanalysis Methods (661)Transference

• the patient will transfer strong feelings from
  his earlier relationships onto the therapist
• The patient blames the therapists - but this is
  a good step in the therapy
• this is another way for repressed ideas to be
  discovered

12
Current Psychodynamic Therapy (662)

• try to understand a patient's current symptoms by
  exploring childhood experiences.
• probe for repressed information
• face-to-face therapy has replaced the couch

13
Interpersonal Therapy (662)

• an alternative to psychodynamic therapy
• focuses on current relationships rather than
  childhood and assists people to improve their
  current relationship skills

14
Humanistic Therapies (663)

• emphasizes humans inherent potential for
  self-fulfillment
• aims to boost self-fulfillment by helping people
  grow in self-awareness and self-acceptance
•  Focuses on
• the present and future rather than the past
  (childhood)
• conscious rather than the unconscious
• taking responsibility for your feelings/actions
  rather than uncovering hidden reasons
• growth rather than curing illness

15
Humanistic Therapies (663)Carl Rogers
Client-Centered Therapy

• focus on client's conscious self perceptions
  rather than the therapist's interpretations
• non-directive therapy where the therapist
  refrains from directing the client towards
  certain insights
• therapist shows acceptance, genuineness and
  empathy to allow client to feel unconditionally
  accepted and deepening their self-understanding
  and self-acceptance
•  used active listening (echoing/restating/ 
  seeking clarification/acknowledging expressed
  feelings) to give client unconditional positive
  regard.

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Behavior Therapies (665)

• Unlike the psychoanalysts and humanists, the
  behavior therapists doubt the healing power of
  self-awareness.
• they assume that the problem behaviors ARE the
  problem
• they apply learning principles to eliminate
  unwanted behaviors (rather than look for the
  cause of the behavior)
• they replace maladaptive behavior with
  constructive behaviors

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Behavior Therapies (665)Classical Conditioning
Techniques

• assumes that we learn behavior and emotion and
  therefore we can "unlearn" behavior and emotion
• O.H. Mowrer - uses classical condition to cure
  bed wetters - a liquid sensitive pad sounds an
  alarm waking the child - the child learns to
  associate a relaxed bladder with waking up -

18
Behavior Therapies (665)Counter-Conditioning

• pair a trigger stimulus (ie small space) with a
  NEW response that is incompatible with fear (ie
  relaxation).  The relaxation then displaces the
  old response of fear to the stimulus.
• 2 Types of Counter-Conditioning
• 1.    Systematic Desensitization
• 2.    Aversive Conditioning

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Counter-ConditioningSystematic Desensitization
Therapies

• replace a fear response with a response that is
  incompatible with fear - the theory is that you
  cannot be relaxed and fearful at the same time -
  the relaxation will eventually displace the fear
• Mary Jones used a technique of having a child eat
  close to a rat that it feared - eventually the
  pleasure associated with the eating displaced the
  fear response to the rat

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Counter-ConditioningSystematic Desensitization
Therapies

• Joseph Wolpe used a method called Exposure
  Therapy - people are over-exposed to a fearful
  stimulus and eventually they become habituated to
  the stimulus
• Progressive Relaxation - you relax one muscle
  group at a time until you achieve a drowsy state
  of relaxation and comfort - then the therapist
  has you imagine a mildly anxiety-arousing
  situation - this imagined scene is paired with
  your state of relaxation until you no longer feel
  the anxiety.

21
Counter-ConditioningSystematic Desensitization
Therapies

• Anxiety Hierarchies - as you are in your relaxed
  state you imagine "worse" situations and then you
  eventually experience actual anxiety causing
  situation.
• Virtual-Reality Exposure Therapy - client wears
  goggles that give them a 3D image of what they
  fear (ie flying)

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Counter-ConditioningAversive Conditioning (667)

• the therapist tries to replace a positive
  response to a harmful stimulus (ie alcohol) with
  a negative/aversive response.  (The therapist
  will put a nausea drug in the alcohol)
• Note - for alcohol treatment only 33 of clients
  are still booze-free after 3 years using this
  method

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Counter-Conditioning

• Systematic Desensitization
• pair a stimulus (elevator) with a new response
  (relaxation) that is incompatible with
  anxiety                                           
                                                    
    

• Aversive Conditioning
• Replace a positive response to a harmful
  stimulus (alcohol) with a negative response
  (nausea)

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Behavior Therapies (668)Operant Conditioning

• voluntary behaviors are strongly influenced by
  consequences (reward and punishments)
• operant conditioning is used to deal with
  specific behaviors
• token economy - used in institutions - exchange
  tokens for concrete rewards

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Ideas

• The only normal people are the ones that you
  dont know very well. Alfred Adler
• Follow your heart but take your brain with you.
  Alfred Adler
• Except our own thoughts, there is nothing
  absolutely in our power. Rene Descartes

26
Critics of Behavior Modification (668)

• will the behavior stop when the reward stops?
• The behaviorists say that you can wean people off
  of the rewards and move towards more intrinsic
  rewards
• is it ethical to control another's behavior with
  reward/punishment?
• The behaviorists say that behavior will always be
  "controlled" so we may as well control it for the
  "good"

27
Cognitive Therapies (669)

•  behavior therapy is good for treating specific
  fears and behaviors.
• when the client's fear/anxiety is less clearly
  defined, cognitive therapy is useful
• assumes that our thinking colours our feelings
• aims to teach people new, more positive ways of
  thinking

28
Cognitive Therapy for Depression (670)

• reverse client's catastrophic beliefs
• teach clients to view life differently and
  discover their irrationalities  (Aaron Beck -
  therapist)
• depressed people don't exhibit the self-serving
  bias common in healthy people
• depressed people attribute their failures to
  themselves and their successes to external
  circumstances
• Adele Rabin (therapist) has clients record a
  day's positive events and their contribution to
  each event

29
Cognitive-Behavior Therapy (671)

• an integrated therapy that seeks to teach
  positive thinking and also alter behaviors
• ie - OCD patients are taught to re-label their
  compulsions.  Instead of hand washing they force
  themselves to take a walk and they acknowledge
  and label the hand washing as an irrational urge.

30
Stress Inoculation Training

• trains people to restructure your thinking in
  stressful situations
• self-talk - "relax - if the exam is hard it is
  hard for everyone.  You studied and will do
  well."
• you are trained to dispute your negative
  thoughts.

31
Groups and Family Therapy (672)

• saves time and money
• all but traditional psychoanalysis can be done in
  a group setting
• often used for family conflict
• group context allows people to discover that
  others share their problems
• allows people to try out new ways of behaving
• ex. AA 12 step program

32
Evaluating Psychotherapies (674)Clients
Perspective

• 3 out of 4 are satisfied with the effectiveness
• However, the critics of psychotherapy say
• people enter therapy in crisis and then attribute
  normal improvement (that would have happened
  anyway) to therapy
• client's spend time/money on therapy therefore
  they "need" to believe that therapy is effective
• clients like their therapists so they find
  something positive about the therapy
• selective/biased recall by clients

33
Joan McCord Study

• 500 boys aged 5 to 13 headed for delinquency
• half were put into counseling and the control
  group was not. 
• 30 years later although the counseled group
  attributed their success to the counseling, there
  was not a statistically significant difference
  between the 2 groups - in fact - in second crime,
  alcoholic tendencies, death rate and job
  satisfaction, the control group actually had
  fewer problems

34
Evaluating PsychotherapiesClinicians
Perceptions (675)

• Clients over-estimate problems when entering
  therapy, over-emphasize their well being when
  leaving therapy and stay in touch only if
  satisfied
• therapists are more aware of other therapists'
  failures
• clients find a new therapist if their problems
  reoccur

35
Outcome Research (676)

• Hans Eysenck (1952) found that
• 2/3rds of people suffering non-psychotic
  disorders improved markedly after psychotherapy
• HOWEVER
• 2/3rds of untreated people with non-psychotic
  disorders also improved

36
Outcome Research

• Today meta-analysis (statistically combining the
  results of many different studies as if they had
  come from one huge study with thousands of
  participants) is finding
• the average therapy patient ends up better off
  than 80 of the untreated individuals
• depression is better improved with treatment
• psychotherapy is more effective than medical
  therapy
• therapy is most effective for clear-cut, specific
  problems (ie phobia)
• depression and anxiety therapy works in the short
  term but relapses frequently occur
• chronic schizophrenia is rarely helped by
  psychotherapy alone

37
Regression Toward the Mean (676)

• the tendency for unusual events or emotions to
  return to a more average state on their own

38
Placebo Effect (676)

• the belief in a treatment will cause the
  treatment to succeed
• therefore what ever we doing following a "low"
  will be perceived as an improvement - we are
  naturally regressing to the mean (back to normal)
  but in comparison to the low  - normal is an
  improvement
• SO, when we evaluate whether a therapy is
  effective we must ask whether the improvement
  that follows a therapy exceeds what we could
  expect from the placebo effect and the regression
  toward the mean effect.

39
The Relative Effectiveness of Different
Therapies   p. 678Mary Smith's meta-analysis
reveals
Disorder Best Therapy
Depression Cognitive, interpersonal and behavior
Anxiety Cognitive, exposure and stress inoculation
Bulimia Cognitive-behavioral
Bed Wetting Behavior modification
Phobia/OCD Behavioral conditioning
Sex Disorders Behavioral conditioning
40
Therapeutic Touch (680)

• popular alternate therapy
• hands move a few inches from your body and push
  energy fields into balance
• used for headaches to cancer
• Rosa (1998) - using 9 year old Emily doing
  research for a science fair - therapists could
  not tell whether they were close to Emily's hand
  more than 47 of the time (less than chance odds)

41
Eye Movement Desensitization and Reprocessing
(680)

• Francine Shapiro discovered that anxious thoughts
  vanished as her eyes spontaneously darted about. 
  She developed a technique where she treats
  anxiety patients by triggering eye movement as
  they recall traumatic memories.
• 40,000 health professionals now trained in this
  method
• critics say this is just exposure therapy in a
  safe context (in trials patients had the same
  results with and without the eye movement)

42
Light Exposure Therapy (681)

• Seasonal Affective Disorder - a form of
  wintertime depression
• treated with doses of intense light
• the light affects our circadian clock - morning
  light exposure decreases the hormone melatonin.
  In evening darkness increases melatonin.
• controlled trials show a difference in
  effectiveness between using morning light,
  evening light and placebo - morning light is best

43
Commonalities Among Psychotherapies (682)

• All therapies offer at least 3 benefits
• 1.    hope for demoralized people
• 2.    a new perspective on yourself and the world
• 3.    empathetic, trusting, caring relationships
• These 3 things are also offered by self-help
  groups, support groups, traditional healers,
  elders, etc.

44
Culture and Values in Psychotherapy (683)

• Clients often adopt their therapist's values.
• Do the patient's and therapist's religious
  beliefs affect the therapy?
•  Albert Ellis (1980) - a therapist that says "no
  one and nothing is supreme.  Self-gratification
  should be encouraged, unequivocal love,
  commitment, service and fidelity, especially
  marriage, leads to harmful consequences.
•  Bergin (1980) - says "because God is supreme,
  humility and the acceptance of divine authority
  are virtues.  Self-control and commitment, love
  and self-sacrifice are to be encouraged. 
  Infidelity to any personal commitment, especially
  marriage, leads to harmful consequences."

45
Cultural Differences

• North America, Europe, Australia - individualism
  is reflected by the therapists
• Asia - more collectivist
• Training in cultural sensitivity for therapists
  becomes important given the different types of
  societies.

46
The Biomedical Therapies (685)

• Drugs
• Electroconvulsive therapy
• Surgery

47
Biomedical TherapyDrug Therapy (685)

• most common biomedical therapy
• introduced in the 1950's
• reduced hospitalizations and surgeries
• Psychopharmacology - the study of drug effects on
  the mind and behavior
• Double Blind - is important technique to reduce
  placebo effect and the regression to the mean
  effect

48
Antipsychotic Drugs (686)

• accidental discovery that certain drugs used for
  other medical purposes calmed psychotic patients
• antipsychotic drugs mimic dopamine and occupy its
  receptor sites and block its activity
• Chlorpromazine (thorazine) - used with
  schizophrenic patients with positive symptoms
  (thought to be caused by too much dopamine)
• Note that thorazine can have the side effect of
  tremors/twitches similar to Parkinsons (which is
  caused by too little dopamine)
• Clozapine - used with schizophrenic patients with
  negative symptoms

49
Antianxiety Drugs (687)

• ex.  alcohol - valium  - xanax
• depress central nervous system activity
• help people cope with fear and anxiety
• dependency on drug and on withdrawal issues
• critics say the drugs reduce symptoms without
  resolving underlying problems

50
Antidepressant Drugs (687)

• increase norepinephrine and seratonin which
  elevate mood and arousal
• ex. Prozac partially blocks the reuptake of
  seratonin -
• Prozac takes about 4 weeks for relief of symptoms
  - why - increased seratonin promotes growth of
  new brain cells

51
Antidepressant Drugs

• drug therapy is often combined with cognitive
  therapy and exercise
• placebos that mimic the real drug's side effects
  are nearly as effective as the actual drug in
  double-blind trials
• Prozac does not result in an elevated rate of
  suicide although their are individual anecdotes
  of users of Prozac committing suicide
• Lithium - used for bipolar patients

52
Electroconvulsive Therapy (689)

• shock treatment - introduced in 1938
• electricity produces convulsions and brief
  unconsciousness
• used for severe depression that does not respond
  to drugs
• some memory loss is a side effect
• How does it work??????   We don't know!!!!!
• maybe it causes release of norepinephrine???
• maybe it calms brain area where over-activity
  would cause depression?????
• ECT treated patients often have relapses of
  depression
• http//www.youtube.com/watch?vzYl13Relzbs

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Some Gentler Alternatives

• Vagus Nerve stimulation - chest implant
  intermittently stimulates the vagus nerve which
  sends impulses to the limbic system. Video clip
  http//www.youtube.com/watch?vG7uu1dcc-qofeature
  related
• Repetitive Transcranial Magnetic Stimulation -
  magnetic coil held close to the skull above the
  right eye - energizes the left frontal lobe -
  produces no seizures or memory loss and shows 50
  improvement in trials of depressed patients

54
Psychosurgery (690)

• least commonly used
• 1930's - Egas Moniz developed the lobotomy (won
  the Nobel prize) - sever nerves connecting
  frontal lobe with the emotion-controlling centres
  of the inner brain
• used to calm uncontrollably emotional and violent
  patients
• hammer an ice-pick like instrument through each
  eye socket and wiggle it to sever connections to
  the frontal lobe
• lobotomies - effects - permanent lethargic,
  immature, impulsive personality
• today lobotomies are almost never performed
• today psychosurgery used for extreme seizures and
  excessive OCD patients

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Prevention (690)

• deal with poverty, work issues, racism, sexism to
  prevent psychological disorders
• keep our bodies healthy
• mind body connection