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Overview of Psychological Treatment - Coggle Diagram
Overview of Psychological Treatment
Overview
Conviction underlying psychotherapy: People with psychological problems can change
Why people seek therapy
Psychological disorders and stressful life circumstances
Reluctant clients: Court-ordered, physician
Personal growth
Who provides psychotherapeutic services
Mental health professionals
Clinical psychologists
Psychiatrists: Can prescribe medications
Psychiatric social workers
The Therapeutic Relationship
Sense of working collaboratively on the problem
Agreement between the patient and therapist about the goals and tasks of therapy
An affective bond between patient and therapist
Client's motivation to change
Client's expectation of receiving help: Placebo
Protected setting: Client must feel safe and not judged
Good match between client and therapist
Measuring success in psychotherapy by objectifying and quantifying change
Client's ratings to determine how much change has occurred
Not very reliable, clients may report change to please their therapists
Clinician's ratings
Maybe biased in favour of seeing themselves as competent and successful
Limited observational sample (client's in-session behaviour)
May inflate improvements to encourage difficult clients to discontinue therapy
Third-party ratings: Reports from client's family, friends, or trained independent evaluators
Objective measures: Client's performance on psychological tests
Regression to the mean: Extreme scores tend to be less extreme on repeated testing
Overt behaviours: Observe behaviour of clients directly
Less appropriate for problems that are less easily observed (e.g. suicidal thoughts
Psychotherapy Approaches
Behaviour Therapy: Direct and active treatment that recognises the importance of behaviour, acknowledges the role of learning, and includes thorough assessment and evaluation. Focuses on presenting problem. Assumption that abnormal behaviour is acquired through learning. Techniques are to unlearn maladaptive behaviors
Exposure Therapy: Guided exposure to anxiety-provoking stimuli
Systematic desensitisation
: Exposing client to stimulus in controlled and gradual manner
Finding a bahaviour that is incompatible with being anxious (e.g. being relaxed) and pairing is with the stimulus repeatedly in an attempt to countercondition the client
Assumption: Most anxiety-based patterns are conditioned responses
Flooding
: Patient directly confronts the feared stimulus at full strength
Exposure can be
real (in vivo exposure)
or
Imaginary (imaginal exposure)
In vivo trumps imaginal: Some clients cannot imagine stimulus vividly. However, imaginal exposure is important for stimuli that cannot be replicated physically
Aversion Therapy: Modifying undesirable behaviour by the old-fashioned method of punishment
Aversive stimuli: Drugs that have noxious effects (e.g. Antabuse, which induces nausea and vomiting when a person who has taken it ingests alcohol)
Wearing elastic band on wrist and snapping it (administering self-punishment)
Modelling: The client learns new skills by imitating another person who performs the behaviour to be acquired
Usually used in conjunction with other forms of behaviour therapy
Systematic Reinforcement
Contingency management programmes: Systematic programmes that use reinforcement to increase the frequency of desired behaviour
Suppressing problematic behaviour by removing reinforcers
Note that reinforcers may be hard to identify
Response shaping
: Positive reinforcement is used to establish a response that is actively resisted or is not initially in an individual's behaviour repertoire
Token Economies: Individual is paid for his or her work in tokens that can later be exchanged for desired objects and activities
More useful for children
Challenge: Weaning off the reward system
Behaviour activation: Client and therapist work together to help client find ways to become more active and engaged with life
Improved mood would lead to better ways of coping with specific life problems
Evaluation: Achieves results in shorter period of time because it is directed to a specific symptom, leading to faster relief of client's distress and to lower costs. However, not useful for vaguely-defined and pervasive problems
Cognitive and Cognitive-behavioural Therapy: Stem from both cognitive psychology and behaviourism
Cognitive processes influence emotion, motivation, and behaviour
The use of cognitive and behaviour-change techniques in a pragmatic (hypothesis-testing) manner
Rational Emotive Behaviour Therapy (REBT): Change a client's maladaptive thought processes on which maladaptive emotional responses and behaviour are presumed to depend on
Restructure an individual's belief system and self-evaluation, especially those that prevent them from having a more positive sense of self-worth and an emotionally satisfying, fulfilling life
Dispute a person's false beliefs through rational confrontation
Behaviourally oriented techniques (e.g. homework assignments to encourage clients to have new experiences)
Increase an individual's feelings of self-worth and clear the way for self-actualisation by removing the false beliefs that have been stumbling blocks to personal growth
Beck's Cognitive Therapy
Problems result form biased processing of external events or internal stimuli, which distort the way that a person makes sense of the experiences that she or he has in the world, leading to cognitive errors
Underlying these biases is a relatively stable set of schemas that contain dysfunctional beliefs. These lead them to perceive the world selectively as harmful while ignoring evidence to the contrary, overgeneralise on the basis of limited examples, magnify the significance of undesirable events, and to engage in absolutistic thinking
Encouraged to gather information about themselves, then encouraged to discover the faulty assumptions or dysfunctional schemas that may be leading to problem behaviours and self-defeating tendencies
Evaluation: Strong efficacy with depression, anxiety, conduct disorders, and bulimia. Long term advantages in preventing relapse. However, some disagreements about whether the effects of cognitive treatments are the result of cognitive changes
Humanistic-Experiential Therapies: A client must take most of the responsibility for the direction and success of therapy, with the therapist serving merely as counsellor, guide, and facilitator
People have both the freedom and responsibility to control their own behaviour. Focus on expanding client's awareness
Client-centred therapy: Focus on natural power of organism to heal itself
Helping clients accept and be themselves: Establishing a psychological climate in which clients can feel unconditionally accepted, understood, and valued as people
Therapist listens attentively and acceptingly to what the client wants to talk about, interrupting only to restate in different words what the client is saying. Restatements help client to clarify their feelings and ideas and to acknowledge them.
As self-concept becomes more congruent with their actual experience, they become more self-accepting and better-integrated
Motivational interviewing (MI): Help people resolve their ambivalence about change and make a commitment to treatment
Discuss client's desire, ability, reasons, and need for change
Delivered in 1-2 sessions, most often used in substance abuse and addiction; large effect on ethnic minorities and adolescents suffering from drug abuse
Gestalt therapy: Increase the individual's self-awareness and self-acceptance
Commonly used in group settings but emphasis on one individual at a time
Person asked to act out fantasies concerning feelings and conflicts or to represent one side of a conflict while sitting in one chair and then switching chairs to take the part of the adversary
Emphasis on dreams: All elements of a dream, including seemingly inconsequential, impersonal objects, are considered to be representations of unacknowledged aspects of the dreamer's self
Evaluation: Major impact on contemporary views of human nature and and good psychotherapy. Lack of agreed-upon procedures and vagueness of client-therapist relationship
Psychodynamic Therapies: Focus on individual personality dynamics
Freudian psychoanalysis
Free association: An individual must say whatever comes to mind regardless of how personal, painful, or seemingly irrelevant it may be
To explore the contents of the preconscious (subject to conscious attention but largely ignored)
Analytic interpretation: Therapist tying together client's thoughts into meaningful explanation, helps client to gain insight into the relationship of maladaptive behaviour and repressed events that drive it
Analysis of dreams: Forbidden desires and feelings may find an outlet in dreams
Manifest content: Dream as it appears to the dreamer
Latent content: Actual motives that are seeking expression, but are so painful or unacceptable that they are disguised
Analysis of resistance: Unwillingness or inability to talk about certain thoughts, motives, or experiences
Helping clients to uncover the problem and learn to deal with it in a realistic manner
Analysis of Transference: People can carry over and unconsciously apply attitudes and feeling that they had in their relations with others in the past to their therapist.
Can be highly revealing of client's central issues
Therapist may introduce corrective emotional experience by refusing to engage the person on the basis of their unwarranted assumptions about the nature of the therapeutic relationship. The negative effects of an undesirable early relationship are counteracted by working through a similar emotional conflict with the therapist in a therapeutic setting
Transference neurosis: A person's reliving of a pathogenic past relationship that recreates the neurosis in real life
Resolution to transference neurosis is the key element in a psychoanalytic cure
Countertransference: Therapist reacting in accordance with the client's transferred attributions instead of reacting objectively. This is undesirable and should be addressed by the therapist
Since Freud
Procedures that focus on interpersonal relationship issues, particularly as they play out in therapeutic relationship
Retain classical psychoanalytical goal of understanding the past
Evaluation: Time consuming and expensive, neglects a client's immediate problems, no adequate proof of genera effectiveness. Newer approaches may be helpful in depression, panic, PTSD, substance abuse, borderline personality disorder
Couples and Family Therapy
Couples Therapy: Short term therapy based on social learning model
Traditional Behavioural Couple Therapy (TBCT): Marital satisfaction and marital distress in terms of reinforcement. Goal to increase caring behaviours and teach partners to resolve conflict in a constructive way through training in communication skills and adaptive problem solving
Integrative Behavioural Couple Therapy (IBCT): Focus on acceptance and include strategies that help each member of the couple come to terms with and accept some of the limitations of their partner
Family Therapy
Structural Family Therapy: If the family context can be changed, the individual members will have altered experiences in the family and will behave differently in accordance with the changed requirements of the new family context
Changes the organisation of the family so that family members will behave more supportively and less pathogenically towards each other
Eclecticism and Integration
Eclecticism: Borrows and combines techniques and concepts from various approaches, depending on what seems best for the individual case
Interpersonal Therapy (IPT): Focuses on current relationships in client's life and goals of reducing symptoms and improving functioning
Rebooting psychotherapy: Focus on advances in technology and other areas to become more efficient in making assessments and treatments available (using smartphones, internet, etc.)
What therapeutic approaches should be used
Evidence-Based Treatment: Empirically supported, efficacy studies to determine that therapy works
Medication or Psychotherapy
Combined treatment: Integration of medication and psychotherapy
Sociocultural Perspectives
Social values and psychotherapy: Therapy involves the values of therapist, client, and society they live in
Psychotherapy and cultural diversity: No evidence that psychotherapy outcomes are diminished if client and therapist are of different ethnicities. However, minorities are under-represented in research (hard to assess needs and outcomes), underserved by mental health system, lack of trained therapists familiar with issues important to different ethnic groups. Lack of culturally adapted interventions.
Biological Approaches to Treatment
Antipsychotic Drugs: Treat psychotic disorders (e.g. schizophrenia) by alleviating or reducing intensity of delusions and hallucinations by blocking dopamine receptors
Treats: Schizophrenia, mania, psychotic depression, schizoaffective disorder, transient psychotic symptoms in borderline personality disorder and schizotypal personality disorder, Alzheimer's (delusions, hallucinations paranoia, agitation)
Associated with increased risk of death
Tablets or depot neuroleptics (long-acting, injectable form)
Side effects: Tardive dyskinesia (movement abnormality that is a delayed result), weight gain, diabetes
Examples: Clozapine (Clozaril) and olanzapine (Zyprexa) are often preferred for schizophrenia
Antidepressant drugs: For depressive disorders
Selective Serotonin Reuptake Inhibitors (SSRIs): Inhibit the reuptake of the neurotransmitter serotonin following its release into the synapse
Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox) (treats OCD), citalopram (Celexa), escitalopram (Lexapro). All equally effective
Fewer side effects, not fatal in overdose, not more effective than other antidepressants
Side effects: Nausea, diarrhoea, nervousness, insomnia, sexual problems (diminished sexual interest and difficulty with orgasm). Fluoxetine (Prozac) and patoxetine (Paxil) may increase risk of heart abnormalities in baby
Tend to improve 3-5 weeks in, 50% improvement in symptoms. Period of remission (after treatment removes all patient's symptoms) 6-12 months or more patient = recovered
For panic disorder, social anxiety disorder, generalised anxiety disorder, bulimia nervosa, decrease mood liability for borderline personality disorder
Serotonin and norepinephrine reuptake inhibitors (SNRIs): Block the reuptake of both norepinephrine and serotonin
Venlafaxine (Effexor) and duloxetine (Cymbalta)
Slightly more effective than SSRIs in treatment of major depression, safe in overdose, similar side effects to SSRIs
Viibryd (vilazodone): Combination of SSRI and serotonin receptor agonist. Safe and well tolerated.
Monoamine Oxidase Inhibitors (MAOIs): Inhibit activity of monamine oxidase, an enzyme present in the synaptic cleft that helps break down monoamine neurotransmitters that have been released into the cleft
Isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate), selegiline (Eldepryl)
For atypical depression that are characterised by hypersomnia and over-eating and do not respond well to other antidepressants
Must avoid foods rich in amino acid tyramine (e.g. salami and Stilton cheese)
Tricyclic Antidepressants (TCAs): Inhibit the reuptake of norepinephrine and serotonin once they have been released into the synapse
Imipramine
For bulimia nervosa
Others
Trazodone (Desyrel): Inhibits the reuptake of serotonin. Heavy sedating properties that limits usefulness, priapism (prolonged erection in the absence of sexual stimulation), used in combination with SSRIs at night to counter insomnia side effect
Bupropion (Wellbutrin): Inhibits the reuptake of both norepinephrine and dopamine. Reduces nicotine cravings and symptoms of withdrawal in people who want to stop smoking. Does not inhibit sexual functioning
Antianxiety drugs: Tension and anxiety (to keep symptoms under control until patients can receive other forms of effective psychological treatments)
Side effects: Addictive and sedating
Benzodiazepines: Enhances the activity of Gamma Aminobutyric acid (GABA) receptors, which is important in inhibiting anxiety in stressful situations, in parts of the brain known to be implicated in anxiety
For acute anxiety and agitation, insomnia
Rapidly absorbed from digestive track and work quickly
Low doses: Quell anxiety
High doses: Sleeping agent for insomnia
Side effects: Psychological and physiological dependency, high relapse rates following discontinuation of drugs
Others
Buspirone (Buspar): Act on serotonergic functioning
No side or addictive effects (low abuse potential)
Drawback: 2-4 weeks to exert any effects
Lithium and Other Mood-Stabilising Drugs
Lithium salts effective in treating manic disorders, bipolar disorder. Has antidepressant effects among those with bipolar and uni-bipolar depression. Marketed as Eskalith and Lithobid. May be less reliable at preventing future manic episodes. Side effects: Thirst, gastrointestinal difficulties, weight gain, tremor, fatigue, toxic if overdose or kidneys cannot excrete it --> neural damage or death. Requires blood monitoring of patients.
For bipolar (and epilepsy, convulsion): Valproic acid (Depakote) (mildest side effects: nausea, diarrhoea, sedation, tremor, weight gain), carbamazepine (Tegretol)
Rapid cycling bipolar disorders (and epilepsy, convulsion): Gabapentin (Neurontin), lamotrigine (Lamictal), topiramate (Topomax)
Non-medical Biological Treatments: Changing the activity of the brain directly by using electrical activity or surgery
Electroconvulsive Therapy (ECT): Passing an electric current through patient's head. Downregulate the receptors for norepinephrine, increasing functional availability of this neurotransmitter
For patients with severe depression or suicidal thoughts that did not respond to other forms of treatment. For severe psychotic-level depression and mania.
For pregnant women who are severely depressed or those who cannot take antidepressants
Unilateral ECT: Current flow in one side of the brain, typically the nondominant side
Bilateral ECT: Electrodes placed on either side of head and electrical current passed from one side to the other
More effective, but more severe cognitive side effects and memory problems
Side effects: Amnesia and confusion in the following hour
Transcranial Magnetic Stimulation (TMS): Positioning a pulsed magnet over a carefully selected area of patient's scalp and using it to create an electrical field that increases or decreases neuronal activity in the brain
For major depression
Less invasive than surgical intervention and less severe and fewer side effects than ECT
Side effects: Mild headache, small risk of seizure
Neurosurgery: Selective destruction of minute areas of the brain
Last resort for patients who have not responded to any other form of treatment for a period of 5 years and who are experiencing extreme and disabling symptoms
Psychosurgery: Debilitating OCD, treatment-resistant self-injury, intractable anorexia nervosa. Very serious risks
Deep brain stimulation: Stimulating patients' brains electrically over a period of several months