This class… Treatment. Care as a Social Issue What to do with the Severely Disturbed? throughout history, people with mental disorders were often considered

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


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


Dorothea Dix campaigned profusely as a leader of the moral-treatment movement in the US

Unfortunately, funding seldom held up for long

Titicut Follies


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


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


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


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


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


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


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


why it works is not understood there are some temporary

disruptions in cognition, especially memory


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


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


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


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


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


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 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: 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


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


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


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)

Documents

This class… Treatment. Care as a Social Issue What to do with the Severely Disturbed? throughout history, people with mental disorders were often considered