A. History of treatment:

1. Middle Ages (attributed to being possessed by the devil or supernatural powers): torture, hanging, burnt at stake, "ships of fools."

2. 18th Century (attributed to degeneracy or unworthiness): chained in prisons or dark, damp hospitals.

B. Reform"moral-treatment movement," 19th Century:

1. Philippe Pinel, Paris: unchained, sunny, airy rooms, exercise.

2. Dorothea Dix, U.S.: publicized appalling conditions.

3. State-supported asylums built.

C. Lack of financial support:

1. 1940's: overcrowded, understaffed, poor treatment.

2. 1950's: deinstitutionalization inspired by effective drugs and optimism.

3. 1960's: community-based mental health centers.

4. Current: debatable improvement in treatment.

D. David Rosenhan’s Study (1973):

1. Little contact with psychiatrists.

2. Dehumanizing interactions.

3. Physical and verbal abuse.

E. Illinois Study (1977):

1. Standard hospital treatment.

2. Milieu therapy: frequent interaction, respect, high expectations, democratic decision, reduction/elimination of antipsychotic drugs.

3. Social-learning therapy: milieu conditions plus social skills training.

4. 97% of social-learning group were able to live in the community.

F. Places of Treatment:

1. Mental hospitals: public, private.

2. General hospitals.

3. Nursing homes.

4. Halfway houses.

5. Private offices (72% of patients).

6. Community mental health centers (16% of patients).

G. Providers of treatment:

1. Psychiatrist.

2. Clinical psychologist.

3. Counseling psychologist.

4. Counselors.

5. Psychiatric social workers.

6. Psychiatric nurses.

7. Other: religious organizations, self-help groups.

H. Recipients of Treatment:

1. Definition of mental disorder (see chp 16).

2. Most people with mental disorders never seek or obtain treatment.

3. Demographics of individuals with diagnosable disorders who seek help:

a. Sex: 25% women; 20% men.

b. Education: 43% college graduates; 11% less then high school.

c. Race: 27% white; 17% non-white.

d. Income level: 37% <$35,000; 20% <$10,000.

e. Higher income >> less the incidence of mental disorder and seeing a professional.

4. Other reasons for seeking mental health treatment:

a. Life problems, marital problems.

b. Anxiety disorder.

c. Major depression.

d. Substance abuse or dependence.

II. Methods of clinical assessment.

A. Assessment: process by which a mental health professional gathers and compiles information about a patient or client for the purposes of developing a plan of treatment.

Assessments are used for:

1. Diagnosis.

2. Understand the individual, life circumstances, thoughts and behaviors.

3. Monitor changes for determining treatment modification or discontinuation.

4. Theoretical orientations that guide assessment:

a. Psychodynamic: assess repressions and revelations.

b. Humanistic: assess perceptions and beliefs.

c. Cognitive: assess thought patterns.

d. Behavioral: assess actual behaviors and settings in which they occur.

B. Assessment interviews and objective questionnaires:

1. Assessment interview: (most common procedure) dialogue to learn about client.

a. Unstructured or highly structured.

b. Topics: symptoms, environments, history and non-verbal behaviors.

2. Objective questionnaire: self report of feelings, thoughts and behaviors. (Example: Beck Depression Inventory.)

C. Minnesota Multiphasic Personality Inventory (MMPI) (1930): psychometric personality test.

1. Purpose: to provide an objective means of diagnosing mental disorders, uncontaminated by the biases of a clinician.

2. Criticism: cultural biases.

3. MMPI-2 (1980s): revised to increase validity.

D. Projective tests: designed to provide clues about the unconscious mind with standard procedures for rating degree of morbidity and aggressiveness.

1. Free association: free mind constraints of logic and say whatever comes to mind in response to a word or other stimuli.

2. Rorschach test: symmetrical inkblots.

3. Thematic apperception test (TAT): pictures of ambiguous scenes.

E. Behavioral monitoring: counting and recording instances of behaviors to assess improvement or deterioration.

1. Self-monitoring: client records his/her own behaviors.

F. Brain damage and neuropsychological functioning:

1. Electroencephalogram (EEG): measures patterns of electric activity.

2. Computerized axial tomography (CAT) scan: multiple x-rays from various angles.

3. Magnetic resonance imaging (MRI) scan: strong magnetic field constructs pictures based on electromagnetic radiation given off by molecules in the brain.

4. Positron emission tomography (PET) scan: images of patterns of blood flow and oxygen use.

5. Halstead-Reitan battery: identification of functional deficits related to brain damage.

III. Biological approaches to treatment: directly altering bodily processes.

A. Historical treatments:

1. Trephination: drilling holes in the brain to allow evils spirits to escape.

2. Bloodletting.

B. Antipsychotic drugs: for treatment of schizophrenia.

1. Phenothiazines: decreases dopamine activity.

a. Reduces positive symptoms (hallucinations, delusions, etc.).

b. Fails to reduce negative symptoms (flat affect, low motivation, etc.).

c. Unpleasant side effects: dizziness, nausea, sexual impotence, tardive dyskinesia (involuntary facial movements), etc.

d. May cause permanent biochemical changes reducing possible eventual full recovery.

2. Clozapine: blocks less dopamine and blocks more serotonin.

a. Reduces both positive and negative symptoms.

b. Fewer side effects; does not cause tardive dyskinesia.

c. Problem: produces a potentially lethal blood disorder.

C. Antidepressant drugs:

1. Tricyclics: increases availability of serotonin and norepinephrine by blocking their reuptake in the synapse. (Examples: imipramine, amitriptyline.)

a. 70% of those who take tricyclics recover.

b. Side effects: fatigue, dry mouth and blurred vision.

2. Selective serotonin reuptake inhibitors (SSRIs): increases availability of serotonin by blocking its reuptake only. (Examples: Prozac.)

a. As effective as tricyclics.

b. Fewer side effects.

c. Elevate mood and confidence.

D. Lithium: for treatment of bipolar disorder.

1. Mineral element that stabilizes monoamines.

2. Controls both mania and depression.

3. Serious side effects at high doses.

E. Antianxiety drugs: for treatment of generalized anxiety.

1. Tranquilizers. (Example: phenobarbital.)

a. Highly addictive.

2. Benzodiazepines: augments the inhibitory transmitter gammaaminobutyric acid (GABA) which decreases neuron excitability. (Examples: Librium and Valium.)

a. Side effects: drowsiness, low motor coordination.

b. Potentiate the action of alcohol.

c. Moderately addictive.

F. Electroconvulsive shock therapy (ECT): electric current passed through the skull causing a brain seizure.

1. Used for severe depression that has not responded to conventional therapies.

2. Criticism: possibility of permanent brain damage.

3. Problem: may cause temporary memory loss.

4. Bilateral ECT: electric current passes through both hemispheres; unilateral ECT: current passes through only one hemisphere (usually the right).

G. Psychosurgery: surgically cutting or producing lesions on the brain.

1. Frontal lobotomy (1930s-50s, Egas Moniz): the front portions or the brain’s frontal lobes are surgically separated from the rest of the brain.

a. Lost favor as drugs were developed.

b. Produced deficits in integrating plans with actions.

2. Cingulotomy: destruction of small areas of the brain by applying radio-frequency current through wire electrodes.

a. Rarely left patient worse off.

b. Often reduced symptoms of major depression and obsessive-compulsive disorder.

c. Not effective for schizophrenia.

3. Procedures are irreversible; appropriate for disorders persisting for 10 or more years, when conventional treatments have failed and patient is suicidal.

IV. Major forms of psychotherapy: formal, theory-based systematic treatment for mental problems or disorders that use psychological means and conducted by a trained therapist.

A. Psychodynamic therapies: therapy based on the premise that psychological problems are manifestations of inner mental conflicts and that conscious awareness of conflicts is key to recovery. (Psychoanalysis: term coined by Freud.)

1. Wishes and memories (especially sex and aggression) are unconscious.

2. Repression: defense mechanism to keep wishes unconscious.

3. Neuroses: emotional disorders arise from memories or wishes becoming conscious and causing emotional breakdown.

a. Predisposing experiences (infancy to 5-6 years).

b. Precipitating experiences (later in life).

4. Free association (defined above).

5. Dream interpretation: purest form of free association.

a. Latent content: unconscious meaning of dreams.

b. Manifest content: what is remembered of dreams.

c. Freudian symbols: universal disguises of content in dreams.

6. Mistakes (i.e., "slip of the tongue", "Freudian slip"): expressions of unconscious wishes.

7. Resistance: refusal to talk about a topic, forgetting or arguing as defenses against unconscious memories becoming conscious.

8. Transference: patient’s unconscious feelings about a person are experienced as conscious feelings about the therapist.

9: Cure: Memories and wishes become conscious and experienced directly or modified. Patient no longer represses freeing psychic energy for other pursuits.

B. Modern psychodynamic therapies:

1. Similar to Freud’s psychoanalysis.

2. Differences:

a. Fewer sessions.

b. No couch.

c. Use of role play to facilitate transference.

d. Less focus on repressed memories; more focus on adult experiences.

3. Non-Freudian psychodynamic therapies (Adler, Jung, Horney): emphasizes other conflicts (not just sex and aggression).

C. Humanistic therapy: focuses on actualizing (inner potential positive growth).

1. Roger’s client-centered therapy: focuses client’s positive attributes and how he/she can use them to identify problems and make improvements.

a. Therapists role: sounding board.

i. Empathy: gain client’s perspective.

ii. Unconditional positive regard: client is worthy and capable.

iii. Genuineness: empathy and positive regard cannot be fake.

b. Problem: client disregards feelings and defers to authority resulting in distrust of one’s ability to make decisions.

c. Therapy goals: awareness of feelings; learn to trust decisions.

D. Cognitive therapy: focuses on thought patterns; problem-centered.

1. Therapist’s role: directive, teaching.

2. Problem: people are disturbed by maladaptive thoughts that produce anxiety or depression.

3. Therapy goals: identify maladaptive thought patterns; replace with adaptive thoughts.

4. Ellis’s rational-emotive therapy (RET) (1955): negative emotions arise form people’s irrational interpretations of their experiences, not objective experiences.

a. Musterbation: happiness/worthiness is a result of specific things or acts.

b. Awfulizing: mental exaggeration of setbacks.

c. ABC theory of emotions: recognize and change irrational habitual beliefs.

i. A = activating event in the environment.

ii. B = belief triggered when the event occurs.

iii. C = emotional consequence of that belief.

5. Beck’s cognitive therapy: negative self-concept due to routine distortion of experience.

a. Therapist’s role: use of leading questions; assist client in helping self.

b. Problem: thought patterns promote anxiety.

c. Therapy goals: identify and correct thought distortions.

E. Behavior therapy: focuses on relationship between observable environments and behaviors.

1. History: based on laboratory work of Pavlov, Watson and Skinner.

2. Cognitive-behavior therapy: focuses on mental process as mediators between stimuli and responses.

a. Therapist’s role: monitor behaviors; modify techniques as needed.

b. Problem: learned ways of thinking or acting.

c. Therapy goals: unlearn problem thoughts or actions; learn new thoughts or actions.

3. Exposure treatments: fear paired with harmless contexts until it is habituated (for unconditioned fears) or extinguished (for conditioned fears).

a. Systematic desensitization (Wolpe, 1958): muscle relaxation while imagining increasingly anxious scenes.

b. Flooding: inundated with fear inducing (imagined or real) stimuli until it declines or disappears. (Useful with post-traumatic stress disorder.)

4. Aversion treatments: reduction or elimination of a harmful habit by applying aversive stimuli immediately after it occurs. (Example: antabuse.)

a. Criticism: learned aversions do not generalize beyond the condition in which they are applied.

5. Other techniques:

a. Token economies: exchange system where tokens are use as reinforcers which are traded later for a desired reward.

b. Contingency contracts: formal, written agreement between the client and therapist regarding expected behaviors and their rewards.

c. Assertiveness/social skills training: teaching social interaction or assertive behaviors through practice and role play.

d. Modeling: teaching by having the client watch someone else.

F. Other therapies:

1. Group therapies: one therapist meeting with more than one client at once.

a. Group psychodynamic therapy: clients’ interactions provide insights.

b. Humanistic client-centered groups: honest expression in a safe place.

c. Group cognitive and behavioral therapies: practice or role play ways of thinking and acting with other clients.

d. Benefits: support, feelings of less isolation, shared experience.

e. Self-help groups. (Examples: Alcoholics Anonymous (AA), Gamblers Anonymous, Weight Watchers.)

2. Couple/family therapy: one therapist meets with a married or cohabiting couple, or a whole family.

a. Family systems perspective: each person’s role functions to accommodate the needs of the family as a whole.

b. Intergenerational approach: family members’ behavior may be affected by events in previous generations.

c. Genogram: diagram of family members’ perceptions or beliefs.

V. Evaluating psychotherapies:

A. Controlled experiments. (Example: Philadelphia experiment, 1975.)

B. Therapy outcome experiments conclusions:

1. Psychotherapy produces improvement more than no treatment.

2. No single type of therapy is generally superior.

3. Some types of therapy work best with specific kinds of disorders or problems.

a. Cognitive and behavioral therapies work best for fear and anxiety.

b. Humanistic therapy works best for raising self-esteem.

c. Psychodynamic therapies work best for achievement problems and addictions.

d. Cognitive therapy works best for depression.

4. The therapist matters.

a. Degrees of training and experience.

b. Personality.

c. Motivation.

C. Non-specific factors in therapy outcome: factors unrelated to the specific therapy principles.

1. Support: acceptance, empathy, encouragement, guidance.

a. Devoted time.

b. Listening warmly and respectfully.

c. Not responding with shock to statements or actions.

d. Communicating a belief that the client is worthwhile.

2. Hope: faith in the therapy process.

a. Placebo-effect: the phenomena of improvement due to belief in the treatment rather than from therapeutic factors.