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Microsoft word - 302 chapter17therapy.doc

Chapter 17: Therapies
I. Therapies: Psychological interventions designed to promote new
understandings, behavior, or both on the part of the client. The different
ways these are introduced is what determines the differences between the
interventions
A. Assumes also that the therapist is receptive, warm, empathetic & B. Assumes that people are able to make changes C. Although several hundred different types of therapy are listed, therapy be empirically demonstrated: This chapter discusses the most widely accepted pharmacological and psychological
II. Who seeks treatment?
A. Those experiencing a recent crisis B. Physician referrals for patients whose physical symptoms may be psychologically influenced C. Parent-child, & relationship problems D. Fewer men than women E. Long term chronic problems of poor adjustment and unhappiness F. Those seeking self-growth and greater individual motivation and potential Conclusion: There is no typical client and no "model therapy"
III. The Therapeutic Relationship: the therapeutic alliance is in itself a
form of therapy: a sense of working together; agreement about treatment
goals; and the emotional bond between the client and the therapist:
similarity; client motivation and therapist personality
IV. Problems with measuring therapy:
A. Therapist impressions? Client's reports? Pre-post test measures? Control groups? Changes in specific behaviors? Placebo effects? Regression -to- the- mean effects? Testing effects? Are the tests reliable and valid? What about follow up studies? Systematic self monitoring of specific behaviors still doesn't rule out the effect of placebo. How much improvement occurs w/o therapy? B. Data: significant changes by 21 sessions; after 40 sessions, 75% C. Efficacy Studies using randomized clinical trials (RCTs) are
used by drug companies to test the efficacy of their medications. Blind -double blind procedures using placebo controls. 1. When using this model to evaluate psychotherapy, need to come up with a reasonable placebo group or non-therapeutic control (waiting list control?). 2. Even when using manualized therapy, personality differences, appearances, and styles and presence are still differences that may render some therapeutic control. 3 Even when considering the efficacy studies on specific psycho-social treatments, large numbers of clients are omitted from these studies (can only have one Dx and no co-morbidities, e.g), so the results of the research may not be generalizable to all clients
IV. Medication or Psychotherapy: Osherhoff vs Chestnut Lodge:
A. The case of Osherhoff vs Chestnut Lodge resulted in a lawsuit
because a depressed doctor was not being given anti-depressant medication. It is now required that all mental health professionals present their clients all the treatment options. 1.Based on the results of this case, therapists may now be
liable for failing to provide medication to patients with
certain disorders for which medications are known to be
effective

B. Research agrees that with one or the other, effectiveness is about
55%; when meds and therapy are combined, effectiveness is
85% for such conditions as intractable depression.
III. Early attempts at biological interventions
A. Included primitive techniques such as purging (laxatives and emetics), and bleeding, and later electrical shocks to the body. B. By 1917, Wagner-Jauregg discovered a treatment for general paresis: a mental condition due to syphilis (neuro- syphilis). Treatment involved infecting patients with malaria producing fever that would kill the syphilis spirochete. C. Convulsions induced by drinking camphor to cure “mania”: Paracelsus (15 hundred Swiss physician). Used until the end of the 18th century, but not used in the 19th. D. In 1934, Von Meduna (Hungarian physician) induced epileptic seizures in schizophrenics, because he thought that schizophrenia (erroneously) did not occur in epileptics. First done with rats, then induced camphor into a schizophrenic, which returned him to normal. Later he used Metrazol rather than camphor because it Insulin Coma Therapy: Used by Sakel in 1932 : used to
treat schizophrenia and also used for morphine withdrawal. Administer increasing amounts of insulin (hormone used to regulate sugar metabolism in the body) until the patient goes into shock (causes a hypoglycemic coma caused by an acute deficiency in sugar). Pt goes through 50- 1-hour comas, which were then terminated q by the administration of glucose. This caused stress to cardiovascular and nervous systems. Not effective: high
relapse rate; did not help severe schizophrenics; hard
to know what the real causes for improvement, when
they occurred, were.
F. Electroconvulsive Shock Therapy
1. 1849: John Bucknill used electrical stimulation of the skin & potassium oxide to treat patients with melancholic 2. Value of electro-stimulation was considered after Von
Meduna's work on Metrozol-induced seizures in the
treatment of mental disorders.
3. In 1938, two Italian physicians, Cerletti & Bini visited
a slaughter house and observed animals rendered
unconscious by electric shock; tried to pass electric current
through a patient's head. Became known as ECT
(electroconvulsive shock therapy). Widely used today
to treat depressive and manic episodes.
Do not know the
mechanism through which it works (maybe through the
changes in certain neurotransmitters or by changes in
receptor sensitivity).
A. We do know that stimulation of seizures in B.Two types of ECT: Bilateral and uni-lateral.
General theory of both is to pass a brief electrical impulse from one side of the head to the other for up to 1.5 ". Patient looses consciousness and undergoes muscle contractions (seizures). Anesthetics and muscle relaxant pre-medications are used to prevent violent contractions that in the past have been known to induce fractures of the vertebrae. 1. Patient wakes up several minutes later and has amnesia for the period of events preceding the therapy and is confused for the next hour or so. Tx consists of @ 12 sessions (3 x /wk for 4 weeks). Disorientation occurs and clears after termination of the treatment. through one side of the brain (the non-dominant side, which is usually the right side for most people). This has fewer side
effects ( memory impairment). Other studies suggest that
Unilateral ECT is not as effective as Bi-lateral. Some suggest
starting with unilateral and then switching to bi-lateral.
it is highly effective for pts who do not respond to anti-
depressant medication
, pregnant women who cannot take anti-
depressant medication, and the elderly who have pre-existing
medical conditions. Data also show that it is an effective
treatment for recurring mania that does not respond to
medication
™ New data show that ECT does not produce structural
damage to the brain if properly administered. ™ NIMH panel has determined that mortality rates following ECT have been reduced to 2.9 deaths/10,000 patients. ™ Recommended for (1) psychotic depression and (2) acute mania. NOT recommended for dysthymia or schizophrenia ™ Relapse rates for depression and mania following ECT
were high unless the treatment was followed by
maintenance doses of medication for unipolar or bi-polar
disorders
™ New guidelines have been established for the training and standards used in ECT, along with new policies for obtaining informed consent from those who may not be competent to give it ( to prevent lawsuits). ™ Virtually every neurotransmitter system is affected by
ECT. This technique downregulates the receptors for
norepinephrine, increasing the functional availability of
the transmitter, but we still don't know how.
™ Recommendations: Start with unilateral first; If no
improvement switch to bilateral after 5-6 treatments. (With bilateral, patients cannot form new memories {anterograde amnesia} for about 3 months). 4. Neurosurgery (used to be called psychosurgery: surgery for
CNS disorders): Today both terms refer to brain surgery for emotional disorders a. 1935: Antonio Moniz from Portugal: Frontal lobes of the brain were severed from the deeper centers underlying them. Now
known as prefrontal lobotomy: resulting in permanent
structural changes in the brain.
Won the 1949 Nobel Prize
in Medicine
b. Side effects included inability to inhibit impulses or c. 1935-1955 tens of thousands of such surgeries. Then the anti- psychotic meds were developed and the surgeries decreased.
1951 the Soviet Union banned these surgeries but they are still
legal in the US and are making a comeback for some hard to
treat psychiatric problems (intractable psychoses; severe
OCD, & severe pain in terminal illness)

d. Surgeries are more carefully monitored and permanent brain damage has been minimized. Surgeries involve the selective
destruction of minute areas of the brain, such as the
"cingulotomy" which seems to relieve the subjective
experience of pain: the cingulus is a small bundle of nerve
fibers connecting the frontal lobes with the limbic system,
which is interrupted with virtually pinpoint precision
e. In the capsulotomy, small holes are drilled into the patients
skull, and tiny electrodes are inserted into the brain by
destroying adjacent cellular structures. Sometimes hole
drilling is replaced by the use of a gamma knife or proton
beam

f. Such neurosurgery is only used for pts who have not responded to other standard forms of treatment for a period of
5 years
, who have extreme and disabling symptoms, and are
rational enough to be able to sign informed consent papers ( to
avoid legal lawsuits).
g. Strong data to support the use of psychosurgery for some extreme forms of OCD: also reports of absences of negative
side effects such as seizures and headaches. Rare effects on cognition or personality, and no risk of suicide following such surgery as in the past 5. Psychopharmacological Txs: These drugs are called
Psychotropic Drugs, meaning mind altering
. (Important to
remember there are great individuual differences in the rate in which
people metabolize drugs {how quickly the bodies break down the
drugs after they have been ingested}
: Af. Am. Metabolize anti-
depression sand anti-psychotic medications more slowly: therefore,
show a more rapid and a greater response to these drugs but also
show more side effects.
a. There are 4 major categories of Psychotropics: {1} Antipsychotics, {2}antianxiety (minor
tranquilizers), {3}anti-depressants, and {4}Lithium and
other mood stabilizing drugs
1. Antipsychotics: as a group are called neuroleptics or major
tranquilizers: Used for schizophrenia and psychotic mood
disorders
: affect psychotic symptoms of delusions and
hallucinations and often remove negative symptoms. With the
treatment of psychotic symptoms, other forms of therapy may be
introduced. All these drugs block dopamine but in varying
degrees. 60% of schizophrenic patients show a near complete
remission of positive symptoms within 6 weeks compared to
20% treated with a placebo. About 20-30% do not respond to
these meds, esp those with prominent negative symptoms or
chronic schizophrenia

Class Trade
Used to Treat
Effects & Side Effects
Conventional
Antipsychotic
psychotics effective
*only for positive.
symptoms
(b) Moderate Trilafon
dopamine
block
(d) Atypical
Antipsychotic Zyprexa
Risperdal
vomiting, weight gain & diabetes problems Fewer negative side effects than Conventional. psychotics is that they also treat
negative symptoms. 1% of those
psychotics Neuroleptics are distinguished also by their doseage level fdifferences and the Half-life of each drug. The half-life is the time it takes for the level of the active drug in the body to be reduced by 50% ( through metabolisis & excretion): 1. Advantages of a long half-life: (a) less frequent dosing (b)less variation of the concentration of the drug in the blood plasma (c) less severe withdrawal 2. Disadvantages of a long half life: (a) risk of drug accumulation in the body (b)increased sedation and psychomotor impairment during the day 2. mania, psychotic depression, schizoaffective disorder, psychotic symptoms in borderline personality disorder, Tourette's, and Alzheimer's: the delusions, hallucinations, and paranoia and agitation that accompanies this disorder c. Side effects of antipsychotics: Dryness of the throat & mouth, sedation, weight gain. Also extrapyramidal symptoms, which mimic the classic symptoms of Parkinson's disease: tremors in the extremities, muscle tightening, akinesia (decrease in spontaneous movements), akathesia (motor restlessness: fidgety, purposeless movements). Many side effects are temporary and can be relieved by substituting another drug in the same class, switching classes, or changing the dosages. i.Tardive dyskinesia, disfiguring disturbance of motor control of the facial muscles. Can be progressive and irreversible. Symptoms appear absent when sleeping. Symptoms include: involuntary thrusting movements of the tongue, chewing movements, lip smacking, eyeblinking, and dancing like movements in the extremities: these are due to the chronic blocking of dopamine in the brain, creating supersensitive
dopamine receptors. Symptoms may appear years after
the drug treatment has been initiated or stopped. TD has higher rates if schiz are alcohol abusing, and in those over 55. More common in women who are not d. Usually dose daily by mouth; or depot neuroleptcs are injected (* injection effects can last for up to 4 weeks, which can be good for non-compliance of medication problems) B. Anti-depressants
Class of anti-
depressants
(a) Tricyclics
found that schizophrenics who used them got increases in mood norepinepherine & lesser degree,serotonin at Inhibitors:
foods rich in the amino-acid : tyramine (Salami & Stilton they were first used to treat tuberculosis! (Inhibits the
depression chacterized by overeating and hypersomnia and serotonin & norepinepherine) at the synapse. Serotonin &
Norepinephrine
Re-uptake
inhibitors
SSRIs:

Response: when
Remission: 100%
Recovery: if remission
exceeds 6-12 months
fatal in overdose. Not better than Tricyclics, but safer and better tolerated. (d)Atypical
antidepressants (trazadone)
cognitive slowing; Desyrel first non-lethal SSRI in overdose.But has heavy sedation effects Usuaslly taken with other SSRIs. Can produce priapism in men: prolonged erection in the absence of sexual stimulation. does increase noradrenergic function in other ways. No sexual (e) Antimanic
stabilizers
side effects; high toxicity, requires careful monitoring: increased thirst, gastrointestinal problems, weight gain, tremor, fatigue,; can be toxic at high levels or if kidneys fail to excrete. Still not clear how lithium works: may alter electrolyte balance that then effect neurotransmitter functions. Effective with Bipolar diorder; neurotoxic side effects inc tremor, unsteady gait & Fewer side effects than lithium; sometimes with bipolar pts who cannot take lithium Side effects of Lithium
a. Blood levels must be monitored: Too little lithium and the drug
will be ineffective; too much lithium and the drug can be lethal;
b.Other side effects include lethargy, decreased motor coordination,
gastrointestinal problems, increased thirst and urination, & weight
gain.
c. Prolonged use could result in thyroid dysfunction and kidney
damage, as well as motor and memory problems.
d. These side effects plus missing the mood swings, causes many to
stop taking the medication. Lithium is 70% effective w/in 10 days
for reducing mania; it is more effective when used in conjunction
with an antipsychotic drug or a benzodiazepine
C. Anti-anxiety Drugs: minor tranquilizers
Trade Name Used to Treat Effects/side-effects (a)Barbiturates Phenobarbitol
(b)Propanediols
benzodiazepines
1-4 wks; Not good for acute anxiety; no addiction potential 3. Side effects include relapse after discontinued use of drug, esp, Xanax used in the TX of panic
disorder, which is sometimes chronic
4. Benzodiazepines produce their effects through stimulating the action of GABA ( gamma
aminobutyric acid), a neurotransmitter thought to
be functionally deficient in people with
Generalized anxiety. GABA usually INHIBITS
anxiety in stressful situations

IV. Psychological Approaches to Treatment

A. Behavior Therapy
1. Assumes that abnormal behaviors are learned in the same
way as normal behaviors, and therefore can be unlearned a. Exposure Therapy (Classical Extinction or
Pavlovian Extinction): Patient is exposed to anxiety Systematic Desensitization when items on a fear hierarchy are paired
with relaxation, and the patient is slowly moved up the fear hierarchy after 0- SUDS are reported to the item on the hierarchy below it ii. Flooding (agorophobics are taken outside)
iii.
the exposure can be real (in vivo
exposure) or imaginary (imaginal exposure) or artificially constructed
(Virtual reality exposure). In vivo has been shown to be most effective
but some patients are just too fearful; imaginal can be a problem if the
patient cannot make visual pictures in his mind; virtual is important if the
situation that causes the fear is not easily reproducible, but the technology
here is still very new.
b. Aversion Therapy
i. Operant: Applying punishement to an unwanted
behavior, such as snapping a rubberband on your wrist every time you are about to say something negative ii. Classical: Pairing Antabuse with the ingestion
of alcohol to create nausea and vomiting in an alcoholic. Usually use noxious drugs or electric shock iii. Covert or Vicarious Sensitization:
Thoughts of abusing children in a pedophile are paired with slides of possible negative consequences (his own rape in prision) ™ In all of these situations, the patient is taught some alternative and acceptable way of achieving gratification. Just punishing the unwanted behavior will not maintain the reduction of the inappropriate behavior; must be able to be reinforced for an alternative response c. Modeling : Modeling is usually combined with
instruction and guided exposure to achieve the best effect in conditioned fears d. Systematic use of Reinforcement ( Contingency
management or Behavior Modification): changing the existing contingencies for appropriate and inappropriate behavior. Token
Economies
are a form of this.
™ Overall: Most effective for anxiety disorders, sexual disorders,
inpatient treatment programs (autism, retardation, adolescent, drug abuse, psychotic patients) child management: anything where problem behaviors are specific and contingencies are controllable. Leads to fast relief in a shorter amount of time. Cognitive and Cognitive Behavioral Therapy
a. REBT (Rational Emotive Behavior Therapy):Albert
i. Teaches people to re-evaluate our "shoulds,
stupid?" The process used by Ellis is debate
persuasion
ii. Also uses homework assignments to provide b. Stress Inoculation Therapy: Type of self
c. Aaron Beck's Cognitive Therapy Originally
mood logs
"automatic
thoughts" to
vulnerable to depression, to help the person identify "You feel what you think"
MOOD LOGS & COGNITIVE DISTORTION LISTS HERE
™ RET: research suggests little effect for carefully diagnosed clinical populations. May be helpful to more healthy people to help them avoid anxiety and depression ™ Stress inoculation: Successful with anger, pain, mild anxiety, surgical procedures. Need more research on its actual preventive value
™ Beck's Cognitive Therapy: Efficacy is well documented. As
effective as drugs for most depressions except for extreme cases
such as psychotic depression; research shows strong effectiveness
for panic disorder and GAD, and is the treatment of choice for
bulimia. Also showing good promise in the areas of conduct
disorder, substance abuse, and personality disorders.

C. Humanistic -Experiential Therapies
1. Assumptions: Man has the freedom and the responsibility to control his own behavior; the central focus is to expand a client's "awareness" Client-Centered: Carl Rogers: Uses reflective listening to
provide empathetic environment to help client make his own changes . Therapist does not give opinions or (Rarely used today but the listening skills
are incorporated into all form of therapy to some extent to make the client feel understood, accepted, and values b. Existential: The focus is on the person's own
reality. Therapist is asked to comment on his own reality Gestalt : Emphasis on the "whole body": emphasis on
integration of thought, feeling and action. Dream analysis; switching of chairs; uses much group therapy format: Be the other person and act out his experience or ™ Overall Humanist Summary:
™ Not much research
™ Maybe the search for meaning and fulfillment has to remain
ambiguous, but it is not clear what is supposed to happen in the sessions
D. Psychodynamic: Goal is to try to understand the present in terms

of one's past
2 forms: classical psychoanalysis & psycho-analytically a. Classical Psycho-analytic.: several sessions a week for
several years to try to uncover repressed memories, thoughts, fears and conflicts stemming from problems in early psychosexual development; To gain "insight" (e.g., excessive orderliness and a focus on humorless self control derived from being toilet trained too i. Free Association: client is on the couch and therapist
whatever comes to mind, regardless of how painful or Goal: To explore the pre-
conscious, and to try to determine how all these thoughts ii. Analysis of Dreams: To identify repressed motives
the goal is to analyze the Manifest content of the dream
the hidden meaning or the latent content
Analysis of resistance: Try to discover why the
iv. Analysis of transference: Pts. Unconsciously
transference neurosis); when this happens, the responds in a neutral, non-judgmental manner, to help the pt. work through the negative feelings. The psychoanalytic "cure". Therapists must countertransference, where he responds to the transference issues with his own transference. Psychoanalytically oriented Approaches
Interpersonal:
counter-transfernce phenomena in all of the patient's relationships b. Object Relations, Self Psychology (attachment
early development but NOT focusing on the psycho-sexual ™ Classical Psychoanalysis: no controlled outcome studies ™ Interpersonal Therapy as done by Klerman has some good outcome data for depression& bulimia. More research is needed and is being done. Marital Therapy
i. Traditional Behavioral Couple Therapy (TBCT):
Integrated Behavioral Couple Therapy: IN this approach,
the focus is on acceptance rather than change ( preliminary Family Systems Therapy: One family member's disruptive
behavior is simply a symptom if the dysfunction in the family: so 1. Structural Family Therapy: Focuses on enmeshment,
,rigidity, and poor communication skills. Usually the "identified patient {child}" is the product of the family's tendency to avoid conflict (good research outcomes) Multi-modal Therapy: Uses the best techniques of many

4. Problems:

{a} Need more minority therapists to meet the needs of a {b} Ethical dilemmas that are faced by therapists every day (e.g., Should a 15 year old be counseled to abstain from sex as her parents wish, or should the parents be counseled to accept th

Source: http://faculty.salisbury.edu/~nhlion/302Chapter17Therapy.pdf

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