The Treatment of Mental Disorders

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Chapter 18

• The Treatment of Mental Disorders

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Road Map
gt Brief history of Mental Illness and
Treatment gt Insight Therapy gt Behavior
Therapy gt Cognitive-Behaviour Therapy gt Group
Therapy (not going to cover in class) gt
Biological Therapies (drugs and operations)
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Mental Illness Time Animals
Mental illness (abnormalities) has likely been
around as long as we are and likely exists in
the animal worlds as well. As one example
killer whales generally exist in pods (extended
families of sorts) and the pods have rights to
the prime salmon runs. However members are
sometimes kicked out of the pods and become
rogues (sometimes by themselves sometimes in
small groups). These rogues are the ones that
eat seals and such. They are denied access to
the good salmon. Why were they kicked out
Mental Illness Psychopathy
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Human History of Mental Illness
One bit of evidence suggesting a history of human
mental illness and attempted treatments of it
come from skulls that have been found that bear
man-made holes in them. Apparently these holes
were cut into the skull to allow the evil spirits
that had invaded the persons mind to
leave allowing the person some sanity
again. The notion of possessions and exorcisms
also likely reflect age old attempts to treat
schizophrenia or multiple- personality
disorder. Witch hunts are another example with
many cases of witches (e.g. salem) being
directly attributable to the effects of a
natural LSD like substance in bread.
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More Humane Treatments
In the not-to-distant past THE way to treat
mental disorders was to literally chain the
sufferer to a wall in an asylum or some similar
demobilization technique. gt e.g. the
tranquilizing chair in figure 18.2 Sometime
around the French revolution people with mental
disorders started to be thought of as patients
suffering from some malady of the mind. One
famous doctor named Pinel was largely
responsible for this shift in attitude as a
result of his liberation policies. The actual
medical treatment of disorders largely
began with the work of Mesmer Charcot Freud.
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Insight Therapies - Generally Speaking
The first really formal treatment method was that
used by Sigmund Freud. His psychoanalysis is now
viewed as one instance of a class of therapies
termed insight therapies. These therapies rest
on the assumption that the true causes of our
maladaptive behaviours are largely (if
not totally) unconscious. If these true causes
could be brought to consciousness the
problematic behaviours should cease. Thus the
therapy is focussed on bringing the
unconscious motivations to light mainly through
talk.
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Psychoanalysis
Freud believed that although the conflicts that
give rise to maladaptive behaviour are largely
kept from awareness by unconscious defense
mechanisms (the veil of amnesia) However hints
of the conflict do get through these defenses.
Examples of them getting through involve the
latent (as opposed to the manifest) content of
dreams and slips of the tongue. A trained
practitioner who knows what to look for
can interpret these things so long as the
patient gives them something to interpret. When
the conflict is discovered the veil is lifted.
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Psychoanalytic Techniques
Free association - the purpose of this technique
is to encourage the patient to speak freely about
things without censoring embarrassing or socially
unacceptable thoughts. Explains typical couch
situation. Dream analysis - the manifest content
of a dream is assumed to hide the latent content
in symbolic form. Via proper analysis the
therapist can get to the latent content which
gives clues to the underlying conflict. Hypnosis
- early in his career Freud also supported
the use of hypnosis as a way to get at underlying
conflicts. However he eventually dropped it
finding the other techniques more fruitful.
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Things that Happen During Psychoanalysis
Freud also specified certain reactions that can
occur during psychoanalysis that he described in
some detail including Resistance - at some
point in therapy as the therapist begins to close
in on the conflict patients normally back away
a bit as the revelations they are experiencing
are painful. Transference - sometimes during
therapy the patient will use the therapist as a
surrogate for someone else and will begin to
react to them accordingly. Freud eventually
saw this as useful to therapy. Countertransferenc
e - the therapist is also human and
may experience feelings of countertransference.
These were seen as bad for therapy. Therapists
should see therapists.
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Humanistic Therapy
A different insight therapy is based on the
notions of self-actualization we discussed
early. One example of this is Rogers
client-centered therapy. The basic assumption of
this therapy is that many of the psychological
problems we have relate to the difference between
the person we are and the person we wish to
be. Rogers called this difference
incongruence. The goal of the therapy is to
reduce incongruence by encouraging experiences
that will make the ideal self more realizable.
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Techniques of Client-Centered Therapy
The focus of this therapy is on the client and
helping the client to realize the source of their
problems with as little input from the therapist
as possible. Thus the major technique involves
something called reflection the sensitive
rephrasing or mirroring of the clients
statements. This is thought to allow the
therapist to demonstrate empathy which is
critical for encouraging the client to deal with
the incongruence and attempt to lessen it. It
is this type of therapy that is represented in
computer therapy programs such as Eliza.
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Weaknesses of Insight Therapies
In order to benefit from insight therapies a
person must intelligent articulate and
sufficiently motivated to commit several hours a
week for months or years. gt rules out
psychotics people with low intelligence
anyone who does not have the time or money. Hard
to evaluate success because success is usually
defined in terms of successful patients
feeling better. What about the others There
is also the insight escape clause that
always allows a therapist a ready excuse for
failures. Given the time and money that patients
commit they may be biased to feel that the
therapy is helping.
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Behaviour Therapy
Behaviour therapies are based on the basic
principles of learning theories (classical and
operant conditioning). Recall that learning
theory holds that a response (CR) can be learned
to a previously neutral stimuli (CS) if
that stimulus predicts the occurrence of some
other stimulus (UCS) that is linked to some
response (UCR). The CR is similar though not
identical to the UCR. From a behaviourist
standpoint this view accounts for the formation
of adaptive and maladaptive behaviours. Given
this assumption it should be possible to alter
maladaptive behaviours using learning
principles. Note that focus is on the
behaviours themselves
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Reward and Punishment
At their most basic level these therapies
involve administering either rewards
punishments or both. As an example of a reward
therapy (gone wrong) Steve will now relate his
story about when he served as a reinforcer. As
an example of the use of punishment Steve will
now relate some of the plotline of Clockwork
Orange hopefully without spoiling the ending
for you. Also flooding In some cases the use
of behaviourist principles are more complicated
...
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Systematic DesensitizationReplacing the bad CR
with a better one
In situations where the client suffers from an
anxiety disorder (e.g. a phobia) the
problematic CR is the anxiety response. An
opposite response to this would be relaxation.
If clients could be reinforced for relaxing in
the presence of the phobic-stimulus this
incompatible relaxation response could replace
the negative anxiety response. To be successful
this procedure seems to require a slow approach
to the actual phobic stimulus via a
hierarchy (Steve will explain). This procedure
is VERY successful at treating anxiety
disorders taking an average of 11 sessions.
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Other Positive Reinforcement StrategiesToken
Economies
One behavioural method that seems to work fairly
well within institutional situations (e.g. youth
offender centers) is something called token
economies. Essentially a token economy is a
situation wherein people are given some form of
reward (e.g. poker chips) for performing good
behaviours. These chips can then be turned in
for positive rewards such as special snacks or
activities (e.g. access to a games room). -
Mix99 Interactive Screen Saver This notion can
also include a punishment factor whereby people
would lose chips for behaving inappropriately.
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Techniques Based on Extinction
Recall that if the some behaviour is no longer
rewarded that behaviour tends to stop occurring.
- Extinction By the same token if the
reinforcing nature of some maladaptive behaviour
can be figured out and that reinforcer can be
prevented from occurring the maladaptive
behaviour should extinquish. This is the basis
of a several techniques including a
technique termed time-out in which social
attention is withdrawn anytime a person (or
child) performs a bad behaviour that is meant
to draw attention to them.
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A Slightly Different Kind of Extinction
A therapy called implosion therapy uses a
slightly different kind of extinction to treat
anxiety disorders. Rather than allowing a client
to escape some fear-inducing stimulus (and
thereby reward it via negative reinforcement) impl
osion therapy involves forcing the client to
have very close contact with the anxiety
producing stimulus and not allowing them to
escape. The idea is that the client will
eventually come to realize that the stimulus
will not harm them though this realization may
not come until after the person experiences a
certain amount of terror.
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Modeling A Kinder/Gentler Implosion Therapy
For some anxiety disorders a kinder/gentler
version of implosion therapy is just as
effective. Modeling involves having an authority
figure slowly demonstrate to the client that a
fear-inducing stimulus is in fact not to be
feared. This is a gradual process that proceeds
at whatever pace the client is comfortable
with. It is often very effective and does not
involve the high levels of stress that often
accompany implosion therapy.
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Cognitive-Behaviour Therapy
Some psychologists think that maladaptive (and
adaptive) behaviours are due to more than just
environmental variables Rather they believe
that the clients thoughts expectations percepti
ons and self-statements interact with the
environment to determine behaviour. gt Steves
SM example Given this viewpoint they believed
that the best therapy would be one that combines
behavioural treatments with a consideration of
the cognition the person brings to
bear. Sometimes it may be the cognition that
needs changing.
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Rational-Emotive Therapy
Developed by Ellis (circa 50s) rational-emotive
therapy is based on the assumption that
psychological problems are based on the way
people think about upsetting events and
situations. The therapy is therefore based on
changing peoples beliefs. It is a very direct
and confrontational therapy. The therapist
assesses the situation then tells the client
how they should change. Ellis identified several
irrational beliefs that many people share. He
would try hard to show the client that
these beliefs were irrational and should not be
bought into.
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Sample Irrational Beliefs
Wanting to be loved by everyone. Believing you
must be completely competent efficient and
goal directed in everything you do. Believing
that unhappiness is externally caused
and therefore out of your control. Believing
that your past behaviour completely
determines your future behaviour. Believing
there is a best solution to every problem and
that bad things happen if that solution is not
found.
gt Steve read passage from pp. 617
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Becks Depression Therapy
Beck believed that sometimes bad cognition was
caused by faulty logic as well as holding false
beliefs. He found that if you challenged a
depressed patient to expand on some depressing
comment they made you would often find that
there was little evidence to support the
comment. Perhaps if the patients logical
thinking could be more focussed they could
evaluate depressing thoughts and perhaps dispel
some of them.
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Evaluation of Cognitive/Behavioural Therapy
Insight therapists criticize the manner in which
behaviour based therapies focus on the symptoms
as opposed to underlying causes. They worry that
if one symptom is removed the underlying
conflict will simply produce another a process
called symptom substitution. gt Bed-wetting
example against substitution By and large these
therapies appear very successful AND they can
document their success with behavioural evidence.
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Group Therapies
The textbook discusses the issue of group
therapy at this point. Time does not permit me
to go into detail on group therapy so I leave
that section to you. I will now go on to talk
about biological treatments. gt Psychosurgery gt
Drugs
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Biological Treatments
The basic premise behind biological treatments of
mental disorders is that the disorder is due to
some biological problem with the brain. Perhaps
the brain is not constructed properly or
perhaps there is some kind of imbalance in
the neurotransmitters that pass around
communication in the brain. If this is true
then it might be possible to treat the disorder
by restructuring the brain or by affecting the
way neurotransmitters work. Similar to insight
therapies in terms of treating cause but
different as well (no psychodynamic stuff).
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Psychosurgery
One class of biological procedure that used to
be quite common is called Psychosurgery and
includes such procedures as Electroconvulsive
Therapy (ECT) and Frontal Lobotomies. Weve
basically went through the story of
frontal lobotomies already so I wont take that
up much more. However the Electroconvulsive
Therapy story is a different and interesting
one.
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Electroconvulsive Therapy (ECT)
It was noticed that schizophrenics who were
epileptic tended to feel better than normal after
a seizure. As a result physicians wondered if
inducing seizures could relieve the symptoms of
schizophrenia nope. However they noticed that
the convulsive treatment did tend to elevate the
mood of the patients. So it is now used to
treat depression especially as a quick fix
until a drug treatment can become effective. Why
does it elevate mood Possibly it does so
by somehow reducing REM sleep depressed people
tend to get too much REM sleep.
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Dangers of Psychosurgery
Psychosurgery involves making permanent changes
to the structure and/or functioning of the brain
usually it involves damaging the
brain. Clearly this is a procedure of last
resort and should only be used when no other
treatment options are available. Given this the
more common biological treatment for mental
disorders is no longer psychosurgery it is now
drugs.
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Pharmacotherapy
Our bodies are electro-chemical mechanisms which
means that they pass information as electrical
synapses which are transmitted via chemical
reactions. Given this it should not be
surprising that chemicals (drugs) can strongly
affect the way our machinery works. Thus in
line with the biological viewpoint
mental disorders may simply reflect imbalances in
chemicals. If the balance could be restored
perhaps the problematic behaviours would go
away. Here is a sample of some drugs used to
treat mental disorders ...
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Antipsychotic Drugs
These drugs are mainly given to schizophrenics as
they are quite effective at easing the positive
symptoms of that disorder (as we talked about re
Chlorpromazine) They do so by blocking the
dopamine receptors in the brain thereby
effectively reducing the influence of dopamine
in the brain. Unfortunately they do so in a
global fashion. The parts of the brain thought
to be responsible for schizo symptoms (cerebral
cortex and limbic system) are positively
effected. However so are other areas one of
which is involved in motor movements.
Antipsychotics actually cause problems for that
area which can lead to Parkinsons symptoms
(motor problems tardive dyskinesia).
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Antidepressant Drugs Tricyclics
Similar to ECT one class of antidepressants
called tricyclics were originally developed in
hopes they would benefit schizophrenics they
did not help the symptoms of schizophrenia but
they did make the schizos feel better. It is
thought that depression may result deficiencies
in the neurotransmitters norepinephrine and
sarotonin. The drugs slow the re-uptake of these
neurotransmitters thereby making it as if
there were more. Unfortunately tricyclics have
many side effects including dizziness sweating
weight gain constipation increased pulse poor
concentration and dry mouth.
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Antidepressant Drugs Prozac
As many of you likely know the new wonder
drug for treating depression is called
prozac. Prozac also inhibits the re-uptake
process but its effects are limited to the
serotonin neurotransmitter. For some reason
this seems to mostly take care of the depression
while causing many fewer side effects (perhaps
targeting the emotion without mobilizing
the body). The lower incidents of side effects
allows larger doses to be used.
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End of Chapter 18
The text discusses a number of other drug
therapies including drugs to help gt mania gt
bipolar disorder gt anxiety disorders It lays
out the pros and cons of drug therapy but
it most cases the moral is gtHow well do we
understand the biological causes gtCan we find a
drug that targets those causes only gtSo far
there has been some success in some areas. Now
moving forward to the past Chapter 15