This class

1
This class

• Clinical Social Work
• Clients With Mental Illness

2
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

3
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

4
Attempts at Reform In and Out of Asylums

• 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

5
Attempts at Reform In and Out of Asylums

• Dorothea Dix campaigned profusely as a leader of
  the moral-treatment movement in the US
• Unfortunately, funding seldom held up for long
• Titicut Follies

6
Attempts at Reform In and Out of Asylums

• 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

7
Attempts at Reform In and Out of Asylums

• This wasn't necessarily working out too well,
  either--just because you're out of the hospital
  doesn't necessarily mean you're cured

8
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

9
Hospital "Treatment" from a Patient's-Eye View
Rosenhan's 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

10
Hospital "Treatment" from a Patient's-Eye View
Rosenhan's 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

11
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

12
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

13
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

14
Places of Treatment

• nursing homes - usually for older patients these
  usually don't employ specialized personnel for
  treating people with mental disorders

15
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

16
Places of Treatment

• private office - run-of-the-mill psychologist
  visits outpatient care
• community mental health centres - cheaper
  versions of outpatient care

17
Providers of Treatment

• psychiatrists
• clinical psychologists
• counseling psychologists
• counselors
• psychiatric social workers
• psychiatric nurses

18
Recipients of Treatment

• the number of people whove received treatment
  for mental disorders is much smaller (approx 1/4)
  than the number whove 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

19
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

20
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

21
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

22
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

23
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

24
Projective Tests

• Rorschach classic ink-blot test people are
  shown symmetrical ink blots and are asked what
  they see

25
Projective Tests

• Thematic Apperception Test here, people see a
  picture and are asked to make up a story to go
  with the scene

26
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

27
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

28
Assessment of Brain Damage and Neuropsychological
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

29
Assessment of Brain Damage and Neuropsychological
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

30
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

31
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

32
Antipsychotic Drugs

• nausea
• dry mouth
• blurred vision
• constipation
• sexual impotence (in males)
• shaking
• difficulty in controlling voluntary movements

33
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

34
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

35
Antidepressant Drugs

• most are believed to work by increasing the
  availability of monoamines, especially serotonin
  and norepinephrine
• Good effectiveness in treating depression

36
Antidepressant Drugs

• there are, however (of course) side effects,
  including
• fatigue
• dry mouth
• blurred vision

37
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

38
Lithium for Bipolar Disorder

• side effects - serious dehydration, at high
  doses--an overdose of lithium can be lethal

39
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

40
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

41
Antianxiety Drugs

• just in case that wasn't enough, these are also
  addictive withdrawal symptoms include
• sleeplessness
• shakiness
• anxiety
• headaches
• nausea

42
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

43
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

44
Electroconvulsive Shock Therapy

• 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

45
Electroconvulsive Shock Therapy

• why it works is not understood
• there are some temporary disruptions in
  cognition, especially memory

46
Electroconvulsive Shock Therapy

• 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

47
Psychosurgery

• Id rather have a bottle in front of me than a
  frontal lobotamy

48
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

49
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

50
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

51
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

52
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

53
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

54
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

55
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

56
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

57
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

58
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

59
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

60
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

61
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

62
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

63
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

64
Rogers's Client-Centred Therapy

• 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

65
Rogers's Client-Centred Therapy

• 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

66
Rogers's Client-Centred Therapy

• 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

67
Rogers's Client-Centred Therapy

• 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

68
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

69
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

70
Ellis's Rational-Emotive Therapy

• 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

71
Ellis's Rational-Emotive Therapy

• 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

72
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

73
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

74
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

75
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

76
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

77
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

78
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

79
Aversion Treatment to Eliminate Bad Habits

• 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

80
Aversion Treatment to Eliminate Bad Habits

• 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

81
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

82
Some Other Behavioural Techniques

• 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

83
Some Other Behavioural Techniques

• Modeling teaching people to do something by
  having them watch someone else do it

84
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

85
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

86
Yaloms Therapeutic Factors

1. Instillation of hope
2. Universality (inadequacy, inability to love,
   sexual secrets)
3. Imparting information
4. Altruism
5. Corrective recapitulation of family
6. Socialization

87
Yaloms Therapeutic Factors

1. Imitative behaviour
2. Interpersonal learning (social microcosm)
3. Group cohesiveness
4. Catharsis
5. Existential factors

88
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

89
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

90
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

91
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

92
Psychotherapy Research

• Smith, Glass Miller (1980)
• Meta-analysis of 475 studies
• Mean effect size of .85
• Similar results from numerous other studies

93
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 (gt 6 months) better than
  short term therapy
• No particular therapeutic modality is better than
  others

94
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

95
Psychotherapy with children adolescents

• The average treated child is better off than
  70-75 of those with similar problems who do not
  receive treatment
• Behavioral techniques generally produce greater
  effects than non-behavioral techniques,
  regardless of type of problem, therapist
  training, or child age/gender

96
Psychotherapy with children adolescents

1. Therapy is equally effective for undercontrolled
   and overcontrolled problems
2. Therapy outcome is better for adolescents
   (especially girls) than for children

97
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

98
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

99
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

100
Therapist Factors

• Experience Some evidence that greater therapist
  experience related to lower dropout rates and
  better outcomes
• Competence more important than specific
  treatment modality

101
Client-Therapist Factors

• Therapeutic Alliance
• Attraction
• Expectations
• Similarity

102
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

103
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

104
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

105
Treatment Factors

• Placebo effects
• Impact on medical utilization
• Eclecticism

106
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

107
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

108
Personality

• States vs. traits
• Cattell, Eysenck, Big Five
• Evolutionary implications/theory
• Sibling differences
• Psychodynamic theory of personality
• Freuds defense mechanisms
• Rotter - locus of control
• Bandura - self-efficacy

109
Mental Disorders

• How do various theories explain cause/etiology of
  mental disorders?
• Anorexia
• Anxiety Disorders
• Phobia
• GAD
• OCD
• Panic Disorder

110
Mental Disorders

• Mood Disorders
• Depression
• Bipolar Disorder
• Beck Seligmans theories
• Schizophrenia
• symptoms (positive, negative, types)
• types of schizophrenia
• culture

111
Mental Disorders

• Somatoform disorder
• Dissociative Identity Disorder

112
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)