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Treatment

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Acute Stressful current life circumstances. Chronic People with long ... I don't get an A, my GPA is going to plummet and I'll never get into med school. ... – PowerPoint PPT presentation

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Title: Treatment


1
Treatment
  • 11.21.2007
  • (NO CLASS)

2
Why do people seek treatment?
  • Distress
  • Acute Stressful current life circumstances
  • Chronic People with long-standing problems
  • Reluctant clients
  • Physician referred
  • Martial problems (therapy or divorce)
  • Legal issues
  • Children brought by angry parents
  • Males tend to be more reluctant than females
  • Personal Growth

3
Who provides psychotherapeutic services?
  • People Team approach is often used
  • Clinical/Counseling Psychologists
  • Psychiatrists
  • Psychiatric Social Workers
  • Physicians
  • Psychiatric nurses
  • Clergy
  • School Psychologists
  • Places
  • Private clinics
  • Community clinics
  • Hospitals
  • ER
  • Churches, temples, mosques, etc.
  • Schools

4
Therapeutic Relationship
  • Factors Important for the Client
  • Motivation to change is the most crucial factor
    for success
  • Expectation the you are receiving help (placebo
    effect)
  • Factors Important for the Therapist
  • Personal characteristics (e.g. empathy,
    trustworthiness, etc.)
  • Level of expertise
  • Experience
  • Key Elements of the Relationship
  • Sense of working collaboratively on a problem
  • Agreement between patient and therapist about
    goals and tasks
  • Affective bond between patient and therapist

5
Measuring Success
  • Assessing Change
  • Therapists impression
  • Clients self-report
  • Report from family and friends
  • Objectifying and Quantifying Change
  • General terms like recovery, marked
    improvement, and moderate improvement are open
    to interpretation
  • Comparison of pretreatment and posttreatment
    scores on structured assessments and
    questionnaires
  • Measures of change in certain selected overt
    behaviors
  • In research settings perhaps using fMRI to
    compare brain activity before and after treatment

6
Measuring Success
  • Would change occur anyway?
  • Improvement often takes place without
    professional help
  • Some disorders have a specific brief course
  • Treatment attempts to accelerate change and/or
    provide change where none would likely occur
  • 50 of patients show clinical improvement after
    21 sessions 75 after 40 sessions
  • Can therapy be harmful?
  • Often it feels worse before it gets better
  • 5-10 of patients deteriorate during treatment
    highest rates among borderline personality
    disorder and OCD
  • Sex between therapist and client is unethical and
    almost always destructive

7
What Treatments Should Be Used?
  • Good Question.
  • Empirically Supported Treatments
  • In order to compare psychological therapies, need
    to conduct randomized clinical trials
  • Treatment manuals need to be created
  • Used to study efficacy as well as cost
  • Becoming more common and more similar to natural
    settings
  • Medication or Psychotherapy
  • Has led to decreases in hospitalization,
    restraints, and locked wards
  • Unwanted side effects
  • Difficult to match drug and dosage to needs of
    specific client
  • High rates of relapse

8
What Treatments Should Be Used?
  • Combined Treatments
  • Using both medication and psychotherapy
  • Medication can often help get a client to a
    place where therapy will be effective
  • Integration is now common (55 of clients receive
    both)
  • Patients appear to prefer combined approaches
  • Evidence suggests that especially for serious
    cases, combined approach is more successful

9
Antipsychotics
  • Alleviate or reduce the intensity of delusions
    and hallucinations in 60 of patients (block
    dopamine receptors)
  • Typical antipsychotics dont treat negative
    symptoms well
  • Problematic side effects (tardive dyskinesia)
  • Newer atypical antipsychotics reduce the
    incidence of movement-related side effects and
    may effectively treat both the positive and
    negative symptoms

10
Antidepressants
  • Tricyclics
  • Inhibits the reuptake of serotonin and
    norepiphrin
  • Alter the way neurons function, how cells respond
    to activation of receptors, and the synthesis of
    neurotransmitters
  • Selective serotonin re-uptake inhibitors (SSRIs)
  • Increases serotonin by blocking re-uptake process
  • Often produces dramatic results within 3-5 weeks
    (at least 50 improvement)
  • Better tolerance and fewer side effects than
    tricyclics, but not more effective
  • SSRIs also used for panic disorder, social
    phobia, GAD, OCD, bulimia, and Cluster B
    personality disorders

11
Antidepressants
  • Monoamine oxidase inhibitors (MAOIs)
  • Used infrequently today
  • Inhibit the activity of monoamine oxidase
  • Patients must avoid foods high in the amino acid
    tyramine
  • Other antidepressants
  • Trazodone first antidepressant not lethal on
    overdose
  • Wellbutrin increases noradrenergic function but
    does not inhibit sexual functioning (like most of
    the SSRIs do)
  • Serzone/Nefazodone does not inhibit sexual
    functioning or produce insomnia

12
Antianxiety Drugs
  • Benzodiazapines
  • Widely prescribed by physicians
  • Believed to enhance the activity of GABA
    receptors (primary inhibitory neurotransmitters
    in the brain)
  • Used as sleeping pills and to diminish
    generalized fear
  • Significant potential for abuse, serious
    withdrawal symptoms
  • Relapse rates are extremely high
  • Buspirone
  • Unrelated to benzos thought to work on serotonin
    rather than GABA
  • Those who have previously taken benzos dont
    respond as well to Buspirone
  • No sedative or muscle-relaxing properties
  • Low potential for abuse
  • Takes 2-4 weeks to show symptom relief

13
Mood-Stabalizers
  • Lithium
  • Biochemical mechanism unknown thought to act on
    neurotransmitter systems
  • 70-80 effective in resolving manic states
    maintenance treatment may be less reliable at
    preventing future episodes
  • Side effects include increased thirst, GI
    problems, weight gain, tremor, and fatigue, can
    be toxic on overdose
  • Discontinuation is very risky relapse rates 28
    times higher after withdrawal

14
Mood-Stabalizers
  • Other mood-stabilizing drugs
  • Other bipolar drugs include Depakote and Tegretol
  • Depakote - fewest and mildest side effects
    nausea, diarrhea, sedation, tremor, and weight
    gain
  • Tegretol significant side effects blood
    problems, hepatitis, serious skin conditions,
    careful blood monitoring required
  • Some antipsychotics are also used off-label to
    treat bipolar disorder, research is being done to
    substantiate anecdotal evidence, Abilify already
    being marketed for bipolar disorder

15
Electroconvulsive Therapy
  • Results indicate ECT can be safe and effective
    especially for
  • Severely depressed pregnant women
  • Elderly depressed patients
  • Severely depressed and suicidal patients who have
    failed to respond to other treatments
  • Patients with manic disorders who have not
    responded to treatments
  • How ECT works is still not fully understood but
    virtually every neurotransmitter system is
    impacted

16
Psychological Approaches to Treatment
  • Behavior therapy
  • Cognitive and Cognitive-Behavior Therapy
  • Humanistic-Experiential Therapy
  • Psychodynamic Therapy
  • Marital and Family Therapy

17
Behavior Therapy
  • Self-monitoring
  • Exposure therapy
  • Aversion therapy
  • Modeling
  • Systematic use of reinforcement
  • Token economies

18
Behavior Therapy
  • Self-monitoring
  • Increases awareness
  • Reactive
  • Activity
  • 1. Select a behavior that you would like to
    change (e.g. smoking, biting nails, saying um,
    etc.)
  • 2. Record the occurrence of the behavior
    immediately after is occurs for one week
  • 3. Plot the data by day (i.e. x-axis day,
    y-axis frequency of behavior)
  • 4. Observe whether or not the reactivity of
    self-monitoring produces a decrease in the
    behavior

19
Behavior Therapy Self-Monitoring
Behavior chewing on fingernails
Amount of time spent
Day/ Time
Mood
Place
Thoughts
5/1 1245 pm
Class
15 minutes
Anxious 70
The final is coming up in a few days and I have
to get an A. If I dont get an A, my GPA is going
to plummet and Ill never get into med school.
20
Behavior Therapy Self-Monitoring
FREQUENCY OF BEHAVIOR
1
2
5
6
7
3
4
DAY
21
Behavior Therapy
  • Exposure therapy (Classical Conditioning)
  • Widely used in the treatment of anxiety
    disorders, especially social/specific phobias,
    panic disorder, and OCD
  • Involves guided exposure to anxiety provoking
    stimuli can be accomplished slowly (systematic
    desensitization) or quickly (flooding)
  • Research as well as anecdotal evidence has shown
    significant success
  • Relaxation is paired with exposures because
    relaxation is an incompatible response to anxiety

22
Behavior Therapy
  • Aversion Therapy (Operant Conditioning)
  • Punishment is used to modify behavior
  • Used successfully with smoking, drinking,
    overeating, drug dependence, gambling, sexual
    deviance, etc.
  • Use of this technique is on the decline
  • Modeling (Observational Learning)
  • Behavior is learned by imitating others
  • Modeling is combined with instruction

23
Behavior Therapy
  • Systematic Use of Reinforcement (Operant
    Conditioning)
  • Often referred to as contingency management
  • Must first identify and remove contingencies that
    reinforce/maintain maladaptive behavior
  • Then Replace and reinforce more adaptive behavior
  • Token Economies (Operant Conditioning)
  • Originally developed for use with hospitalized
    schizophrenia patients
  • Patients earn tokens that can later be exchanged
    for rewards or privileges
  • Now being used to effectively treat other
    disorders in inpatient settings as well

24
Evaluating Behavior Therapy
  • Distinct advantages over other treatments
  • Achieves results quickly
  • Low costs
  • Methods clear and can be readily evaluated
  • Proven effective
  • Works better with some types of problems than
    others

25
Cognitive Cognitive-Behavior Therapy
  • Becks cognitive therapies
  • Orignially developed for depression, but later
    expanded to anxiety disorders, eating disorders,
    conduct disorder, personality disorders, and
    substance abuse
  • Problems result from biased processing of
    external events or internal stimuli leading to
    cognitive errors
  • Teach clients the relationship between thinking
    and emotional responses identify automatic
    thoughts and logical errors
  • Clients gather information about themselves and
    then are assigned tasks to test their hypotheses
  • The precise underlying automatic thoughts and
    accompanying dysfunctional schemas vary from one
    disorder to another

26
Cognitive Cognitive-Behavior Therapy
Consequence
Belief
Activating Event
New Consequence
New Belief
27
Evaluating Cognitive Cognitive-Behavior Therapy
  • Becks type of therapy is extremely effective for
    many disorders
  • Comparable to medication for depression in
    reducing symptoms better at preventing relapse
    than medication
  • Neurological exams show actual functional changes
    in the brain following cognitive and
    cognitive-behavior therapies
  • Research has shown efficacy in treating panic
    disorder, bulimia, personality disorders, conduct
    disorders, substance abuse, and GAD

28
Humanistic-Experiential Therapies
  • Client-centered therapy (Carl Rogers)
  • The primary objective is to resolve incongruence
    help clients accept and be themselves
  • Nondirective techniques such as empathic
    reflecting or restatement of the clients
    description of life difficulties are used
  • Psychological climate of acceptance is created
  • Self-concept becomes congruent with actual
    experiences
  • Pure client-centered therapy is rarely used today
    in NorthAmerica, although it is popular in Europe

29
Humanistic-Experiential Therapies
  • Gestalt therapy (Fritz Perls)
  • Gestalt means whole therapy emphasizes the
    unity of mind and body integrating thought,
    feeling, and action
  • Goal is to increase awareness and acceptance of
    self
  • Commonly used in group setting
  • Dreams are thought to be representations of the
    dreamers self
  • Process-Experiential Therapy
  • Combines client-centered and Gestalt therapies
  • Emphasizes the experiencing of emotions during
    therapy clients also reflect on their emotions
    and are encouraged to create meaning from them

30
Evaluating Humanistic-Experiential Therapies
  • Have influenced contemporary views of human
    nature and good psychotherapy
  • Criticized for lack of agreed-upon therapeutic
    procedures and vagueness
  • Research in past lacking newer research suggests
    these approaches may be helpful for depression,
    anxiety, trauma, and marital difficulties

31
Psychodynamic Therapies
  • Freudian psychoanalysis
  • Free association
  • Dream analysis
  • Analysis of resistance
  • Prevents talking about painful experiences
  • Forgetting
  • Analysis of transference
  • React as to another person in ones life
  • Counter-transference therapists reactions that
    are evoked by client

32
Psychodynamic Therapies
  • Interpersonal therapy (IPT)
  • Transferential and counter-transferential
    phenomena in all aspects of the persons life
  • All of us involuntarily invoke schemas acquired
    from our earliest interactions with others, such
    as our parents, in interpreting what is going on
    in our relationships
  • Introjected characteristics of early rejection or
    abuse may distort the individuals ability to
    process accurately and objectively the
    information contained in current interpersonal
    transactions

33
Evaluating Psychodynamic Therapies
  • Classical psychoanalysis is time-consuming,
    expensive, based on questionable approach,
    neglects a persons immediate problems, and lacks
    proof of effectiveness
  • Proponents still argue that the approach may be
    of benefit even if efficacy studies do not
    support it
  • Newer brief versions of psychodynamic-interpersona
    l therapies show some efficacy

34
Marital and Family Therapy
  • Marital therapy
  • Growing field
  • Gold standard Traditional Behavioral Couple
    therapy based on a social learning model,
    empirically effective
  • Integrative Behavioral Couple Therapy (IBCT)
    focuses on acceptance rather than change
    preliminary findings are quite positive
  • Family therapy
  • Developed from fact that many patients relapse
    when returned to their families
  • Based on systems theory and focuses on changing
    the organization of the family
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