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Chapter 6

Ch. 6 notes - Psychopathology 2.doc

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Christopher Teeter

Ch. 6 – Psychological Treatment Introduction • Potential barriers to seeking psychological treatment: • Internal – ex. self-defeating thoughts • External – ex. lack of funds to pay for treatment • Overwhelming number of options Section 1: Diversity of Treatment Consumers Tailoring Treatment to the Disorder • Accurate and comprehensive clinical diagnosis of a psychological disorder/conceptualization of a psychological condition is an important precursor to choosing appropriate treatment • Accurate diagnosis has implications for the likelihood that the person will seek treatment in the first place • Ego syntonic disorders – symptoms are perceived by the patient as valued/advantageous • Ego dystonic disorders – symptoms are perceived by the patient as undesirable • Ex. OCD is ego dystonic – view their own obsessions and compulsions as irrational and cause of psychological stress • Ex. Obsessive-Compulsive Personality Disorder (OCPD) is ego syntonic – view their rigid and perfectionist tendencies as pos. character traits Tailoring Treatment to the Individual • Accurate diagnosis doesn’t provide complete picture of patient’s needs – ex. each person diagnosed with MDD has different needs, depending on the source of their depression (ex. 67yr old homeless man vs. an 11yr old child/ post-partum mom) • Effective psychological treatment should account for individual, family, social, circumstantial, and cultural contexts that the client is in • Prochaska and DiClemente (1983) – stages of change – originally developed based on the study of people who successfully quit smoking – stages identify a stepwise progression of thoughts and actions that characterize effective change of problematic behaviours/thoughts 1. Precontemplation – inability/unwillingness to acknowledge the existence of a problem 2. Contemplation – acknowledges the existence of a problem, but may be unsure/unwilling to change it 3. Preparation – recognition of the problem and preparation for change 4. Action – taking steps to change behaviour 5. Maintenance – continuation of health habits formed at the action stage – watch out for potential stressors that may trigger re-emergence of unhealthy behaviours • People can move forwards and backwards through the stages • Relapse – not one of the stages – full re-emergence of old unhealthy behaviours – often returns person back to Precontemplation stage Section 2: Diversity of Treatment Providers Range of Provider Backgrounds and Licensure • Search for a “therapist” can yield an overwhelming array of options • “psychologist” – usually restricted to those that hold a doctoral degree in psychology • “therapist” – freely available to be used by anyone who provides mental health services • Licensed psychologists – ones with specific training and certification in clinical/counselling psychology • Psychiatrists – medical doctors who have advanced training and certification in the practice of psychiatry • Other professionals who provide psychological treatment incl. social workers, counsellors, mental health workers, and marriage/family counsellors – many are subject to licensure requirements – demonstrates they have basic competencies to practice according to ethical and professional standards of their chosen field • When choosing a mental health professional, it is a good idea to choose a licensed professional and to research the specific requirements for licensure in that individual’s field The Art and Science of Psychological Treatment • One key factor that has been shown to have an important effect is a therapeutic relationship between the therapist and the patient • APA found that the quality of the therapeutic relationship accounts for as much of the treatment outcome as the treatment methods • “demonstrably effective” relationship qualities:  Degree to which the therapist and patient form an alliance (in individual therapy)/show group cohesion (in group therapy)  Degree to which the therapist is able to demonstrate empathy (understanding of the patient’s emotions and thoughts)  Degree to which the therapist collects and responds to feedback from the patient • “probably effective” relationship qualities:  Positive regard – therapist views patient as a fundamentally good person  Goal consensus  collaboration Section 3: Diversity of Treatment Options • treatment can be broken into 2 categories: psychological and biomedical • it is not uncommon for these to be provided together in combination treatment – sometimes together, sometimes one after the other, depending on the presenting symptoms, client preferences, and provider offerings • evidence-based practice movement proposes: 1. patient care is enhanced by the use of up-to-date knowledge 2. there is a gap between advances in knowledge and individual clinicians’ abilities to keep up with these advances 3. summaries of evidence presented by experts will bridge this gap and enable clinicians to keep up with important advances • clinicians should be held accountable for keeping practices up to date • trainees should learn most up to date treatments • led to creation of expert panels within major professional bodies of psychology (ex. Task Force on Promotion and Dissemination of Psychological Procedures of Division 12 [Clinical Psychology] of the American Psychological Association) that set up decision rules for evaluating evidence for specific treatments and applied these rules to create lists of empirically supported therapies for specific psychological disorders • concerns:  extent to which clinicians would have to restrict their practices to treatments on the list (by managed care companies/threat of malpractice lawsuit)  Existence of the list would prevent clinicians from using treatments they had previously found useful but lacked formal research support and prevent them from trying new and potentially innovative strategies  Validity of the process by which treatments were deemed to be empirically supported  Addressed issues of treatment efficacy and effectiveness Efficacy • Ability of treatment to produced desired effect in highly controlled settings • Efficacy studies for pharmacological treatments – designed to demonstrate that a medication has a desirable effect on a medical condition • Randomized controlled trial design is used to test this – participants with the condition (an no other condition) are randomly assigned to a treatment group (gets the new med)/control group (gets a placebo)  Single-blind trial – participants are not aware which group they are in  Double-blind – neither participants nor researcher is aware which group they are in • Easy to tell if med is effective/not • Efficacy studies for psychological treatments – complicate to implement • Issues:  Hard to find patients with a single condition of interest  Operationalizing the new treatments (ex. writing detailed treatment manuals)  Selecting appropriate placebos (ex. wait-list groups/education-only groups)  “blinding” both participants and researchers (virtually impossible)  Evaluating treatment outcomes (how is “improved” decided?) • Often criticised for failing to differentiate between statistical significance and clinical significance Effectiveness • Ability of a treatment to produce a desired effect in the real-world settings • Attempts to gauge the utility of a treatment for a real patient in an ordinary treatment setting • Prevalence of comorbidity of psychological disorders is high • Effectiveness studies of psychological treatments are more relaxed that efficacy studies in order to study treatment in a more naturalistic setting • Popular study by Consumer Reports magazine (1990s) – asked people who had received treatment for a mental health problem about their experience – 9/10 reported symptom improvement after treatment – longer therapy was associated with greater reported treatment  Degree of symptom improvement was not different depending on the profession of the therapist  Degree of symptom improvement was not different depending on whether individuals reported receiving psychotherapy alone/in addition to meds • Weaknesses:  Respondents may be a representative sample of the pop. of those who seek out and persist with treatment for psychological disorders, but may not be representative sample of the entire pop.  Absence of control group of similar individuals who did not receive treatment – unable to differentiate the effects of psychotherapy from “placebo” effects (ex. expectations of improvement associated with any therapy and related effects like social contact and simple passing of time)  Potential bias in the self—report data and limitations if the scale by which improvement was measured Evaluating the Evidence • Alan Kazdin – list of questions to guide research on psychological treatments: • Effect of treatment compared to no treatment? • Specific treatment components contribute to pos. change? • Treatment components added to optimize change? • Characteristics can be changed to improve outcome? • Effective compared to other treatments? • Contextual features mediate (cause) and moderate (influence) therapeutic change? • Treatment effects are generalizable to other psychological problems and treatment settings? Section 4: Historical Psychological Treatments • Psychotherapy – “talk” therapy – process of treating mental and emotional problems through verbal communication between a patient and therapist Psychoanalytic and Psychodynamic Therapy • Freud’s psychoanalysis is generally thought of as the first of the “talk” therapies • Worked primarily with female patients with hysteria • Developed theories on the origins and treatment of psychological disorders • Some of his ideas have been heavily criticised and are discordant with our current cultural context • Traditions of this school of therapy inform our popular culture representations of therapy and are well-represented in the treatment options available to us today • Conceptualization of psychological maladjustment: • Psychological distress is thought to arise from the presence of internal, unconscious conflicts, usually rooted in psychological trauma associated with childhood development • In Freud’s view, the mind (psyche) contained 3 levels of awareness:  Conscious – thoughts and feelings that you have access to at any given moment  Preconscious – contents can be actively brought to mind as needed  Unconscious – inaccessible thoughts, repressed traumatic memories, and primitive urges • Individual’s personality was composed of:  Id – operating at the unconscious level – motivated to fulfill our innate, primitive instincts  Ego – bridging the unconscious, preconscious, and conscious levels – responsible for executing urges of the id in a way that is acceptable to the ext. environment  Superego – bridges all 3 levels and seeks to govern your behaviour in such a way that is congruent with parental and societal standards of morality  Unsuccessful management of the conflicting urges of the id, ego, and superego at the unconscious level is thought to drive unhealthy behaviours and cause anxiety and distress • Goal of psychoanalytic therapy is to resolve suffering by bringing unconscious conflicts into conscious awareness – provides patient with insight and enables them to delve deeper in search of unconscious conflicts • Process of resolving conflicts into conscious awareness is thought to relieve psychological distress through catharsis and free patient to develop more adaptive patterns of behaviour • Therapeutic Techniques: • To successfully complete psychotherapy, the patient must bring thoughts, emotions, memories and actions of the unconscious into the conscious awareness – ego defense mechanisms make it difficult • Analyst has to circumvent the defenses so patient can reveal info that may provide insight into the unconscious  Freud developed techniques to diminish influence of the ego and facilitate access to the unconscious – one was patient lying on couch with therapist out of view – place patient at ease and minimize feeling of being observed • Free association – patient encouraged to let mind wander – report content to therapist without self-censorship – analyst attends to content with minimal verbal feedback – patients feels like they are alone with their thoughts • Dream analysis – similar to uncensored mind-wandering – defenses of the ego are relaxed – ego’s defenses are not completely eliminated during sleep so it involves 2 levels of contents:  Manifest content – elements of the dream (ex. unlocking the door to their house)  Latent content – underlying meaning of the dream • Analysis of resistance – analyst is cued to the emergence of painful/potentially embarrassing thoughts and feelings by the patient’s resistance (unwillingness/inability) to discuss certain topics – the more potentially damaging the emergence of an unconscious thought/memory could be, the more patients would be motivated to steer clear of it • Transference – process by which patient’s thoughts, feelings and drives developed in early childhood and experienced in significant relationships, are re- expressed/“transferred” onto the relationship with the analyst  Analysis of the thoughts, feelings, and behaviours of the patient toward the analyst can provide insight into unconscious conflicts causing distress in the patient’s relationships with others • Counter-transference – analyst’s reaction to patient’s transference  In classic psychoanalysis, the therapist undergoes significant personal psychoanalysis to gain insight into their own counter-transference reactions to minimize them and present a blank slate for the patient to re- enact their own relationship style, free from any potentially modifying influence from the reactions of the analyst • Mechanism by which psychoanalysis brought about the relief of psychological distress:  Techniques can provide catharsis associated with bringing unconscious material into conscious awareness  Material generated using these techniques serve as the raw material for analyst’s most critical task (interpretation) º To form interpretations, analyst sifts through free association, dream analysis, analysis of resistance and transference – identifies patterns, illuminates hidden conflicts, and explains true meaning of patient’s thoughts, feelings, drives, and conflicts º Goal is to provide patient with insight – patient can work thorough identified conflicts and delve deeper into the unconscious to discover further truths • Critique: • Freud’s conceptualization of psychological maladjustment cannot be directly observed (unconscious conflicts) – difficult to validate scientifically  If patient improves clinically, it is assumed to be because they have gained insight, but if they gain insight and do not improve clinically, it is assumed that the insight was no fully accepted • Classic psychoanalysis has limited generalizability – to participate, a patient must be intelligent, motivated, articulate, and rational – not the case for all people with psychological disorders • Modern iterations of psychoanalytic therapy are known as psychodynamic approaches – differ from historical approaches in that therapist takes a more active stance, engaging with the patient to discover areas of present-day (rather than childhood) conflict • Interpersonal therapy – psychodynamic approach that is patient-focused, time- limited, empirically supported for the treatment of depression, and applicable to a broader range of psychological problems  Therapy focuses on current relationships and issues within those relationships  By helping patient to learn to solve present relationship problems, the goal is to provide them with skills to develop more healthy relationships, reducing the psychological symptoms that come with unhealthy relationships with others Behavioural Therapy • Behaviourist ignores patient’s unobservable internal state and focuses on observable behaviours – allow for change in a measurable way • Built on the principles of classical and operant conditioning (Pavlov, Thorndike, and Skinner) – therapist considers themselves as an applied scientists, identifying a patient’s problematic behaviours, uncovering the reinforcement contingencies that perpetuate them, and implementing strategies to eliminate them • Conceptualization of psychological maladjustment: • Psychological symptoms and disorders arise as a result of maladaptive learning histories that give rise to problematic behaviours – consequences of maladaptive behaviours are often negative and lead to psychological distress • Modifying patients present-day maladaptive behaviour patterns and replacing them with more adaptive ones will lead to pos. consequences incl. dec. psychological distress – consequences will pos. reinforce adaptive behaviours • Pos. therapeutic change can occur without attention to patient’s int. thoughts and feelings – behaviourist don’t deny existence of patient’s int. world, but regard it as unobservable, immeasurable, and unessential for effecting behavioural change • Patient’s early life learning history is not a focus of attention • Therapeutic Techniques: • Use a wide range of tools based on the principles of classical and operant conditioning • Systematic desensitization – developed by Joseph Wolpe – principles of classical conditioning are used to decouple the stimulus-response association – achieved by taking gradual steps to counter-condition the feared stimulus with an adaptive response that is incompatible with fear – multi-step process that typically begins with practice in a response incompatible with fear:  First stage: relaxation training – therapist instructs the client in skills such as progressive muscle relaxation and abdominal breathing – patient and therapist work at these skills (often incl. homework for patient) until the patient is able to efficiently and effectively put themselves in a relaxed state on demand  Second stage: anxiety hierarchy is generated where feared situations are listed in order of least to most anxiety provoking – may incl. real and imagined events º Therapist and patent work up the hierarchy form least to most threatening and at each stage, the conditioned fear responses are slowly extinguished through exposure o Therapist guides the patient in putting themself into a state of deep relaxation using their practiced techniques – then guides them to imagine/actually put themself in a feared situation º Goal is over repeated trials to slowly re-condition the feared stimuli in the hierarchy with an adaptive relaxation response º Once a stimulus at the bottom of the hierarchy can be reliably encountered without fear, the patient and therapist move up to the next one on the ladder until the most feared stimuli at the top can be faced without fear • Behaviour modification – based on operant conditioning – analysis of specific behaviours is undertaken to understand how certain contingencies inc./dec. the likelihood of recurrence of the behaviours • Critique: • Effective for reducing symptoms of mood disorders (especially MDD and dysthymia), anxiety disorders (especially phobias and OCD), and substance- related disorders • Can be applied to a much broader range of patients than psychoanalysis • Effective behavioural treatments have been developed for people with autism, mental retardation, brain injury, and Alzheimer’s • First critique relates to generalizability – skills learned in the therapy relationship may not easily translate to the real world setting • Second critique relates to ethics of behaviour modification – it is unethical for one person to endeavour to change the behaviour of another Humanist/Client-Centered Therapy • Influenced most by Carl Rogers – emphasizes and celebrates the autonomy of the patient – patent is not seen as a collection of unconscious drives and conflicts/a set of maladaptive behaviours – treated as a whole person, expert in their own feelings, thoughts, and desires • Goal of therapy is to work with the patient, joining in their current thoughts, feelings, and struggles, and working together to enable her to follow her own innate tendencies towards self-actualization – realization of full potential • Conceptualization of psychological maladjustment: • Psychological distress develops when a person’s sense of self-concept (int. representation of themselves as worthwhile human beings) becomes incongruent with their experience (moment-to-moment interactions with the ext. world) • One of the main precursors to the development of incongruence is the formation of conditions of worth within the self-concept (ex. a student believes they are only worthwhile if they get straight A’s – when they get a B, experience doesn’t match their self-perceived conditions of worth and they experience incongruence and psychological distress) • A person’s self-concept is heavily influenced by their relationships with significant others • A healthy self-concept contained few conditions of worth and developed through the experience of unconditional pos. regard in relationships, especially formative relationships with caregivers in early life – demonstrate (through words and actions)an unwavering empathy for their feelings, understanding of their thoughts, and prizing of their inner experience as a human being  In such a relationship, individual’s develop a self-concept that is free from restrictive conditions of worth  Ex. a mom saying to her child who received an A “I am proud of you always and happy you got an A”  Conditional pos. regard is shown in the statement, “I am proud of you if you earn A’s.”  Unconditional pos. regard doesn’t dictate universal acceptance of behaviour (ex. “I can see that you are upset and I understand, but throwing your food at the table is not an acceptable action.” Vs. conditional pos. regard “You are a bad boy for throwing food.” • Therapeutic Techniques: • Nondirective therapy – therapist’s techniques restricted to reflection and response to the client’s stated thoughts and feelings  Humanists prefer the term “client” to “patient”  Therapist was instructed to never direct the conversation  Later the name was changed to client-centered therapy – emphasis on the client rather than the therapist  Goal is to enhance healthy functioning by enhancing a person’s congruence between self-concept and their experience – can be achieved in the context of a safe, social relationship in which the client is free to discover and explore their areas of incongruence  Therapist’s task is to foster this social environment be demonstrating 3 core conditions in the therapeutic relationship: º Unconditional positive regard – therapist shows through words and actions that the client is a person of worth and goodness, and that no revelation, however embarrassing/anxiety-provoking for the client, will be met with judgement º Empathy – therapist makes every effort to understand the client’s feelings in the moment and validates those feelings back to the
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