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Chapter 17

Ch. 17 - Therapy.pdf

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Department
Psychology
Course
PSYCH 2AP3
Professor
Richard B Day
Semester
Winter

Description
 Why do peopleseektherapy  Stressful current life circumstances  People with long-standing problems  Reluctant clients who had to go Want personal growth   Have chronic, severe problems and just want slight help  There is no "typical client" or model therapy  Outcomeoftherapydependson… o Motivation to change o Severity of symptoms  Menare morereluctant to entertherapy  Why? o Less able to recognize and label distress o Threat to self-esteem o Should be able to help themselves o Poorly informed about mental health  Should have celebrities advocate for them to go get help  Therapeutic Alliance  Definition o Work collaboratively on the problem o Agreement about the goals and therapy tasks c. Affective bond between the patient and therapist o Clear communication  How well clients do in treatment is related to the strength of alliance they have with their therapists  Expert therapist are better than either experienced or novice therapists o Better at case formulation and making appropriate treatment plans  Pessimistic or ambivalent clients respond less well to treatment  Otherqualitiesthatenhancetherapy o Client's motivation to change o Client's expectation to receive help  Placebo; expect it to help, they engage more in the process o Therapist must be flexible to try different strategies if clients aren't interested  Measuringsuccessin therapy Evaluating clients' gains depend on 1 or more of these following sources of information:  Therapist's impression of change that has occurred o Biased that they are helping o Limited observation sample, in office o Inflate improvement averages by encouraging difficult clients to discontinue therapy  Client's reports of change o Dissonant to pay money and not get better, so want to believe they are 3. Reports from the client's family or friends o More realistic than the therapist or client o Still want the client to be getting better 4. Comparison of pretreatment and post-treatment scores on relevant tests o Regression to the mean Very high or very low scores tend to drift towards the average on repeated  measurements  False impression of change o Not necessarily valid  May be suiting the researcher's predictions 5. Measures of change in select overt behaviours o Outside, independent observer may be the best way to evaluate a client  Objectifyingandquantifyingchange o Beck Depression Self report measure of depression severity Hamilton Rating Set of rating scales used by clinicians to measure depression Scale severity o Both give summary scores o Pre- and post-therapy assessment of depression  Psychotherapyismoreeffectivethanno treatment o Can improve overtime with no intervention but… o After 21 sessions, 50% of patients show clinically significant change o After 40 sessions, 75% of patients show " o "sudden gains" can even occur in one therapy session if the person has a big insight in a critical session  Psychotherapycanbe rarelyharmful o 5 - 10% of clients deteriorate during treatment o Negative outcomes are mostly seen in  OCD  Borderline personality disorder o Why  Negative Process (Binder and Strupp)  Client and therapist are mutually antagonistic and downward spiraling  Mismatch of C and T personality characteristics or problem types  Sex between C and T  What therapeuticapproaches shouldbe used?  Evidence-BasedTreatments o Drugs  Health Protection Branch (HPB)  Must approve a drug to then be marketed in Canada  Randomized controlled trials (RCTs)  EfficacyTrials  Testing to make sure a drug has efficacy  That it does what it is supposed to do in relieving or curing a target condition  Use placebo/active drug trial and double-blind etc.  If subjects on the active drug improved significantly more than those on the placebo, there is evidence for the drug's efficacy o Therapy  Manualized Therapies  Minimize the variability in patient's clinical outcomes that might be due to the therapist themselves  Originated in hopes of standardizing psychosocial treatments -> Fit the RCT paradigm  Without a manual, therapists won't know how to do the therapy exactly the way it needs to be done to get the supported results (efficacy)  Efficacystudies about psychosocial treatment procedures are very rigorous  If a therapy works it becomes… empirically validated or supported  Cons  Participants are not comorbid and mostly highly motivated  Being treated by highly trained professionals  Test treatments under the most ideal conditions  Effectiveness  Does a treatment lead to change under less than optimal conditions  Want a therapy evaluation to include efficacy studies and effectiveness studies  MedicationorPsychotherapy o Drugs alleviate symptoms, but don't change the personal or situational factors that may be creating or reinforcing the maladaptive behaviours / symptoms o Drugs have helped reduce hospitalization intake and shorten stays and lead to a more favorable hospital climate o For some disorders the failure to use medication can have very serious problems Therapists may be liable for failing to provide medication to patients with certain  disorders forwhich medications are known to be effective and available  CombinedTreatment: biopsychosocial perspective o 55% of patients receive both medications and psychotherapy for their problems o Medication and psychotherapy may be targeting different symptoms at different rates  Medication = short and fast/ Psychotherapy = long and broad o Very effective for Schizophrenia and bipolar disorder  But need to have psychotic episode starting to subside Not necessarily more Anxiety disorders effective than medication or  Medication may interfere with psychotherapy for therapy alone for panic disorders o Keller et al.  Compared outcomes of 519 depressed patients  Overall positive response rate was reported  Medication only = 55% improvement  Therapy only = 52% improvement  Medication and therapy = 85% improvement  PharmacologicalApproaches  Psychoactive drugs, aka. Mind-altering drugs  Drug half-life o Time it takes for the level of active drug in the body to be reduced by 50% o Advantage of long half-life Disadvantage Less frequent dosing Drug could accumulate in the body Less variation in concentration of drugIncreased sedation and psychomotor in the plasma impairment during the day Less severe withdrawal  Depot neuroleptics o Long-acting injectable drug that can last forup to 4 weeks o For patients who are unwilling or unable to take medication  Antipsychoticdrugs o Block dopamine receptors o Alleviate or reduce the intensity of delusions and hallucinations o Exp. Schizophrenia drug  60% treated with antipsychotic had resolution of positive symptoms in 6-weeks (vs. 20% on placebo) o Conventional antipsychotic (Exp. Chlorpromazine) problems  Tardive dyskinesia  Movement abnormalities, weird  Work mostly on positive symptoms o More atypical drugs are better  Less chance of movement abnormalities  May treat both positive and negative symptoms  Side-effects = weight gain and diabetes  Exp. Clozapine  Good forpsychotics at high risk forsuicide  Agranulocytosis  Life-threatening drop in white blood cells  0.5 - 2% of patients o Conventional antipsychotics and clozapine should be the 2nd choice and atypical should be the first choice  AntidepressantDrugs o Classic (older) antidepressants  Monoamine oxidase inhibitors  First one found, 1950 by looking fortuberculosis treatment  Inhibit activity of monoamine oxidase: enzyme that breaks down serotonin and norepinephrine in the cleft  Best forcases of hypersomnia and overeating depression  Tricyclic antidepressants  Inhibit reuptake of both norepinephrine and serotonin (to a lesser extent)  Found by looking forschizophrenia treatment  Also influence many other aspects of cellular function when working for many weeks  Also used in bulimia, reduce binging and purging  Can be lethal if overdosed on o New, preferred SSRI:Selective serotonin reuptake inhibitor  Inhibits reuptake of serotonin after it is released into the synapse  Increases availability of serotonin  Not more effective, just better tolerated  Less side-effects, easy to use, safe etc.  Show improvement after 3 - 5 weeks of treatment  Other uses  Social phobia, panic disorders, GAD and OCD  Also used in bulimia, reduce binging and purging o SNRI: Serotonin norepinephrine reuptake inhibitors  More effective than SSRI in treatment of major depression  Keeps both serotonin and norepinephrine available in the cleft o Prozac: better living through chemistry: world around us  People claim it transforms personality in a positive, self-esteem enhancing way  And diminishes sensitivity to disapproval, criticism and rejection by others o Other antidepressants  Trazodone  First to not be lethal with overdose  Inhibits serotonin reuptake  Possible priapism in men  Prolonged erection with no sexual stimulation  Bupropion  Does something else, not reuptake inhibition: increase noradrenergic function via other mechanisms  Does not inhibit sexual functioning  Not good foranxiety disorder treatment  Terminology o Positive response to treatment  50% improvement in symptoms o Remission  All symptoms have been removed o Recovered  Remission was maintained for 6 - 12 months  Anti-anxietydrugs o Anxiolytic  Effecton GABA to decrease anxiety  Widely prescribed o Benzodiazepines  Most important and widely used anti-anxiety drug  Enhances GABA activity; enhances the inhibitory neurotransmitter that reduces anxiety in stressful situations  Addictive  Must be weaned, withdrawal risk  60 - 80% of panic patients relapse after discontinuing Xanax o Buspirone  New class released after  Acts on serotonergic function  As effective on GAD  Has low potential for abuse and no withdrawal  But takes a long time to activate, not good for critical help  LithiumandMoodstabilizers o Took 2 decades to come to Canada  A mineral salt, so untenable and non-profitable  Used a salt substitute for hypertension and some people had died so they were weary o Mineral salt  Hypothesis: may affectelectrolyte balance and alter neurotransmitter systems o Therapeutic effect is unknown o Very effective  70 - 80% of patient in a manic stat show marked improvement after 2 - 3 weeks  Prevents future mania, less so fordepression o Discontinuation is risky  Relapse is 28x higher after withdrawal  50% relapse rate within 6 months o Side effects:can be toxic, kidney failure, neuron death etc. benefits > costs o Valproate has the fewest and mildest side effects  ElectroconvulsiveTherapy o History  Paracelsus (1500s)  Ladislas von Meduna  Modern originator of approach  Thought that you could cure schizophrenia with epilepsy o Function 
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