Unit 12: Pages 610 – 648
An Overview of Treatment
- Psychotherapy: the belief that people with psychological problems can change – can learn more adaptive ways of perceiving,
evaluating and behaving.
- Therapy takes time and offers no magical transformations. However, it does hold promise even for the most severe mental
disorders and contrary to the common opinion, psychotherapy can be less expensive in the long run than alternative modes of
- Several hundred therapeutic approaches exist
Why do People Seek Therapy?
Stressful Current Life Circumstances
- Vary widely in their problems and in their motivations to solve them.
- Sudden and highly stressful situations such as divorce or unemployment. People who feel so overwhelmed by a crisis that they
cannot manage on their own. They are motivated to alter their present intolerable mental states. In such situations, clients may
improve considerably in brief time by adopting the perspective provided by their therapist
People with Long-Standing Problems
- Lengthy histories of maladjustment and long-term psychological distress. They may have had interpersonal problems such as
inability to be comfortable with intimacy or has felt susceptible to low moods. These people seek psychological assistance out of
dissatisfaction and despair. They may enter treatment with a high degree of motivation but as therapy proceeds, their persistent
patterns of maladaptive behaviour may generate resistance.
- Indirect route such as being referred to a therapist by a physician. Reluctant clients may come from many sources (ex. “therapy
or divorce” or a suspected felon that has “entered therapy” will often do better in trial). In general, males are more reluctant to
enter therapy than females. A number of angry parents demand that their therapist fix their child’s “uncontrollable behaviour” –
the parents may be reluctant to recognize their own role in shaping the behaviour.
People Who Seek Personal Growth
- Have problems we would consider relatively normal. They enter therapy not out of personal despair or impossible interpersonal
involvements, but out of a sense that they have not lived up to their own expectations and realized their own potential. These
people may make substantial gains in personal growth partly because their problems are generally more manageable.
- Psychotherapeutic interventions have been applied to a wide variety of chronic problems.
- There is no “typical” client, neither is there a “model” therapy. Client variables such as motivation to change and the severity of
symptoms are exceedingly important to the outcome of therapy.
Who Provides Psychotherapeutic Services?
- Physicians often become trusted advisers in emotional matters as well and refer patients to psychological specialists or
psychiatrists if needed.
- Clergy also deal with emotional problems – minister, priest, or rabbis are frequently the first professional to encounter a person
experiencing an emotional crisis. Most limit their counselling to religious matters and spiritual support and do not attempt to
- The 3 types of mental health professionals who most often administer psychological treatment in mental health settings are
clinical psychologists, psychiatrists, and clinical social workers.
- The medical training and licensure qualifications of psychiatrists enable them to prescribe psychoactive medications and also to
administer other forms of medical treatment such as electroconvulsive therapy, in addition to providing psychotherapy.
Generally, psychiatrists differ from psychologists in their predilection for treating mental disorders with a biological approach
(medications) whereas psychologists generally treat patients’ psychopathology by examining/changing the patients’ behaviours
and thought patterns.
- Willingness to use a variety of procedures is reflected in the frequent use of a team approach to assessment and treatment,
particularly in group practice and institutional settings. This approach ideally involves the coordinated efforts of medical,
psychological, social work, and other mental health personnel working together as the needs of each case warrant – integrates
family and community resources in the total treatment approach
The Therapeutic Relationship
- The client’s major contribution is their motivation
The Therapeutic Alliance
- Establishment of an effective “working alliance” – essential to therapeutic gain. The relationship with the therapist is therapeutic
in its own right.
- Therapists’ personal characteristics help determine therapeutic outcome. How well clients do in treatment is related to the
strength of the alliance. Other factors like the level of expertise and experience of the therapist also appear to be important,
although there is variability across studies. Expert therapists have been shown to be better than either experienced or novice
therapists in ability to provide clear, coherent, and succinct account of a patient’s problems and develop a treatment plan - Key elements of the therapeutic alliance are: (1) a sense of working collaboratively on the problem (2) agreement between
patient and therapist about the goals and tasks of therapy (3) an effective bond between patient and therapist. Clear
communication is also important – facilitated by the degree of shared experience in the background of the two.
Other Qualities that Enhance Therapy
- Client’s motivation to change = crucial element in determining the quality of therapeutic alliance and hence level of success to be
- Client’s expectation of receiving help. This expectancy is often sufficient in itself to bring about substantial improvement (may
engage more in the process). If a therapy or therapist fails to inspire client confidence, the effectiveness of treatment is likely to
- A therapist brings a variety of professional skills and methods to help people see themselves and their situations more
objectively, to gain a different perspective. Therapy situations also offer a client a safe setting to practice new ways of feeling
- An effective psychotherapist must help the client give up old/dysfunctional behaviour patterns and replace them with
new/functional ones. The therapist must be flexible enough to use a variety of interactive styles
- A therapist’s own personality is an important factor in determining therapeutic outcomes.
Measuring Success in Psychotherapy
- Attempts at estimating clients’ gains generally depend on one or more of the following sources of information: (1) a therapist’s
impression of changes (2) a client’s reports of change (3) reports from the client’s family or friends (4) a comparison of
pretreatment and post-treatment scores on personality tests or on other instruments measuring relevant facets of psychological
functioning (5) measures of change in selected overt behaviours each of these sources has its own limitations
- A therapist may be biased in favour of seeing themselves as competent and successful. The therapist typically has only a limited
observational sample (client’s in-session behaviour)
- Client biases and an attempt to please the therapist they may report that they are being helped. Relatives may also be inclined to
“see” improvement they had hoped for, although they often seem to be more realistic than either the therapist or client.
- Clinical ratings by an outside, independent observer are sometimes used in research on psychotherapy outcomes to evaluate
progress – may be more objective. Another objective measure is to measure performance on various psychological tests – the
differences in scores are assumed to reflect progress, or lack of progress, or even deterioration. However, some of the changes
that such tests show may be artifactual, as with regression to the mean, wherein very high (or very low) scores tend on repeated
measurement to drift toward the average of their own distributions, yielding a false impression that some real change has been
documented. The particular tests selected are also likely to focus on the theoretical predictions of the therapist or researcher (not
necessarily valid predictors of the changes). Without follow-up assessment, they provide little information on how enduring any
change is likely to be.
Objectifying and Quantifying Change
- Generalized terms such as recovery, marked improvement and moderate improvement which were often used in outcome
research in the past are open to considerable differences in interpretation. Today the emphasis is on using more quantitative
methods of measuring change (ex. The Beck Depression Inventory – a self-report measure of depression severity and the
Hamilton Rating Scale for Depression – a set of rating scales used by clinicians to measure the same thing) – both yield summary
scores and have become almost standard in the pre- and post-therapy assessment of depression.
- Such techniques, including client self-monitoring, have been widely and effectively used, mainly by behaviour and cognitive
behavioural therapists. Also, fMRI to examine brain activity before and after treatment.
Would Change Occur Anyway?
- Treatment offered by therapists has not always been clearly demonstrated to be superior in outcome to nonprofessionally
administered therapies. However, psychotherapy can often accelerate improvement or bring about desired behaviour change that
might not otherwise occur. Psychotherapy is more effective than no treatment. Research suggests that about 50% of patients
show clinically significant change after 21 therapy sessions and after 40, about 75% improved
- Progress in therapy is not always smooth and linear – some people have “sudden gains” between sessions appear to be
triggered by cognitive changes or by psychodynamic insights that patients experience in certain critical sessions.
Can Therapy Be Harmful?
- Somewhere between 5 -10% of clients deteriorate during treatment. Patients suffering from borderline personality disorder and
OCD typically have higher rates of negative treatment outcomes.
- Obvious ruptures of the therapeutic alliance – “negative process” – client and therapist become embroiled in a mutually
antagonistic and downwardly spiralling course, account for only a portion of the failures. In other instances an idiosyncratic array
of factors operate together to produce deteriorating outcomes.
- It is ethically required of all therapists (1) to monitor their work with various types of clients to discover any such deficiencies (2)
to refer to other therapists those clients with whom they may be ill-equipped to work
What Therapeutic Approaches Should be Used?
- When a pharmaceutical company develops a new drug, it must obtain approval of the drug from Health Canada’s Health
Protection Branch (HPB) before the drug can be marketed in Canada. This involve demonstrating through research on human
subjects that the drug has efficacy – it does what it is supposed to do in curing/relieving some target condition. These tests, uing
voluntary and informed patients as subjects are called randomized controlled trials (RCTs) or efficacy trials randomly
assigning to active drug group or placebo group. Usually neither the patient nor the prescriber is informed which is to be rd
administered; that info is recorded by a 3 party. This double-blind procedure is an effort to ensure that expectations on the part
of the patient and prescriber play no role in the study. There has been difficulty concocting a credible placebo condition therefore
the adopted strategy is either comparing two or more purportedly “active” therapies or using a no-treatment (“waitlist”) control
of the same duration as the active treatment
- Although manualized therapies originated principally to standardize psychosocial treatments to fit the randomized controlled
trail (RCT) paradigm, some therapist recommend extending use of these manualized therapies to routine clinical practice after
efficacy for particular disorders has been established.
- Efficacy/RCT studies of psychosocial treatments are time-limited and usually focus on patients who have a single DSM-IV-TR
diagnosis and involve 2 or more treatment or control (e.g. waitlist) conditions where at least one of the treatment conditions is a
psychosocial one (another could be some biological therapy). Efficacy studies of the outcomes of specific psychosocial treatment
procedures are considered the most rigorous type of evaluation we have for establishing that a given therapy “works” for clients
with a given DSM-IV-TR diagnosis. Treatments that meet this standard are “empirically validated” or “empirically supported”.
- Efficacy studies have been criticised for testing treatments under the most ideal conditions rather than circumstances in which
they are typically administered in real life. Researchers are increasingly testing the effectiveness (extent to which a treatment
leads to change under less than optimal conditions) of their treatments in addition to their efficacy
Medication or Psychotherapy?
- Issues with psychopharmacology: aside from possible unwanted side effects, there is the complexity of matching drug and drug
dosage to the needs of the specific patient as well as changing medications. Drugs themselves do not generally cure disorders,
they tend to alleviate symptoms by inducing biochemical changes.
- For many disorders the integration or medication and psychotherapy is common in clinical practice. 55% of patients receive both
medications and psychotherapy in one study. This integrative approach is an example of the biopsychosocial perspective. For
certain kinds of problems such as anxiety disorders, there is little evidence that a combined approach is more effective
medications may interfere with the effects of psychotherapy for panic disorder
- The combined use of drugs and psychosocial approaches have been beneficial in some severe disorders such as schizophrenia
and bipolar disorder clinical benefits. Medication and psychotherapy may target different symptoms and work at different
Pharmacological Approaches to Treatment
- These drugs are sometimes referred to as “psychoactive” (literally, “mind-altering”) medications, indicating that their major
effects are on the brain.
- Used to treat psychotic disorders such as schizophrenia and psychotic mood disorders. Key therapeutic benefit = ability to
alleviate or reduce the intensity of delusions and hallucinations by blocking dopamine receptors.
- The half-life of the drug is the time it takes for the level of the active drug in the body to be reduced by 50% (being metabolized
and excreted). Advantages of a long half-life = less frequent dosing, less variation in the concentration of the drug in the plasma,
less severe withdrawal. Disadvantages = risk that the drug will accumulate in the body as well as increased sedation and
psychomotor impairment during the day.
- These drugs are also useful in treating other disorders with psychotic symptoms such as mania, psychotic depression, and
schizoaffective disorder, and they are occasionally used to treat transient psychotic symptoms when these occur in people with
borderline personality disorder. They are also useful in treating Tourette’s syndrome and delirium and sometimes in treatment of
delusions, hallucinations, paranoia, and agitation that can occur with Alzheimer’s disease.
- Usually administered daily by mouth. Sometimes depot neuroleptics are administered in a long-acting, injectable form (one
injection can last up to 4 weeks).
- One problematic side effect of these medications such as chlorpromazine is tardive dyskinesia – movement abnormality that is a
delayed result of taking antipsychotic medications. Movement-related side effects are much less common with atypical
medications such as clozapine (Clozaril) and olanzapine (Zyprexa) – these are preferred in the clinical management of
schizophrenia. Clozapine also seems to be beneficial for psychotic patients at high risk of suicide.
- Atypical antipsychotic advantages: evidence that they may effectively treat both the positive and negative symptoms of
schizophrenia whereas older, traditional neuroleptics worked mainly on the positive symptoms. However, side effects include
weight gain and diabetes. A more serious side effect of clozapine is a potentially life-threatening drop of white blood cells called
“agranulocytosis” which occurs in 0.5 – 2% of patients.
- Current thinking is that atypical antipsychotics (with the exception ondclozapine) are the 1 choice treatments for psychosis and
that clozapine and conventional antipsychotics (e.g. Haldol) are 2 line therapies.
Selective Serotonin Reuptake Inhibitors (SSRIs)
- The “classical antidepressants” such as monoamine oxidase inhibitors and tricycle antidepressants have now been replaced by
routine clinical practice by “second-generation” treatments such as SSRIs. In the late 80s fluoxetine (Prozac) became the 1 SSRI
released in Canada. There are now sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa) and
escitalopram (Cipralex) – the newest SSRI approved in 2004.
- Most antidepressants work by increasing the availability of serotonin, norepinephrine or both. SSRIs inhibit the reuptake of the
neurotransmitter serotonin following its release in the synapse. Unlike tricyclic’s (inhibit the reuptake of both serotonin and
norepinephrine), the SSRIs selectively inhibit the reuptake of serotonin. They have become the preferred antidepressant drugs because they are thought to be relatively “safe”. However, they are not considered more effective than the classic tricyclic
- Another widely used antidepressant in this drug family is venlafaxine (Effexor) – blocks reuptake of both norepinephrine and
serotonin and is part of a new category called SNRIs (serotonin norepinephrine reuptake inhibitors). It appears more effective
than SSRIs in the treatment of severe major depression. Another SNRI, duloxetine was introduced in 2007 in Canada.
- Clinical trials with SSRIs indicate that patients tend to improve after 3 – 5 weeks of treatment. Patients who show at least 50%
improvement in their symptoms are considered a positive response. When treatment removes all symptoms, patients are
considered to be in a period of remission (if sustained for 6 – 12 months, considered recovered).
- Side effects of SSRIs = nausea, diarrhea, nervousness, insomnia and sexual problems. Prozac is no more associated with suicide
than other antidepressants. Although there have been recent reports of increased suicidal ideation for children and adolescents
taking a range of SSRIs.
Monoamine Oxidase (MAO) Inhibitors
- Used infrequently now but were the first antidepressant medications developed in the 50s. Were being studied for the treatment
of tuberculosis when they were found to elevate the mood in patients. MAO inhibitors include isocarboxazid (Marplan),
phenelzine (Nardil), tranylcypromine (Parnate) and selegiline (Eldepryl). They inhibit the activity of monoamine oxidase, an
enzyme present in the synaptic cleft that helps break down the monoamine neurotransmitters (serotonin and norepinephrine) that
have been released into the cleft.
- Patients taking MAO inhibitors must avoid foods rich in amino acid tyramine (salami and Stilton cheese). They are used in
certain atypical depression cases characterized by hypersomnia and overeating.
- Operate to inhibit the reuptake of norepinephrine and (to a lesser extent) serotonin. The first TCA – imipramine- was being
studied as a possible treatment for schizophrenia when it was found to elevate mood. They tend to alter a number of other aspects
of cellular functioning including how receptors function and how cells respond to the activation of receptors and the synthesis of
neurotransmitters – mediate the antidepressant effects
- Trazodone (Desyrel) was the first antidepressant to be introduced in North America that was not lethal if overdosed. It inhibits
the reuptake of serotonin and has heavy sedating properties that limit its usefulness. Sometimes used in combination with SSRIs.
In rare cases it can produce priapism in men – prolonged erection.
- Bupropion (Wellbutrin) – not structurally related to other antidepressants and does not block reuptake of serotonin and
norepinephrine but does increase noradrenergic function through other mechanisms. Clinical advantage: unlike some SSRIs, it
does not inhibit sexual functioning. However unlike other antidepressants it is not effective in the treatment of anxiety disorders.
- Mirtazapine (Remeron) is a recently introduced antidepressant that facilitates serotonin and norepinephrine neurotransmission.
Side effect = weight gain
Using Antidepressants to Treat Anxiety Disorders, Bulimia and Personality Disorders
- SSRIs are widely used in the treatment of panic disorders, social phobia, and generalized anxiety disorder, as well as OCD.
SSRIs and tricyclic antidepressants are also used in the treatment of bulimia. Patients with Cluster B personality disorders like
borderline personality disorder may show a decrease in certain symptoms, most notably mood lability, if they take SSRIs
- Most widely used class of anti-anxiety (anxiolytic) drugs – another class of drugs, the barbiturates are seldom used today except
to control seizures or as anesthetics. The first benzodiazepines were releases in the early 60s and are now drugs of choice for
acute anxiety and agitation. They are rapidly absorbed and work very quickly. One problem is that patients can become
psychologically and physiologically dependent – risk of withdrawal symptoms so must be weaned. Relapse rates are extremely
- Rarely recommended as first-line treatments for anxiety disorders. They are believed to work by enhancing the activity of GABA
receptors (GABA is an inhibitory neurotransmitter that plays an important role in the way out brain inhibits anxiety). Enhances
GABA activity in certain parts of the brain known to be implicated in anxiety – limbic system.
- Broad range of applications. Also used as supplementary treatment in certain neurological disorders but they have little place in
the treatment of psychosis. Among the most widely prescribed drugs.
Other Anxiety Medications
- Only new class since the early 60s is buspirone (Buspar) which is unrelated to benzodiazepines and is thought to act in complex
ways on serotonergic functioning rather than on GABA. Effective in treating generalized anxiety disorder. Low potential for
abuse, however it takes 2 – 4 weeks to exert any anxiolytic effects. Cannot be used to treat insomnia since it is nonsedating
Lithium and Other Mood-Stabilizing Drugs
- In 1940s John Cade in Australia discovered that lithium salts were