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PSY 240 CH 17.docx

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Shaun Burns

PSY 240 CH. 17 Therapy • Therapists introduce you into the relationship psychological interventions that are designed to promote new understandings, behaviours, or both. An Overview of Treatment • Psychotherapy: Treatment of mental disorders by psychological methods. • Psychotherapy takes time and money, though it may be less expensive in the long-run than alternative intervention methods. Why Do People Seek Therapy Stressful Current Life Circumstances • Divorce or unemployment as well as other stressful situations lead people to seek therapy. People with Long-Lasting Problems • They have a long-term history of distress. These people seek help out of dissatisfaction or despair. Reluctant Clients • May be referred from a physician and be told their symptoms are psychological. Often reluctant to believe that is the case. • People given ultimatums (therapy or divorce) are also reluctant. • Males are more reluctant than females to enter. 17.1 The WorldAround Us: WhyAre Men So Reluctant to Enter Therapy? o This observation is made regardless of age, social class, ethnicity. o Men may be less likely to label their feelings as distressful. o Men who see masculine stereotypes around may have their self-reliance emphasized, as well as their lack of emotionality. This leads to men thinking they should suck it up. o Men may be more poorly informed about treatment options. o Solution is to develop treatment approaches based around men, and the theories surrounding them. o Promote masculine men getting help in popular media. People Who Seek Personal growth • They enter out of a sense that they have not lived up to their own potential. • Client variables such as motivation to change and the severity of the symptoms are incredibly important to the outcome of therapy. Who Provides Psychotherapeutic Services? • Physicians are trusted by patients, so they often tell them about their emotional problems. • Members of the church often deal with people experiencing an emotional problem. • 3 types of mental health professionals who administer psychological treatment in mental health settings are clinical psychologists, psychiatrists, and clinical social workers. • Psychiatrists focus more only treatment with drugs whereas psychologists focus more by looking at their behaviours and thought patterns. • In hospitals, many treatments can occur, ranging from group help sessions to biological treatments. • Alot of the time, a group of experts work together, coordinating efforts from a medical, psychological, social approach. The Therapeutic Relationship • The therapy outcome depends on whether or not the patient client relationship works. • Aclient’s major contribution is their motivation. The TherapeuticAlliance • The relationship between the therapist and patient is therapeutic in its own right. • The level of expertise and experience may affect the alliance. • The key elements of a therapeutic alliance are 1) a sense of working collaboratively on the problem, 2) agreement between patient and therapists about the goals and tasks of therapy, and 3) an affective bond between patient and therapist. Clear communication is also important. Other Qualities that Enhance Therapy • Motivation is the main one, though a client’s expectations of receiving help is also very important. • This expectancy to receive help can be a placebo whereby people feel as though it has helped. • The therapist offers a new, safe setting where they can be open about anything that they wish. • The style used by the therapist depends on the client, as the client is there to change old habits, and those vary from person to person. • Atherapist’s personality is important for determining the outcome of therapy as well. Measuring Success in Psychotherapy • Estimating gain from therapy depends on the following sources of information: 1) a therapists impression of changes that have occurred, 2) a client’s report of change, 3) reports from the client’s family and friends, 4) comparison of pre-treatment and post- treatment scores on personality tests or other instruments used to measure psychological functioning, and 5) measures of change in selected overt behaviours. • Atherapist is likely to be biased, and they only have a limited observational sample to draw information from. Clients can be affected by the placebo effect, or even try to please a therapist by saying they have improved. Often due to the commitment involved, people will say they have improved to justify it. Relatives may simply see changes that they had hoped for. • Clinical ratings by an outside independent observer are sometimes used in research on psychotherapy outcomes to evaluate progress. • Tests can yield false results due to regression to the mean.Also tests are often selected based on the focus of the therapist’s predictions. Objectifying and Quantifying Change • Rating scales and self-report measures are mostly used now. • Changes in certain behaviours can be observed (such as hand washing). This is done through client monitoring. 17.2 Developments in Research: Using BrainActivation to Measure Therapeutic Change o fMRI can be used to measure changes in brain activation. o By measuring the amount of blood flow to certain areas, they can tell which are the most active. Would Change OccurAnyway? • Getting support from family and friends can be just as effective as therapy at times. • Psychotherapy can often accelerate the improvements though. • Over 40 sessions, 75% of patients generally have improved when in psychotherapy. Can Therapy Be Harmful? • Estimates of around 5-10% deteriorate with treatment. • Some failures arise from the disrupt to the therapeutic alliance. Many factors can work together o make therapy unhelpful, such as the lack of relationship with the therapist, personalities, etc. • Therapists are required to refer a patient to another therapist if things are not working out between them. What TherapeuticApproaches Should Be Used? Evidence-Based Treatments • Efficacy: In a situation where treatment is tested under ideal conditions (usually in a controlled clinical trial) efficacy is how well a given treatment improves clinical outcome compared to a control or comparison condition. • Randomized control trials (RCT): A randomized involves a specific treatment group (the group the researchers are most interested in) as well as a control treatment group (against with the treatment group will be compared). Participants have an equal chance of being placed in either group because placement is determined randomly. • Placebo: An inert pill or otherwise neutral intervention that produces desirable effects because of the subject’s expectations that it will be beneficial. • Double blind study: Often used in studies examining drug treatment effects, a condition where neither the subject nor the experimenter has knowledge about what specific experimental condition (or drug) the subject is receiving. • In psychotherapy, a placebo condition is hard to do. Often what happens is a person is put on a waitlist and receives no treatment. It is hard to compare therapies as it differs drastically from client to client and therapist to therapist. • Therapists in a study are trained in a treatment manual to ensure they are all treated the same way. • Manualized therapies: Standardization of psychosocial treatments (as in development of a manual) to fit the randomized clinical paradigm. • Efficacy studies are the most useful for evaluating whether a therapy will work. Critics of efficacy studies point to them having to have 1 disorder only. It is hard to apply that to a clinical setting where people have multiple disorders.Also criticize the long list of criteria that people need to meet to take part in the study. • Now effectiveness studies are done as well that look at the extent of change under less than ideal situations. Medication or Psychotherapy? • Psychopharmacology: Science of determining which drugs alleviate which disorders and why they do so. • Medication has led to a more favourable climate for hospital workers and patients alike. • Drugs affect symptoms, not the individual. The drugs do not encourage change as does psychotherapy, so when drugs are discontinued, the patients may relapse. • Failure to incorporate medicine into treatment for certain disorders could have drastic consequences. 17.3 The WorldAround Us: Osherhoff vs. Chestnut Lodge o Osherhoff is a physician who was depressed and hospitalized at Chestnut. He received only psychotherapy, no drugs as treatment. He had not progress, and was actually losing weight, experiencing more sleep disturbances, and had marked psychomotor agitation. o When his family had him moved to another hospital, where he was treated with phenothiazines and tricyclic antidepressants, he improved markedly and was soon discharged. o Osherhoff sued Chestnut Lodge for not providing accurate treatment and won. Combined Treatments • Acombined approach is best for a lot of disorders, though for some there is little evidence of it being better. • Therapy can be patient or family directed. • Combined treatments are often well-received by patients. • Combination treatment is often more successful on severe disorders. PharmacologicalApproaches to Treatment • Psychoactive medications have their effects on the brain. Antipsychotic Drugs • Antipsychotic drugs ( AKA neuroleptics): Medications that alleviate or diminish the intensity of psychotic symptoms such as hallucinations or delusions. They are used to treat psychotic disorders (like schizophrenia). • They often block dopamine receptors. • Half-life: Time taken for the level of an active drug or medication in the body to be reduced to 50% of the original level. • Advantages of long half life are dosing less often, more constant blood concentration, less severe withdrawal. Risks include accumulation in the body as well as increased psychomotor impairment. • Often taken orally. For those who are prone to forgetting, the drugs can be administered in a long-acting, injecectable form. • Tardive dyskinesia: Neurological disorder resulting from excessive use of antipsychotic drgs. Side effects can occur months to years after treatment has been initiated or has stopped. The symptoms involve involuntary movements of the tongue, lips, jaw, and extremities. • Movement related side-effects are less common with atypical antipsychotic medication such as clozaril and ilanzapine. • Atypical antipsychotics can treat both positive and negative symptoms. • Weight gain is the most common side effect of atypical antipsychotics. Antidepressant Drugs Selective Serotonin Reuptake Inhibitors (SSRIs) • Monomine oxidase inhibitors and tricyclics antidepressents were among the forst wave of antidepressants. Second generation treatments include SSRIs. • Most antidepressents work by increasing the levels of NE, serotonin, or both. • Tricyclics inhibit the uptake of both NE and serotonin, SSRIs only inhibit serotonin. • Antidepressant drugs: Drugs that are used primarily to elevate mood and relieve depression. Often also used in the treatment of certain anxiety disorders, bulimia, and certain personality disorders. • SSRIs are not necessarily more effective then tricyclics, just better tolerated by patients and less side effects. • SNRIs are serotonin norepinephrine reuptake inhibitors. Its side effects resemble those of SSRIs and is relatively safe in overdose. • SNRI are apparently more effective then SSRIs in treating major depression. • A50% improvement when on medication is considered to be improvement in the disorder and the patient then enters remission. If the patient is well for 6-12 months, they are considered recovered. • SSRI side effects: Nausea, diarrhea, nervousness, insomnia, and sexual problems. • Small link between SSRIs and suicide, though the link is slightly greater in adolescents. 17.4 The WorldAround Us: Better Living through Chemistry? o Prozac tends to make people feel better. It makes them feel like a new them. It gets to the point that they are reluctant to stop taking it. o Many people end up taking Prozac that just want to feel better, not just those who need it. Monoamine Oxidase (MAO) Inhibitors • These drugs inhibit monoamine oxidase activity. Since this is the complex that breaks down serotonin and NE in the synapse, inhibiting its activity will lead to more serotonin in the synapse. People taking MAOs need to avoid theAAtyramine. TricyclicAntidepressants • Tricyclic antidepressants (TCAs) inhibit the reuptake of NE and serotonin, though to a lesser extent. • These drugs can also alter cellular functioning. Other Antidepressants • Trazodone was the first antidepressant to be introduced into NorthAmerica that was not lethal when overdosed on. • It inhibits serotonin reuptake. • It is often taken with SSRIs to counter the effect SSRIs have on sleep. • Bupropion increases noradrenergic function and has been found to be effective in treating depression. It does not inhibit sexual functioning. UsingAntidepressants to TreatAnxiety Disorders, Bulimia, and Personality Disorders • SSRIs have been helpful for panic disorders, social phobias, generalized anxiety disorder, OCD, binge eating, purging, and certain patients with borderline personality disorder. Anti-Anxiety Drugs Benzodiazepines • They are used for treating people who get nervous before surgery because they act rapidly. • People often gain a dependence on them. • Benzodiazephones are rarely recommended for first line treatments due to their side0- effects. • Anti-anxiety medications appear to work by reducing GABA activity. Though benzodiazepines appear to enhance GABAactivity in certain parts of the brain. • Anti-anxiety drugs: Drugs that are used primarily for alleviating anxiety. Other Anti-anxiety Medications • Buspirone is thought to act on serotonin functioning instead of GABA. It is as effective as benzodiazepines in treating anxiety. • Low potential for misuse, and no withdrawal effects. • Primary drawback is that it can take 2-4 weeks to become effective. Lithium and Other Mood-Stabilizing Drugs • The medical community was weary of Lithium due to previous toxic effects that it was known to cause. • It is unpatentable, so drug companies did not find it profitable. Bothe these factors led to it only being available in the last 20 years. • How it works is still unknown. • 70-80% showed improvements when on Lithium after 2-3 weeks. • It is used to treat bipolar disorder, though can sometimes help with depression. Relapse is high when discontinuation occurs. • Side effects: increased thirst, GI difficulties, weight gain, tremors, and fatigue. Other Mood-Stabilizing Drugs • Drugs are in research for rapid cycling bipolar disorder. Many of which are already used in the cases of epilepsy. Electroconvulsive Therapy • Drugs were initially used to induce convulsions. • Electroconvulsive therapy (ECT): Use of electricity to produce convulsions and unconsciousness; a treatment used primarily to alleviate depressive and manic episodes. • ECT is safe, effective, and an important form of treatment as it often works on people who drugs have no effect on. • ECT is known to down-regulate receptors for NE, increasing the functional availability of this neurotransmitter. • In bilateral ECT, electrons are placed on both sides of a patient’s head. Currents are passed from one side to the other. • Unilateral ECT involves limiting the current to one side of the brain, typically the n
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