Chapter 17.docx

Chapter 17: Treating Psychological Disorders Helping Relationship  Overall goal: help people change maladaptive, self-defeating thoughts, feelings and behaviour patterns so they can live happier and more productive lives  Healthy relationship between person & therapist = key factor  Group A o Counselling & clinical psychologists o Psychologists  Hold Ph.D (Doctor of Philosophy) or Psy.D (Doctor of Psychology)  Received 5 or more years of intensive training & supervision in various psychotherapeutic techniques  Group B o Psychiatrists  Medical doctors who specialize in psychotherapy & biomedical treatments  Group C o Psychiatric social workers o Marriage & family counsellors o Pastoral counsellors o Abuse counsellors Psychodynamic Therapies  Focuses on internal conflict & unconscious factors that underlie maladaptive behaviour  Psychoanalysis o Refers to Freud's theory of personality & specific approach to treatment Psychoanalysis  Goal: help clients achieve insight o Conscious awareness of psychodynamics that underlie their problems o Permits clients to adjust their behaviour to their current life situations  Client repeatedly encounters & deals with buried emotions, motives, and conflicts  psychic energy can be released and redirected to more adaptive ways of living Free Association  Mental events are meaningfully associated with one another  Clues to contents of unconscious are to be found in the constant stream of thoughts, memories, images, and feelings we experience  Asked his clients to recline on a couch and to report verbally without censorship any thoughts, feelings, or images that entered awareness  Freud sat out of sight behind client so that client's thought processes would be determined primarily by internal factors Dream Interpretation  Dreams express impulses, fantasies, and wishes that defences keep in unconscious during waking hours  Defensive processes usually disguise threatening material to protect dreamer from anxiety that material might evoke  Tries to help client search for unconscious material contained in dreams  Ask client to free associate to each element of dream and to help client arrive at an understanding of what symbols in dream really represent Resistance  Avoidance patterns emerged in course of therapy  Defensive manoeuvres that hinder process of therapy  Client may experience difficulty in free-associating  May come late or ―forget about‖ a therapy appointment  May avoid talking about certain topics  Sign that anxiety-arousing sensitive material is being approached  Explore reasons for resistance  promote insight & guard against dropout Transference  Occurs when client responds irrationally to te analyst as if he or she were an important figure from the client's past  Most important process  brings out into open repressed feelings and maladaptive behaviour patterns  Two Forms o Positive Transference  Client transfers feelings of intense affection, dependency, or love o Negative Transference  Irrational expressions of anger, hatred, or disappointment  Until transference reactions are analyzed and resolved  no full resolution Interpretation  Any statement by therapist intended to provide client with insight into their behaviour or dynamics  Confronts clients with something that they have not previously admitted into consciousness o Ex. It's almost as if you're angry with me without realizing it  Interpret what is already near surface and just beyond client's current awareness  Deep interpretation - removed from awareness - cannot be informative or helpful Brief Psychodynamic Therapies  Expensive & time-consuming process - goal is rebuilding client's personality  Not uncommon for client to be seen 5 times a week for 5 years or more o Modern therapists consider level both impractical & unnecessary  Studies show regardless of how many sessions clients attended, rate of improvement was highest at beginning & decreased over time  Modern Therapies o Brief o Emphasize understanding maladaptive influences of past & relating them to current patterns of self-defeating behaviour o Therapist and client are likely to sit facing each other o Conversation typically replaces free association o Clients are seen once or twice a week rather than daily o Goal: typically limited to helping client deal with specific life problems rather than complete rebuilding of the client's personality o More likely to focus on the client's current life  Interpersonal Therapy o Highly structured and no longer than 15 to 20 sessions o Focuses on the client's current interpersonal problems  Dealing with role disputes such as marital conflict  Adjusting to the loss of a relationship or changed relationship  Identifying and correcting deficits in social skills o Very effective for depression Humanistic Psychotherapies  Humans capable of consciously controlling & taking responsibility for choices & behaviour  Everyone possesses inner resources for self-healing & personal growth  Disordered behaviour reflects a blocking of natural growth process o Blocking due to distorted perceptions, lack of awareness about feelings, or a negative self- image  Goal: Create environment in which clients can engage in self-exploration and remove barriers that block natural tendencies toward personal growth o Barriers often result from childhood experiences that fostered unrealistic or maladaptive standards for self-worth  People try to live lives according to expectations of others rather than in terms of own desires and feelings o Often feel unfulfilled & empty o Unsure about who they really are as people  Focus primarily on present & future instead of past  Therapy directed at helping clients become aware of feelings as they occur rather than at achieving insight into the childhood origins of the feelings Client-Centered Therapy  Most widely used form of humanistic therapy - Carl Rogers  Relationship that develops between client and therapist – key ingredient  Identified 3 important & interrelated therapist attributes: o Unconditional Positive Regard  Therapists show clients that they genuinely care about & accept them, without judgment or evaluation  Communicates sense of trust in clients o Empathy  Willingness & ability to view world through client's eyes  Therapist reflects back to client what he or she is communicating—perhaps by rephrasing something the client has just said in a way that captures the meaning and emotion involved o Genuineness  Consistency between way therapist feels & way they behave  Therapist must be open enough to honestly express feelings, whether positive or negative  Clients experience constructive therapeutic relationship  exhibit increased self-acceptance, greater self-awareness, enhanced self-reliance, increased comfort with other relationships, and improved life functioning Gestalt Therapy  Gestalt (organized whole) o Perceptual principles through which people actively organize stimulus elements into meaningful ―whole‖ patterns  Percieve external stimuli, ideas, or emotions  concentrate on only part o our whole experience— figure—while largely ignoring background  Psychological difficulties – background includes important feelings, wishes, & thoughts blocked from ordinary awareness because they would evoke anxiety  Goal: bring them into immediate awareness so that client can be ―whole.  Often carried out in groups  Developed variety of imaginative techniques to help clients ―get in touch with their inner selves.‖  More active, dramatic & confrontational in nature  Often ask clients to role-play different aspects of themselves so that they directly experience inner dynamics  Empty-Chair technique o Client may be asked to imagine his mother sitting in chair, & then carry on conversation in which he alternatively role-plays his mother & himself o Changing chairs for each role & honestly telling her how he feels about important issues in their relationship o Evoke powerful feelings & make clients aware of unresolved issues Cognitive Therapies  Focus on role of irrational & self-defeating thought patterns  Help clients discover and change cognitions that underlie their problems  Do not emphasize importance of unconscious psychodynamic processes  Habitual thought patterns are so well-practised & ingrained  tend to run off almost automatically – minimally aware of them & accept as reflecting reality  Clients often need help in identifying beliefs, ideas, & self-statements that trigger maladaptive emotions & behaviours  Cognitions can be challenged and, with practice and effort, changed Albert Ellis’s Rational-Emotive Therapy  Convinced that irrational thoughts, rather than unconscious dynamics, were most immediate cause of self-defeating emotions  ABCD Model o A - activating event that seems to trigger emotion o B - belief system that underlies way in which a person appraises event o C - emotional & behavioural consequences of that appraisal o D - key to changing maladaptive emotions & behaviours - disputing, or challenging erroneous belief system  People accustomed to viewing emotions (C) as caused directly by events (A) o Ex.  Man turned down for a date may feel rejected & depressed  Ellis insists - woman's refusal is not reason for emotional reaction  Reaction caused by man's irrational belief that ―to be a worthwhile person, I must be loved and accepted.‖  If man does not want to feel rejected, belief must be countered & replaced by a more rational interpretation (Ex. Would have been nice if she had accepted invitation, but I don't believe that no one will ever care about me) Beck’s Cognitive Therapy  Goal: Point out errors of thinking & logic that underlie emotional disturbance & to help clients identify & reprogram overlearned ―automatic‖ thought patterns  Treating depressed clients  help clients realize that thoughts, not situation, cause maladaptive emotional reactions  Realization sets the stage for identifying and changing the maladaptive thoughts.  Therapy with booster sessions after depression decreased resulted in improvement maintenance in 97% of depressed clients, with non-recurrence of depression in 75%  Therapy has been extended to treatment of anger & anxiety disorders  Self-Instructional Training o Very influential in treatments related to stress and coping Behaviour Therapies  Behaviour disorders are learned in the same ways normal behaviours are  Maladaptive behaviours can be unlearned by classical & operant conditioning  Change behaviours of schizophrenics, treat anxiety disorders & modify many child & adult behaviour problems Classical Conditioning Treatment  Used in two major ways o Reduce, or decondition, anxiety responses o Condition new anxiety responses to stimuli (alcoholic drinks or inappropriate sexual objects)  Procedures: exposure therapy, systematic desensitization & aversion therapy Exposure: An Extinction Approach  Phobias & other fears result from classically conditioned emotional responses  Conditioning experience - pairing of phobic object (NS) with aversive unconditioned stimulus (UCS)  Phobic stimulus becomes conditioned stimulus (CS) that elicits conditioned response (CR) of anxiety  Avoidance responses to phobic situation are then reinforced by anxiety reduction (operant conditioning based on negative reinforcement) o Person injured in automobile accident may find herself afraid to ride in car o Each time she avoids exposure to cars  avoidance response is strengthened through anxiety reduction  Direct way to reduce fear is through classical extinction of anxiety response  Reduction requires exposure to feared CS in absence of UCS while using response prevention to keep operant avoidance response from occurring  Client may be exposed to real-life stimuli (flooding) or may be asked to imagine scenes involving stimuli (implosion therapy)  Extinguish in time if person remains in presence of CS and UCS does not occur  Treatment of choice for post-traumatic stress disorder o Agoraphobics  Feared leaving safety of homes & going into public  Used therapy that required clients to confront feared situations such as driving alone & going into crowded centres  Both before & after therapy - client was assessed on series of real-life performance tasks  Asked to go & stand in a long checkout line in crowded market  Before treatment  Phobics able to pass 27% of tasks  After treatment - able to perform 71% of the tasks  Degree of improvement was maintained or even increased at follow-ups ranging from three months to two years  Clients can administer exposure treatment to themselves under therapist's direction, with high success rates  Can be used for obsessive-compulsive disorder Systematic Desensitization: A Counterconditioning Approach  New learning-based treatment for anxiety disorders  Success rate in treating a wide range of phobic disorders has been 80% or better  Viewed anxiety as a classically conditioned emotional response  Counterconditioning o New response that is incompatible with anxiety is conditioned to the anxiety-arousing CS  Train client in skill of voluntary muscle relaxation  Client is then helped to construct stimulus hierarchy of 10 to 15 scenes relating to fear  Hierarchy is carefully arranged in roughly equal steps from low-anxiety scenes to high-anxiety ones  Therapist deeply relaxes client and then asks client to vividly imagine first scene in the hierarchy (least anxiety-arousing) for several seconds  Client can't be both relaxed and anxious at same time, so if relaxation is strong enough, it replaces anxiety as CR to that stimulus - counterconditioning process  When client can imagine that scene for increasingly longer periods without experiencing anxiety, therapist proceeds to next scene  In Vivo Desensitization o Carefully controlled exposure to hierarchy of real-life situations o Ex. Individual with a height phobia walk across a suspension bridge  Client will experience far less anxiety during treatment Aversion Therapy  Goal: not to reduce anxiety & actually condition it to particular stimulus so as to reduce deviant approach behaviours  Therapists pairs stimulus that is attractive to person & that stimulates deviant or self-defeating behaviour (CS) with no anxious UCS in attempt to condition aversion to CS  Ex. Alcoholics o Involve injecting clients with a nausea-producing drug, and then having them drink alcohol (CS) as nausea (UCS) develops  Ex. Pedophiles o Strong electric shock is paired with slides showing children similar to those the offenders sexually abused  Sometimes fail to generalize from treatment setting to the real world Operant Conditioning Treatments  Behaviour Modification o Attempt to increase or decrease a specific behaviour o Techniques may use any of operant procedures for manipulating environment: positive reinforcement, extinction, negative reinforcement, or punishment o Measurement allows therapist to track progress of treatment program and to make modifications if behaviour change begins to lag o Yielded impressive results: chronic hospitalized schizophrenics, disturbed children, & mentally retarded individuals Positive Reinforcement  Token Economy o System for strengthening desired behaviour o Ex. Personal grooming, appropriate social responses, housekeeping behaviours, working on assigned jobs—through application of positive reinforcement o Rather than giving tangible reinforcers (food or grounds privileges) a specified number of plastic tokens is given for performance of each desired behaviour o Tokens can be redeemed by patients for wide range of tangible reinforcers (private room, rental of radio or TV, personal furniture, freedom to leave ward & walk around) o Goal: desired behaviours started with tangible reinforcers until they eventually come under control of social reinforcers and self-reinforcement processes (such as self-pride) o Tokens phased out o Used with schizophrenic patients Therapeutic Use of Punishment  Punishment: least preferred because of aversive qualities & negative side effects  Before deciding to use - ask two important questions o Are there alternative, less painful approaches that might be effective? o Is behaviour to be eliminated sufficiently injurious to anyone to justify severity of punishment?  Ex. Self-destructive autistic children o Successfully eliminated such behaviours using limited contingent electric shocks Modeling & Social Skill Training  Modeling o Most important & effective learning processes in humans o Have been used to treat a variety of behavioural problems  Social Skills Training o Clients learn skills by observing & then imitating model who performs socially skilful behaviour Third-Wave: Cognitive Behavioural Therapies  Behaviour Therapies - three phases of development o First Phase Treatments  Based on animal models of classical & operant conditioning & explicitly excluded cognitive principles o Second Phase Treatments  Emergence of cognitive-behavioural approaches  Rational-emotive behaviour therapy (Ellis), cognitive therapy (Beck), & modeling & role- playing approaches (Bandura) o Third Phase Treatments  Incorporate concepts of mindfulness as a central objective of behaviour change  Represent addition of humanistic concepts & eastern methods to behaviour therapy  Variety of mindfulness-based approaches to various problems, such as acceptance and commitment therapy, & dialectical behaviour therapy Mindfulness-Based Techniques  Mindfulness o Mental state of awareness, focus, openness, and acceptance of immediate experience o Involves nonjudgmental appraisal, so that in a state of mindfulness, difficult thoughts and feelings have much less impact o Similar to association cognitive techniques (focusing nonjudgmentally on sensations rather than trying to distract oneself) that increase ability to tolerate painful stimuli  Meditation o Tool for learning mindfulness o People develop tranquil state & focus closely on sensations, thoughts, & feelings, allowing them to come and go without a struggle o Incorporated into variety of cognitive behavioural treatments (mindfulness-based stress reduction and mindfulness-based relapse prevention) o Reduces physiological arousal & detached cognitive outlook helps to free people from emotion- escalating emotional processes o Added to relapse prevention techniques  Prevent relapse by increasing awareness of thoughts & emotions that trigger lapses, thereby interrupting previous cycle of automatic substance abuse behaviour  Helps abusers deal with lapse by helping to neutralize self-blame & thoughts of hopelessness Acceptance and Commitment Therapy  Focuses on process of mindfulness as a vehicle for change  Don't teach people to exert control over thoughts and feelings  Teaches clients to ―just notice,‖ accept, and embrace them, even previously unwanted ones  Helps to reduce emotional impact of thought & to defuse the anxiety it would ordinarily evoke  Anxiety were to be aroused  be examined & accepted as temporary experience  Commitment o Examining one's life, deciding what is most important to one's true self o Setting life goals in accordance with those values.  Therapist then helps client develop strategies to work toward those goals & remain committed to them Dialectical Behaviour Therapy  Treatment developed specifically for the treatment of borderline personality disorder  Includes ―package‖ of elements from cognitive, behavioural, humanistic, and psychodynamic therapies  Behavioural Techniques o Used to help clients learn interpersonal, problem-solving, & emotion-control skills  Cognitive Approaches o Used to help clients learn more adaptive thinking about world, relationships, & themselves  Psychodynamic Element o Traces history of early deprivation & rejection that created many of the problems  Humanistic Emphasis o Acceptance of thoughts & feelings has been added to help clients better tolerate unhappiness & negative emoti