B IOLOGICAL T REATMENTS
Practices such as bleeding, often by cuts to the body or application of leeches, were designed to
correct biological imbalances presumed to underlie psychological symptoms.
In the nineteenth century, disturbed patients were protected from self-harm by physical
restraints and were subjected to prolonged warm baths, or were placed under cold packs
designed to pacify them.
In the 1930s, seizures were provoked by the application of an electrical current to the patient’s
temples in a procedure now known as electroconvulsive therapy (ECT).
With the advent of effective antipsychotic medication, ECT was abandoned in the treatment of
schizophrenia, but it is still used to treat severe depression.
Adverse effects have been minimized, and now the most commonly reported side effect is
retrograde amnesia, and the mortality rate has been reduced to 2 per 100 000.
More than 50 percent of those treated with ECT are likely to relapse.
ECT is considered appropriate only in the treatment of life-threatening severe depression that
has not responded to other treatment.
Pharmacological agents that affect the individual’s psychological functioning are known as
Some drugs that are effective in one age group may not be suitable for administration to other
age groups, such as older adults.
Prior to the development of this class of drugs in the 1950s, patients diagnosed with
schizophrenia typically spent their lives confined in psychiatric institutions.
The development of phenothiazines and related major tranquilizers offered the possibility of
reducing psychotic symptoms.
o Following stabilization on the drug, formerly institutionalized patients were able to
return to the community.
Antipsychotics do not cure schizophrenia; instead, they control its symptoms.
Many patients are tempted to discontinue their medication when they are feeling symptom-
free, increasing the risk of relapse. After a few weeks of taking major tranquilizers, some patients experience extrapyramidal
o These side effects may be relieved by anti-Parkinsonian drugs.
After prolonged administration, patients may begin to show tardive dyskinesia.
Clozapine and olanzapine have fewer extrapyramidal effects.
Second-generation antipsychotics have mood-stabilizing properties, which may make them
effective in the treatment of bipolar disorder.
Anxiolytics are used to alleviate symptoms of anxiety and muscle tension by reducing activity in
parts of the central nervous system, which lowers activity in the sympathetic nervous system,
leading to lower respiration and heart rate and decreased muscle tension.
Patients develop a tolerance for barbiturates, requiring larger doses over time.
Benzodiazepine offers effective control of anxiety without toxicity at high doses.
Benzodiazepines are also highly addictive. Sudden withdrawal can provoke convulsions.
Drugs used in the treatment of depression fall into four major categories:
o Monoamine oxidase inhibitors (MAOIs).
A major drawback is the severe dietary restrictions they impose.
o Tricyclics (TCAs).
Although commonly used, they provoke many unpleasant side effects.
o Selective serotonin reupdate inhibitors (SSRIs).
o Serotonin-norepinephrine reuptake inhibitors (SNRIs).
Flu-like symptoms can occur if stopped abruptly.
Canadian guidelines for the pharmacotherapy of depression recommended SSRIs and SNRIs as
first-line medication options.
Improvement is typically evident only after one to two weeks of treatment, with optimal
response by the third or fourth week.
Thirty to 50 percent of patients do not response favorably to antidepressants.
The benefits of antidepressants are most pronounced in those with severe depression, but only
minimal or nonexistent at mild and moderate levels of symptom severity.
SSRIs may provide substantial relief for adults suffering from eating and anxiety disorders.
Depressed children and adolescents were at greater risk for suicidal behavior when taking SSRIs. MOOD STABILIZERS
Although lithium salts have long been the medication of choice for bipolar disorder, their use
has decreased in favor of other mood stabilizers and the newer antipsychotics.
Lithium and related mood stabilizers reduce rapid cycling between depressive and manic or
hypomanic stress and reduces the risk of relapse.
Lithium has a narrow window of effectiveness.
Other mood stabilizers may have less of an effect on depressive symptoms.
Stimulants are mostly commonly used in the treatment of children and adults with attention
Stimulants reduce hyperactive and impulsive behavior.
Stimulants combined with psychological treatment should be the first-line treatment for severe
ADHD in children and for moderate and severe ADHD in adults.
LIMITS ON EFFICACY
No class of drugs is efficacious for all people with a particular disorder, and it is not possible to
predict who will respond to a particular class of drugs.
Medication may be helpful in symptom control, but without concomitant psychological
interventions, the person may be prone to relapse and chronic disorder.
P SYCHOTHERAPY : A D EFINITION
Psychotherapy is defined as a process in which a professionally trained therapist systematically
uses techniques derived from psychological principles to relieve another person’s psychological
distress or to facilitate growth.
In most jurisdictions in Canada, the title psychotherapist is not licensed or restricted.
T HEORETICAL O RIENTATIONS
As approaches evolve, there is considerable “cross-pollination” so that ideas from one approach
are integrated into other approaches.
Classic psychoanalysts rely heavily on five basic techniques:
o 1. Free association. The analyst helps the patient recognize unconscious motives and
conflicts expressed in spontaneous speech. o 2. Dream interpretation. The analyst distinguishes between the manifest content of the
dream and the more important latent content.
o 3. Interpretation. First, the analyst interprets behavior that the client is already on the
verge of understanding. Later, the therapist interprets the unconscious conflicts that
induce defence mechanisms.
o 4. Analysis of resistance. Resistance prevents painful thoughts from entering awareness;
thus, therapists must determine the source of resistance if the client is to deal
effectively with the problem.
o 5. Analysis of transference. The core of psychoanalytic therapy is transference, which
occurs when the client responds to the therapist as he or she responded to significant
figures from his or her childhood.
BRIEF PSYCHODYNAMIC PSYCHOTHERAPY
Therapy tends to be short term: session occur twice a week rather than daily.
Goals are concrete, conversation replaces free association, therapists are empathetic, and
interpretations focus on current life events.
Ego analysts use Freudian techniques to explore the ego rather than the id.
Therapists help clients understand how they have relied on defence mechanisms to cope with
ADLER’S INDIVIDUAL PSYCHOLOGY
Adler’s individual psychology was based on the assumption that mental disorders are the
consequences of deeply entrenched mistaken beliefs, which lead individuals to develop a
maladaptive style of life that protects them from discovering their own imperfections.
Adlerian therapists interpret dreams in terms of current behavior, offer direct advice, and
encourage new behaviors.
INTERPERSONAL PSYCHODYNAMIC PSYCHOTHERAPY
This type of therapy emphasizes the interactions between the client and his or her social
Interpersonal therapists provide feedback that help the client understand how his or her
personal styles are perpetuating or provoking conflicts.
The therapist helps the client learn to interact with others in more flexible and positive ways and
must be careful not to reinforce the client’s maladaptive behaviors.
TIME-LIMITED DYNAMIC PSYCHOTHERAPY
TLDP approaches tend to be briefer and to involve the client in face-to-face contact with the
therapist, but retain Freud’s emphasis on analysis of transference. The TLDP therapist helps identify patterns of interaction with others that strengthen unhelpful
thoughts about self and others.
The quality of the relationship between therapist and client is recognized to be a predictor of
Humanistic and experiential approaches focus on the person’s subjective experience, giving
particular attention to emotional aspects of experience and place emphasis on the person’s
current experience, rather than on the past.
Humanistic-experiential approaches value the individual’s free will and encourage the client to
take responsibility for personal choices.
Therapists working with different approaches are more effective when their clients feel that
they are genuine, that they make efforts to understand their experience, and that they accept
them despite their problems.
Client-centered therapy emphasizes the warmth and permissiveness of the therapist and the
tolerant climate in which the feelings of the client can be freely expressed.
The therapist qualities that facilitate the client’s growth: genuineness, empathy, and
“unconditional positive regard.”
Clients are not diagnosed, evaluated, or given advice; they are valued as unique individuals.
Existential therapy focuses on the importance of the human situation as perceived by the
individual, with the ultimate goals of making the client more aware of his or her own potential
for growth and capacity for making choices.
The therapist helps the client relate authentically to others through the therapeutic encounter.
Existential therapists share themselves, their feelings, and their values with the client.
This type of therapy examines the lack of meaning in a person’s life.
This therapy works best with those with anxiety or personality disorders rather than psychosis.
Gestalt therapy emphasizes the idea that individuals have a distorted awareness of genuine
feelings that leads to impairments in personal growth and behavioral problems.
The key goal of Gestalt therapy is client awareness.
Gestalt therapies often interpret dreams. They also attend to nonverbal cues and ask clients to
focus on their body and the meaning that these paralinguistic cues are communicating. EMOTION-FOCUSED THERAPY
In emotion-focused therapy, the client enters into an empathic relationship with a therapist
who is directive and responsive to his or her experience.
These psychologists enhance and then focus on clients’ emotional reactions.
Behavior therapy was first used in the 1950s to describe an operant conditioning treatment for
Behavioral approaches emphasize that problem behaviors are learned behaviors and that faulty
learning can be reversed through the application of learning principles.
Behavioral treatment requires clear identification of goals and is oriented toward the future.
Self-efficacy is the best predictor of behavior.
Cognitive and cognitive-behavioral approaches rely on the application of empirically derived
strategies in the treatment of diverse disorders.
Several developments in cognitive-behavioral approaches have shifted the emphasis on
attending to and accepting the presence of maladaptive thoughts.
Efforts to reinforce desirable behaviors are at the heart of behavioral approaches.
Response shaping is used to shape behavior in gradual steps toward a goal.
The essence of behavioral activation in the treatment of depression is to help patients develop
strategies to increase their overall activity and to counteract their tendencies to avoid activities.
Helping clients to relax, both physically and mentally, is a component of many treatments for
anxiety disorders, as well as for interventions focused on helping people to cope with pain or
Also called in vivo exposure, exposure involves gradually exposing the client to a series of
increasingly anxiety-provoking situations or stimuli.
In the process of systematic desensitization, fear-inducing stimuli are arranged in a hierarchy.
Individuals are trained in techniques to achieve deep muscle relaxation. They gradually progress
through the hierarchy while maintaining their relaxed state.
Assertiveness training is designed to help clients who have difficulty in conflict situations. The therapist’s role is to encourage and guide the client in practicing new, more appropriate
assertive behaviors and more effective interpersonal skills.
The key elements of problem solving are problem definition and formulation, generating
alternative solutions to deal with the problems, deciding on the best solution to implement, and
implementing and evaluating the solution.
The initial step of cognitive restructuring involves having people become more aware of their
thoughts when they are experiencing strong emotions.
The nature and accuracy of these thoughts are questioned by the therapist, and patients are
encouraged to conduct behavioral experiments to determine the validity and accuracy of them.
Mindfulness-based strategies are designed to help