Chapter 16 Therapies for Personal Change As presented by Dr. Shannon Wright-Johnson This multimedia product and its contents are protected under copyright law. The following are prohibited by law: any public performance or display, including any transmission of any image over a network; preparation of any derivative work, including the extraction, in whole or in part, of any of the images; any rental, lease, or lending of the program

Lecture Objectives Examine the goals of therapy Briefly examine the historical treatment of the mentally ill Introduce the main types of therapy interventions used and a few of techniques employed Examine the effectiveness of treatment modalities

Therapy What is Therapy? What do you think therapy entails? What theoretical orientation do you gravitate towards? Despite differences in intervention types – all therapies are designed to change a person’s functioning in some way

Goals of Major Therapies Reaching a diagnosis Proposing a probable etiology Making a prognosis Treatment

Goals of Major Therapies Therapy Types can be further catergorized as Biomedical therapies Alter brain functioning with chemical or physical interventions (e.g., ECT) Psychotherapy Focus on changing faulty behaviors, thoughts, perceptions, and emotions (cognitive)

Problems Happen to everyone at sometime in their life Who do people typically talk to?

Therapists and Therapeutic Settings Counseling psychologist Clinical social worker Pastoral counselor Clinical psychologist Psychiatrist Psychoanalyst (MD or Ph.D)

Therapists and Therapeutic Settings Patient Used by biomedical approach Client Used by clinicians who think of psychological disorders as problems in living

Historical and Cultural Contexts History of Western treatment Bedlam (orig Bethlehem) 1400’s – London hospital First pt w/psychological problem adm mental patients chained, tortured Mental illness Late 18th century- concept emerged in Europe First time seen as “sick people” U.S. – housed but no tx Cult of curability – environment Madness cured via mental hygiene

Historical and Cultural Contexts History of Western treatment Rehabilitation 1900s – asylum – from stress Overcrowded – good intentions simply became a human warehouse Deinstitutionalization 1960s – reformers Mainstream back into society Increase in homelessness, Increase in arrests

Historical and Cultural Contexts Not covering in class but just remember that our culture’s cure are not the only solutions (avoid ethnocentrism) Cultural symbols and rituals of curing Shamanism Ritual healing Dissociation of consciousness Mana

Therapies to be discussed Psychodynamic Behavior Therapy Cognitive Therapy Existential-Humanistic Group Therapies Biomedical Therapies

Psychodynamic Therapies Developed by Sigmund Freud Explores unconscious motivations and conflicts in neurotic, anxiety-ridden individuals Before exploring techniques, let’s review some of Freud’s main tenets of how he viewed behavior

Psychoanalysis Breuer and Freud: Freudian Theory Structure of the Mind The “Talking Cure” Freudian Theory Structure of the Mind The Mind’s Protective Mechanisms Stages of Psychosexual Development If this picture is in the book, I’d like to keep it in.

20th Century traditions Psychoanalytic Theory- Mesmer, Charcot, Freud and Breuer Discovered unconscious Id, ego superego (structural theory) Defense mechanisms Psychosexual stages of development

Ego id The Structure of the Mind ID Libido Pleasure Principle Primary Process Thinking id Is the ego/id picture something you made up?

Ego id The Structure of the Mind ID EGO Reality Principle “Executive of Personality” Secondary Process Thinking id

Ego id The Structure of the Mind SUPEREGO Rules / Standards of Conduct Right vs Wrong id

Ego id Defense Mechanisms Ego’s Battles Keep Id in Check Anxiety results with inability to resolve inner conflicts between the unconscious, irrational impulses of the id AND the superego id

Ego id Defense Mechanisms Anxiety -inner conflicts between id AND the superego Thus 1 Goal of tx – intrapsychic harmony Strengthen ego Reduce demands of superego Increase awareness of the id id

Ego id Defense Mechanisms Displacement - kick dog Reaction formation – do opposite Most important =Repression – very important in handling conflicts messages from the unconscious that something is wrong id

Ego id Defense Mechanisms Repression – very important in handling conflicts Goals – Bring repressed thoughts to consciousness ; Gain insight about the relationship between current symptoms and repressed conflicts id

Psychodynamic Therapies Freudian psychoanalysis Intensive and prolonged technique for exploring unconscious motivations and conflicts Insight therapy Therapist guides patient toward discovering insights (increased awareness) between present symptoms and past origins YAVIS Takes long time

Psychodynamic Therapies Main Techniques employed include: Free association Thoughts, wishes, physical sensations, and mental images as they occur volunteer Catharsis Expressing strongly felt but usually repressed emotions

Psychodynamic Therapies Resistance- understanding the role of Barrier between unconscious and conscious(e.g., sex life,anger) Dream analysis – “unconscious”; manifest (openly visible) and latent (hidden content) Transference Countertransference

Psychodynamic Therapies Neo-Freudian therapies Borne out of reaction to Freud’s theory Kept some main tenets but added a diff twist

Neo-Freudian therapies Harry Stack Sullivan Added importance of social relationships Need for acceptance, respect and love “troubled interpersonal relationships” and societal pressures Melanie Klein Death instinct - aggression Building blocks of how people experience the world emerge from their relations to loved and hated objects

Psychoanalysis Descendents: Heinz Kohut Emphasis on self ( and how others and objects play a role in shaping our interpretation of self) Founder of Object Relations Object relations theory Building blocks of how people experience the world emerge from their relations to loved and hated objects

Premise of Behavior Therapy All (most) behavior is learned Focus on observable behaviors Abnormal behavior is learned similar to normal behaviors via conditioning and learning Thus therapy applies principles of conditioning and reinforce to modify unwanted behavior

Premise of Behavior Therapy Works best with specific behaviors Could care less about underlying cause Symptom substitute? Research indicates “no” Let’s briefly review some of the main tenets

Behavioral Model Important to understanding the role of counterconditioning Pavlov- classical conditioning (UCS,UCR,CS,) Some Sexual disorders begin Men and shoe example

Conditioning Theory Pavlov Dog, salivation, bell CSCR UCSUCR CS UCSUCR/CR Tone + Meat Powder -> Salivation CS UCS UCR Tone ----------------------> Salivation CS CR

Counterconditioning New response is conditioned to replace a maladaptive response Types of counterconditioning include: Systematic desensitization Implosion Flooding Aversion Therapy

Behavioral Model Watson- systematic desensitization B.F. Skinner- science of human behavior should be based on observable events -operant conditioning

Conditioning Theory When behavior is reinforced – either through pleasure, reward, or removal of some unpleasant stimulus – it is likely to be REPEATED. Negative consequences of a behavior through unpleasant results, pain, or loss of rewarding stimuli tend to DECREASE THE FREQUENCY of the behavior.

Conditioning Theory Operant Conditioning Response that is voluntarily emitted is learned as a result of how it operates on the environment Thorndike –Law of Effect Learned as a result of environmental consequences that follow that behavior, either positive or negative

Reinforcement Punishment Conditioning Theory by definition, the “targeted” behavior increases Punishment by definition, the “targeted” behavior decreases

OPERANT CONDITIONING: ADD REMOVE Positive Reinforcement Behavior increases Negative Reinforcement Positive Punishment Behavior decreases Negative Punishment

Behavior Therapies Thus, Behavior therapy (behavior modification) Systematic use of principles of learning to increase or decrease the frequency of behaviors

Behavior Therapies Counterconditioning Systematic desensitization Substitute a new response for a maladaptive one Systematic desensitization Reciprocal inhibition Incompatible behaviors cannot occur simultaneously Client is taught to prevent arousal of anxiety by confronting feared stimulus while relaxed

Behavior Therapies Systematic desensitization Gradual Steps Employed Identify anxiety provoking stimuli via hierarchy Deep-muscle relaxation Desensitization – pairing of weakest stimuli (visually) with relaxation Impotence Stage fright Test anxiety

Behavior Therapies Implosion therapy Flooding (in –vivo) Opposite of SD Exposes client to most anxiety-provoking stimuli through visual imagery in safe setting Karen Flooding (in –vivo) Clients are exposed to stimuli most frightening to them physically rather than via imagery More effective than SD in some cases (e.g., agoraphbia) Key to ALL is “ EXPOSURE

Behavior Therapies Aversion therapy Attractive stimulus is paired with noxious stimulus (uses counterconditioning procedures) Cigarette smoking (rubber band around wrist), child molesters (shock tx); self-injurious behaviors (mild shock)

Behavior Therapies Contingency management Changing behavior by modifying its consequences Positive Reinforcement Strategies Token economies (autistic child) Extinction Strategies Dysfunctional beh maintained by unrecognized reinforcers

Behavior Therapies Social-learning therapy Imitation of models Clients observe models’ desirable behaviors being reinforced phobias Imitation of models Participant modeling ( on film or in person see success w/feared stimuli) Social-skills training Behavioral rehearsal Assertiveness training

Behavioral Model Cognitive-behavioral or social learning model A B C’ S of EMOTIONS A Perceptions (Activating Event – anything you can see, hear, smell, taste, or touch.) B Self-Talk C Feelings Actions Consequences

Cognitive Therapies Cognitive therapy Attempts to change feelings and behaviors by changing the way a client thinks about or perceives significant life experiences

Cognitive Therapies Cognitive therapy Abnormal behavior/emotional distress start with what you think Goal – change your thought process

Cognitive Therapies Cognitive behavior modification Tenets Focus on the present We all engage in self-talk You are what you tell yourself You are guided by what you believe Faulty thinking can lead to unproductive or dysfunctional behaviors There is power in thought, how do you use your power?

Cognitive Therapies Cognitive behavior modification Combines cognitive emphasis on thoughts and attitudes, and behavioral emphasis on changing performance Unacceptable behavior modified via cognitive restructuring Change negative self-statements into constructive coping statements Key to process -First identify thought content Fosters self-efficacy and + expectations about your ability to cope and deal effectively

Cognitive Therapies Changing false beliefs Cognitive therapy for depression Replace faulty patterns of thinking by substituting more effective problem solving techniques Aaron Beck (time permitting, take BDI) Identify warped thinking –learn more realistic ways to formulate his experiences Maintained b/c unaware of negative automatic thoughts

Beck’s Cognitive Model of Depression 1.Thinking (content) becomes negative(re: self, world, future) (past, present, future) 2.Systematic bias and distortion in info processing results cognitive distortions and errors in reasoning

Cognitive Therapies Changing false beliefs Aaron Beck Challenge basic assumptions about functioning Evaluate evidence client has for and against accuracy of automatic thoughts Reattribute blame to situational factors rather than to patient’s incompetence Discuss alternative solutions to complex tasks that could lead to failure experiences

Cognitive Therapies Changing false beliefs Rational-emotive therapy (RET) Albert Ellis 1.Basis of Undesirable behavior/reactions is “irrational beliefs” 2. Beliefs are powerful in controlling our behavior 3. Goal – teach clients to recognize “shoulds, oughts, and musts

Cognitive Therapies Changing false beliefs Rational-emotive therapy (RET) Albert Ellis 4. faulty beliefs are openly and strongly disputed; very confrontational 5. Increase sense of worth

Humanistic Approaches Jung and Adler- broke from psychoanalysis and are thought of as humanistic today Maslow- self-actualization; hierarchy of needs Rogers- person-centered therapy; unconditional positive regard

Existential-Humanistic Therapies Human-potential movement Release the potential of the average human being for greater levels of performance and greater richness of experience

Existential-Humanistic Therapies Client-centered therapy Emphasizes the healthy psychological growth of the individual Unconditional positive regard Gestalt therapy Focuses on the ways to unite mind and body to make a person whole

Group Therapies Marital and family therapy Community support groups Couples counseling Family therapy Community support groups Self-help groups

Biomedical Therapies Psychosurgery Prefrontal lobotomy Electroconvulsive therapy (ECT)

Mood Disorders Drug Treatment

Antidepressants Do not work quickly (2- 6 weeks to become effective) Effective in alleviating depression, but they do not cause euphoric states

Antidepressants Three classes of antidepressants Tricyclics Selective Serotonin Reuptake Inhibiots (SSRIs) Monoamine Oxidase inhibitors (MAOIs)

Imipramine (Tofranil), Clomipramine (Anafranil) TRICYCLICS Include Imipramine (Tofranil), Clomipramine (Anafranil) and Amitriptyline (Elavil)

TRICYCLICS Side effects include: Tachycardia Palpitations Dry mouth Constipation Blurred vision Urinary retention Tachycardia Palpitations Skin Rash Memory Impairments Impaired sexual functioning

Include SSRIs Fluoxetine (Prozac) Setraline (Zoloft) Paroxetine (Paxil)

Also used in the treatment of OCD and eating disorders SSRIs Also used in the treatment of OCD and eating disorders Increase serotonin

SSRIs SIDE EFFECTS: Gastrointestinal problems Decreased libido Headaches At least initially, may worsen sleep and anxiety problems Can cause serious problems when combined with a tricyclic or MAOI

MOOD STABILIZERS Lithium treatment-of-choice for bipolar disorder Reduces or eliminates symptoms of mania and levels out mood swings

LITHIUM SIDE EFFECTS Gastric distress Weight gain Tremor (most affects the fingers) Fatigue Mild Cognitive impairment

LITHIUM SIDE EFFECTS Too high a dosage can cause lithium toxicity (vomiting abdominal pain, profuse diarrhea, severe tremor, and ataxia) Can lead to seizures, coma, and/or death

BENZODIAZEPINES Include Valium Xanax Klnopin Ativan

Used to treat anxiety symptoms such as generalized anxiety or panic BENZODIAZEPINES Used to treat anxiety symptoms such as generalized anxiety or panic Enhance the activity of the neurotransmitter GABA

BENZODIAZEPINES SIDE EFFECTS: Motor disturbances Anteriograde amnesia Drowsiness Sedation Weight gain Apathy Dry mough Gastric distress Ataxia Motor disturbances Anteriograde amnesia chronic use-results in tolerance and severe withdrawal symptoms mixing w/alcohol or other CSN depressant can be fatal

Drug therapy Antipsychotic drugs Chlorpromazine Haloperidol Clozapine

Does Therapy Work? Evaluating therapeutic effectiveness Spontaneous-remission effect Placebo effect Meta-analysis

Today Scientific Method- Integrated Approach 1.increased sophistication of science, technology, and methodology 2. No one influence occurs in isolation