Ch. 16, Psychological Treatment Flashcards
why do people who don’t meet criteria for psychological disorder seek treatment?
However, most people who receive treatment do not meet full criteria for a psychological disorder (WHO World Mental Health Survey Consortium, 2004). So why would they be seeking treatment? Many people seek therapy due to sudden and highly stressful situations such as a divorce or unemployment—situations that can lead people to feel so overwhelmed by a crisis that they cannot manage on their own.
Reluctant clients
Some people enter therapy by an indirect route. Perhaps they were court-ordered to do so by a judge because of substance abuse or domestic violence, or maybe they had consulted a physician for their headaches or stomach pains, only to be told that nothing was physically wrong with them. Motivation to enter treatment differs widely among psychotherapy clients. Reluctant clients may come from many situations—for example, a person with a substance abuse problem whose spouse threatens “either therapy or divorce,” or a suspected felon whose attorney advises that things will go better at trial if it can be announced that the suspect has “entered therapy.” A substantial number of angry parents bring their children to therapists with demands that their child’s “problematic behavior,” which they view as independent of the family context, be “fixed.” These parents may be surprised and hesitant to recognize their own roles in shaping their child’s behavior patterns.
male vs females seeking help
In general, males are more reluctant to seek help when they are experiencing problems than are females. In the case of depression, far more men than women say that they would never consider seeing a therapist; when men are depressed they are even reluctant to seek informal help from their friends. Moreover, when men do seek professional help, they tend to ask fewer questions than women do
why do men seek less treatment
One answer is that men are less able than women to recognize and label feelings of distress and to identify these feelings as emotional problems. In addition, men who subscribe to masculine stereotypes emphasizing self-reliance and lack of emotionality also tend to experience more gender-role conflict when they consider traditional counseling, with its focus on emotions and emotional disclosure. For a man who prides himself on being emotionally stoic, seeking help for a problem like depression may present a major threat to his self-esteem. Seeking help also requires giving up some control and may run counter to the ideology that “a real man helps himself.”
People Who Seek Personal Growth and therapy
It should be clear from these brief descriptions that there is no typical client. Neither is there a model therapy. No currently used form of therapy is applicable to all types of clients. Most authorities agree that client variables such as motivation to change and severity of symptoms are exceedingly important to the outcome of therapy
The three types of mental health professionals who most often administer psychological treatment in mental health settings
clinical psychologists, psychiatrists, and psychiatric social workers
therapeutic relationship e
therapeutic relationship evolves out of what both client and therapist bring to the therapeutic situation. The outcome of psychotherapy normally depends on whether the client and therapist are successful in achieving a productive working alliance. The client’s major contribution is his or her motivation. Clients who are pessimistic about their chances of recovery or who are ambivalent about dealing with their problems and symptoms respond less well to treatment
-key elements are (1) a sense of working collaboratively on the problem, (2) agreement between patient and therapist about the goals and tasks of therapy, and (3) an affective bond between patient and therapist
client expectancy in therapy
Almost as important as motivation is a client’s expectation of receiving help. This expectancy is often sufficient in itself to bring about substantial improvement, perhaps because patients who expect therapy to be effective engage more in the process (Meyer et al., 2002). Just as a placebo often lessens pain for someone who believes it will do so, a person who expects to be helped by therapy is more likely to benefit. The downside of this fact is that if a therapy or therapist fails for whatever reason to inspire client confidence, the effectiveness of treatment is likely to be compromised.
Attempts at estimating clients’ gains in therapy generally depend on one or more of the following sources of information:
(1) a client’s reports of change in their symptoms or functioning, (2) a clinician’s ratings of changes that have occurred, (3) reports from the client’s family or friends, (4) comparison of pretreatment and posttreatment scores on instruments designed to measure relevant facets of psychological functioning, and (5) measures of change in selected overt behaviors. Each of these sources has strengths, but also some important limitations.
Beck Depression Inventory
Beck Depression Inventory (a self-report measure of depression severity) is widely used to measure the degree of severity of a client’s depression. It has become almost standard in the pretherapy and posttherapy assessment of depression.
-. Not only may clients want to believe for various personal reasons that they are getting better, but in an attempt to please the therapist they may report that they are being helped. In addition, because therapy often requires a considerable investment of time, money, and sometimes emotional distress, the idea that it has been useless is a dissonant one.
Hamilton Rating Scale for Depression / problems with clinician rating
s a rating scale used by clinicians to measure the severity of a patient’s depression—similar to the Beck Depression Inventory previously mentioned, but completed by the clinician rather than the client. Although the clinician may be more objective than the patient, clinicians also may not be the best judge of clients’ progress because they may be biased in favor of seeing themselves as competent and successful. In addition, the clinician typically has only a limited observational sample (the client’s in-session behavior) from which to make judgments of overall change. Furthermore, clinicians can inflate improvement averages by deliberately or subtly encouraging difficult clients to discontinue therapy.
Third-Party Ratings and therapy effectiveness
Client change also can be evaluated by third-party raters, meaning people not involved in the treatment. This may include family members or trained independent evaluators. The latter are people who are trained to conduct clinical interviews and to rate the amount of clinical change that has occurred in a patient. Of course, relatives of the client may be inclined to “see” the improvement they had hoped for, although they often seem to be more realistic than either the therapist or the client in their evaluations of outcome. Because of their objectivity and consistency, independent evaluators who are blind to condition (meaning they do not know what kind of treatment a person received and so cannot be biased to say that one form of treatment is more effective than another) are used frequently in rigorous studies of treatment effectiveness.
Objective Measures and rating client improvement
Another widely used objective measure of client change is performance on various psychological tests. A client evaluated in this way takes a battery of tests before and after therapy, and the differences in scores are assumed to reflect progress, or lack of progress, or occasionally 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.
Regression to the Mean
This reflects the statistical tendency for extreme scores (e.g., very high or very low scores) on a given measure to look less extreme at a second assessment (as occurs in a repeated-measures design). Because of this statistical artifact, people whose scores are farthest away from the group mean to begin with (e.g., people who have the highest anxiety scores or the lowest scores on self-esteem) will tend to score closer to the group mean at the second assessment, even if no real clinical change has occurred.
Overt Behaviors and measuring therapy outcomes
Perhaps the most direct way to know if someone has improved in treatment is to observe their behavior directly. For instance, if someone is being treated for a bug phobia, the clinician can observe the client’s ability to approach and hold bugs of different sizes before, during, and after treatment to see if the individual’s behavior has changed. The advantage of behavioral observation is that it is objective, difficult to “fake,” and often reflective of precisely the change that is intended in treatment. The downside is that it may be less appropriate for problems that are less easily observed (e.g., suicidal thoughts).
Would Change Occur Anyway? without therapy/ why do patients improve
Most researchers today would agree that psychotherapy is more effective than no treatment (Shadish et al., 2000), and indeed the pertinent evidence, widely cited throughout this entire book, confirms this
=But why do patients improve? Remarkably, we know very little about the mechanisms through which therapeutic change occurs, or about the “active ingredients” of effective therapy (Hayes et al., 2011; Kazdin & Nock, 2003). We do know that progress in therapy is not always smooth and linear, however. Sudden gains can occur between one therapy session and another (Tang & DeRubeis, 1999; Wucherpfenning et al., 2017). These clinical leaps appear to be triggered by cognitive changes that patients experience in critical sessions. Researchers are now actively exploring how such factors as therapist adherence (how well a therapist delivers a particular type of therapy) and therapist competence (how skillfully the therapist administers the therapy) impact how well a patient does
Can Therapy Be Harmful?
The outcomes of psychotherapy are not invariably either neutral (no effect) or positive. Some clients are actually harmed by their encounters with psychotherapists (see The World Around Us box). It has been estimated that between 5 and 10 percent of clients deteriorate during treatment
Unfortunately, clinicians are often quite bad at recognizing when their clients are not doing well (Whipple & Lambert, 2011). To address this problem, research-based measures to assess clinical deterioration are now being developed. Clinicians who use these measures in their routine clinical practice will be warned when their clients are not progressing in an expected manner. A major hurdle, however, is implementation. We would not be surprised to learn that the least effective therapists are the ones most reluctant to use such patient-monitoring methods.
“rebirthing” therapy
One example is “rebirthing” therapy for children with attachment problems. This approach, which involves therapists wrapping children in blankets, sitting on them, and squeezing them in an attempt to mirror the birth process, has resulted in several children dying of suffocation.
facilitated communication
Another problematic technique is facilitated communication, which is based on the premise that children with autism can communicate if they have the assistance of a facilitator who helps the child communicate using a computer keyboard. Facilitated communication has been linked to dozens of child sexual abuse allegations against the parents of children with autism. This has exposed these families to a great deal of needless emotional pain and suffering because studies show that the communications in facilitated communication do not come from the children themselves. Rather, they are unknowingly generated by the facilitators themselves as they guide the child’s hands over the keyboard.
boundary violations.
A special case of therapeutic harm concerns what are called boundary violations. This is when the therapist behaves in ways that exploit the trust of the patient or engages in behavior that is highly inappropriate (e.g., taking the patient to dinner, giving the patient gifts).
drug efficacy
that is, that the drug cures or relieves some target condition. These tests, using voluntary and informed patients as subjects,
randomized clinical trials (RCTs) or, more simply, efficacy trials.
Although these trials may become quite elaborate, the basic design is one of randomly assigning (e.g., by the flip of a coin) half the patients to the supposedly “active” drug and the other half to a visually identical but physiologically inactive placebo. Usually, neither the patient nor the clinician is informed which is to be administered; that information is recorded in code by a third party. This double-blind study (see Chapter 1) is an effort to ensure that expectations on the part of the patient and prescriber play no role in the study. After a predetermined treatment interval, the code is broken and the active-drug or placebo status of all subjects is revealed. If subjects on the active drug have improved in health significantly more than subjects on the placebo, the investigator has evidence of the drug’s efficacy. Obviously, the same design could be modified to compare the efficacy of two or more active drugs, with the option of adding a placebo condition
problems with creating placebo coditionsd
A source of persistent frustration has been the difficulty of creating a placebo condition that will appear credible to patients. Most such research has thus adopted the strategy of either comparing two or more purportedly “active” therapies or using a no-treatment (“wait list”) control of the same duration as the active-drug treatment. However, withholding treatment from patients in need (even temporarily) by placing them on a wait list sometimes raises ethical concerns. Another problem is that therapists, even those with the same theoretical orientations, often differ markedly in the manner in which they deliver therapy.
testing efficacy of therapy vs drugs
Another problem is that therapists, even those with the same theoretical orientations, often differ markedly in the manner in which they deliver therapy. (In contrast, pills of the same chemical compound and dosage do not vary.) To test a given therapy, it therefore becomes necessary to develop a treatment manual to specify just how the therapy under examination will be delivered. Therapists in the research trial are then trained (and monitored) to make sure that their therapy sessions do not deviate significantly from the procedures outlined in the manual
manualized therapies
Efforts to “manualize” therapy represent one way that researchers have tried to minimize the variability in patients’ clinical outcomes that might result from characteristics of the therapist themselves (such as personal charisma). Although manualized therapies originated principally to standardize psychosocial treatments to fit the RCT paradigm, some therapists recommend extending their use to routine clinical practice after efficacy for particular disorders has been established
evidence based or empirically supported therapies
Efficacy studies of the outcomes of specific psychosocial treatment procedures are considered the most rigorous type of evaluation researchers have for establishing that a given therapy “works” for clients with a given diagnosis. Treatments that meet this standard are often described as evidence based or empirically supported.
psychopharmacology
the use of medications to treat mental disorders—have allowed many people who would otherwise need hospitalization to remain with their families and function in the community. These advances have also reduced the time patients need to spend in the hospital and have made restraints and locked wards largely relics of the past. In short, medication has led to a much more favorable hospital climate for patients and staff alike.
Combined Treatments
It is important to note that combined treatments are not always superior to single treatments. Adding psychiatric medications does not generally improve the clinical efficacy of psychosocial treatments for anxiety disorders, for example. However, for people suffering from chronic or recurrent depression, combined treatments often result in better clinical outcomes
Behavior therapy i
s a direct and active treatment that recognizes the importance of behavior, acknowledges the role of learning, and includes thorough assessment and evaluation. Instead of exploring past traumatic events or inner conflicts, behavior therapists focus on the presenting problem—the problem or symptom that is causing the patient great distress. A major assumption of behavior therapy is that abnormal behavior is acquired in the same way as normal behavior—that is, by learning. A variety of behavioral techniques have therefore been developed to help patients “unlearn” maladaptive behaviors by one means or another.
systematic desensitization, flooding
During exposure therapy, the patient or client is confronted with the fear-producing stimulus in a therapeutic manner. This can be accomplished in a very controlled, slow, and gradual way, as in systematic desensitization: Find a behavior that is incompatible with being anxious (such as being relaxed or experiencing something pleasant) and repeatedly pair this with the stimulus that provokes anxiety in the patient. Because it is difficult if not impossible to feel both pleasant and anxious at the same time, systematic desensitization is aimed at teaching a person, while in the presence (real or imagined) of the anxiety-producing stimulus, to relax or behave in some other way that is inconsistent with anxiety. It may therefore be considered a type of counterconditioning procedure. The term systematic refers to the carefully graduated manner in which the person is exposed to the feared stimulus.
or in a more extreme manner, as in flooding, in which the patient directly confronts the feared stimulus at full strength.
in vivo vs imaginal exposure
Moreover, the form of the exposure can be real (also known as in vivo exposure) or imaginary (imaginal exposure).
Joseph Wolpe (1958) elaborated on the procedure developed by Jones and coined the phrase systematic desensitization
On the assumption that most anxiety-based patterns are, fundamentally, conditioned responses, Wolpe worked out a way to train a client to remain calm and relaxed in situations that formerly produced anxiety. Wolpe’s approach is elegant in its simplicity, and his method is equally straightforward.
-A client is first taught to enter a state of relaxation, typically by progressive concentration on relaxing various muscle groups. Meanwhile, patient and therapist collaborate in constructing an anxiety hierarchy that consists of imagined scenes graded as to their capacity to elicit anxiety. For example, for a patient with a dog phobia, a low-anxiety step might be imagining a small dog in the distance being walked on a leash by its owner. In contrast, a high-anxiety step might be imagining a large and exuberant dog running toward the patient. Therapy sessions consist of the patient’s repeatedly imagining, under conditions of deep relaxation, the scenes in the hierarchy, beginning with low-anxiety images and gradually working toward those in the more extreme ranges.
Imaginal procedures and limitations
s have some limitations, an obvious one being that not everybody is capable of vividly imagining the required scenes. In an influential early study of clients with agoraphobia, Emmelkamp and Wessels (1975) concluded that prolonged exposure in vivo is superior to imaginal exposure. Since then, therapists have sought to use in vivo exposure whenever practical, encouraging clients to confront anxiety-provoking situations directly.
limitations of in vivo procedures
Of course, in vivo exposure is not possible for all stimuli. In addition, occasionally a client is so fearful that he or she cannot be induced to confront the anxiety-arousing situation directly. Imaginal procedures are therefore a vital part of the therapeutic exposure repertoire. An important development in behavior therapy is the use of virtual reality to help patients overcome their fears and phobias (North et al., 2015). Such approaches are obviously needed when the source of the patient’s anxiety is something that is not easily reproduced in real life, such as flying. Overall, the outcome record for exposure treatments is impressive (Barlow et al., 2007; Emmelkamp, 2004). It is also encouraging that the results from virtual reality exposure are comparable to the results obtained from in vivo exposure
Aversion Therapy
Aversion therapy involves modifying undesirable behavior by the old-fashioned method of punishment. Probably the most commonly used aversive stimuli today are drugs that have noxious effects, such as Antabuse, which induces nausea and vomiting when a person who has taken it ingests alcohol. In another variant, the client is instructed to wear a substantial elastic band on the wrist and to “snap” it when temptation arises, thus administering self-punishment.
modeling
the client learns new skills by imitating another person, such as a parent or therapist, who performs the behavior to be acquired. A younger client may be exposed to behaviors or roles in peers who act as assistants to the therapist and then be encouraged to imitate and practice the desired new responses. For example, modeling may be used to promote the learning of simple skills such as self-feeding for a child with profound intellectual disability or more complex skills such as being more effective in social situations for a shy, withdrawn adolescent.
Systematic Reinforcement
Systematic programs that use reinforcement to increase the frequency of desired behavior have achieved notable success. Often called contingency management programs, these approaches are typically used in institutional settings, although this is not always the case.
Suppressing problematic behavior may be as simple as removing the reinforcements that support it, provided, of course, that they can be identified. Sometimes identification is relatively easy, as in the following case. In other instances, it may require extremely careful and detailed observation and analysis for the therapist to learn what is maintaining the maladaptive behavior.
response shaping
In response shaping, positive reinforcement is used to establish, by gradual approximation, a response that is actively resisted or is not initially in an individual’s behavioral repertoire. This technique has been used extensively in working with children’s behavior problems (Kazdin, 2007). For example, a child who refuses to speak in front of others (selective mutism) may be first rewarded (with praise or a more tangible treat) for making any sound. Later, only complete words, and later again only strings of words, would be rewarded.
Token Economies
oken economies based on the principles of operant conditioning were developed for use with patients experiencing long-term stays in psychiatric hospitals. When they behaved appropriately on the hospital ward, patients earned tokens that they could later use to receive rewards or
- token economy resembles the outside world, where an individual is paid for his or her work in tokens (money) that can later be exchanged for desired objects and activities. Although sometimes the subject of criticism and controversy, token economies remain a relevant treatment approach for individuals with serious mental illness and those with developmental disabilities
advantages of behavioural therapy
Compared with some other forms of therapy, behavior therapy has some distinct advantages. Behavior therapy usually achieves results in a short period of time because it is generally directed to specific symptoms, leading to faster relief of a client’s distress and to lower costs. The methods to be used are also clearly delineated, and the results can be readily evaluated. Overall, the outcomes achieved with behavior therapy compare very favorably with those of other approaches
-Generally, the more pervasive and vaguely defined the client’s problem, the less likely behavior therapy is to be useful. For example, it appears to be only rarely employed to treat complex personality disorders, although dialectical behavior therapy (see Chapter 10) for patients with borderline personality disorder is an exception
-Because behavioral treatments are often quite straightforward, behavior therapy can be used with patients with psychosis (Kopelowicz et al., 2007). Recent research also shows that behavior therapy is an effective treatment for the vocal and motor tics that are found in people with Tourette’s syndrome (Wilhelm et al., 2012). This is welcome news because the alternative treatment approach involves the use of antipsychotic medications.
behavioral activation and depression
A recent development in the treatment of depression is a brief and structured form of therapy called behavioral activation (see Chapter 7). In this treatment the patient and the therapist work together to help the patient find ways to become more active and engaged with life. The patient is encouraged to engage in activities that will help improve mood and lead to better ways of coping with specific life problems. Although this sounds quite simple, it is not always that easy to accomplish. However, evidence to date suggests that this form of therapy is very beneficial for patients and can lead to enduring change (
Cognitive and cognitive-behavioral therapy and 2 main themes
(terms for the most part used interchangeably) stem from both cognitive psychology (with its emphasis on the effects of thoughts on behavior) and behaviorism (with its rigorous methodology and performance-oriented focus). No single set of techniques defines cognitively oriented treatment approaches. However, two main themes are important: (1) the conviction that cognitive processes influence emotion, motivation, and behavior; and (2) the use of cognitive and behavior-change techniques in a pragmatic (hypothesis-testing) manner
rational emotive behavior therapy (REBT)
. REBT attempts to change a client’s maladaptive thought processes, on which maladaptive emotional responses and, thus, behavior are presumed to depend.
Ellis posited that a well-functioning individual behaves rationally and in tune with empirical reality. Unfortunately, however, many of us have learned unrealistic beliefs and perfectionistic values that cause us to expect too much of ourselves, leading us to behave irrationally and then to feel that we are worthless failures.
-The task of REBT is to restructure an individual’s belief system and self-evaluation, especially with respect to the irrational “shoulds,” “oughts,” and “musts” that are preventing the individual from having a more positive sense of self-worth and an emotionally satisfying, fulfilling life. Several methods are used. One method is to dispute a person’s false beliefs through rational confrontation
Rational emotive behavior therapy aims to increase an individual’s feelings of self-worth and clear the way for self-actualization by removing the false beliefs that have been stumbling blocks to personal growth.
Beck’s Cognitive Therapy
Beck’s cognitive therapy approach was originally developed for the treatment of depression and later for anxiety disorders. Now, however, this form of treatment is used for a broad range of conditions, including eating disorders and obesity, personality disorders, substance abuse, and even schizophrenia (Beck & Haigh, 2014). The cognitive model is basically an information-processing model of psychopathology. A fundamental assumption of the cognitive model is that problems result from biased processing of external events or internal stimuli. These biases distort the way that a person makes sense of the experiences that she or he has in the world, leading to cognitive errors.
why do people make cognitive errors at all?
According to Beck (Beck & Haigh, 2014), underlying these biases is a relatively stable set of cognitive structures or schemas that contain dysfunctional beliefs. When these schemas become activated (by external or internal triggers), they bias how people process information. In the case of depression, people become inclined to make negatively biased interpretations of themselves, their world, and their future.
identifying logical errors in thinking and beck’s cognitive therapy
(1) to perceive the world selectively as harmful while ignoring evidence to the contrary; (2) to overgeneralize on the basis of limited examples—for example, seeing themselves as totally worthless because they were laid off from work; (3) to magnify the significance of undesirable events—for example, seeing the job loss as the end of the world for them; and (4) to engage in absolutistic thinking—for example, exaggerating the importance of someone’s mildly critical comment and perceiving it as proof of their instant descent from goodness to worthlessness
difference between beck’s cognitive therapy and REBT
however, that in Beck’s cognitive therapy, clients do not change their beliefs by debate and confrontation as is common in REBT. Rather, they are encouraged to gather information about themselves
WHEN IS rebt MOST USEFUL
In general, this approach may be most useful in helping people to cope better with everyday stress and perhaps in preventing them from developing full-blown anxiety or depressive disorders (David et al., 2018; Oltean et al., 2017). With respect to controlled research studies with carefully diagnosed clinical populations, REBT shows moderate to strong effects in the treatment of a range of mental disorders such as anxiety and depression, as well as psychological and behavioral problems such as poor quality of life and school performance
advantages of beck’s cognitive therapies
the efficacy of Beck’s cognitive treatment methods has been well documented. Research suggests that these approaches are extremely beneficial in alleviating many different types of disorders (Beck & Haigh, 2014). For all but the most severe cases of depression (e.g., psychotic depression), cognitive-behavioral therapy (CBT) is at least comparable to drug treatment. It also offers long-term advantages, especially with regard to the prevention of relapse (Craighead et al., 2007). In addition, cognitive therapy produces dramatic results in the treatment of panic disorder and generalized anxiety disorder and CBT is now the treatment of choice for bulimia (Wilson, 2010; Wilson & Fairburn, 2007). Finally, cognitive approaches have promise in the treatment of conduct disorder in children (Kazdin, 2007), substance abuse (Liese & Tripp, 2018), and certain personality disorders
behavioural activation component of cbt for depression
, some have suggested that the behavioral activation component of CBT, in which the clinician works with the client to identify and schedule pleasurable activities, may be what actually causes the anti-depressant effects of CBT. Interestingly, studies comparing CBT with a behavioral activation only treatment have shown that the latter is just as effective as the former
cbt for depression and 4 facts
(1) CBT has been an effective treatment for depression since the 1970s, (2) female patients benefit more from treatment than do men, (3) more experienced clinicians have better treatment effects than less experienced ones, and (4) most alarmingly, the effectiveness of CBT seems to be decreasing over time. This last fact is puzzling; however, there are two leading explanations. One is that as more and more people are getting trained in using CBT over time, more inexperienced clinicians are providing the intervention, and given point (3) above, this is causing CBT to appear less effective than it used to be. Another possibility is that the novelty of CBT led to stronger expectations on the part of both clinician and client early on, but as CBT has become more common, those expectations have decreased, leading to smaller positive changes in depression.
humanistic-experiential therapies historical roots
emerged as significant treatment approaches after World War II. In a society dominated by self-interest, mechanization, computerization, mass deception, and mindless bureaucracy, proponents of the humanistic-experiential therapies see psychopathology as stemming in many cases from problems of alienation, depersonalization, loneliness, and a failure to find meaning and genuine fulfillment. Problems of this sort, it is held, are not likely to be solved either by delving into forgotten memories or by correcting specific maladaptive behaviors.
=The humanistic-experiential therapies are based on the assumption that people have both the freedom and the responsibility to control their own behavior—that they can reflect on their problems, make choices, and take positive action. Humanistic-experiential therapists feel that a client must take most of the responsibility for the direction and success of therapy, with the therapist serving merely as counselor, guide, and facilitator. Although humanistic-experiential therapies differ in their details, their central focus is always expanding a client’s “awareness.”
client-centered (person-centered) therapy
of Carl Rogers (1902–1987) focuses on the natural power of the organism to heal itself (Rogers, 1951, 1961). Rogers saw therapy as a process of removing the constraints and restrictions that grow out of unrealistic demands that people tend to place on themselves when they believe, as a condition of self-worth, that they should not have certain kinds of feelings such as hostility. By denying that they do in fact have such feelings, they become unaware of their actual “gut” reactions. As they lose touch with their own genuine experience, the result is lowered integration, impaired personal relationships, and various forms of maladjustment.
=The primary objective of Rogerian therapy is to resolve this incongruence—to help clients become able to accept and be themselves. To this end, client-centered therapists establish a psychological climate in which clients can feel unconditionally accepted, understood, and valued as people. Within this context, the therapist employs nondirective techniques such as empathic reflecting, or a restatement of the client’s descriptions of life difficulties. If all goes well, clients begin to feel free, for perhaps the first time, to explore their real feelings and thoughts and to accept hates and angers and ugly feelings as parts of themselves. As their self-concept becomes more congruent with their actual experience, they become more self-accepting and more open to new experiences and new perspectives; in short, they become better-integrated people.
passiove nature of clinet centered therapy
In contrast to most other forms of therapy, the client-centered therapist does not give answers, interpret what a client says, probe for unconscious conflicts, or even steer the client toward certain topics. Rather, he or she simply listens attentively and acceptingly to what the client wants to talk about, interrupting only to restate in different words what the client is saying. Such restatements, devoid of any judgment or interpretation by the therapist, help the client to clarify further the feelings and ideas that he or she is exploring—really to look at them and acknowledge them. The following excerpt from a therapist’s second interview with a young woman will serve to illustrate these techniques of reflection and clarification.
Motivational Interviewing
is a brief form of therapy that can be delivered in one or two sessions. It was developed as a way to help people resolve their ambivalence about change and make a commitment to treatment (Miller, 1983). At its center is a supportive and empathic style of relating to the client that has its origins in the work of Carl Rogers. However, MI differs from client-centered counseling because it employs a more direct approach that explores the client’s own reasons for wanting to change. The therapist encourages this “change talk” by asking the client to discuss his or her desire, ability, reasons, and need for change. These are reflected back by the therapist, thus exposing the client to periodic summaries of his or her own motivational statements and thoughts about change. The result is that clients can develop and strengthen their commitment to change in an active, accepting, and supportive atmosphere.
use for MI
Motivational interviewing is most often used in the areas of substance abuse and addiction. When added to the beginning of a treatment program, it appears to benefit patients, perhaps because it facilitates patients’ staying in treatment and following the treatment plan. A meta-analysis of the MI literature also has shown that MI has a large effect when it is used with ethnic minorities
Gestalt Therapy
the term gestalt means “whole,” and gestalt therapy emphasizes the unity of mind and body—placing strong emphasis on the need to integrate thought, feeling, and action. Gestalt therapy was developed by Frederick (Fritz) Perls (1969) as a means of teaching clients to recognize the bodily processes and emotions they had been blocking off from awareness. As with the client-centered and humanistic approaches, the main goal of gestalt therapy is to increase the individual’s self-awareness and self-acceptance.
Although gestalt therapy is commonly used in a group setting, the emphasis is on one person at a time, with whom a therapist works intensively, trying to help identify aspects of the individual’s self or world that are not being acknowledged in awareness. The individual may be asked to act out fantasies concerning feelings and conflicts or to represent one side of a conflict while sitting in one chair and then switch chairs to take the part of the adversary.
advantages / cons of humanistic experentyial therapies
Many of the humanistic-experiential concepts—the uniqueness of each individual, the importance of therapist genuineness, the satisfaction that comes from realizing one’s potential, the importance of the search for meaning and fulfillment, and the human capacity for choice and self-direction—have had a major impact on our contemporary views of both human nature and the nature of good psychotherapy.
However, humanistic-experiential therapies have been criticized for their lack of agreed-on therapeutic procedures and their vagueness about what is supposed to happen between client and therapist. In response, proponents of such approaches argue against reducing people to abstractions, which can diminish their perceived worth and deny their uniqueness. Because people are so different, they argue, we should expect different techniques to be appropriate for different cases.
Controlled research on the outcomes achieved by many forms of humanistic-existential therapy was lacking in the past. However, research in this area is now on the increase. Evidence suggests that these treatment approaches are helpful for patients with a variety of problems including depression, anxiety, trauma, and marital difficulties (Elliot et al., 2004). And, as we have already noted, motivational interviewing is now established as an effective method for promoting behavior change in people with substance abuse problems
Psychodynamic therapy and its 2 divisions
a broad treatment approach that focuses on individual personality dynamics, usually from a psychoanalytic or some psychoanalytically derived perspective. Psychoanalytic therapy is the oldest form of psychological therapy and began with Sigmund Freud. The therapy is mainly practiced in two basic forms: classical psychoanalysis and psychodynamically oriented psychotherapy.
classical psychoanalysis
intensive (at least three sessions per week), long-term procedure for uncovering repressed memories, thoughts, fears, and conflicts presumably stemming from problems in early psychosexual development—and helping individuals come to terms with them in light of the realities of adult life.
Four basic techniques are used in psycodynamic therapy
(1) free association, (2) analysis of dreams, (3) analysis of resistance, and (4) analysis of transference.
f free association and anlytic interpretation
s that an individual must say whatever comes into her or his mind regardless of how personal, painful, or seemingly irrelevant it may be. Usually a client lies in a relaxed position on a couch and gives a running account of all the thoughts, feelings, and desires that come to mind as one idea leads to another. The therapist normally takes a position behind the client so as not to disrupt the free flow of associations in any way.
=Analytic interpretation involves a therapist’s tying together a client’s often disconnected ideas, beliefs, and actions into a meaningful explanation to help the client gain insight into the relationship between his or her maladaptive behavior and the repressed (unconscious) events and fantasies that drive it.
Analysis of Dreams and content
(1) manifest content, which is the dream as it appears to the dreamer, and (2) latent content, which consists of the actual motives that are seeking expression but are so painful or unacceptable that they are disguised.
resistance
During the process of free association or of associating to dreams, an individual may show resistance—an unwillingness or inability to talk about certain thoughts, motives, or experiences
Analysis of Transference
As client and therapist interact, the relationship between them may become complex and emotionally involved. Often people carry over, and unconsciously apply (or “transfer”) to their therapist, attitudes and feelings that they had in their relations with a parent or other person close to them in the past, a process known as transference. Thus, clients may react to their analyst as they did to that earlier person and feel the same love, hostility, or rejection that they felt long ago. If
how therapists should deal with transference / transference neurosis
In essence, the negative effects of an undesirable early relationship are counteracted by working through a similar emotional conflict with the therapist in a therapeutic setting. A person’s reliving of a pathogenic past relationship in a sense re-creates the neurosis in real life, and therefore this experience is often referred to as a transference neurosis.
countertransference,
. In addition, the problems of transference are not confined to the client, for the therapist may also have a mixture of feelings toward the client. This countertransference, wherein the therapist reacts in accord with the client’s transferred attributions rather than objectively, must be recognized and handled properly by the therapist. For this reason, it is considered important that therapists have a thorough understanding of their own motives, conflicts, and “weak spots”; in fact, all psychoanalysts undergo psychoanalysis themselves before they begin independent practice.
Interpersonally oriented psychodynamic therapists
vary considerably in their time focus, whether they concentrate on remote events of the past, on current interpersonal situations and impasses (including those of the therapy itself), or on some balance of the two. Most seek to expose, bring to awareness, and modify the effects of the remote developmental sources of the difficulties the client is currently experiencing. These therapies generally retain, then, the classical psychoanalytic goal of understanding the present in terms of the past. What they ignore are the psychoanalytic notions of staged libidinal energy transformations and of entirely internal (and impersonal) drives that are channeled into psychopathological symptom formation.
Evaluating Psychodynamic Therapies
The practice of classical psychoanalysis is routinely criticized for being relatively time consuming and expensive; for being based on a questionable and sometimes cult-like approach to human nature; for neglecting a client’s immediate problems in the search for unconscious conflicts in the remote past; and for there being no adequate proof of its general effectiveness. Indeed, there have been no rigorous, controlled outcome studies of classical psychoanalysis.
In contrast, much more research has been done on some of the newer psychodynamically oriented approaches. There are signs that psychodynamic approaches may be helpful in the treatment of depression, panic disorder, PTSD, and substance abuse disorders (Gibbons et al., 2008). Recent research also supports the idea that increases in insight (“insight” is a key construct in psychodynamic theory and involves cognitive and emotional understanding of inner conflicts) must occur before there is long-term clinical change
advantages to psycoanalysius
transference-focused psychotherapy, or TFP
. Developed by Kernberg and colleagues (Kernberg, Yeomans, Clarkin, Levy 2008), this treatment approach uses such techniques as clarification, confrontation, and interpretation to help the patient understand and correct the distortions that occur in his or her perception of other people, including the therapist. In a clinical trial, patients with borderline personality disorder who received TFP did as well as those who were assigned to receive dialectical behavior therapy
couple therapy
has been traditional behavioral couple therapy (TBCT) (Christensen et al., 2007). TBCT is based on a social-learning model and views marital satisfaction and marital distress in terms of reinforcement. The treatment is usually short term (10 to 26 sessions) and is guided by a manual. The goal of TBCT is to increase caring behaviors in the relationship and to teach partners to resolve their conflicts in a more constructive way through training in communication skills and adaptive problem solving.
f integrative behavioral couple therapy (IBCT)
These limitations of TBCT led researchers to conclude that a change-focused treatment approach was not appropriate for all couples. This created the impetus for the development of integrative behavioral couple therapy (IBCT) (Jacobson et al., 2000; Wheeler et al., 2001). Instead of emphasizing change (which sometimes has the paradoxical effect of making people not want to change), IBCT focuses on acceptance and includes strategies that help each member of the couple come to terms with and accept some of the limitations of his or her partner. Of course, change is not forbidden. Rather, within IBCT, acceptance strategies are integrated with change strategies to provide a form of therapy that is more tailored to individual characteristics, relationship “themes” (long-standing patterns of conflicts), and the needs of the couple.
TBCT behavoural couple therapy vs IBCT outcomes
Although these differences are not statistically different from each, other data show that couples who stay together after receiving IBCT are significantly happier than couples who stay together following treatment with TBCT (Atkins et al., 2005). Most recently, ICBT has been translated into a format in which couples can work through therapy via an online self-help website
Family therapy
began with the finding that many people who had shown marked clinical improvement after individual treatment—often in institutional settings—had a relapse when they returned home. As you have already learned, family-based treatment approaches designed to reduce high levels of criticism and family tension have been successful in reducing relapse rates in patients with schizophrenia and mood disorders
structural family therapy
. This approach, which is based on systems theory, holds that if the family context can be changed, then the individual members will have altered experiences in the family and will behave differently in accordance with the changed requirements of the new family context. Thus, an important goal of structural family therapy is changing the organization of the family in such a way that the family members will behave more supportively and less pathogenically toward each other.
role of therapist in structural family therapy
Structural family therapy is focused on present interactions and requires an active but not directive approach on the part of a therapist. Initially, the therapist gathers information about the family—a structural map of the typical family interaction patterns—by acting like one of the family members and participating in the family interactions as an insider. In this way, the therapist discovers whether the family system has rigid or flexible boundaries, who dominates the power structure, who gets blamed when things go wrong, and so on. Armed with this understanding, the therapist then operates as an agent for altering the interaction among the members, which often has transactional characteristics of enmeshment (overinvolvement), overprotectiveness, rigidity, and poor conflict resolution skills. The “identified client” is often found to play an important role in the family’s mode of conflict avoidance
multimodal therapy
Today, clinical practice is characterized by a relaxation of boundaries and a willingness on the part of therapists to explore differing ways of approaching clinical problems (Castonguay et al., 2003), a process sometimes called multimodal therapy
When asked what their orientation is, most psychotherapists today reply “eclectic,” which usually means that they try to borrow and combine concepts and techniques from various schools, depending on what seems best for the individual case.
interpersonal therapy
One example of an eclectic form of therapy is interpersonal therapy (IPT; see also Chapter 7). Developed by Klerman and colleagues (1984) as a treatment for depression, IPT focuses on current relationships in the patient’s life and has the goals of reducing symptoms and improving functioning. Interpersonal therapy was based on the interpersonal theory of Harry Stack Sullivan as well as on Bowlby’s attachment theory. Its central idea is that all of us, at all times, involuntarily invoke schemas acquired from our earliest interactions with others, such as our parents, in interpreting what is going on in our current relationships.
Social Values and Psychotherapy
Each time therapists decide that one behavior should be eliminated or substituted for another, however, they are making a value judgment. For example, is a therapist to assume that the depression of a young mother who is abused by an alcoholic husband is an internally based disorder requiring “treatment,” as once would have been the routine interpretation? Or does the therapist have a larger responsibility to look beyond individual pathology and confront the abnormality of the marital relationship? Therapy takes place in a context that involves the values of the therapist, the client, and the society in which they live.
culturally adapted interventions
When specialized, culturally adapted interventions are made available in community settings, ethnic minority clients are less likely to drop out of treatment and often do well (Snowden & Yamada, 2005). However, such programs are still lacking in many communities. Also lacking are research investigations designed to understand how culture and ethnicity affect a person’s ability to access and receive psychiatric and psychological treatments. Nonetheless, there are encouraging developments.
antipsychotics and outcomes dependent on diff disorders
Studies have found that approximately 60 percent of patients with schizophrenia who are treated with traditional antipsychotic medications have a resolution of their positive symptoms within 6 weeks, compared to only about 20 percent of those treated with placebo (Sharif et al., 2007). 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 and schizotypal personality disorder (Koenigsberg et al., 2007). Finally, antipsychotic medications are sometimes used to treat the delusions, hallucinations, paranoia, and agitation that can occur with Alzheimer’s disease. However, antipsychotic medications pose great risks to patients with dementia because they are associated with increased rates of death (Sultzer et al., 2008). Because of this, there is now a “black box warning” about using these medications for patients with dementia. (A black box warning is a warning on the outside of a medication package about the potential dangers of that medication that literally appears inside a black box.)
is tardive dyskinesia
Tardive (from tardy) dyskinesia is a movement abnormality that is a delayed result of taking antipsychotic medications. Because movement-related side effects are a little less common with atypical antipsychotic medications such as clozapine (Clozaril) and olanzapine (Zyprexa), these medications are often preferred in the clinical management of schizophrenia. Clozapine also seems to be especially beneficial for patients with psychosis who are at high risk of suicide
first gen vs second gen anti depressants
As is the case for antipsychotic medications, the drugs that were discovered first (so-called classical antidepressants such as monoamine oxidase inhibitors [MAOIs] and tricyclic antidepressants [TCAs], both discussed next) have now been replaced in routine clinical practice by “second-generation” treatments such as the SSRIs.
tricylic vs ssri function
Unlike the tricyclics (which inhibit the reuptake of both serotonin and norepinephrine), SSRIs selectively inhibit the reuptake of serotonin (see Figure 16.2). They have become the preferred antidepressant drugs, in large part due to very aggressive advertising by the pharmaceutical companies. SSRIs are also easier to use, have fewer side effects, and are generally not found to be fatal in overdose, as the tricyclics can be. However, there is no compelling evidence that they are more effective than other types of antidepressants
amino acid serotonin is synethsized from
Serotonin is synthesized from the amino acid tryptophan. After being released into the synaptic cleft, it binds to receptors on the postsynaptic neuron. A serotonin reuptake transporter then returns it to the presynaptic neuron. SSRI medications block this reuptake process, leaving more serotonin available in the synapse.
SNRIs
block the reuptake of both norepinephrine and serotonin. They have similar side effects to the SSRIs, and they are relatively safe in overdose. SNRIs seem to help a significant number of patients who have not responded well to other antidepressants, and they are slightly more effective than SSRIs in the treatment of major depression
Side effects of the SSRIs
s include nausea, diarrhea, nervousness, insomnia, and sexual problems such as diminished sexual interest and difficulty with orgasm
Monoamine Oxidase Inhibitors
They inhibit the activity of monoamine oxidase, an enzyme present in the synaptic cleft that helps break down the monoamine neurotransmitters (such as serotonin and norepinephrine) that have been released into the cleft. Patients taking MAOIs must avoid foods rich in the amino acid tyramine (such as salami and Stilton cheese). This limits the drugs’ clinical usefulness.
SIDE EFFECTS: Nevertheless, MAOIs are used in certain cases of atypical depression that are characterized by hypersomnia and overeating and do not respond well to other classes of antidepressant medicatio
first antidepressant to be introduced in the United States that was not lethal when taken in overdose.
Trazodone (
Bupropion
n antidepressant that is not structurally related to other antidepressants. It inhibits the reuptake of both norepinephrine and dopamine. In addition to being an antidepressant medication, bupropion also reduces nicotine cravings and symptoms of withdrawal in people who want to stop smoking. One clinical advantage of bupropion is that, unlike some of the SSRIs, it does not inhibit sexual functioning
Benzodiazepines and how they work
The most important and widely used class of antianxiety (or anxiolytic) drugs are the benzodiazepines.
-Benzodiazepines and related anxiolytic medications are believed to work by enhancing the activity of GABA receptors (Stahl, 2000). GABA (gamma aminobutyric acid) is an inhibitory neurotransmitter that plays an important role in the way our brain inhibits anxiety in stressful situations. The benzodiazepines appear to enhance GABA activity in certain parts of the brain known to be implicated in anxiety such as the limbic system.
barbiturates
s seldom used today except to control seizures or as anesthetics during electroconvulsive therapy.
buspirone
s buspirone (Buspar), which is completely unrelated to the benzodiazepines and is thought to act in complex ways on serotonergic functioning rather than on GABA. It has been shown to be as effective as the benzodiazepines in treating generalized anxiety disorder (Roy-Byrne & Cowley, 2007), although patients who have previously taken benzodiazepines tend not to respond as well as patients who have never taken them. Buspar has a low potential for abuse, probably because it has no sedative or muscle-relaxing properties and so is less pleasurable for patients. It also does not cause any withdrawal effects. The primary drawback to the use of buspirone is that it takes 2 to 4 weeks to exert any anxiolytic effects. It is therefore not useful in acute situations. Because it is nonsedating, it cannot be used to treat insomnia.
Lithium
As many as 70 to 80 percent of patients in a clear manic state show marked improvement after 2 to 3 weeks of taking lithium (Keck & McElroy, 2002). Lithium also has antidepressant effects among those with both bipolar and unipolar depression (Young, 2017). There is increasing evidence that lithium maintenance treatment may be less reliable at preventing future episodes of mania than was once thought. For example, several studies of patients with bipolar disorder maintained on lithium for 5 years or more found that only just over one-third remained in remission. Nevertheless, discontinuation of lithium is also very risky. The probability of relapse is estimated to be 28 times higher after withdrawal than when the patient is on lithium, with about 50 percent relapsing within 6 months
Side effects of lithium
include increased thirst, gastrointestinal difficulties, weight gain, tremor, and fatigue. In addition, lithium can be toxic if the recommended dose is exceeded or if the kidneys fail to excrete it from the body at a normal rate. Lithium toxicity is a serious medical condition. If not treated swiftly and appropriately, it can cause neuronal damage or even death.
Commonly Prescribed Mood-Stabilizing Medications
lithium and anticonvulsants
disruptive mood dysregulation disorder.
This disorder is characterized by temper tantrums in a child older than 6 years of age. In order for the diagnosis to be made, the angry outbursts must occur at least three times a week and be inconsistent with the child’s developmental level. On the plus side, this diagnosis may allow children with very irritable temperaments to receive specialized help at an early age. However, there is also a risk that many children whose parents might benefit from parental skills training will instead receive powerful tranquilizing medications while their young brains are still maturing and developing.
DSM 4 TR VS DSM 5 ADHD AGE ONSET
To be diagnosed with attention-deficit/hyperactivity disorder (ADHD) in DSM-IV-TR, symptoms had to develop before the child reached the age of 7. In DSM-5 this age of onset has been raised to age 12. Many children who would not have been eligible to be diagnosed with ADHD (because their symptoms developed when they were age 8, 9, or 10) will now receive the diagnosis. This simple change in the diagnostic criteria will dramatically increase the prevalence of ADHD. And, although it will allow many more children to receive treatment, it will undoubtedly result in many more children being medicated.
Electroconvulsive Therapy Ladislas von Meduna,
a Hungarian physician, is generally regarded as the modern originator of this treatment approach. Von Meduna noted—erroneously, as it turned out—that schizophrenia rarely occurred in people with epilepsy. This observation caused him to infer that schizophrenia and epilepsy were somehow incompatible and to speculate that one might be able to cure schizophrenia by inducing convulsions. In an early treatment effort, von Meduna used camphor to induce convulsions in a patient with schizophrenia, who relatively quickly regained lucidity after the convulsive therapy. Later, von Meduna began to use a drug called Metrazol to induce convulsions because it operated more rapidly than camphor.
founders of passing an electric current through a patient’s head
, Italian physicians Ugo Cerletti and Lucio Bini tried the simplest method of all—passing an electric current through a patient’s head. This method, which became known as electroconvulsive therapy (ECT), is still used today (see Chapter 7). In the United States, about 100,000 patients are treated with ECT each
advantages of ect
. However, despite the distaste with which some people regard ECT, it is a safe and effective form of treatment. In fact, it is the only way of dealing with some patients who are severely depressed or suicidal—patients who may have failed to respond to other forms of treatment. In addition, it is often the treatment of choice for pregnant women who are severely depressed for whom taking antidepressants may be problematic, as well as for elderly people, who may have medical conditions that make taking antidepressant drugs dangerous (Pandya et al., 2007).
Reviews evaluating research on ECT have concluded that it is an effective treatment for patients with severe or psychotic-level depression, as well as for some patients with mania (Prudic, 2009). Properly administered, ECT does not cause structural damage to the brain, as was once thought, but it does lead to structural changes in the brain (Bouckaert et al., 2014). Every neurotransmitter system is affected by ECT, and ECT is known to downregulate the receptors for norepinephrine, increasing the functional availability of this neurotransmitter. However, exactly how ECT works is still not fully clear
bilateral ECT
n bilateral ECT, electrodes are placed on either side of the patient’s head (see Figure 16.4), and brief constant-current electrical pulses of either high or low intensity are passed from one side of the head to the other for up to about 1.5 seconds.
Empirical evidence suggests that bilateral ECT is more effective than unilateral ECT. Unfortunately, bilateral ECT is also associated with more severe cognitive side effects and memory problems (Reisner, 2003). For instance, patients often have difficulty forming new memories (anterograde amnesia) for about 3 months after ECT ends. Physicians must therefore weigh the greater clinical benefits of bilateral ECT against its tendency to cause greater cognitive side effects. Some clinicians recommend starting with unilateral ECT and switching to bilateral after five or six treatments if no improvement is seen
unilateral ECT
involves limiting current flow to one side of the brain, typically the nondominant side (right side, for most people). A general anesthetic allows the patient to sleep through the procedure, and muscle relaxants are used to prevent the violent contractions that, in the early days of ECT, could be so severe as to cause the patient to fracture bones.
how ect procedure works
A patient who receives ECT today is given sedative and muscle-relaxant medications prior to the procedure to prevent violent contractions. In the days before such medication was available, the initial seizure was sometimes so violent as to fracture vertebrae.
Transcranial Magnetic Stimulation
TMS is a treatment in which the clinician positions a pulsed magnet over a carefully selected area of the patient’s scalp and uses it to create an electrical field that increases or decreases neuronal activity in the brain (see Figure 16.5). Scientists have been using magnets to create electrical fields since the 1830s; however, it wasn’t until 1985 that magnets were used for the purposes of brain stimulation (Barker et al., 1985). During the past 30 years, technological advances have led to the ability to carefully control the location, intensity, frequency, and pattern of the electrical currents directed at very specific parts of the brain. At this point, numerous studies have shown that TMS can be used to effectively treat major depression, with additional evidence supporting its use with other conditions
effects of tms
TMS is less invasive than surgical interventions and has fewer and less severe side effects than ECT. The most commonly reported side effects from repeated TMS sessions are mild headache and a small risk of seizure. However, there are no impairments in memory or concentration as there are with ECT. Although TMS has shown effectiveness for treating depression and other conditions, it is still a very new approach and typically is only considered after several courses of psychotherapy and antidepressant medication have proven ineffective.
Antonio Moniz
introduced a neurosurgical procedure in which the frontal lobes of the brain were severed from the deeper centers underlying them. This technique eventually evolved into an operation known as prefrontal lobotomy, which stands as an infamous example of the extremes to which professionals have sometimes been driven in their search for effective treatments for the psychoses.
when is psycosurgery used
Psychosurgery is sometimes used for patients with debilitating OCD (Dougherty et al., 2007), treatment-resistant severe self-injury (Price et al., 2001), or even intractable anorexia nervosa (Morgan & Crisp, 2000). However, such approaches carry serious risks. In one study, 25 patients who had received brain lesions to treat severe OCD were followed up an average of 11 years later. Twelve of the 25 patients experienced significant relief from their OCD symptoms after the surgery. They also showed reductions in depression. However, 10 of the patients who showed clinical improvement also showed evidence of frontal lobe dysfunction at follow-up, including impaired executive functioning on cognitive tests, problems with apathy, and disinhibited behavior (Rück et al., 2008). These results highlight the risks of brain surgery even when it is effective in treating the symptoms of OCD.
Deep Brain Stimulation for Treatment-Resistant Depression
An important development in the treatment of patients with severe and chronic mental health problems is deep brain stimulation. This involves stimulating patients’ brains electrically over a period of several months. First, surgeons drill holes into the brain and implant small electrodes (see Figure 16.6). Because this procedure is done under local anesthetic, patients can talk to the doctors about what is happening to them and tell the doctors about the changes they experience. In an early study involving six patients, all reported a response to the electrical stimulation even though they had no cues to tell them when current was being passed through the electrodes or when the current was off (Mayberg et al., 2005). When current was flowing into an area of the brain that is thought to be metabolically overactive in depression (the cingulate region), patients reported that they felt better and had experiences of “sudden calmness or lightness,” “connectedness,” or “disappearance of the void.”
