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Treatment of Psychological Disorders I. Introduction and Overview A. Definition of psychological treatment When a psychological disorder becomes serious enough to cause problems in every day functioning, the client may seek to have the disorder treated. Clients can be treated as inpatients (24-hour care in a treatment center or hospital) or ou tpatients (periodic appointments in an office/clinic setting). 1. Psychotherapy This therapy applies psychological principles and techniques to treatment of a psychological disorder. Psychotherapy includes discussion of the psychological problem and specific exercises/techniques that are designed to help a client fu nction better in everyday life. 2. Biological This is the term when physiological methods are used to treat psychological ill ness. Examples of medically based treatments include medication and electroconv ulsive therapy (ECT). 3. Combined treatments The combined use of medication and psychotherapy is a common approach to treati ng psychological disorders (Sammons & Schmidt, 2001). B. History of treatment Historically, treatment of people with psychological disorders ranged from lack of care to extreme and often violent mistreatment of individuals with serious psychological disorders. 1. Early treatment approaches (circa 1300 1900) Early psychological treatment consisted primarily of imprisonment, rather than specific techniques to help people with mental illness. Bethlam (or the more co mmon name of Bedlam) is located in London and is considered the oldest hospital caring for people with mental illness. The term bedlam aptly describes the con ditions that were present in hospitals at that time. Treatment facilities, call ed asylums or mental hospitals, were built to house people with mental illness in the mid-1500s. Patients often were chained and mistreated in the early attem pts to treat psychological illness. a. Phillipe Pinel (1745 1826) was the first physician to remove the chains from seriously mentally ill patients, which resulted in calmer patients. In the 1840s, in the United States , Dorothea Dix (1802 1887) also initiated freeing the mentally ill from mistreatment in jails and ot her locations. She was instrumental in helping to establish state-funded mental hospitals (Weiten, 1994). b. The precursor to modern psychotherapy began with a physician, Josef Breuer ( 1845 1925), who used hypnosis to get his patients to talk about their problems or wh

at became known as cathartic therapy (Sternberg, 1995). 2. Contemporary treatment approaches (1900 2000) Early twentieth century treatments also included harsh medical interventions (e .g., ECT, prefrontal lobotomy), which were performed in mental hospitals. Althou gh these hospitals remained operational, they failed to reach their full potent ial, and in the 1950s, efforts were undertaken to close many large mental hospi tals. Deinstitutionalization of patients resulted in release of many patients. Treatment of psychological disorders now includes hospital inpatient treatment s and community mental health or outpatient treatments. Several specific treatm ent modalities were introduced in the second half of the twentieth century. Freud s (1856 1939) approach to therapy, or psychoanalysis, is perhaps the most well-known co ntemporary approach to therapy. Freud emphasized understanding the unconscious mind as a central tenet of treating psychological disorders. Freud s patients would lie on a couch and talk about their problems through free association or reporting dream s. Humanistic therapy, which consists of more egalitarian behavioral treatments that emphasize change in actions; cognitive therapy, designed to change a person s thought processes; and biomedical treatments are among the specific techniques that will be outlined. C. Those who provide treatment Professionals who treat people with psychological problems have training as med ical doctors (psychiatrists), psychologists, or other professions with speciali zed mental health training (e.g., social workers, nurses, counselors). 1. Psychiatrist A psychiatrist is a medical doctor who specializes in treating psychological di sorders. A psychiatrist can diagnose a mental illness, prescribe medication, or administer other biomedical treatments. 2. Psychologist A clinical or counseling psychologist has a doctoral degree (PhD or PsyD) that i ncludes training in diagnosis and treatment of psychological illnesses. 3. Psychiatric social worker or psychiatric nurse This social worker or nurse works as part of a team of people in a hospital sett ing. Services include monitoring treatments that are prescribed by a psychiatri st or psychologist. 4. Counselor A counselor provides limited psychotherapy for individuals who do not have a ser ious mental illness. D. Ethical issues in treatment Professionals should adhere to a set of ethical standards issued by their respe ctive organizations. For example, psychologists should adhere to the ethical pr inciples of the American Psychological Association. In addition to ethical stan dards, professionals must adhere to legal stipulations governing the practice o f psychology. One example of the nexus of law and ethical code relates to the r ight to privacy, which is granted by the U.S. Constitution. Although this right to privacy is a legal mandate, specific application of this right to privacy i s specified in the ethics code (Koocher & Keith-Speigel, 1998). Essentially, pr actitioners should be sure that they keep all information confidential. Informat ion about a client should be released only under very specific circumstances, a

nd the client has a right to know, in advance, about the conditions under which information will be released. For example, if a client tells a psychologist th at (s)he plans to hurt someone, the psychologist must break confidentiality. Add itional reference materials related to the application of ethics are included a t the end of this lesson plan. II. PsychoanalyticTreatment Approaches A. Introduction and overview Psychoanalytic, humanistic, and cognitive approaches to therapy are often calle d insight therapies. Insight therapy helps patients develop an understanding of their inner conflicts. It is through understanding himself or herself that a p atient can begin to solve the problems of daily living. B. Psychoanalytic approaches Sigmund Freud (1856 1939) pioneered work in psychodynamic therapies. His particular type of therapy has been labeled psychoanalysis. 1. Psychoanalysis emphasizes the importance of the unconscious mind. Freud atte mpted to help people understand, or develop insight, into their unconscious con flicts as a way to relieve neurotic anxiety (Dryden & Mytton, 1999). Techniques Psychoanalysis is an intensive and long-term therapy that may include several s essions per week over a period of several years. A psychoanalyst helps the pati ent to discover unconscious conflicts, yet the therapist remains neutral, does not reveal personal information, and does not give advice. (1) Free association During a therapy session, psychoanalysts encourage patients to verbalize any th oughts or feelings that come into their consciousness. Resistance occurs when p atients unconsciously try to censor their thoughts/feelings or sabotage therap y by missing appointments or holding back their thoughts. Transference occurs w hen patients treat the psychoanalyst like someone from their past (e.g., a pare nt). For example, a patient may have unconscious hostile feelings toward an ove rly domineering parent. When the patient was a young child, a parent may have required the patient to continue an unpleasant set of piano lessons. If, in the course of therapy, the therapist asks the patient why he or she has not comple ted a project or similar task, then the patient might get angry with the therap ist, thus engaging in transference. (2) Dream analysis According to Freud, dreams reflect symbolic or unconscious desires. A psychoana lyst asks a patient to describe a dream in as much detail as possible. Then, th e psychoanalyst interprets the underlying meaning of the dream. Freud believed that unfulfilled desires that are not expressed consciously during waking hour s may be represented in latent content of dreams. 2. Other psychoanalytic therapies Carl Jung, Erik Erikson, and Karen Horney are neo-Freudians who believed that t herapy should include conscious and unconscious aspects of the patient. A neo-F reudian psychoanalyst seeks to understand the patient s past and helps to understand the patient s future. This type of therapy is usually shorter in duration compared to traditional psy choanalysis. Ego analysis, interpersonal therapy, and individual analysis are a mong some of the neo-Freudian therapies that include both conscious and unconsc

ious aspects. According to the newest neo-Freudian approach, object relations t heory, children should form a secure relationship with a caregiver in order to feel secure as adults. In this case, the object is the ?relationship with the parent.? If a secure bond is not formed, the child may not be able to form strong social relationships as an adult. An object relation s therapist treats a patient with the underlying perspective that object relati ons are influential in the development of the patient. III. Humanistic Treatment Approaches A. Introduction and overview Humanistic or client-centered therapies represent the second set of insight the rapies psychologists use. However, the emphasis on humanism changes how the the rapist views the person who enters therapy. Instead of calling the person a ?patient? as a psychoanalyst might, the humanistic -oriented therapist would call the person a ?client.? The client and the therapist are mor e equal in the therapeutic relationship. Humanistic therapies emphasize free will of th e client and encourage growth or self-actualization. In other words, if the cli ent can understand or develop insight into his or her problems of living, then the client can choose to change his or her behavior. B. Client-centered or nondirective therapy Carl Rogers developed client-centered therapy that allowed clients to direct th e therapeutic process. Rogerian-oriented therapists want to help clients to dev elop insight into themselves as valuable human beings and to worry less about w hat others think of them. Client-centered therapists must ensure the following conditions for therapy. 1. Genuineness The therapist has to be completely honest and genuine. In essence, therapists m odel the type of openness they expect from their clients. 2. Unconditional positive regard The therapist emphasizes the value of the client by fully accepting the worth of the client. Sometimes clients do things to please others. Unconditional positiv e regard suggests that the client does not have to please the therapist. 3. Empathy The therapist has an emotional understanding of the client. In other words, the therapist can truly understand the perspective of the client. C. Gestalt therapy Fritz Perls and his wife, Laura, developed Gestalt therapy from the perspective that people create their own understanding of the world and continue to grow a s long as they have insight into their feelings. Gestalt therapy is more directi ve and confrontational than client-centered therapy. A Gestalt approach may inc lude helping clients to identify inconsistencies between the statements they ma ke about how they see themselves and how they really interact with the world. D. Other humanistic therapies Group therapy and family therapy are treatment modalities. Often they are consi dered within the context of humanistic therapies because an emphasis is placed o n growth of the individual. However, it is possible that the therapist may appr oach treatment from any of the perspectives that have been outlined in this uni

t. 1. Group therapy A group of clients who may be experiencing similar problems (e.g., alcoholism, d omestic abuse, violence) meet under the direction of one or more therapists who help them work through their problems. Advantages of group therapy include helpi ng clients to understand that they are not alone and identifying possible mechan isms for dealing with difficult situations. 2. Family therapy Rather than treating an individual for a specific problem, a family therapist co nsiders the person within the context of a system (family) and treats the entire system. The goal of family therapy is to improve the functioning of the family system as a whole through a better understanding of interactions that occur with in the system. IV. Behavior Therapy Treatment A. Introduction and overview Behavior therapy emphasizes changing learned behaviors rather than understandin g feelings. This relatively new approach (1970) evolved out of general principl es of classical and operant conditioning that were studied by Watson, Pavlov, a nd Skinner. Behavior therapy generally attempts to alter the behavior of the cl ient through specific techniques that are administered during a brief period of time. Common applications of behavior therapy include the treatment of phobias and anxiety disorders. B. Behavior therapy techniques Traditional behavior therapy techniques use conditioning (refer students to cla ssical conditioning principles and operant conditioning examples) to alter the client s behavior. 1. Systematic desensitization Mary Cover Jones pioneered systematic desensitization or counterconditioning as a method for treating phobias. Later, Joseph Wolpe popularized the treatment. Systematic desensitization used the principles of classical conditioning by cre ating new associations for the original phobic stimulus. Although this treatmen t was originally developed using the classical conditioning paradigm, it is imp ortant to emphasize that it is unclear why the treatment works (Bernstein, et a l., 2003). A transparency master is included in this lesson plan for purposes o f illustration. a. First, an anxiety hierarchy must be developed. This hierarchy is a rank orde ring of the anxiety-provoking situation beginning with the least fearful stimul us and ranging to the actual item or situation most 14 feared by the client. b. c. ed 2. Second, the client is then trained in relaxation techniques. Finally, the stimuli identified in the hierarchy are then progressively pair with the relaxation techniques that the client has learned. Aversion therapy

This therapy is the opposite of systematic desensitization. With systematic des ensitization, the client learns to become less fearful of a situation or stimul us. An unpleasant stimulus is introduced at the same time as an undesirable res ponse. Aversion therapy seeks to increase the unpleasant reaction to a stimulus . The most common form of aversion therapy is illustrated in alcoholism treatmen t. Antabuse is a drug that makes people feel physically ill if they drink alcoh ol. This form of aversion therapy pairs a negative outcome with a previously pl

easant stimulus. 3. Extinction techniques Principles of operant conditioning are applied to reduce or eliminate a behavio r. a. Extinction can occur if reinforcements are removed after an undesirable beha vior is exhibited. For example, a student may receive attention from a teacher for being disruptive in class. In this case, the reinforcement was the attentio n received for acting out in class. If, instead of receiving attention, the per son is asked to leave, the reinforcement is removed, and this may result in ext inction of behavior. b. Flooding is a second method of effecting extinction. If someone who is fearf ul of needles is inundated with repeated mild finger pricks, after a period of time, the person will be able to receive injections without the debilitating fe ar associated with the phobia. 4. Token economies Positive reinforcement, or operant conditioning, can be used to encourage peopl e to engage in appropriate behaviors. Token ec onomies involve giving people a ?token,? such as play money, for performing a desired behavior. The tokens can be exchanged for a desired rewar d at a later point in time. A pleasant stimulus is introduced after a desirable response occurs. 5. Punishment Operant conditioning principles can be used to reduce unwanted behavior. An unp leasant stimulus is introduced after an undesirable response occurs. V. Cognitive Therapy Treatment Cognitive therapy techniques Cognitive therapy techniques are designed to help people change the way that th ey think about their problems. Sternberg (1994) suggests that cognitive approac hes are grounded in the theory of modeling or that people can learn from watchi ng the behavior of other people. People can deal with problems by learning to c hange their thoughts or cognitions. Cognitive therapy evolved from two perspecti ves: rational emotive behavior therapy and cognitive therapy. A. Rational emotive behavior therapy (REBT) Albert Ellis is credited with introducing REBT. The premise of REBT or rational emotive therapy (RET) is that people engage in self-talk that is false. If peo ple can change their beliefs, then, according to Ellis, this will produce a cha nge in emotion. The therapist confronts irrational beliefs of the client. For e xample, the client might believe that he or she must perform perfectly on an ex am. The therapist confronts this belief, the client becomes aware of the irrati onality of the thought and begins to create a more realistic perspective. The t herapist acts primarily as a teacher who helps the client develop skills that w ill allow the client to think more rationally. B. Cognitive therapy Aaron Beck is credited with developing cognitive therapy, and his approach is w idely used in the treatment of depression. Cognitive schemas, methods for organi zing the way that we view the world, have evolved into a distorted perception. Examples of these beliefs include minimizing personal accomplishments. In other words, after a major accomplishme nt, a client may state that ?anybody could have succeeded,? thus minimizing his or her own success. A cognitive therapist would draw atten tion to this faulty reasoning of the client. In other words, the therapist woul d challenge the validity of the statement. Therapy often includes a combination

of homework assignments and a series of sessions. In the treatment of depressi on, a cognitive therapist would assign homework requiring the client to write d own automatic thoughts, or the habitual thoughts, that precede feelings of depr ession (Young, Weinberger, & Beck, 2001). A structured form requires the client to write down the situation, emotion, automatic thought, rational response, an d outcome. In this way, the cognitive schema is brought to the fore front of the client s awareness. Clients often are asked to find support for the automatic thought, and this discussion VI. Biomedical Treatments A. Introduction to biomedical treatments Biomedical treatments include specific medical procedures and medications that can help to alleviate symptoms of psychological disorders. Often, biomedical tr eatments are used in conjunction with talk therapies and are described as combi ned approaches to treatment. B. Psychopharmacological treatments Medications have been developed to treat many psychological disorders. Generall y, these medications work by altering neurochemical systems in the brain. Four broad classes of drugs are used for treatment. 1. Neuroleptics (antipsychotics) This class of drugs, also referred to as antipsychotics, helps to reduce seriou s symptoms (e.g., hallucinations, delusions, paranoia) of schizophrenia in part icular. These medications are moderately successfully in reducing hallucination s and similar serious expressions of altered behavior. Essentially, these drugs act as dopamine blockers. The most common trade names of these drugs are Thora zine and Haldol. Side effects, ranging from dryness of mouth to involuntary je rking movements, typically accompany the use of these drugs. Long-term use of these drugs can result in a condition called tardive dyskinesia. This condition is characterized by uncontrollable repetitive movements, such as facial tics. Clozaril is a newer medication that does not have these side effects. 2. Antidepressants This group of medications is used to treat people who are severely depressed. A ntidepressants increase the presence of serotonin and norepinephrine. It usuall y takes several weeks before these drugs have a positive effect on the patient. a. Monoamine oxidase inhibitors (MAOIs) This class of antidepressants is used infrequently because people have to adhe re to a strict diet, or the drug can cause a toxic reaction. b. Tricyclic antidepressants (TCAs) This class is more effective than MAOIs, with fewer side effects. Alcohol shoul d not be used in conjunction with this medication. c. Selective serotonin reuptake inhibitors (SSRIs) This medication, also known under the trade name Prozac (fluoxetine), is widely used because it is both effective in treatment of depression, and it does not have severe side effects. SSRIs also are used to treat panic disorders (Hollan der & Simeon, 2003). 3. Lithium and anticonvulsants Lithium helps to reduce the severity of the highs and lows that someone with bi polar disorder typically experiences. Lithium does not act immediately on the s

ymptoms and must be carefully monitored so that the patient does not experience side effects. Immediate treatment of a manic episode might include an anticonv ulsant, known by the trade name of Depakote. 4. Anxiolytics (antianxiety) Tranquilizers or anxiolytics are used to treat anxiety disorders. Common drugs used today are usually benzodiazepines (e.g., Librium and Valium). These drugs produce an immediate calming effect for a person who may be experiencing anxiet y. Xanax has become popular for treating panic disorders. Patients can become d ependent on these drugs. C. Electroconvulsive therapy (ECT) When ECT was originally introduced, the approach was somewhat barbaric. An elec trical current was passed through the brain, resulting in convulsions. Today, a nesthetic is administered prior to delivering the shock to make the client more relaxed and to reduce the severity of the convulsions. One of the side effects of this treatment is temporary memory loss of the time period immediately prec eding the treatment. This treatment is used only as a last resort for patients who are severely depressed.