Treating Psychological Disorders
The Canadian Mental Health Association estimates that 1 in 5 people in Canada suffer from some type of mental disorder at some point in their lifetime. (Kessler, Berglund et al., 2005). Impairments associated with mental disorders are as severe, and in many cases more severe, than those associated with physical disorders such as cancer, chronic pain, and heart disease. (Ormel et al., 2008). The economic burden for mental illness is estimated to be $51 billion per year (Smetanin et al., 2011).
Only about 40% of Canadians with mental disorders present themselves for diagnosis and treatment (Lesage et al., 2006). Of those who do seek care, nearly 1 in 3 report that their needs were unmet or only partially met. It is clear that most people with a mental disorder do not receive treatment, and among those who do, the average delay from onset until treatment is first received is over a decade. (Wang et al., 2004)
Why do so many people fail to seek treatment?
(1) People may not realize that they have a mental disorder that could be effectively treated. Most do not think that they need it. (Mojtabai et al., 2011)
(2) There may be barriers to treatment, such as beliefs and circumstances that keep people from getting help. The primary reason for not seeking treatment (72.6%) or dropping out of treatment prematurely (42.2 %) is that they believe they should able to handle things themselves. (Mojtabai et al. 2011)
(3) Structural barriers prevent from physically getting to treatment. These can be: not being able to afford treatment (15.3%); lack of clinician availability (12.8%); inconvenience of attending treatment (9.8%); trouble finding transportation to the clinic (5.7%) (Mojtabai et al., 2011)
Finally, most of the treatment of mental disorders is not provided by mental health specialists, but by general medical practitioners. (Wang et. al., 2007).
Psychotherapy is an interaction between a socially sanctioned clinician and someone suffering from a psychological problem. There a five major therapeutic models used: cognitive behavioral (40%); interpersonal (12%); psychodynamic (13%); humanistic/existential (15%) family systems (10%). The other therapies comprise the last 10%. (Hunsley et al., 2013).
Psychodynamic therapies explore childhood events and encourage individuals to use this understanding to develop insights into their psychological problems.
Psychoanalysis was the first to develop, but has largely been replaced by interpersonal psychotherapy.
In traditional Freudian psychoanalysis, the patient lays on a couch while the therapist sits on a chair, behind, or out of the client's view. There are four major areas that are interpreted:
(1) free association, where the client reports every thought that enters the mind, without censorship or filtering. Using this 'stream of consciousness', the therapist may then look for themes that recur during therapy sessions.
(2) dream analysis, where dreams are treated as metaphors that symbolize unconscious conflicts or wishes and contain disguised clues that the therapist can help the client understand.
(3) interpretation of free association and dreams where the therapist suggest possible meanings to the client, looking for signs that the correct meaning has been discovered.
(4) analysis of resistance where resistance is defined as a reluctance to cooperate with treatment for fear of confronting unpleasant unconscious material.
(5) transference occurs when the analyst begins to assume a major significance in the client's life and the client reacts to the analyst based on unconscious childhood fantasies.
Interpersonal therapy (IPT)demonstrates that modern psychodynamic treatments differ from classic psychoanalysis in both their content and procedures. Here, the focus is on helping clients improve current relationships. Therapists using IPT talk to clients about their interpersonal behaviors and feelings. Particular attention is paid to: grief; role disputes; role transitions; interpersonal deficits (lack of necessary skills to start or maintain a relationship).
In terms of practice, IPT therapists typically: sit face-to-face with their clients; less intensive (meetings only once a week, full treatments lasting months rather than years);.
In contrast to Freud, IPT therapists see relief from symptoms as a reasonable goal for therapy. They are more likely to offer support and advice in addition to interpretation. They are less likely to interpret a client's statements as aggressive or sexual.
What has held true since Freud? Transference, resistance and the value of insight.
Comparisons to other forms of treatment such as cognitive behavioral therapy suggest that psychodynamic therapy is somewhat less effective. (Watzke et al., 2012). There is some evidence however, that long-term psychodynamic therapy (one year or more) is more effective than short-term psychotherapy. (Leichzenring & Rabung, 2008). This last point is important because of insurance issues for psychotherapies, which usually only last 12 weeks.
Person-Centered Therapies assume that all individuals have a tendency toward growth and that this growth can be facilitated by acceptance and genuine reactions from the therapist. This is a non-directive treatment, where the therapist tends not to provide advice or suggestions about what the client should be doing, but instead paraphrase the client's words, mirroring the client's thoughts and sentiments. The most famous phrase is: “What I hear you saying is...”
This form of therapy has three basic premises: congruence (openness and honesty in the therapeutic relationship, also ensuring that the therapist communicates the same message on all levels [words, facial expressions, body language]; empathy, the process of trying to understand the client by getting inside his or her way of thinking, feeling, understanding; unconditional positive regard, a non-judgmental, warm and accepting environment in which the client can feel safe expressing their thoughts and feelings. [connect to phenomenological assessment]
The goal is not to uncover repressed conflicts, but to try to understand the client's experience in the here and now, and reflect that experience back to the client.
Gestalt therapy has the goal of helping the client become aware of their thoughts, behaviors, experiences, and feelings and to 'own' or take responsibility for them. Through a technique called focusing, clients are also encouraged to put their feelings into action. I gave an example of this when I described a young woman whose two boy friends suddenly found out about one another. Instead of discussing this distressful encounter, I asked her: “How afraid are your feet, right now?”
Behavior Therapy was developed based on laboratory findings from earlier behavioral psychologists. It assumes that disordered behavior is learned and that symptom relief is achieved through changing over maladaptive behaviors in more constructive behaviors.
A few examples: eliminating unwanted behaviors:
(1) eliminating unwanted behaviors such as tantrums the study of operant conditioning shows that behavior can be influenced by its consequences (those reinforcing or punishing events that follow). The best solution is 'quiet time' facing a wall while the parent watches from nearby will often eliminate the problem behavior.
(2)promoting desired behaviors such as token economy a form of behavior therapy in which clients are given 'tokens' for desired behaviors, which they can later trade for rewards. You have probably been in such a reward system, if you use airline (frequent flyer miles) or credit card reward programs.
(3) reducing unwanted emotional reponses or exposure therapy which involves confronting an emotion-arousing stimulus directly and repeatedly, ultimately leading to a decrease in the emotional response. This technique depends on the processes of habituation and response extinction. (If you do not know what these last two terms mean, google them immediately.) The best example of this is U.S. Navy SEALs 'Hell Week'
Cognitive therapy focuses primarily on helping a client identify and correct any distorted thinking about self, others, or the world (Beck, 2005). Cognitive theorists emphasize the interpretation of the event. The individual's beliefs and assumptions about an event and the fear stimulus that leads to a disturbance in the client's behavior. Cognitive restructuring involves teaching clients to question the automatic beliefs, assumptions, and predictions that lead to negative emotions and to replace negative thinking with more realistic and positive beliefs. The chief focus here is reality testing, for example, a depressed patient who calls herself 'stupid' because she has failed her first university exam. Reality testing would challenge this by grounding her in the facts of her previous academic performance.
One such technique for this approach to therapy is mindfulness meditation which teaches an individual to be fully present to each moment, to be aware of their thoughts, feelings and sensations, and to detect symptoms before they become a problem. I'll use the fear example again: “How scared are you knees?” is an example of mindfulness meditation in action. Teasdale, Segal & Williams, (2000) have found this helpful for preventing relapse in depression. In one study, people recovering from depression were about half as likely to relapse during a 60-week assessment period if they received mindfulness meditation based cognitive therapy than if they received their usual treatment.
On the other hand, Cognitive Behavioral therapy (CBT) acknowledges that there may be behaviors that cannot be controlled through rational thought. It is problem focused, undertaken for specific problems at specific times. (example: panic attacks). The therapist tries to assist in selecting specific strategies to help address specific problems. Goals are explicitly discussed: (1) the number of times in exposure exercises; (2) behavior change skills; (3) daily monitoring of symptoms, such as severity of depressed mood. CBT is transparent; nothing is withheld from the client.
Butler et al., 2006 reports that CBT is substantially successful in treating: unipolar depression; generalized anxiety disorder; panic disorders; social phobia; post-traumatic stress disorder; childhood depressive and anxiety disorders. CBT has moderate but less substantial effects for marital distress, anger, somatic disorders, and chronic pain.
Group Treatments interactions with others may intensify or even create disorders; recovery needs to be a social process. Couples therapy occurs when a married, co-habiting, or dating couple is seen together in therapy to work on problems usually arising within the relationship. Treatment strategies would target changes in both parties, focusing on ways to break their repetitive dysfunctional pattern. Family therapy is what it claims, the whole family unit must come to grips with a problem, usually in a child or adolescent. (Master, 2004). The best known therapist in this field was John Bradshaw, who coined the term 'inner child'.
Which leads us to self-help and self-support group therapies focus on a particular disorder or difficult life experience and often run by people who themselves struggled with the same issues. The most famous is Alcoholics Anonymous. In addition to being cost-effective, self-help and support groups allow people to realize that they are not the only ones with a particular problem and are given the opportunity to offer guidelines and support. A few studies examining the effectiveness of AA have been conducted, overall, individuals who participate tend to overcome problem drinking with greater success than those who do not participate in AA (Florentine, 1999).
Treating Severe Mental Disorders
Drug treatments based on the medical model are the most common form of insured treatment, worldwide. Chlorpromazine was the first in a series of antipsychotic drugs, which treat schizophrenia and related psychotic disorders. In the period following the introduction of these drugs, the number of people in psychiatric hospitals decreased by more than two thirds.
Antipsychotic medications are believed to block dopamine receptors in parts of the brain such as the mesolimbic area, an area between the tegmentum (in the midbrain) and various subcortical structures. The medication reduces dopamine activity. The effectiveness of schizophrenia medications led to the dopamine hypothesis; and Marangel et al., (2003) has reported that dopamine overactivity in the mesolimbic is related to the more positive symptoms, such as hallucinations and delusions.
The negative symptoms of schizophrenia, such as emotional numbing and social withdrawal, may be related to dopamine underactivity in the mesocortical area of the brain (connections between parts of the tegmentum and the cortex). This is a good example of how medical treatments can have broad psychological effects but not target specific psychological symptoms.
The new atypical antipsychotic drugs[clozapine, risperidone,olanzepine] affect both the dopamine and the serotonin systems, blocking both types of receptors. The ability to block serotonin receptors appears to be a useful addition because enhanced serotonin activity in the brain has been implicated in some of the core difficulties in schizophrenia, such as cognitive and perceptual distortions, and mood disturbances.
Why then, do patients go 'off their meds'? One side effect of long-term use of the older antipsychotics is tardive dyskinesia, a condition of involuntary movementsof the face, mouth and extremities.
Anti-anxiety medications help reduce a person's experience of fear or anxiety. The most common is benzodiazepine (diazepam, lorazepam, alprazolam). It works by facilitating the action of the neurotransmitter GABA, which inhibits certain neurons in the brain, producing a calming effect. This drug family takes effect in a matter of minutes and effective for reducing symptoms of anxiety disorders. (Roy-Bryne & Cowley, 2002).
There are problems with drug tolerance, and effect of drug withdrawal. Symptoms include: increased heart rate; shakiness; insomnia; agitation; and anxiety! Users should discontinue these medications gradually. (Schatzberg, Cole & DeBattista, 2003).
Antidepressants and Mood Stabilizers Ipronniazid was the first such drug discovered in the 1950s. It is a monoamine oxidase inhibitor.(MAOI), an drug that prevents the enzyme monoamine oxidase from breaking down neurotransmitters such as norepinephrine, serotonin, and dopamine. It is rarely used anymore, because its side effects include dizziness and loss of sexual interest. MAOI can also created dangerous increases in blood pressure when taken with foods that contain tyramine, found in aged cheeses, beans, aged meats, soy products, and draft beer.
The second class are called tricyclic antidepressants, such as impramine and amitriptyline. These block the reuptake of norepinephrine and serotonin. Side effects include dry mouth, constipation, difficulty urinating, blurred vision, and racing heart. (Marangell et al., 2003).
The third (and most commonly used) class are the selective serotonin reuptake inhibitors (SSRI) , which include drugs such as fluoxetine; citalopram; and paroxetine. The SSRIs work by blocking the reuptake of serotonin in the brain, which makes the neurotransmitter more available at the synaptic space between neurons.
Practice using the Internet for a 'SSRI synaptic cleft' image; it will be on the next exam.
Selective Serotonin / Norepinephrine Reuptake Inhibitors (SNRI) such as venlafaxine and ibupropion are self-explanatory. Wellbutrin is in contrast, a norepinephrine and dopamine reuptake inhibitor. These antidepressants have fewer side effects than the tricyclic antidepressants or MAOIs.
And now to a real problem: antidepressants are not prescribed for bipolar disorder, because in lifting a depressed mood, they might actually trigger a manic episode. Instead, the disorder is treated with mood stabilizers, Lithium has been the traditional choice, but it has dangerous side effects. Valproate is now the most commonly prescribed drug for bipolar disorder. (Schatzberg et al., 2003).
Combining Medication and Psychotherapy In cases of schizophrenia and bipolar disorder, it has been found that medication is more effective than psychological treatment. In cases of mood and anxiety disorders,both are equally effective. One study compared CBT, imipramine, and the combination of these treatments with a placebo for treatment of panic disorder. (Barlow et al., 2000) After 12 weeks of treatment (note the time length) either CBT or imipramine alone was found to be superior to a placebo. CBT + imipramine had a slightly higher response rate than for the placebo, but not significantly better that for either CBT or imipramine.
Both therapy and medication affect the brain in regions associated with threat. A study of people with social phobias examined patterns of cerebral blood flow (PET scans) using either an SSRI or CBT. (Furmark et al., 2002). Those who responded to the treatment showed similar reductions in activation in the amygdala and hippocampus.
Note: the text includes other rare and exotic treatments, that you can read on your own.
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Treatment Effectiveness
Treatment Illusions can be produced by natural improvement, placebo effects and by reconstructive memory. A placebo is an inert substance or procedure that has been applied with the expectation that a healing response will be produced.
Fournier et al., (2010) compared the decrease in symptoms of depression seen in 718 patients randomly assigned to receive either antidepressant medication or a pill placebo. Participants receiving the medication showed a dramatic decrease in symptoms, but so did the placebos! Medication is superior for severe depression only.
A third treatment illusion can come about when the client's motivation to get well causes errors in reconstructive memory for the original symptoms.
Treatment Studies or Applied Meta-Analysis To test whether a particular treatment is effective, it is necessary to create a double-blind experiment where neither the control or the experimental group has knowledge of the treatment, and neither do the researchers. Even so, treatment studies need to be done on a large scale using meta-analysis, where tight experimental protocols allow a super-experiment of dozens, or even hundreds of double-blind experiments to be combined.