PL3106: Mental Health and Distress
LECTURE 4: TREATMENT OF PSYCHOPATHOLOGY
Lecture 4 Objectives
By the end of the lecture, you should be able to:
• Evaluate the various ways of measuring success in psychotherapy
• Describe factors to be considered to identify optimal treatment approaches
• Describe the biological and psychological approaches used to treat mental health conditions
• Articulate the theoretical mechanisms underlying the treatment approaches
Part 1 – Treatment
Overview
Why Do People Seek Therapy?
• Stressful life circumstances
• At the request of someone (courts, doctor, spouse, or friend)
• Personal growth
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Measuring Success in Psychotherapy
• Client’s self-report of change in their symptoms or functioning
• Clinician’s ratings of changes that have occurred
• Reports from client’s family or friends
• Comparison of pre-treatment and posttreatment scores on instruments designed to measure
relevant facets of functioning (“Objective measures”)
• Measures of change in overt behaviors
Measuring Success in Psychotherapy
Would Change Occur Anyway?
In some instances, people improve over time for reasons that are not apparent (i.e.,
spontaneous remission).
Research suggests that psychotherapy can often accelerate improvement or bring about
desired behavior that might not occur otherwise.
Researchers are actively exploring how certain factors impact how well a patient does:
◦ Therapist adherence: how well a therapist delivers certain type of therapy
◦ Therapist competence: how skillfully the therapist administers the therapy
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Measuring Success in Psychotherapy
Can Therapy Be Harmful?
Between 5 and 10 percent of patients deteriorate during treatment.
Research-based methods to assess clinical deterioration are now being developed.
A special case of therapeutic harm concerns what are called boundary violations: when the
therapist behaves in ways that exploit the trust of the patient or engages in behavior that is
highly inappropriate, such as:
◦ taking the patient to dinner
◦ giving the patient gifts
◦ conducting a sexual relationship with the patient
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What Therapeutic Approaches Should Be
Used?
• Evidence-Based Treatment
• New drugs require approval from the U.S. Food and Drug Administration
(FDA).
– Involves demonstrating efficacy (ability to cure or relieve some
target condition) through research on humans
• Randomized clinical trials (RCTs) (efficacy trials): tests using voluntary
and informed patients as subjects
• Manualized therapies originated in order to:
– Standardize psychosocial treatments to fit the RCT paradigm
– Minimize variability in clinical outcomes that might result from
characteristics of the therapist him or herself
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What Therapeutic Approaches Should Be
Used?
Efficacy, or RCT, studies of psychosocial treatments are increasingly common.
◦ Focus on patients who have a single DSM diagnosis
◦ Involve two or more treatment or control conditions, where at least one of the treatment conditions is
psychosocial
Efficacy studies of the outcomes of specific psychosocial treatment procedures are considered
the most rigorous type of evaluation that researchers have for establishing that a given therapy
“works” for clients with a given diagnosis.
Treatments that meet this standard are often described to be evidence based or empirically
supported.
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What Therapeutic Approaches Should Be
Used?
Effectiveness trials, on the other hand, are much less controlled RCTs compared to efficacy trials
◦ Meant to test whether an intervention developed in a tightly controlled efficacy trial context can work
in “the real world”
◦ May involve deployment of a treatment approach in community health settings, where time, financial
resources, and manpower are more limited
◦ Oftentimes, the patient populations are more complex
Yet effectiveness trials are key tests of whether an intervention is suited for broad dissemination
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Differences between Efficacy and
Effectiveness Studies
• Treatment outcome studies
• Efficacy studies
• Main goal: assessing whether a treatment can successfully treat individuals under ideal circumstances
• Effectiveness studies
• Main goal: assess how successful a treatment can be under typical circumstances (real-world condition)
Differences between Efficacy and
Effectiveness Studies
Efficacy study Effectiveness study
Question Does the intervention work under ideal Does the intervention work in real-
circumstance? world practice?
Setting Resource-intensive ‘ideal setting' Real-world everyday clinical setting
Study population Highly selected, homogenous Heterogeneous population
population Few to no exclusion criteria
Several exclusion criteria
Providers Highly experienced and trained Representative usual providers
Intervention Strictly enforced and standardized Applied with flexibility
No concurrent interventions Concurrent interventions and cross-
over permitted
(Singal et al., 2014)
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Part 2 – Different types of
psychological interventions
What Therapeutic Approaches Should Be Used?
• Medication or Psychotherapy?
• Psychopharmacology: use of medications to treat mental disorders
• Issues arising from the use of psychotropic drugs:
◦ Possible unwanted side effects
◦ Complexity of matching drug and dosage to the needs of each patient
◦ Sometimes necessary for patients to change medication
• Use of medications in isolation from other treatment methods may not be ideal for some
disorders
◦ Drugs do not help the person to understand and change the personal or situational factors that may
have created the behaviors
◦ Patients are at risk of relapse after discontinuing the drugs
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What Therapeutic Approaches Should Be Used?
Combined Treatments
Integration of medication and psychotherapy is common in clinical practice, particularly for
disorders such as schizophrenia and bipolar disorder.
◦ Combined approaches are appreciated and regarded as essential by patients.
Medications can be combined with a broad range of psychological approaches.
◦ Typically, psychosocial interventions are combined with psychiatric medications.
◦ They may be especially beneficial for patients with severe disorders.
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An Overview of Treatment
The Therapeutic Relationship
Evolves out of what both client and therapist bring to the therapeutic situation
◦ Pessimistic clients respond less well to treatment
Three key elements of the therapeutic alliance are:
◦ A sense of working collaboratively on a problem
◦ Agreement between patient and therapist about the goals and tasks of therapy
◦ An affective bond between patient and therapist
Client’s expectation of receiving help can act as a placebo
Therapist uses a variety of skills and methods to help client gain a new perspective
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Common Factors in Treatment
Wampold (2015)
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Types of Treatment
• Biological – Pharmacological, Non-medicinal
• Psychological
• Social
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Biological Approaches (Pharmacological
Treatment)
• Antipsychotics
• Reduce symptoms of psychosis (hallucinations, delusions)
• Antianxiety
• Reduce fearfulness, worry and tension
• Antidepressants
• Reduce symptoms of sadness, loss of appetite, sleep disturbance
• Lithium
• Reduce mania (agitation, excitement, grandiosity)
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Biological Approaches (Non-Medicinal)
ELECTROCONVULSIVE THERAPY
•Results indicate that ECT can be an effective treatment for individuals with:
• severe or psychotic-level depression
• some patients with mania.
•Every neurotransmitter system is affected by ECT, and ECT is known to downregulate the
receptors for norepinephrine, increasing the functional availability of this neurotransmitter.
•ECT can be administered in one of two ways: bilateral ECT and unilateral ECT.
•Patients often have difficulty forming new memories (anterograde amnesia) for about three
months after ECT ends.
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Biological Approaches (Non-Medicinal)
TRANSCRANIAL MAGNETIC STIMULATION
Transcranial magnetic stimulation (TMS): treatment in which the clinician positions a pulsed
magnet over a chosen area on the patient’s scalp to create an electrical field that increases or
decreases neuronal activity in the brain
Can be used to effectively treat major depression, with additional evidence supporting its use
with other conditions
◦ Less invasive than surgical interventions; fewer and less severe side effects than ECT with no
impairments in memory
◦ Side effects: headache and a small risk of seizure
Typically considered as a treatment option only after psychotherapy and antidepressants have
proven ineffective
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Transcranial Magnetic
Stimulation
In TMS, a pulsed magnetic coil is
carefully positioned on the
patient’s scalp and an electrical
field is created to increase or
decrease brain activity in specific
brain regions or circuits.
Treatment typically is repeated
several days per week for 4 to 8
weeks.
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Psychological Treatment
Psychodynamic Humanistic
Behavioural Cognitive
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Psychodynamic Approaches
Psychodynamic Therapies
Psychodynamic therapy: a broad treatment approach that focuses on individual personality
dynamics, usually from a psychoanalytic or psychoanalytically derived perspective
FREUDIAN PSYCHOANALYSIS
◦ Four basic techniques:
◦ Free association
◦ Analysis of dreams
◦ Analysis of resistance
◦ Analysis of transference
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Psychodynamic Approaches
◦ Free association
◦ Individual must say whatever comes into her or his mind, regardless of how
personal, painful, or seemingly irrelevant it may be
◦ Purpose is to explore thoroughly the contents of the preconscious
◦ Analysis of dreams
◦ When a person is asleep, repressive defenses are said to be lowered, and
forbidden desires and feelings may find an outlet in dreams.
◦ A dream has two kinds of content:
◦ (1) manifest content: the dream as it appears to the dreamer
◦ (2) latent content: the actual motives that are seeking expression but are
so painful or unacceptable that they are disguised
◦ Forbidden desires and feelings may find an outlet in dreams
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Psychodynamic Approaches
◦ Analysis of 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
◦ Resistance may also be evidenced by the client’s giving a superficial interpretation of some association, coming
late to an appointment, or even “forgetting” an appointment altogether
◦ Analysis of transference
◦ People often unconsciously apply (or “transfer”) to their therapist attitudes and feelings that they had in past
relationships: transference
◦ Countertransference: therapist reacts in accord with the client’s transferred attributions, rather than objectively
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Psychodynamic Approaches
PSYCHODYNAMIC THERAPY SINCE FREUD
◦ Original version of psychoanalysis is rarely practiced
◦ Most extensive and recent revisions have been related to the object-relations / attachment
perspective
◦ Psychodynamic therapists increasingly focus on interpersonal relationship issues: seek to expose,
bring to awareness, and modify the effects of the remote developmental sources of the client’s
present difficulties
◦ Retain the classical psychoanalytic goal of understanding the present in terms of the past
• Insight is thought to free clients from the grip of the past and give them a sense of agency in making
changes in the present
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Psychodynamic Approaches
EVALUATING PSYCHODYNAMIC THERAPIES
◦ Classical psychoanalysis has been criticized for being:
◦ Relatively time-consuming and expensive
◦ Neglectful of client’s immediate problems in search of past causes
◦ Lacking adequate proof of effectiveness
◦ Proponents argue that the approach may still be of benefit
◦ Newer, brief versions of psychodynamic-interpersonal therapies have shown some efficacy
Behavioral Approaches
Behavior therapy: a direct and active treatment that recognizes the importance of behavior, acknowledges the
role of learning, and includes thorough assessment and evaluation.
• EXPOSURE
– Widely used in the treatment of anxiety disorders
– Involves guided exposure to anxiety-provoking stimuli
▪ Can be accomplished slowly (systematic desensitization) or quickly (flooding)
▪ Form of exposure can be real (in vivo exposure) or imaginary (imaginal exposure); in vivo
exposure tends to be more effective
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Behavioral Approaches
SYSTEMATIC REINFORCEMENT
• Often referred to as contingency management programs, systematic programs that use
reinforcement to increase the frequency of desired behavior have achieved notable success.
• Reinforcing contingencies maintaining maladaptive behavior must first be identified and
removed and then replaced and reinforced by more adaptive behavior.
• In response shaping, positive reinforcement is used to establish a response that is actively
resisted or is not initially in an individual’s behavioral repertoire.
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Behavioral Approaches
TOKEN ECONOMIES
• A token economy resembles the outside world: an individual is paid for his or her work in
tokens (money) that can be exchanged for desired objects and activities.
• Originally developed for use with patients experiencing long-term stays in psychiatric
hospitals
• When patients behaved appropriately, they earned tokens that could later be exchanged for rewards
or privileges.
• Similar reinforcement-based methods are now being used to treat substance abuse.
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Behavioral Approaches
EVALUATING BEHAVIOR THERAPY
Behavior therapy has some distinct advantages over other treatments:
◦ Achieves results in a short period of time
◦ Has lower costs
◦ Methods are clearly delineated
◦ Results can be readily evaluated
◦ Proven to be effective
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Cognitive Approaches
BECK’S COGNITIVE THERAPY
• Originally developed to treat depression and anxiety disorders; now used for a broad range of
conditions, including eating disorders and obesity, personality disorders, substance abuse, and
schizophrenia
• Basically an information-processing model of psychopathology: problems result from the
biased processing of external events or internal stimuli, leading to cognitive errors
• Clients are made aware of the connection between their patterns of thinking and their
emotional responses and are taught to identify negative automatic thoughts and logical errors
• Learn to challenge validity of their automatic thoughts
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Thinking Errors
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Thinking Errors
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Cognitive Approaches
EVALUATING COGNITIVE-BEHAVIORAL THERAPIES
• Efficacy of Beck’s cognitive treatment methods is well documented
• Combined use of cognitive and behavioral techniques is now quite common
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Humanistic Approaches
CLIENT-CENTERED THERAPY
•Humans have innate capacity for goodness & living full lives
• Primary objective is to resolve incongruence and to help clients accept and be themselves
•Therapist provides optimal conditions for the client to heal
• Nondirective techniques: empathic reflecting or restatement of the client’s description of life
difficulties
• Relationship built between the client and the therapist causes change; psychological climate of
acceptance is created
• Client-centred
• Genuineness
• Authentic
• Unconditional positive regard
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Humanistic Approaches
EVALUATING HUMANISTIC-EXPERIENTIAL THERAPIES
• Have had a major impact on our contemporary views of both human nature and the nature of
good psychotherapy
• Criticized for their lack of agreed-upon therapeutic procedures and vagueness about what is
supposed to happen between client and therapist
• Newer research suggests these approaches may be helpful for depression, anxiety, trauma,
and marital difficulties
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Eclecticism and Integration
◦ Various “schools” of psychotherapy once stood more in opposition to one another than they do now.
◦ 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, a process sometimes called
multimodal therapy.
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Summary: Treatments
Different levels of explanation guide different types of treatment (biology, behavioural,
cognitions)
Different treatments may be better for different problems, be guided by the evidence-base!
A combination is often practiced
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Thank You!