Treatment of Abnormal Behavior for AP Psychology (page 2)
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Mental Health Practitioners
- A psychiatrist is a medical doctor (M.D.) and the only mental health professional who can prescribe medication (in most regions) or perform surgery. Psychiatrists generally take a biological approach to treating major disorders such as schizophrenia and depression. Their medical training includes an approved residency in a psychiatric section of a hospital. Psychiatrists are not required to take courses dealing with insight, psychoanalytic, behavioral, cognitive, or humanistic therapeutic approaches.
- Clinical psychologists must earn a doctoral degree (Ph.D. or a Psy.D.), which includes a supervised internship, then they must pass a licensing exam. Their training does emphasize different therapeutic approaches. Both psychiatrists and clinical psychologists see patients with similar disorders. Since many problems respond best to a combination of medication and supportive psychotherapy, clinical psychologists often work with psychiatrists.
- Counseling psychologists typically have one of a number of different advanced degrees (Ph.D., Ed.D., Psy.D., or M.A. in counseling) and tend to deal with less severe mental health problems in college settings, or in marital and family therapy practices. In the latter, they try not to assign blame but provide a supportive ear to all parties and help clarify the feelings of each individual to the others.
- Psychoanalysts may or may not be psychiatrists, but all follow the teaching of Freud and practice psychoanalysis or other psychodynamic therapies. They receive extensive training and self-analysis with a more experienced psychoanalyst before they begin their treatment of patients.
- Clinical or psychiatric social workers typically have earned a Master's degree in social work
(M.S.W.), which includes a supervised internship, and have taken a certification exam. Other mental health care professionals include psychiatric nurse practitioners and pastoral counselors, who combine spiritual guidance with practical counseling.
While many medical insurance plans will pay for the services of psychiatrists, clinical psychologists, counseling psychologists, and clinical social workers, they will not pay for the services of unlicensed therapists. In most places, anyone can call himself/herself a therapist without having any training.
Brief History of Therapy
Archeological evidence and historical documents suggest that early humans believed people with mental health problems were possessed by evil spirits. Trephining, drilling holes in skulls, also indicates that early practitioners attempted to release these spirits.
Over 2,000 years ago, Greek physician Hippocrates proposed that psychological problems have physical causes for which he prescribed rest, controlled diets, and abstinence from sex and alcohol. More than 1,500 years ago, Greek physician Galen believed that medicine was needed to treat abnormal behavior, which he thought was a result of an imbalance in the four bodily humors, similar to today's biomedical approach. Unfortunately, during the Medieval period, most societies returned to the belief that demons or Satan possessed people suffering from mental problems. Victims were punished with exorcisms or tested by drowning and burning.
The Enlightenment brought reformers: in the 18th century, Philippe Pinel of France and, in the 19th century, Dorthea Dix of the United States were champions of humane treatment for the mentally ill. Instead of treating those with mental health problems as sinners or criminals, they created separate institutions for them, and pioneered more individualized and kinder treatment strategies.
Serious overcrowding of most mental institutions became a problem by the 1950s. As a result, the needs of many patients were neglected. When better psychotropic drugs were created, a movement, deinstitutionalization, began to remove patients who were not considered a threat to themselves or the community from mental hospitals. Similar to the more humane goals of Pinel and Dix, the intent was that patients would improve more rapidly in familiar community settings. In the 1960s, Congress passed aid bills to establish community mental health facilities in neighborhoods across the United States.
An unintended problem of deinstitutionalization is today's homeless population. A substantial proportion of this group is thought to be made up of schizophrenic patients, mostly off their medications and in serious need of care. Families and communities have failed to meet the needs of these people.
No one approach for treating people with psychopathologies has been shown to be ideal. Multiple approaches can often be more helpful than using one specific approach. For example, a depressed patient might benefit from cognitive therapy, social skills training, and antidepressant drugs. Research is being conducted to determine the most effective (efficacious) treatments for clients with different disorders. One method for evaluating outcome research is meta-analysis. Meta-analysis, the systematic statistical method for synthesizing the results of numerous research studies dealing with the same variables, indicates that clients who receive psychotherapy are better off than most of those who receive no treatment. Treatments that appear more effective than others for particular disorders are noted in the following sections.
Insight therapies include psychoanalysis, psychodynamic therapy, interpersonal psychotherapy; humanistic client-centered; and Gestalt psychotherapy. They all agree that their goal is to help clients develop insight about the cause of their problems, and that insight will lead to behavior change; problems will decrease as self-awareness increases.
Sigmund Freud believed that abnormal behavior was the result of unconscious conflicts from early childhood trauma experienced during the psychosexual stages of development. He thought that the way to relieve the anxieties is to resolve the unconscious conflicts, which are covered by layers of experience. Psychoanalysis involves going back to discover the roots of problems, then changing one's misunderstandings and emotions after identifying the problem. His treatment plan to bring the conflict into the conscious mind, enabling the client to gain insight and achieve personality change, includes the techniques of free association and dream interpretation.
In traditional psychoanalysis, the client participates in several sessions every week for 2 or 3 years, during which the therapist sits behind the patient and asks him/her to say whatever comes to mind, called free association. If clients do not censor what they say, key thoughts will make unconscious conflicts accessible. Since threatening experiences and feelings can be revealed when controls of the ego and superego are relaxed during sleep, the analyst may ask the client to recall his/her dreams. The recalled dream—the surface meaning—is called the manifest content. The therapist works with the client to find the hidden, underlying meaning (the latent content), by analyzing symbols within the dream. Hypnosis and Freudian slips, Freud's "faulty actions," for which his editor/translator adopted the term parapraxes, may also reveal hidden conflicts. Resistance—blocking of anxiety-provoking feelings and experiences, evidenced by behavior such as talking about trivial issues or coming late for sessions—is a sign that the client has reached an important issue that needs to be discovered. Although the analyst's behavior is neutral, the client may respond to the analyst as though he/she is a significant person in the client's emotional life. Known as transference, this behavior can allow the client to replay previous experiences and reactions, enabling him/her to gain insight about current feelings and behaviors.
Catharsis, the release of emotional tension after remembering or reliving an emotionally charged experience from the past, may ultimately result in relief of anxiety. Traditional psychoanalysis requires too much time and is too expensive for the vast majority of people seeking help.
Psychodynamic and Interpersonal Psychotherapy
Psychoanalytic theory influences modern psychodynamic psychotherapy, which is typically shorter in duration, less frequent, and involves the client sitting up and talking to the therapist. The more active therapist is likely to point out and interpret relevant associations and help the client uncover unresolved conflict more directly to gain insight into the problem and work through feelings. Although psychodynamic therapists think that anxieties are rooted in past experiences, they do not necessarily assume the problems arose in infancy and early childhood.
Even shorter interpersonal psychotherapy aims to enable people to gain insight into the causes of their problems, but it focuses on current relations to relieve present symptoms.
Humanistic therapies include client-centered or person-centered therapies, and Gestalt therapy. Humanists think that problems arise because the client's inherent goodness and potential to grow emotionally have been stifled by external psychosocial constraints. The goal of client-centered therapy is to provide an atmosphere of acceptance (unconditional positive regard), understanding (empathy), and sharing that permits the client's inner strength and qualities to surface so that personal growth can occur and problems can be eliminated, ultimately resulting in self-actualization. According to humanist Carl Rogers, the greater the difference between the ideal self and the real self, the greater the problems of the client. His emphasis on developing a more positive self-concept through unconditional positive regard, active listening, and showing both sensitivity and genuineness is a central focus of nondirective, Rogerian psychotherapy. Nondirective therapy encourages the client to take the lead in determining the direction of therapy. Rogers's technique of active listening involves echoing, restating, and seeking clarification of what the client says and does, and acknowledging feelings.
Influenced by Gestalt psychology, which emphasized that people organize their view of the world to make meaning, psychoanalyst Fritz Perls said that people create their own reality and continue to grow psychologically only as long as they perceive, stay aware of, and act on their true feelings. He developed Gestalt therapy. The therapist's goal is to push clients to decide whether they will allow past conflicts to control their future or whether they will choose right now to take control of their own destiny. In contrast to clientcentered therapy, Gestalt therapists are directive in questioning and challenge clients to help them become aware of their feelings and problems, and to discard feelings and values that are not their own. Similar to psychoanalysts, Gestalt therapists use dream interpretation to help the client gain a better understanding of the whole self. Through role playing, the therapist gets the client to express his/her true feelings. Like other humanistic therapies, the emphasis is on present behavior, feelings, and thoughts to get the client aware of how these factors interact to affect his/her whole being.
Insight therapies have been demonstrated to be effective for treating eating disorders, depression, and marital discord.
B. F. Skinner and other behaviorists discount the insight therapies. To Skinner, abnormal behavior is a result of maladaptive behavior learned through faulty rewards and punishment. The goal of behavior therapy is to extinguish unwanted behavior and replace it with more adaptive behavior. Therapies are based on the learning principles of classical conditioning, operant conditioning, and observational or social learning theory.
Classical Conditioning Therapies
After Watson conditioned Baby Albert to fear a rat, he planned to remove the fear but Albert was taken away. Soon thereafter, Mary Cover Jones worked with a young child who feared white rabbits, rats, and similar stimuli. Over several months, she gradually introduced a rabbit closer and closer to the child while he ate and played. The boy's fear was gradually eliminated. Joseph Wolpe dubbed her "the mother of behavior therapy."
Classical conditioning therapies involving reconditioning include the counterconditioning techniques of systematic desensitization, flooding, and aversive conditioning.
- Originally called reciprocal inhibition, systematic desensitization is a behavior therapy founded on the idea that an anxiety response is inhibited by an incompatible relaxation response. Joseph Wolpe explained systematic desensitization as reconditioning so that the crucial conditioned stimulus elicits the new conditioned response. The procedure has three steps. First, the client is taught progressive relaxation. Next, the therapist and client create an anxiety hierarchy of all associated fears from the least-feared to the most-feared stimulus. For example, for school phobia, they may list the following situations: thinking about going to school, seeing a picture of the school, getting on the school bus, walking toward the school, opening the school door, and finally sitting in the classroom. Third, the therapist has the student imagine each of the fearful associations beginning with the least feared stimulus, the mere thought about going to school. After the student can relax with this fear, the process is repeated, finally ascending to the most fearprovoking stimulus of actually sitting in the classroom. When the student can sit in the classroom and be completely relaxed, the relaxation response is effective for inhibiting the fear response. Systematic desensitization is typically accomplished within 10 sessions.
- Flooding is an exposure technique, another classical conditioning treatment for phobias and other anxiety disorders, that extinguishes the conditioned response. As a result of the client directly confronting the anxiety-provoking stimulus, extinction is achieved; the feared stimulus (the conditioned stimulus) is repeatedly presented without the reason for being afraid (the unconditioned stimulus). For example, if someone afraid of dogs is repeatedly exposed to friendly dogs that do not bite, the fear associated with the dogs will eventually be extinguished.
- Yet another form of behavior therapy based on the principles of classical conditioning, aversive conditioning, trains the client to associate physical or psychological discomfort with behaviors, thoughts, or situations he/she wants to stop or avoid. One example of aversive conditioning uses a drug called Antabuse (US) to discourage the use of alcohol. By itself, the drug has no chemical effect, but when paired with alcohol (CS), the combination causes extreme nausea (CR). Similar to taste aversions discussed in Chapter 10, after very few pairings of Antabuse and alcohol, the client learns to avoid alcohol. Without an occasional pairing of the Antabuse with the alcohol again, this new response can easily be extinguished.
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