Treatment of Abnormal Behavior for AP Psychology (page 4)
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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Archeological evidence and historical documents suggest that early humans believed people with mental health problems were possessed by evil spirits.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.
Operant Conditioning Therapies
Operant conditioning therapies include contingency management techniques of behavior modification and token economies designed to change behavior by modifying its consequences. In both, rewards are used to reinforce target behaviors.
- In behavior modification, the client selects a goal and, with each step toward it, receives a small reward until the intended goal is finally achieved. Weight Watchers and other weight-reducing programs use this method to keep clients motivated.
- In token economies, positive behaviors are rewarded with secondary reinforcers (tokens, points, etc.), which can eventually be exchanged for extrinsic rewards, such as food. Token economies are often used in institutions to encourage socially acceptable behaviors and to discourage socially unacceptable ones.
Other Behavior Therapies
Social skills training is a behavior therapy, based on operant conditioning and Albert Bandura's social learning theory, to improve interpersonal skills by using modeling, behavioral rehearsal, and shaping. With modeling, the client is encouraged to observe socially skilled people in order to learn appropriate behaviors. In behavioral rehearsal, the client practices the appropriate social behaviors through role-playing in structured situations. The therapist helps the client by providing positive reinforcement and corrective feedback. Shaping involves reinforcement of more and more complex social situations. Through social skills training, people with social phobias learn to make friends or date, and former mental patients learn to deal normally with people outside of the hospital. Biofeedback training is a widely used behavioral therapy that involves giving the individual immediate information about the degree to which he/she is able to change anxiety-related responses such as heart rate, muscle tension, and skin temperature to facilitate improved control of the physiological process and, therefore, lessen physiological arousal.
Behavior therapies have been found effective for treating anxiety disorders (generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder), alcohol and drug addictions, bed-wetting, sexual dysfunctions, and autism.
Psychoanalysts discount the quick cure offered by behaviorists. Since behaviorists are unconcerned with the cause of anxiety, analysts believe that it will resurface in a new form. Until the unconscious conflict is made conscious, the behaviorist is only "curing" the symptom of the problem; so through symptom substitution, a new problem will occur. The so-called cured smoker suddenly begins another compulsive habit, like eating or drinking.
Cognitive therapists, sometimes called cognitive-behavioral therapists, think that abnormal behavior is the result of faulty thought patterns. Many psychologists consider cognitive therapy to be an insight therapy. Cognitive-behavior therapy helps clients change both the way they think and the way they behave. Through cognitive restructuring, or turning the faulty, disordered thoughts into more realistic thoughts, the client may change abnormal behavior.
Rational Emotive Behavior Therapy
Albert Ellis developed Rational Emotive Therapy (RET), which is also called rational emotive behavior therapy (REBT), based on the idea that anxiety, guilt, depression, and other psychological problems result from self-defeating thoughts. The therapist has the client confront irrational thoughts by discussing his/her actions, his/her beliefs about those actions, and finally the consequences of those beliefs. The actions, beliefs, and consequences he called the ABCs of treatment. For instance, a young man is feeling guilty about not having helped his mother more before she died. Ellis might have confronted this guilty belief with a statement like "And you were the only person in the entire universe who could have helped her, right?" While defending these beliefs, the client may see how absurd they truly are. Ellis believed that much of this thinking involves the tyranny of the "shoulds," what we believe we must do, rather than what is actually realistic or necessary.
Cognitive Triad Therapy
Aaron Beck also developed a cognitive therapy to alleviate faulty and negative thoughts. His cognitive triad looks at what a person thinks about his/her Self, his/her World, and his/her Future. Depressed individuals tend to have negative perceptions in all three areas. As noted by Martin Seligman, depressed individuals tend to think they caused the negative events, the negative events will affect everything they do, and the negative events will last forever. Such thoughts and beliefs lead to low self-esteem, depression, and anxiety. The goal of therapy is to help them change these irrationally negative beliefs into more positive and realistic views. Failures are attributed to things outside their control and successes are seen as personal accomplishments. Beck suggests specific tactics, including evaluating the evidence the client has for and against automatic thoughts, reattributing the blame to situational factors rather than the client's incompetence, and discussing alternative solutions to the problem. For example, instead of blaming yourself for being stupid when the entire class does poorly on a math exam, you might substitute the thought that you didn't have an adequate opportunity to study, and the test may not have been valid.
Cognitive therapies have been demonstrated to be effective in treating depression, eating disorders, chronic pain, marital discord, and anxiety disorders (generalized anxiety disorder, panic disorder, agoraphobia, and social phobia).
Biological psychologists believe that abnormal behavior results from neurochemical imbalances, abnormalities in brain structures, or possibly some genetic predisposition. Treatments, therefore, include psychopharmacotherapy (the use of psychotropic drugs to treat mental disorders), electroconvulsive therapy, and psychosurgery. Medical doctors, psychiatric nurse practitioners, and a limited number of clinical psychologists can prescribe psychoactive drugs. Four major classifications of psychotropic drugs are anxiolytics (antianxiety medications), antidepressants, stimulants, and neuroleptics (antipsychotics).
Anxiolytics, also called tranquilizers and antianxiety drugs, include quick-acting benzodiazepines such as the widely prescribed drugs Valium (diazepam), Librium (chlordiazepoxide), and Xanax (alprazolam); and slow-acting BuSpar (buspirone). Benzodiazepines increase availability of the inhibitory neurotransmitter GABA to the limbic system and reticular activating system where arousal is too high, reducing the anxiety felt by the patient. Other therapies such as visualization, relaxation, and time management can be used in conjunction with drugs so that the drugs may be tapered off over time, because patients can develop unpleasant side effects and build up a tolerance to these compounds. Anxiolytics are helpful in the treatment of post-traumatic stress disorder, panic disorder, agoraphobia, and generalized anxiety disorder.
Antidepressant medications elevate mood by making monoamine neurotransmitters including serotonin, norepinephrine, and/or dopamine more available at the synapse to stimulate postsynaptic neurons. Types of antidepressants include monoamine oxidase inhibitors (MAOIs), which inhibit the effects of chemicals that break down norepinephrine and serotonin; tricyclics, which inhibit reuptake of serotonin; selective serotonin reuptake inhibitors (SSRIs), which inhibit reuptake only of serotonin; and atypical antidepressants (sometimes called non-SSRIs), some of which may inhibit reuptake of serotonin, norepinephrine, and dopamine, or a combination of two of them. Commonly advertised SSRls include paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa, Lexapro), and fluvoxamine (Luvox). Non-SRRIs include bupropion (Wellbutrin) and velafaxine HCL (Effexor XR). They have all been found effective for treating depression, and some have also been found effective for treating anxiety disorders, such as obsessive-compulsive disorder, panic disorder, and post-traumatic stress disorder (PTSD). For treatment of bipolar disorder, lithium has been widely used to stabilize mood, alone or with antidepressants. Anti-seizure medicines used to treat epilepsy, such as valproic acid (Depakene), divalproex (Depakote), and Topiramate (Topamax) have also been used.
Stimulants are psychoactive drugs, such as Ritalin (methylphenidate) and Dexedrine (dextroamphetamine), that activate motivational centers and reduce activity in inhibitory centers of the central nervous system by increasing activity of serotonin, dopamine, and norepinephrine neurotransmitter systems. They are used to treat people with narcolepsy and people with attention-deficit hyperactivity disorder.
The last class of drugs, neuroleptics, are powerful medicines that lessen agitated behavior, reduce tension, decrease hallucinations and delusions, improve social behavior, and produce better sleep behavior, especially in schizophrenic patients. An excess of dopamine is thought to be the cause of the schizophrenic symptoms; neuroleptics block dopamine receptors. Neuroleptics include Thorazine (chlorpromazine), Haldol, and Clozaril. Unfortunately, these drugs can have serious side effects, including tardive dyskinesia, or problems with walking, drooling, and involuntary muscle spasms, which result from the blocking of dopamine at other sites. These problems cause some patients to abandon the medication after hospitalization, which results in a return of psychotic symptoms.
Other Biological Treatments
Some patients do not respond well to antidepressant drugs or psychotherapy. Electroconvulsive shock treatment (ECT) is used as a last resort to treat severely depressed patients. ECT is administered humanely, with the patient under anesthetic and given a muscle relaxant to prevent injury from convulsions. Then the patient receives a momentary electric shock. Typically, the procedure is repeated about six times over 2 weeks. Just how the procedure works is still unknown, but many depressed, suicidal patients are restored to healthy functioning. The patient usually experiences some (often temporary) memory loss immediately following the procedure, but no apparent brain damage. A promising new painless treatment for severe depression is repetitive transcranial magnetic stimulation (rTMS) in which repeated pulses surge through a magnetic coil positioned above the right eyebrow of the patient. The treatment is administered daily for a few weeks. The treatment may work by stimulating the depressed patient's left frontal lobe.
Psychosurgery, or the removal of brain tissue, can also be used to treat certain organic problems that lead to abnormal behavior. Psychosurgery is a treatment of last resort because its effects are irreversible. From about 1935 to 1955, the prefrontal lobotomy, which cut the main neural tracts connecting lower brain regions to the frontal lobes, was performed on thousands of schizophrenic patients, especially violent ones, to reduce the intensity of their emotional responses. Unfortunately, following the lobotomies, many patients were left as emotional zombies, with extensive brain damage. Today psychosurgery is very limited. One successful procedure used for severe epilepsy is the corpus callosum transection, or split brain surgery, in which only the corpus callosum between the left and right cerebral hemispheres is cut.
Modes of Therapy
So far we have discussed therapies that are largely individual—in other words, one-on-one. Another way that psychological services can be delivered is in groups.
The same types of therapies used in individual counseling can be used with a group of patients. Typically, group therapy is more helpful than individual counseling in enabling the client to discover that others have similar problems. Individuals receive information about their problems from either the therapist or other group members. Financially, group therapy is also cheaper for clients who might otherwise not be able to afford individual counseling. Less verbal clients and those more resistant in individual settings may find it easier to open up about their problems in a group setting. Clients get helpful feedback from peers that may allow them to gain better insight into their own particular situations.
Couples and Family Therapy
This is especially true in family and marital counseling sessions. Trained professionals can direct spouses and family members to openly discuss their individual perspectives on the same issue. In the neutral setting of the therapist's office, individuals can come to better understand others' feelings and beliefs and how their behavior affects others. The therapy can serve as a training ground to practice better communication skills and bring about improved relationships.
Self-help groups are yet another way that individuals who share the same problem may get assistance. One of the best-known examples is Alcoholics Anonymous. Recovering alcoholics get peer support and have an outlet to share their individual experiences. It should be noted, however, that trained psychotherapists do not conduct these sessions. The responsibility for leading the group is up to the group members themselves. Meetings can be attended anywhere in the United States. New members can receive a sponsor, someone who has been in recovery for a longer period of time, to call in emergency situations. A spiritual aspect underlies Alcohol Anonymous's Twelve-Step Program as well.
Community and Preventive Approaches
With deinstitutionalization came the problem of how to help patients released from mental hospitals and an ever-growing number of other people in need of aid in local communities. The vast increase in the homeless population, many of whom have symptoms of schizophrenia, has posed a problem that has not been solved. Yet these problems have led to the rise of a relatively new subfield of psychology, community psychology. Community psychologists aim to promote psychosocial change to prevent psychological disorders as well as to treat people with psychopathologies in their local communities.
As part of the community mental health movement of the 1960s, local clinics cropped up. With continued funding problems, these local clinics try to provide both treatment and preventive services. One of their major goals is to treat people with psychological problems to prevent them from getting worse and help them recover. They address unemployment, poverty, overcrowding, and other stressful social problems that can affect mental health. Other initiatives include prenatal and follow-up well-baby care, dissemination of information on sexually transmitted diseases, suicide prevention programs, child abuse prevention, and training of paraprofessionals to help community members cope with emergency situations. They hold free screenings for depression and anxiety, sponsor suicide hotlines, and provide outreach programs for at-risk children and teens.
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