Introduction to Psychological Science: Integrating Behavioral, Neuroscience and Evolutionary Perspectives - William J. Ray 2021
✵ 15.2 Discuss the history of psychopathology and its treatments.
✵ 15.3 Describe the psychological treatment perspectives for the treatment of mental disorders.
✵ 15.4 Summarize the biological approaches to treating mental disorders.
✵ 15.5 Summarize the effective treatment options for mental disorders.
My students filled the room. They were interested and eager, unusually so, given that they were second-and third-year law students for whom the fear and trembling that came with the first year had long since faded. The course was “Advanced Mental Health Law.” The day’s topic: Billie Boggs. A street person who lived over a hot air vent in midtown Manhattan, she threw food at people who wanted to help her and chased them across the street. Her rantings and ravings seemed crazy to most of the students, and we were discussing whether she should be sent to a psychiatric hospital.
I heard myself speak, surprising myself by the steady sound of my voice as I tried to restore my attention to the group before me : “What if Billie Boggs were your sister—would you put her in a psychiatric hospital then?” Up shot the hands.
Concentrate. These are your students. You have an obligation to them. Canceling class would be admitting defeat. But there are explosions in my head. They’re testing nuclear devices on my brain. They’re very little and they can get inside. They are powerful.
I pulled myself together, enough to point to a young woman who spoke often in class . “I couldn’t let my sister live like that,” she said from across the classroom, which held the students in curved rows, like a giant palm before me. “I know my sister. That wouldn’t be her. There’s one and only one of her—and that’s the one before she got sick.”
Is she trying to kill me? No, she’s a student. But what about the others? The voices inside my head, the explosions. What do they want? Are they trying to interdict me, to hit me with the Kramer device? I went to the store and they said “interdiction.” Interdiction, introduction, exposition, explosion. Voicemail is the issue.
I knew not to say those thoughts out loud. Not because they were crazy thoughts—they were every bit as real as the students sitting right in front of me—but I kept silent because others would think them crazy. People would think me as deranged as Billie Boggs. But I’m not crazy. I simply have greater access to the truth.
“Good,” I replied. “But why isn’t it the case that your sister has two selves, the sick one you see now and the healthy one you’ve known all your life? Why should you get to pick which is real? Shouldn’t your sister make that choice?” Up shot more hands.
My brain is on fire! My head is going to explode right here, right in front of my class!
“But isn’t health always preferred to illness?” a bright-eyed young man countered. “We should prefer the healthy self.” Mercifully, the class ended. A law-school dean spotted me as I walked back to my office. He said I looked as if I were in pain. “Just a lot on my mind,” I heard myself reply as I continued quickly down the hall. Keys out, door open, door shut. I crumpled into my chair and buried my face in my hands.
That was in September of 1991, and it was one of my worst such incidents. Ten years before, in my mid-20s, during my third psychiatric hospitalization, I had been given the diagnosis “chronic paranoid schizophrenia with acute exacerbation.” My prognosis? “Grave.” I was, in other words, expected to be unable to live independently, let alone work. At best I would be in a board-and-care, holding a minimum-wage job—perhaps flipping burgers—when my symptoms had become less severe.
That has not turned out to be my life. I am the Orrin B. Evans professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California’s law school; adjunct professor of psychiatry at the University of California at San Diego’s medical school; and an assistant faculty member at the New Center for Psychoanalysis, where I am also a research clinical associate.
My schizophrenia has not gone away. I still become psychotic, as happened in class that day in 1991. Today my symptoms, while not as severe, still recur and I struggle to stay in the world, so to speak, doing my work. I have written about my illness in a memoir and much of the narrative takes place after I had accepted a tenure-track appointment at USC.
Barring a medical breakthrough of Nobel-Prize-winning proportions, I will never fully recover from schizophrenia. I will remain on antipsychotic medication and in talk therapy for the rest of my life. Yet I have learned to manage my illness.
Some are steps that everyone with mental illness should take. First, learn about the illness you have—the typical signs, symptoms, and course. Many excellent sources are available. Second, understand how your illness affects you. What are your triggers? What are your early warning signs? What can you do to minimize your symptoms when they worsen—e.g., call your therapist, increase your medication, listen to music, exercise? Try to devise some techniques for your own situation. Some colleagues and I are studying how a group of high-functioning people with schizophrenia manage their symptoms. You are in the best position to determine what works for you.
Put a good treatment team in place. You need a therapist you can trust and can turn to in times of difficulty. Does he or she respond if you call in crisis? The same is true of a psychopharmacologist. Make friends and family members part of your team.
Sometimes your team can see early warning signs before you can. For instance, my closest friend, Steve, and my husband, Will, often identify when I am slipping. Will says I become quieter in a particular way that signals all is not well. It’s a blessing to have such people in your life. Seek them out.
We also need to put a face on mental illness. Being open about one’s own illness will probably do more good than all the laws we can pass.
My own “outing” of myself was a bit of a risk, but has turned out well. I am glad and relieved I no longer have to hide. And my story seems to be meaningful to people—it has helped people understand mental illness more and perhaps has led to a decrease in the stigma. I was lucky in that my law school accommodated my teaching needs without my having to invoke the ADA. My colleagues are supportive, and I no longer feel ashamed about needing their help.
Perhaps most important: Seek help when you need it. Mental illness is a no-fault disease like any other, such as cancer or diabetes. Help is available, but you need to ask for it. Don’t let the threat of stigma deter you. You shouldn’t have to suffer.
And you shouldn’t allow mental illness to stand in the way of the wonderful contributions you are poised to make to your students and to your field.
From Chronicle of Higher Education, November 25, 2009 (edited part of a larger article). Elyn R. Saks is a professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California’s law school. She is the author of a memoir, The Center Cannot Hold: My Journey Through Madness (Hyperion, 2007).
You just read the description of one person’s experience with mental illness. In describing her experiences, she also gives you a quick history of how mental illness has been conceptualized in the past and what the future may offer. When Elyn Saks initially went to the hospital, she was told that her prognosis was “grave.” She was also told that she would never live independently, hold a job, find a loving partner, or get married. Her future was described as one in which she would live in a board-and-care facility, spending her days watching TV in a dayroom with other people debilitated by mental illness. For work, she would work at menial jobs when her symptoms were quiet.
Following her last psychiatric hospitalization at the age of 28, she was encouraged by a doctor to work as a cashier making change. Similar to people with cancer who were told in the last century to not expect a long life, individuals with mental illness were not given the possibility of real change. However, Elyn Saks was able to complete her law degree at Yale University and become a professor of law, psychology, and psychiatry at the University of Southern California. You can see her Ted Talk on her experience with mental illness online (https://www.ted.com/talks/elyn_saks_seeing_mental_illness).
This chapter will examine the treatments for mental illness over time. As we developed new scientific techniques for understanding human processes, our conceptualizations of mental illness and its treatment have also changed. We have gone from a worldview hundreds of years ago in which magic, including the idea that you could be possessed by spirits or demons, produced mental illness to a time in which our scientific understanding describes a complex set of processes on many levels that contribute to mental illness. During the current historical period, we have also come to see those with mental illness as whole people with both abilities and difficulties. In terms of the future, Elyn Saks described a movement to allow people with mental disorders to have a say in their treatment. A person’s high functioning and the ability to make decisions is not totally taken away by having a mental disorder. The person is still able to describe her experiences and, in the best of conditions, to ask others for help.
Historical Understanding of Psychopathology and Its Treatment
Although the Greek and Roman periods saw individuals who attempted to understand psychopathology in a more humane way, this disappeared as their civilizations declined. As the Middle Ages approached, disease and especially mental illness was seen from the standpoint of a religious perspective with the devil being a major player. One of the classic books in this genre was the Malleus Maleficarum published in the 1480s. “The Hammer of the Witches” was written by two German priests and approved by the Pope. It went through a number of editions and became the handbook of the inquisition. As such, it explained how witches existed and flew through the air as well as how they should be tortured if they did not confess.
In a “catch-22,” the witches were tied to a device and lowered into cold water. If they floated, they were seen to be possessed by the devil and most likely killed by hanging or fire. If they went to the bottom and drowned, then they were innocent. During the interrogations, witches were not to be left alone or given clothes since the devil would visit them or hide in their clothing. Although the writers did not understand the nature of psychopathology, they did describe in some detail particular characteristics of different disorders including bipolar disorder, depression, and psychotic processes such as hallucinations and delusions.
In 1330, a convent of the order of St. Mary of Bethlehem became the first institution for the mentally ill in England. Two hundred years later, King Henry VIII gave the institution a royal charter. Over the years, the word “Bethlehem” became “Bedlam,” and the institution was referred to as “Old Bedlam.” The English word “bedlam” comes from this institution. Various reports suggested that the inmates were often chained and treated cruelly without proper food or clothing. As depicted in novels of the day, people of the 1700s would go to Bedlam to see the inmates as a form of an outing as we today would go to a zoo. This is depicted in a 1796 illustration (Figure 15-1). In 1814, some 96,000 people visited the asylum.
Figure 15-1 The English word bedlam comes from the name of the first institution for the mentally ill in 14th-century England.
Source: Wellcome Library London.
Another common occurrence of that time is depicted in an illustration of a seaman James Norris who was shackled for 14 years (see Figure 15-2).
Figure 15-2 James Norris was kept in a harness in 1814. He has been confined for more than ten years.
Source: Wellcome Library London.
In the 1800s, there was a campaign in England to change the conditions of the patients, which led to the establishment of the Committee on Madhouses in 1815. This issued in a period of concern for the patients rather than seeing them as objects of curiosity as in the previous century. Treatment for patients during the 1800s brought new practices including the therapeutic value of work.
During this period, there was a spirit throughout the world to adopt a “moral treatment of the insane.” Three important individuals were Benjamin Rush (1745—1813) in the United States, Philippe Pinel (1745—1826) in France, and Vincenzo Chiarugi (1759—1820) in Italy (see Gerard, 1997). In the United States, Rush, who had signed the Declaration of Independence, later established a wing at the Pennsylvania Hospital in Philadelphia for the treatment of mental illness. He is often seen as the father of American psychiatry and saw mental illness as a problem of the mind. He developed a tranquilizing chair that he believed would change the flow of the blood. Modern professionals tend to view this invention as neither helpful nor hurtful to the patient. He also wrote the first psychiatric textbook published in America.
In France, Pinel sought to change the way the insane were treated in France. Pinel supported the idea that mental illness could be studied by the methods of the natural sciences. In 1793, Pinel became the director of the Bicêtre Asylum in Paris. As director, he reviewed the commitment papers of the inmates, toured the building, and met with each patient individually. The building was in bad shape and the patients were chained to walls. Pinel himself wrote “everything presented to me the appearance of chaos and confusion.” Pinel petitioned the government and received permission to remove the chains. He also abandoned the practice of bloodletting.
Pinel began to carefully observe patients and to interact with them. In these discussions, he attempted to create a detailed case history and to better understand the development of the disorder. This led to a classification system, which he published in his Nosographie philosophique ou méthode de l’analyse appliquée à la médecine in 1789, which sorted mental diseases into five categories: melancholia, mania without delirium, mania with delirium, dementia, and idiocy. In 1795, Pinel became the chief physician at the Hospice de la Salpêtrière where he remained for the rest of his life. For many, Pinel is seen as the father of scientific psychiatry.
Vincenzo Chiarugi had been less well known outside of Italy until a paper in the middle of the last century brought his name to the attention of Americans (Mora, 1959). Some eight years earlier than Pinel, Chiarugi began removing chains from his patients. Early in his career, Chiarugi became the director of a large hospital in Florence that included special facilities for the mentally ill. This resulted from the passage of a law in 1774 in Italy that allowed individuals seen as mentally ill to be hospitalized. As director of the hospital, Chiarugi created guidelines concerning how patients were to be treated. One of these rules suggested that patients were to be treated with respect. He also suggested that if restraints were required, they should be applied in a manner to protect the patient from sores and be made of leather rather than chains. He also used psychopharmacological agents such as opium for treatment.
In addition to mental health professionals, the humane care of individuals with mental illness was moved forward by a variety of other individuals. William Tuke (1732—1822) was a successful merchant of tea, coffee, and cocoa in England. He was a Quaker philanthropist and friends had told him of being turned away from an asylum in York when they had tried to visit a fellow Quaker who had been confined there. Within a few days, the patient was reported dead.
Tuke visited the asylum and found the conditions deplorable. Having retired, he decided to devote his life to creating alternative places where “the unhappy might find refuge.” In 1796, near York, England, he created a Retreat for Persons Afflicted with Disorders of the Mind . This Quaker retreat carried with it the idea that the individuals who were there should be given respect as well as good food and exercise. There were to be no chains or manacles. The model for the retreat was that of a farm and the patients performed farm duties as part of their treatment. Others visited to learn of its operation. In 1813, the Quakers of Philadelphia founded the Friends Asylum for the Use of Persons Deprived of the Use of Their Reason, which was the first private psychiatric hospital in the US. Both the retreat in York and the Friend’s Hospital of Philadelphia continue to function as places for mental health treatment.
Another individual who contributed to the American mental health movement was Dorothea Dix (1802—1887). Dix became a schoolteacher but contracted tuberculosis and needed to find a less than full-time position. She found a job teaching women at the East Cambridge House of Correction in Massachusetts. This position opened her eyes to the terrible conditions these women faced. Dix also realized that a number of these women had some type of mental illness. From this experience, she devoted her life to crusading for the improved treatment of the mentally ill. As part of this crusade, she visited every state east of the Mississippi River and testified before local and national legislatures. She encouraged the American congress to give federal land to the states to establish mental hospitals in the same way they created land grant colleges in the 1860s. Both houses of congress passed the bill only to be vetoed by President Franklin Pierce. Although this bill was not passed, it is estimated that her work led to the establishment of some 40 mental hospitals in the US and Europe.
1. What were the unique contributions of the following individuals and groups to our current understanding of the treatment of mental illness—include dates and locations as well in your response:
a. Convent of the order of St. Mary of Bethlehem?
b. Committee on Madhouses?
c. Benjamin Rush?
d. Philippe Pinel?
e. Vincenzo Chiarugi?
f. William Tuke?
g. Quakers of Philadelphia?
h. Dorothea Dix?
The Psychological Treatment Perspectives in the 20th Century
This section will discuss three approaches for the psychological treatment of mental disorders. These are the psychodynamic approach, the existential-humanistic approach, and the cognitive behavioral approach. These approaches were developed somewhat independently and are often seen in opposition to one another. For that reason, they will initially be discussed independently, which will include a historical understanding of each approach, including its broad principles, and then present specific treatments that have been tested in a scientific manner. In addition, many current approaches represent an integration of these three approaches.
Psychodynamic Perspectives on Treatment
The psychodynamic perspective is based on the idea that psychological problems are manifestations of inner mental conflicts and that conscious awareness of those conflicts is a key to recovery. Historically, Sigmund Freud laid the foundation for this perspective. By the beginning of the 20th century, there was an understanding that psychological processes were an important source of information concerning mental illness. Sigmund Freud had worked with Jean-Martin Charcot in Paris. Charcot has been called the founder of modern neurology and is known for his study of hypnosis. He observed individuals with hysteria. In this disorder, the experience, such as not feeling pain in a limb or difficulty hearing, did not match the underlying physiology. For example, with glove amnesia the person would not feel pain in the area of the fingers covered by a glove even when pricked with a pin. However, the nerves related to this pain followed a different pattern, which meant that the pain experience could not have a totally physiological cause. These types of experiences led Freud to seek psychological explanations for the cause and treatment of mental disorders. Psychodynamic therapy is based on Freud’s ideas. Psychoanalysis was the first psychodynamic therapy to develop, and we look at that next.
For Freud, treatment was based on the search for ideas and emotions that are in conflict and the manner in which an individual has relationships with other people. His specific treatment came to be called psychoanalysis. One basic procedure was free association in which an individual lay on a couch with the therapist behind him and said whatever came to mind. It was the therapist’s job to help the client connect ideas and feelings of which he was not aware. One thing Freud was searching for was connections within the person’s psyche when external stimulation was reduced as with free association or during sleep. Dreams were also analyzed in this way since they are produced outside of daily life.
One purpose of psychoanalysis was to examine resistance, or what the client is unwilling to say or experience. That is, clients may not fully say what is coming into their minds or faithfully report what they experienced in a dream. Transference is the manner in which an individual imagines how another person thinks about him or her. For example, a person may expect the therapist to treat him or her just like a parent did. Since the job of the therapist is to only ask a few questions or make interpretations during a session, the client knew little of how the therapist actually felt. Thus, the client’s view of the therapist such as “he is critical of me” or “does not like my ideas” were seen to come from the client’s psyche.
One critical aspect of psychodynamic therapy is the relationship between the therapist and client, which continues to be emphasized in current approaches. The therapeutic relationship that develops between the client and the therapist offers an opportunity to see disturbed relationships in a safe environment. Transference is an important mechanism in which the client tends to see the therapist in terms of significant others in his or her life. As the client talks with the therapist, he or she will replay prior conflicts and enact maladaptive patterns. For example, if one of your parents was very critical of your ideas, then you may initially find it difficult to tell the therapist feelings or thoughts that are very important to you or related to how you see yourself. You could have another situation in which a parent never allowed you to engage in tasks in which you could fail or would save you whenever you encountered problems. These past situations would leave you with unrealistic expectations as to what to expect from the world and others. In these situations, the person has never really learned what the world has to offer and may act as a child expecting someone to protect her and thus miss out on new experiences and learning.
In the last 50 years, a number of dynamically orientated therapies have been shown to be effective (Barber, Muran, McCarthy, & Keefe, 2013). One empirically supported therapy based on dynamic principles was developed by Hans Strupp and his colleagues. Strupp was a researcher who throughout his career sought to understand the important components of successful therapy and how to perform therapy outcome research (Strupp, 1971). He was particularly interested in the psychoanalytic or psychodynamic perspective as it is sometimes called. Strupp demonstrated changes could be seen in a therapy of a few-months duration (Strupp & Binder, 1984). The focus of this therapy is the relationship between the client and other individuals in his or her life. It is assumed that the client’s problems are based on disturbed prior relationships.
Strupp and Binder illustrate how they might initially discuss interpersonal transactions with a client.
Therapist: How do you feel about yourself at those times?
Client: I feel like I don’t have anything to offer.
Therapist: That you have nothing to offer. What do you imagine people are thinking about you then? What’s their attitude toward you when you’re with them and you feel like you have nothing to say?
Client: Really, that I’m present and that’s about all.
Therapist: Really, that I’m present. They’re not attracted to you or they have negative feelings toward you. They just don’t feel about you one way or the other?
Therapist: Like you’re invisible.
Client: Just like I’m not there. It doesn’t really matter whether I’m there or not.
(Strupp & Binder, 1984, p. 115)
The role of the therapist from this approach is mainly to listen. As the therapist listens to a client, the therapist seeks to understand what the client is saying and how he or she feels as the client describes their world. The therapist would note when she or he finds talking to the therapist difficult or experiences distress as she or he talks about their life. On a broader level, the therapist is looking for themes and patterns that came from one’s past. In a relaxed, nonjudgmental manner, it is the task of the therapist to help the client understand the patterns and to see how they interfere with living and having rewarding relationships with others. Different versions of dynamic psychotherapy have been shown to be effective for a number of disorders, especially the personality disorders (Barber, Muran, McCarthy, & Keefe, 2013).
The existential-humanistic perspective begins by asking what is the nature of human existence? This includes both the positive experiences of intimacy and the negative experiences of loss. As the existential-humanistic movement grew, a number of themes became critical. The first is an emphasis on human growth and the need for a positive psychology that moves beyond the discussion of stress and neurosis seen in the psycho-dynamic approaches. A second emphasis is that psychological health is more than just the absence of pathology. Not having a problem is not the same as finding meaning in one’s life. The third theme stresses the importance of not only considering the external world and a person’s relationship to it but also the internal world. In the existential-humanistic perspective, the internal world of a person and his or her experiences are valued. With the emphasis on experience, you will also see the therapies that developed from this approach referred to as humanistic-experiential therapies. One well-known humanistic therapy is client-centered therapy.
Carl Rogers brought the humanistic movement to the forefront by creating client-centered therapy, also referred to as person-centered therapy. He was also one of the first psychologists to record therapy sessions so that they could be used for research. Rogers continued on the theme of potential by saying that psychotherapy is a releasing of an already existing capacity in a potentially competent individual. In fact, it was the interaction with the therapist that allowed for the person to experience himself and come to understand his potential. In this way, Rogers emphasized the relationship between the therapist and client as a critical key to effective therapy.
There are three key characteristics of the client-centered approach. The first is empathic understanding. As the therapist reflects back what the client says, the client begins to experience his innermost thoughts and feelings. The second is what Rogers referred to as unconditional positive regard. That is, the therapist accepts what the client says without trying to change the client. For some individuals who had experienced significant others in their lives as critical of them, to be accepted by the therapist is a new experience. The third characteristic is for the therapist to show genuineness and congruence. In this way, the therapist models what interactions between two real people could be like.
As a person continues in therapy, Rogers suggested that the client goes through seven stages. These stages begin with an unwillingness to share one’s internal world. This is followed by blaming things on others and accepting one’s own experiences. The next set of stages begins with a freer description of feeling and ends with the client’s being comfortable with himself. The stages are:
1. Unwillingness to reveal self, feeling not recognized
3. Wants to be different (not accepting past feelings)
4. Freer description of feelings
5. Recognition of conflict between feelings and thoughts
6. Experience feelings without denial, more willing to risk in relationships
7. Comfortable with self and with having new feelings
One individual who helped to form early ideas of what became the existential humanistic approach was Karen Horney, a German-born psychoanalyst who was introduced to you in Chapter 13. She influenced the movement by emphasizing growth as well as suggesting that Freud’s approach did not fully present a psychology that applied to women. Overall, for both men and women she differentiated between healthy growth in which a person developed to her full potential and neurotic growth in which a person limited her development by unrealistic ideas and feelings. These unrealistic ideas would include the idea that “everyone should love me,” “I should never make mistakes,” or “the world should always give me what I want.” Horney’s final book, Neurosis and Human Growth, describes how these types of unrealistic ideas, along with an idealized self-image, leave the person feeling out of touch with herself and others.
In contrast to an idealized self-image in which one is always perfect and loved by everyone, Karen Horney created the concepts of self-realization and a real self. A real self includes who one is and what one appreciates. It is the alienation from the real self that is seen to constitute a key process of neurotic development. It also requires energy to present a false self, which leaves few resources for developing healthy human growth. Her ideas were echoed later in the century by Abraham Maslow.
One of the best known of the humanistic psychologists is Abraham Maslow. Maslow is well known for his hierarchy of needs described in the chapter on motivation and emotion. Although there are few empirical studies examining the hierarchy, it has remained an important theoretical concept for understanding the nature of human needs. The first level is physiological needs such as hunger and thirst. Before one can seek higher level psychological needs, physiological needs must be met. The second level needs are safety, which includes the desire for safety, and the avoidance of pain and anxiety. The third level of needs includes belongingness and love. These needs are related to intimacy, affection, and being part of a peer group. The fourth level is esteem. It is at this level that one seeks self-respect, adequacy, and mastery of one’s skills. The fifth and highest level is a search for self-actualization.
Self-actualization, according to Maslow, is the situation in which one lives one’s life to the fullest. At times, one may experience peak experiences or flow states in which everything appears to go perfectly with little effort, but this is not a constant state. In general, self-actualized individuals are reality-and problem-centered. It is not their desire to blame others but rather to solve the problem at hand. They also accept others as well as themselves. In their actions, they tend to be spontaneous and live a fairly simple life.
Emotional Focused Therapy
A number of humanistic-experiential oriented therapies have been shown to be effective (Elliott, Greenberg, Watson, Timulak, & Freire, 2013). One of these empirically supported therapies based on humanistic principles was developed by Leslie Greenberg and his colleagues. This approach is known as emotion-focused therapy or process experiential therapy (Greenberg, 2002; Greenberg & Watson, 2006). In this therapy, emotion is viewed as centrally important in the experience of self. Emotion can be either adaptive or maladaptive. However, in either case, emotion is the crucial element that brings about change in therapy. In therapy, clients are helped to identify and explore their emotions. The aim is to both manage and transform emotional experiences.
Greenberg describes five principles that relate emotion-focused therapy to a humanist approach concerning human nature (Pos & Greenberg, 2006). These principles are:
1. Experiencing is the basis of thought, feeling, and action.
2. Human beings are fundamentally free to choose how to construct their worlds.
3. People function holistically while at the same time are made up of many parts, or self-organizations, each of which may be associated with quite distinctive thoughts, feelings, and self-experiences.
4. People function best and are best helped by a therapist who is psychologically present and who establishes an interpersonal environment that is empathic, unconditionally accepting, and authentic.
5. People grow and develop to the best of their abilities in supportive environments.
Emotion-focused therapy can be thought of in three phases (Greenberg & Watson, 2006). The first phase is one of bonding and awareness in which it is the job of the therapist to create a safe environment in which emotional experience can take place. Empathy and positive regard are part of the way the client is helped to feel safe. In the early part of therapy, the client is not only helped to experience an emotion but also to put words to it as illustrated below.
Therapist: So can you pay attention to what you feel inside in that place where you feel your feelings?
Client: I just feel this heaviness inside. I feel the weight of all the things I have to do just pushing down on me.
Therapist: Can you put words to that feeling?
Client: “I have no choice.”
The second phase is evocation and exploration. At this point, emotions are evoked and even intensified. The therapist also helps the client understand how she might be interfering with her own experience of emotion. Such examples of interference would include changing the subject, beginning to talk about the emotion in a cognitive manner as a way to distance one’s self from the experience. The third phase is transformation and generation of alternatives. It is at this point that the therapist helps the client construct alternative ways of thinking, feeling, and doing that are more consistent with her real self. Empirical studies have shown that emotion-focused therapy is effective with depression and emotional trauma (Greenberg & Watson, 2006).
Another therapeutic technique that has gained popularity and been empirically shown to be effective is mindfulness (Creswell, 2017). Mindfulness techniques were originally meditation techniques developed in Theravada Buddhism. These techniques involve an increased focused purposeful awareness of the present moment. The idea is to relate to one’s thoughts and experiences in an open, non-judgmental, and accepting manner (Kabit-Zinn, 1990). The basic technique is to observe thoughts without reacting to them in the present. This increases sensitivity to important features of the environment and one’s internal reactions. This leads to better self-management and awareness as an alternative to ruminating about the past or worrying about the future. This reduces self-criticism.
Non-judgmental observing allows for a reduction in stress, reduction in reactivity, and more time for interaction with others and the world. Also, feelings of compassion for another person become possible. This broadens attention and alternatives. Meta-analysis performed by Hofmann and his colleagues examined 39 studies of mindfulness (Hofmann, Sawyer, Witt, & Oh, 2010). He found significant reductions in anxiety and depression following mindfulness techniques. Grossman and his colleagues examined 20 studies and found overall positive changes following mindfulness approaches (Grossman, Niemann, Schmidt, & Walach, 2010; see also Hofmann, Grossman, & Hinton, 2011). Empirical evidence using mindfulness techniques has shown positive change with a number of disorders including anxiety, depression, chronic pain, and stress. Mindfulness is also a component of dialectical behavior therapy, which is an effective treatment of borderline personality disorder.
Overall, the existential-humanistic perspective emphasizes the emotional level. There is also an emphasis on the value of internal processes and the manner in which the exploration and experiencing of these internal processes can lead to changes in behavior and experience.
Behavioral and Cognitive Behavioral Perspectives
Behavioral therapy focused on changing behaviors through conditioning principles, whereas cognitive behavioral therapy examined the manner in which thoughts influence behaviors. The cognitive behavioral movement seeks to understand how cognitions are disordered or disrupted in mental disorders. Whereas humanistic therapies emphasize emotional processing, cognitive behavioral approaches emphasize thoughts and the manner in which a person thinks about her life and experiences. The basic idea is that psychological disturbances often involve errors in thinking. One real value of many cognitive behavioral approaches is that they have been tested empirically and presented in books and manuals that describe the steps involved in therapy. Cognitive behavioral therapy (CBT) has been developed for a variety of disorders, which will be described later in this chapter.
The behavioral perspective, as the name implies, has focused on the level of actions and behaviors. Most histories of behaviorism begin with a discussion of Ivan Pavlov, the Russian physiologist who won the Nobel Prize in 1904 for his work on the physiology of digestion. Pavlov noted in his Nobel Prize speech that the sight of tasty food makes the mouth of a hungry man water. However, what became of interest to behavioral psychologists was not the salivary reflex itself, but the fact that other objects associated with the presentation of food could also produce salivation. For example, in his work with dogs, the sound of the door of the lab being opened preceding the dogs being presented with food would also produce the reflex. In a variety of studies it was shown that any sensory process such as sound that was paired with the food would produce salivation. After a number of pairings, the sound alone without the food could produce this reflex. This came to be known as classical conditioning, as described in the chapter on learning.
John Watson is often described as America’s first behaviorist. His work set psychology on the course of emphasizing environmental explanations for behavior and rejecting the theoretical value of internal concepts. Watson saw the goal of psychology as identifying environmental conditions that direct behavior. In this perspective, psychological disorders are considered to be under the rules of learning. Watson created a psychology based on observable behaviors alone. This position allowed for and supported the development of a strong stimulus—response psychology. Watson’s statement emphasizing the role of the environment in development is well known.
Give me a dozen healthy infants, well-formed, and my own specified world to bring them up in and I’ll guarantee to take any one at random and train him to become any type of specialist I might select — doctor, lawyer, artist, merchant-chief, and yes, even beggar-man and thief, regardless of his talents, penchants, tendencies, abilities, vocations, and race of his ancestors.
As the quote implies, Watson assumed that there existed “talents, penchants, tendencies, abilities,” which were part of an individual but that these could be overridden by environmental factors. In fact, as described in the chapter on learning, Watson demonstrated that a 9-month-old infant named Little Albert could be conditioned to fear an animal such as a lab rat that the infant had previously enjoyed playing with (Watson & Rayner, 1920). The procedure (which would be considered unacceptable and unethical today) was to create a loud noise while the infant was observing the animal. A loud noise will produce a startle response. In a classical conditioning manner, the pairing of the aversive noise and the animal led to conditioned fear. Behaviorists used classical conditioning as a mechanism for understanding phobias and other processes seen in mental illness. B. F. Skinner became the 20th century’s most vocal proponent of behaviorism. Beginning with his 1938 book, The Behavior of Organisms, Skinner played a significant role in experimental psychology until his death in 1990. His exemplar experimental procedure was to demonstrate that an animal, generally a laboratory rat or pigeon, could be taught to make specific responses if, after the occurrence of the desired response, the animal was given a reward, generally food. This procedure came to be known as operant conditioning. These techniques were applied to the management of individuals with psychological disorders. In institutional settings this approach was called token economies. Individuals with schizophrenia, for example, were rewarded with products they sought for behaviors such as cleaning their room or taking a bath.
Both Skinner and Watson left us with a psychology that emphasized the environment and ignored any discussion of internal processes or mechanisms for understanding life. Their real contribution for understanding mental illness was not their mechanisms per se since it is difficult for learning theory to adequately describe psychopathology across the lifespan, but their emphasis on experimental research and the necessity to evaluate treatment procedures in a scientific manner.
In the middle of the last century, a number of psychologists began to see the limitation of strict behaviorism in that it ignored internal processes. Simple demonstrations such as offering a 6-year-old a candy bar if he would do a particular task showed that the idea of a reward was enough to motivate behavior. Also, behaviorally oriented psychologists such as Albert Bandura showed that humans would imitate the behaviors of others even without reinforcement. This type of learning was called observational learning or modeling. One classic set of studies involved children hitting a Bobo doll after seeing cartoon characters being aggressive. In another study, children watched an adult interact with the Bobo doll in an aggressive or non-aggressive manner. Those children who watched the aggressive adult later showed more aggression than those who watched a non-aggressive adult.
The cognitive behavioral perspective suggests that dysfunctional thinking is common to all psychological disturbances. By learning in therapy how to understand one’s thinking, it is possible to change the way one thinks as well as one’s emotional state and behaviors. One basic feature of our thinking is that it is automatic. Ideas just pop into our mind such as, “I can’t solve this,” or “It is all my fault.” A number of therapies based on cognitive principles along with behavioral interventions have been shown to be effective (Hollon & Beck, 2013). David Barlow at Boston University and Tom Borkovec at Penn State University used cognitive and behavioral research to develop empirically supported treatments for anxiety (Barlow, 2002; Borkovec, 2006).
Aaron Beck developed a cognitive therapy for depression in the early 1960s (Beck, 1967, 2019; see also Judith Beck, 2011 for an overview and update). The model is described in terms of a cognitive triad related to depression (see Figure 15-3).
Figure 15-3 Beck’s cognitive triad.
The first component of the triad is the individual’s negative view of self. This is when the individual attributes unpleasant experiences to his own mental, physical, and moral defects. When something negative happens, the person says, “This is my fault.” In therapy, the client can become aware of the content of his thinking. The second component is the individual’s tendency to interpret experiences in a negative manner. That is, the person tailors the facts to fit negative conclusions. The basic idea is that thinking influences emotion and behavior. The third component is that the individual regards the future in a negative way. He envisions a life of only hardships and anticipates failure in all tasks. In therapy, the basic idea is that the individual can modify his cognitive and behavioral responses. Overall, the therapy is directed at the automatic thoughts in relation to catastrophizing—believing that nothing will work out; personalization—believing that everything relates to you; overgeneralization—believing that one event is how it always is; and dichotomous thinking—believing that things are either good or bad. The following is an example of a Cognitive Behavioral Therapy (CBT) therapy session:
Therapist: Okay, Sally, you said you wanted to talk about a problem with finding a part-time job?
Patient: Yeah. I need the money… but I don’t know.
Therapist: (noticing that Sally looks more dysphoric) What’s going through your mind right now?
Patient: [automatic thought] I won’t be able to handle a job.
Therapist: [labeling her idea as a thought and linking it to her mood] And how does that thought make you feel?
Patient: [emotion] Sad. Really low.
Therapist: [beginning to evaluate the thought] What’s the evidence that you won’t be able to work?
Patient: Well, I’m having trouble just getting through my classes.
Therapist: Okay. What else?
Patient: I don’t know… I’m still so tired. It’s hard to make myself even go and look for a job, much less go to work every day.
Therapist: In a minute we’ll look at that. [suggesting an alternative view] Maybe it’s actually harder for you at this point to go out and investigate jobs than it would be for you to go to a job that you already had. In any case, is there any other evidence that you couldn’t handle a job, assuming that you can get one? Patient:… No, not that I can think of.
Therapist: Any evidence on the other side? That you might be able to handle a job?
Patient: I did work last year. And that was on top of school and other activities. But this year… I just don’t know.
Therapist: Any other evidence that you could handle a job?
Patient: I don’t know…. It’s possible I could do something that doesn’t take much time. And that isn’t too hard.
Therapist: What might that be?
Patient: A sales job, maybe. I did that last year.
Therapist: Any ideas of where you could work?
Patient: Actually, maybe the [university] bookstore. I saw a notice that they’re looking for new clerks.
Therapist: Okay. And what would be the worst that could happen if you did get a job at the bookstore?
Patient: I guess if I couldn’t do it.
Therapist: And if that happened, how would you cope?
Patient: I guess I’d just quit.
Therapist: And what would be the best that could happen?
Patient: Uh… that I’d be able to do it easily.
Therapist: And what’s the most realistic outcome?
Patient: It probably won’t be easy, especially at first. But I might be able to do it.
Therapist: Sally, what’s the effect of believing your thought, “I won’t be able to handle a job”?
Patient: Makes me feel sad…. Makes me not even try.
Therapist: And what’s the effect of changing your thinking, of realizing that possibly you could work in the bookstore?
Patient: I’d feel better. I’d be more likely to apply for the job.
Therapist: So what do you want to do about this?
Patient: Go to the bookstore. I could go this afternoon.
Therapist: How likely are you to go?
Patient: Oh, I guess I will. I will go.
Therapist: And how do you feel now?
Patient: A little better. A little more nervous, maybe. But a little more hopeful, I guess.
(Beck 2011, p. 23—5)
As with other perspectives, cognitive behavioral approaches have been expanded to include a number of other techniques including those drawn from other perspectives. Some of these approaches are mindfulness approaches and dialectical behavior therapy (DBT) as will be discussed, as well as Acceptance and Commitment Therapy (ACT) and Acceptance-Based Behavioral Therapy (ABBT). ACT and ABBT combine mindfulness with an emphasis of accepting inner experiences without judgment, along with awareness and resilience. These approaches have been referred to as the new wave or third wave of CBT (Hofmann, Sawyer, & Fang, 2010). One common theme in these approaches is the role of acceptance. In each approach, clients are encouraged to not react to negative thoughts and feelings.
1. Describe the following three aspects of psychoanalysis including their role in treatment: free association, resistance, and transference.
2. In what ways did the work of Karen Horney expand on Sigmund Freud’s theories of psychopathology and treatment?
3. Identify and describe the three primary themes of the existential-humanistic movement.
4. Identify and describe the three key characteristics of Carl Rogers’s client-centered approach.
5. Describe the three phases of Leslie Greenberg’s emotion-focused therapy and the role that each plays in the therapy process.
6. What is mindfulness? In what ways is it effective in treating mental illness?
7. List three kinds of evidence used by a number of psychologists to point out the limitations of a strict behaviorist perspective and pave the way to a cognitive behavioral perspective.
8. What are the primary characteristics of the cognitive behavioral perspective?
9. Describe the three components of Aaron Beck’s model of a cognitive triad for depression.
Biological Approaches to Treating Mental Illness
Throughout our history as humans, we have used natural substances to treat illness. Often treatment was a hit-or-miss procedure as people learned which substances were more effective than others. With the development of better chemical methods in the last 100 years, scientists began to modify the substances and create them as drugs. Today, we refer to these as psychotropic medications. Psychotropic medications are those that are used to treat mental disorders. The study of these drugs is the domain of psychopharmacology (Evans, 2019).
As you will see, introduction of medications directed at mental illness allowed individuals to live in more independent settings. In the middle part of the 20th century, this led to the closing of mental hospitals throughout the US. The closing of hospitals is described in the box: The World Is Your Laboratory: Closing Mental Hospitals in America. Today, medication plays an important role in the treatment of mental illness. In addition to medication, there are other treatment approaches that seek to directly change physiological processes. Today, treatments range from the widespread prescribing of drugs to deal with psychological disorders to the less-often used but significant measures involving shock or electrical stimulation of the brain to the rarer use of neurosurgery.
Biological approaches play an important role in the treatment of mental disorders. Treatment effectiveness is not an either/or question of psychological and biological approaches but an attempt to combine treatments that work together in an effective way. For example, research from 2015 shows that psychotherapy along with lower levels of psychotropic medication are very effective for treating schizophrenia (Insel, 2016, Kane et al., 2016).
During the US Civil War, a textbook by Union Army Surgeon General William Hammond suggested that lithium bromide be used to treat manic patients (see Perlis & Ostacher, 2016, for an overview). However, it was not until 1949 that the Australian John Cade reported that lithium had a calming effect on animals and humans with mania. As you will see, lithium is still used to treat mania, which we refer to as bipolar disorder today. Drugs that came to be called antidepressants for the treatment of depression such as monoamine oxidase inhibitors (MAOIs) and the tricyclic antidepressants (TCAs) were discovered by serendipity in the 1950s (Fava & Papakostas, 2016). Some common MAOIs are Nardil and Parnate. Common tricyclics are Elavil and Tofranil. SSRIs (selective serotonin re-uptake inhibitors) such as Prozac and Paxil were developed later. These are typically used for the treatment of mood disorders. Benzodiazepines such as Valium have been used for the treatment of anxiety for at least 50 years.
One significant event came in 1952 when a French naval surgeon was attempting to find medications to give before an operation to reduce stress (see Freudenreich, Goff, & Henderson, 2016 for an overview). What he discovered was that an antihistamine substance, called chlorpromazine, left individuals feeling indifferent about their operation. Noticing its calming effect, he suggested that this might be useful in treatment of mental disorders. In particular, it was discovered that chlorpromazine [Thorazine] helped to reduce the symptoms of schizophrenia and initially became an important antipsychotic medication. This, in turn, led to the reduction in the number of patients in mental hospitals, as noted in the box: The World Is Your Laboratory: Closing Mental Hospitals in America.
Also, in the 1950s, drugs were introduced and accepted by the public, which were designed to treat milder forms of anxiety and stress. These were referred to as minor tranquilizers and included meprobamate (Miltown), chlordiazepoxide (Librium), and diazepam (Valium). In the 1990s, popular press books such as Listening to Prozac suggested that these drugs can help you feel “better than well” (Kramer, 1993).
Although the public accepted medication as safe, it should be noted that some of the early antipsychotic medications had problematic side effects, such as weight gain, tiredness, trouble sleeping, and involuntary movements (tardive dyskinesia). Newer drugs used today have fewer of these side effects but are not totally free of problems.
As you learned in chapter 3, the brain is a complex organ that processes information through chemical and electrical signals. Most of the drugs used in the treatment of mental disorders influence information processing in the brain by influencing neuro-transmitters at the level of the synapse. Since the 1970s, benzodiazepines have been used to treat anxiety. Benzodiazepines are thought to influence the neurotransmitter GABA. Individuals with anxiety have reduced GABA activity, which in turn results in less inhibition of those brain structures that are involved in threat responses. A second class of medication referred to as azapirones were introduced in the 1990s. Buspirone (Buspar and Wellbutrin) is a common azapirone that influences serotonin receptors in the brain. Depression is treated with drugs that also influence the neurotransmitter serotonin. These are referred to as serotonin reuptake inhibitors (SSRIs), such as paroxetine (Paxil). SSRIs block the reuptake of serotonin at the synapse. Specific psychotropic medications will be described in greater detail later in this chapter in terms of the treatment of particular mental disorders.
The World Is Your Laboratory: Closing Mental Hospitals in America
During the first half of the 20th century, state mental hospitals were the main source of treatment and care for those with serious mental disorders in the United States (see Fisher, Geller, & Pandiani, 2009; Torrey, 1997, for overviews). By the 1950s, there were more than a half million individuals in these hospitals. However, during the 1950s and 1960s, a number of events occurred that changed the way individuals with mental disorders were treated in the United States. One significant event was the introduction of antipsychotic medication. Prior to this, individuals with serious mental disorders such as schizophrenia needed a high level of care and protection. With the introduction of medications that would help treat the disorder, it was possible for some of these individuals to live outside the hospital.
The Community Mental Health Act of 1963, signed into law by President John F. Kennedy, reflected the growing understanding that all but a small portion of those in mental hospitals could be treated in the community. The basic idea was that community mental health centers would offer a variety of programs to those with mental illness.
Although the population of the United States increased by 100 million between 1955 and 1994, the number of individuals in mental hospitals decreased from 550,239 to 71,619. The process of moving individuals from mental hospitals to the community was known as deinstitutionalization. Figure 15-4 shows this drastic change.
Figure 15-4 Beginning in the 1960s, the number of individuals in a mental hospital in the US began to decline.
Source: Fuller Torrey (1997).
For some of the individuals today who would have been placed in a hospital in the 1950s, their quality of life in the community is much better than it would have been. However, for many individuals, the ideals of the community mental health movement were never fulfilled. The community facilities for those with mental illness were never fully funded or were not even built. This left many individuals not receiving the type of treatment they needed. Some of these individuals have found themselves homeless and on the streets. Others, who were disruptive or concerned the community, found themselves in jails and prisons with little mental health treatment and care. Similar deinstitutionalization occurred in the United Kingdom and other developed countries.
Thought Question: Our history has shown us that neither institutionalizing nor deinstitutionalizing all individuals with serious mental disorders has been effective. What do you think some characteristics of a workable solution are?
Other current treatment approaches seek to influence the individual’s brain by changing the underlying electrical activity. Some of these treatments are seen as noninvasive (see Camprodon, Kaur, Rauch, & Dougherty, 2016 for overviews). That is, there is no requirement that electrodes or other devices be placed inside the brain itself. The oldest of these techniques is electroconvulsive therapy (ECT) in which electrical activity disrupts the normal brain activity and produces convulsions (see Welch, 2016 for an overview). This electrical activity triggers a brief seizure of less than a minute, which most likely influences changes in brain chemistry and specific networks of the cortex. ECT has changed over the years with a reduction in motor convulsions and a reduction in the number of brain areas affected. It is seen as an effective treatment for those with severe depression that does not respond to other types of medication or psychotherapy (Haq et al., 2015; Ross, Zivin, & Maixner, 2018).
An alternative to ECT, transcranial magnetic stimulation (TMS) disrupts the brain activity using magnetic stimulation to treat mental disorders, including depression. It has been known for a long time that electromagnetic activity can induce electrical changes in various materials. In transcranial magnetic stimulation, an electromagnetic coil is placed on the scalp (see Pitcher, Parkin, & Walsh, 2021, for an overview). From the coil, a magnetic field induces a small electrical current in the first few centimeters of the brain, which depolarizes the neurons. One advantage is that TMS is a noninvasive method for stimulating cortical cells in fully awake and responsive individuals.
Initial research used single-pulse TMS to study underlying motor processes by placing the TMS coil above the motor cortex. One of these studies showed a relationship between motor responses and a measure of depression (Oathes & Ray, 2006). More recently, it was found that repetitive TMS (rTMS) where multiple pulses are generated in rapid succession is effective in the treatment of depression (cf. Loo & Mitchell, 2005). A study from 42 different locations in the United States with 307 outpatients showed significant changes in depression scores following rTMS treatment (Carpenter et al., 2012). In humans who do not respond to antidepressant medication, rTMS has shown similar results to ECT. The advantage of rTMS in comparison with ECT is that no anesthetic is required and no side effects such as memory loss have been reported. Like ECT, rTMS is recommended for those who do not show changes in depression from medication.
More invasive treatments require that electrodes be placed in the brain that change the existing brain networks. The technique has been referred to as deep brain stimulation (DBS) and has been used for the treatment of motor disorders such as Parkinson’s disease, as well as obsessive compulsive disorder (OCD) and depression. Stimulating electrodes are placed deep in the brain and these electrodes are connected to a pulse generator that is placed under the person’s skin, typically below the neck. Current devices allow health care professionals to adjust the stimulation from wireless devices outside the skin. The NPR podcast Invisibilia describes the treatment of a woman for OCD (https://www.npr.org/2019/03/28/707639854/the-remote-control-brain).
The most invasive procedures are surgical procedures in which different areas of the brain are removed or their connections disrupted. Severe epilepsy, in which a person has numerous seizures and cannot work or function in a normal life, has been treated in this manner. Today, surgical procedures of the brain are limited to very small areas. In fact, gamma rays rather than a surgical knife are used to make the small cuts. Such small cuts in the brain are used with individuals who show no improvement in epilepsy, depression, or anxiety using standard treatments.
Not all of the biological treatments have been successful. In the first half of the 1900s, as a treatment for mental illness, the frontal areas of the brain were disconnected from the rest of the brain. This procedure was used until the 1950s and then discontinued. This procedure, which was referred to as frontal lobotomy, left the person with limited emotional and cognitive abilities. Even during its time, there were serious debates as to its ethics and effectiveness.
As you will also learn in the Applying Psychological Science feature, psychotherapy and biological approaches work through different brain mechanisms and at different levels of the brain.
Applying Psychological Science: Mechanisms of Action with Psychotherapy and Medication
Brain-imaging techniques are now allowing scientists to better understand how a particular psychological disorder affects the brain and how various treatments work. For example, with mood disorders, there are changes in the brain in those areas that are involved in emotional regulation (DeRubeis, Siegle, & Hollon, 2008). In particular, individuals with depression often have negative thoughts about themselves and their future that they keep repeating to themselves. These thoughts are associated with increased activity in the limbic areas including the amygdala and decreased activity in the prefrontal cortex. The decreased activity of the prefrontal areas would allow for increased activity in the limbic processes associated with emotionality.
How about treatments for depression? What brain changes would be seen? One possibility is that cognitive therapy and medication work through different pathways in the brain (DeRubeis, Siegle, & Hollon, 2008). As noted previously, brain-imaging studies show greater amygdala activity and less prefrontal cortex activity in those with depression compared to those without depression. After successful treatment for depression, amygdala activity is decreased and prefrontal activity increases.
Different pathways in the brain may be involved in successful treatment of depression. Before treatment, those with depression show more amygdala activity and less prefrontal cortex activity. Cognitive therapy (CT) increases prefrontal cortex activity, which in turn decreases limbic reactivity. Antidepressant medication (ADM) decreases the amygdala activity directly. Thus, as suggested by DeRubeis and his colleagues, cognitive therapy with its focus on cognitive processing may increase prefrontal activity, which in turn is able to inhibit amygdala activity. Antidepressant medication, on the other hand, decreases amygdala activation directly. Thus, neuroscience techniques and findings may help to explain the mechanisms of action as well as the value of utilizing more than one treatment approach.
Thought Question: How might you use brain-imaging techniques to know whether a treatment is effective?
1. Psychotropic medications play an important role in the treatment of mental illness. Describe the circumstances that led to the discovery of three of these medications as well as their current uses in treating mental illness.
2. Some treatment approaches to mental illness seek to influence the individual’s brain by changing the underlying electrical activity. Briefly describe how each of these techniques works and indicate current applications in the treatment of mental illness:
a. Electroconvulsive therapy (ECT)
b. Transcranial magnetic stimulation (TMS)
c. Deep brain stimulation (DBS)
d. Frontal lobotomy
Effective Treatment of Mental Disorders
Before the middle of the 20th century, very little formal research was performed to see how effective psychological interventions were. This was also true of traditional medical procedures. Beginning in the 1950s and 1960s, there were the beginnings of a movement to determine the effectiveness of both medical and psychological treatments in a scientific manner. In medicine, this came to be known as evidence-based medicine. In psychology, the terms empirically based treatments or empirically based principles refer to treatments and their aspects for which there is scientific evidence that the treatment is effective.
Three websites have been developed that list treatments for specific mental disorders. The first is maintained by the Clinical Psychology section of the American Psychological Association (https://www.div12.org/psychological-treatments/). The second is maintained by the US Substance Abuse and Mental Health Services Administration (SAMHSA), which is part of the US Department of Health and Human Services. This website contains a searchable online registry of mental health and substance abuse interventions that have been evaluated (https://www.samhsa.gov/find-treatment). The third website is devoted to effective treatments for children and adolescents (http://effectivechildtherapy.com/). This site is maintained by the Society of Clinical Child and Adolescent Psychology section of the American Psychological Association.
As researchers and clinicians began to focus more on approaches and principles for which there was scientific evidence that they were effective, there began a movement to develop effective treatments for particular disorders that used both biological and psychological treatment approaches. There has also been more willingness to integrate techniques from the different psychological approaches as well as from other perspectives. For example, in the discussion on personality disorders treatment, you will see that one of the most researched treatments—dialectical behavior therapy (DBT)—is based on techniques from each of the three approaches described in this chapter. This effective treatment uses aspects of cognitive behavioral techniques, dynamic techniques, and existential-humanistic techniques.
Treatment for Anxiety Disorders
Anxiety is a common experience of many individuals that they may report to many types of health professionals including psychologists, psychiatrists, and even their family physician. These individuals are often given medications such as benzodiazepines or offered one of the types of psychotherapy described previously. Studies using psychodynamic, existential-humanistic, and cognitive behavioral approaches have all reported reductions in anxiety. At this point, both medications and psychological treatments show similar reductions in generalized anxiety disorder (GAD) in the short term. However, only about 40% to 60% of those treated with either medication or psychological treatments show full improvement. This is in comparison with other anxiety disorders such as phobias, which show higher rates of improvement after treatment.
Psychological Treatment of GAD
The best-studied psychological interventions have involved cognitive behavioral approaches and behavioral approaches with GAD although dynamic approaches have also been shown to be effective (Barber, Muran, McCarthy, & Keefe, 2013). The behavioral approaches include relaxation training and other such techniques. The cognitive behavioral techniques focus on automatic thinking. Typical approaches train clients to detect internal and external anxiety cues and to apply new coping skills that focus on both psychic and somatic symptoms (Borkovec & Ruscio, 2001). Initially, clients are asked to pay close attention to those factors in their daily life that trigger anxiety responses. They are also asked to pay attention to physiological and cognitive responses experienced as anxiety develops. In the therapy itself, the client is asked to imagine a situation that would increase stress or anxiety or choose a topic that he or she would worry about and notice the associated thoughts, feelings, and images. Overall, the major cognitive behavioral approaches are designed to be offered for a specific period of time. These techniques help the client learn how to reduce anxiety and worry, which is a major component of GAD.
Some important components of a cognitive behavioral therapy (CBT) approach are as follows:
1. Identifying the anxiety-associated thoughts, images, beliefs, and so forth
2. Discussing these to bring out their causal role
3. Leading clients to question the validity of thoughts or beliefs, and to search for evidence
4. Helping clients develop alternative, less anxiety-arousing assumptions or interpretations
5. Testing alternative viewpoints in homework assignments or experiments
6. Teaching the above methods as self-helping coping devices to be used in real life
These components were developed by Tom Borkovec and his colleagues, who tested the effectiveness of therapy components in a variety of outcome studies. Additionally, Borkovec and Ruscio (2001) reviewed outcome research from 13 randomized controlled GAD studies that involved a CBT component. As a whole, these CBT studies showed decreases in anxiety and depression following treatment, which was maintained in a 6-to 12-month follow-up. This suggests that CBT is effective not only for GAD but also for some of the comorbid conditions. Successful treatment was also associated with specific psychophysiological changes such as EEG activity in the gamma band (Oathes et al., 2008).
Another effective treatment for GAD is mindfulness (Hoge et al., 2013). Mindfulness-based treatments have the person with GAD focus on the present moment. This attention to the present is performed with openness and a nonjudgmental manner. This allows for better emotional regulation and reduction of anxiety symptoms. In randomized control trials for the treatment of GAD, mindfulness-based treatment has been shown to be more effective than one involving stress-reduction techniques (Hoge et al., 2013). Further, functional magnetic resonance imaging (fMRI) changes were seen following mindfulness training in those with GAD in the amygdala and the connections between the frontal areas and the amygdala (Hölzel et al., 2013). These cortical changes were also associated with symptom reduction.
Mindfulness approaches have also been integrated into traditional CBT. One of these is Acceptance and Commitment Therapy (ACT) (Hayes, 2004; Hayes, Strosahl, & Wilson, 2011). This approach suggests that those with GAD attempt to control their internal experiences, which often does not work. Based on this failure to control such thoughts and feelings, these individuals avoid internal processes. ACT uses acceptance and mindfulness to regain connections with one’s internal processes including thoughts, feelings, memories, and physical sensations.
Another therapy that has integrated mindfulness with CBT is referred to as acceptance-based behavioral therapy (ABBT) (for example, Hayes-Skelton, Roemer, & Orsillo, 2013; Orsillo & Roemer, 2016; Roemer & Orsillo, 2002; Roemer, Orsillo, & Salters-Pedneault, 2008). This treatment involves educating individuals with GAD about their relationship with internal experiences, especially negative reactions to these. The second part of the treatment includes mindfulness exercises. A third component emphasizes behavioral changes rather than reacting to internal processes.
Biological Treatment of GAD
Since the 1970s, benzodiazepines such as Xanax and Klonopin have been used to treat anxiety (Wilson & Stein, 2019). Benzodiazepines are thought to influence the neurotransmitter GABA. Individuals with anxiety have reduced GABA activity, which in turn results in less inhibition of those brain structures that are involved in threat responses. Unlike antidepressant medications, benzodiazepines show their effect within a week. A large number of studies have shown anxiety reductions in approximately 65% to 70% of GAD clients when given benzodiazepines (see Roemer, Orsillo, & Barlow, 2002, for an overview). A smaller percentage shows a full remission of anxiety symptoms. However, when a person discontinues benzodiazepines, GAD symptoms will reappear.
A second class of medication referred to as azapirones (BuSpar) was introduced in the 1990s. Buspirone (Buspar and Wellbutrin) is a common azapirone that influences serotonin receptors in the brain. This drug influences more of the cognitive components of GAD and has fewer side effects than benzodiazepines. A third class of drugs for GAD is antidepressants. Both tricyclic antidepressants, such as imipramine (Tofranil), and serotonin reuptake inhibitors (SSRIs), such as paroxetine (Paxil), have been shown to be effective with GAD.
Treatment for Social Anxiety Disorder
There are a number of psychological therapies that have been developed for treating social anxiety disorder (SAD) (see Hofmann & Barlow, 2002; Rodebaugh, Holaway, & Heimberg, 2004; Weiss, Hope, & Cohn, 2010, for overviews). These therapies include CBT, exposure therapy, social skills training, and group CBT. These different approaches may also be combined in different ways. Both CBT-type therapies and medication have been shown to be effective with SAD. CBT-type therapies show larger changes with fewer side effects than medications (Mayo-Wilson et al., 2014). Medications appear to show a faster reduction in anxiety initially. However, following treatment when no additional medication or psychotherapy is offered, there is a greater relapse with medication treatment than with CBT therapy.
Exposure therapy places a client in a feared situation despite the experience of distress. One technique is for clients to create a hierarchy of situations that they would fear or avoid. They can rank this hierarchy in terms of the level of anxiety they would expect to experience. These situations can then be used in the therapy. Typically, the person begins with the least anxiety-producing situation, such as talking to the staff at the coffee shop. The person then moves to more anxiety-producing situations, such as talking to someone you want to impress. At the top of the hierarchy would be the most anxiety-producing situation, such as giving a talk to an audience evaluating you. The situation can be experienced by either role-playing or actually being in the feared environment. Although the underlying mechanisms leading to change have not been determined precisely, exposure therapy has been shown to reduce anxiety in social situations for individuals with SAD (see Abramowitz, Deacon, & Whiteside, 2011, for an overview).
Social skills training is based on the idea that individuals with social anxiety have inadequate social interaction skills. Social skills training teaches the individual practical social skills through modeling, corrective feedback, reinforcement, and other such techniques. Since this type of training involves trying out new behaviors, it is difficult to separate it completely from exposure therapy in outcome studies.
CBT, as described previously, assumes that social anxiety is produced by the person’s automatic thoughts in the social situation or the expectation of the social situation. The task is to help the person detect and restructure these thoughts and expectations. In the treatment of social anxiety, it has been offered in both individual and group therapy.
Psychopharmacological approaches have been shown to be useful in the treatment of social anxiety (Leichsenring & Leweke, 2017). One of the earliest drugs used was a monoamine oxidase (MAO) inhibitor, phenelzine sulfate (Nardil), which was seen as the drug of choice. More recent medications have included the SSRIs, paroxetine (Paxil) and sertraline (Zoloft). The norepinephrine-SSRI venlafaxine (Effexor) has also been used. The choice of medication is often left with the individual health professional based on a specific person’s side effects.
Treatment for Specific Phobias
It is commonly accepted that phobias are best treated by exposure to the feared object (see Antony & Barlow, 2002; Böhnleina et al., 2020, for overviews). Lars Öst has shown in a number of studies that a phobia such as fear of snakes or spiders can be significantly reduced after a single three-hour session, although similar results are found in a larger number of shorter sessions (Davis, Ollendick, & Öst, 2019; and Öst, 1989, 1996). The basic procedure would be for the client to describe her fears as well as catastrophic expectations and the situations that evoke these in a session with her therapist. This would be followed by the therapist slowly introducing the feared object such as a snake from a distance. The therapist checks with the client as this is happening to determine the magnitude of fear. In general, it is the client who directs the speed of the introduction of the feared object. During the session, the therapist would bring the feared object closer to the person until she was able to touch it with reduced fear.
Using the rapid gradual exposure techniques of Lars Öst, Thomas Straube and his colleagues measured brain changes prior to and following therapy (Straube, Glauer, Dilger, Mentzel, & Miltner, 2006). They studied a group of individuals with spider phobia. These individuals received two sessions of therapy with a duration of four to five hours. Gradual exposure started with the presentation of spider pictures. Then, the individuals were shown the skin of a tarantula, followed by an actual tarantula. Once the actual tarantula was introduced, the goals of the therapy were fourfold. These were (1) to hold a living tarantula for about 10 minutes, (2) to catch moving and non-moving spiders at least ten times with a glass at different locations within the therapy room, (3) to catch any species of spider in the basement of the institute at least three times, and (4) to touch a rapidly moving house spider. By the completion of the therapy, all of the individuals with spider phobia were able to fulfill the four treatment goals without strong feelings of anxiety.
An fMRI session was conducted prior to the beginning of any therapy in which the individuals with spider phobia and a control group were shown pictures of spiders as well as neutral pictures. As expected, individuals with spider phobia showed greater activation in the insula and ACC, which is part of the fear network. Following therapy, this activation was reduced.
Treatment for Panic Disorder
The currently preferred medication treatments for panic disorder are SSRIs, which have been shown to be more effective than placebo treatments. Benzodiazepines have also been shown to be effective. The best-studied psychological treatment for panic disorder is CBT, which has been shown to be effective. In general, CBT approaches educate the individual concerning the nature of panic symptoms and reduce misconceptions. Internal exposure techniques can also be employed. For example, the person could be asked to exercise to increase his or her heart rate or spin around in a chair to feel dizzy. In this way, the person is exposed to the internal situation associated with a panic attack. More global aspects of CBT, such as cognitive restructuring in terms of distortions in thinking, are also used. This helps to reduce the catastrophic expectations, such as thinking that one is going to die when one’s heart rate increases. Meta-analyses have shown that combining CBT and antidepressant medication is more effective than either one alone (Mitte, 2005; Watanabe, Churchill, & Furukawa, 2009).
Treatment for Obsessive-Compulsive Disorder
Both psychopharmacological and behavioral therapies have been shown to be effective for OCD (Hirschtritt, Bloch, & Mathews, 2017). The most common medications are SSRIs and the tricyclic antidepressant clomipramine. Meta-analysis of randomized control trials shows SSRIs effective compared to placebos (Abramowitz & Jacoby, 2014). Changes with CBT have been shown to be greater when CBT is compared to SSRIs. However, both together show the best effects (see Pauls, Abramovitch, Rauch, & Geller, 2014, for an overview). These have been shown to be effective for about 60% of people with the disorder. OCD has been less well studied with randomized control trials in terms of psychotropic medications. For those disorders, CBT is considered the treatment of choice at this point.
The psychosocial treatment that has the best empirical support is exposure and response prevention (EX/RP), which is largely based on the work of Foa and Kozak (1986; see also Franklin & Foa, 2008, 2011, for overviews). One component includes discussions with the client concerning beliefs related to the outcome of feared behaviors. For example, the client may think that he or she would get germs from being in public bathrooms. Discussions can also be focused on what the person needs to do to prevent the expected negative outcome. Another component of this approach includes prolonged exposure to obsessional cues. For example, if the person finds it distressing to go into public restrooms, then he or she would be exposed to that actual situation. By prolonged exposure, rituals can be blocked. In addition to the actual situation, imagery can be used to repeat the situation without the ritual until the anxiety is lessened. Thus, the initial inability to conduct rituals produces distress. The basic idea, according to Foa and Kozak, is that repeated, prolonged exposure to feared thoughts and situations will provide information to the person concerning his or her mistaken beliefs and in turn allow for habituation (Foa & Kozak, 1986).
In February 2009, the US Food and Drug Administration (FDA) approved the use of a device for deep brain stimulation to treat OCD. As with deep brain stimulation for severe depression, an electrode is implanted in the brain along with a generator and battery placed under the person’s skin. Currently, there are a number of clinical trials examining this treatment. One study showed that deep brain stimulation disrupts the maladaptive pathways in OCD between the frontal areas of the brain and subcortical structures and restores normal function (Figee et al., 2013).
Treatment for Depression
Given the prevalence of depression, its treatment has been studied over a number of years (Beck & Bredemeier, 2016). Both medication and a number of different psychological approaches have been shown to be effective. Additionally, the combination of both is also very effective. This section will describe both medications and psychological treatment for the depression. The best treatment results rely on both, as described in the box: Myths and Misconceptions: Medication Shows More Long-Term Effects for Treating Depression.
Myths and Misconceptions: Medication Shows More Long-Term Effects for Treating Depression
Although drugs such as Prozac are often discussed in the popular press, clinical trials suggest that only about 50% of those who take medication for depression are helped (Fava, 2003). Another problem in the treatment of depression is that even in situations in which symptoms are reduced, individuals are at risk for a relapse of the symptoms. This is especially true when medication is used alone. For this reason, professionals have searched for a combination of treatments that might help prevent relapse by involving more than one underlying depressive mechanism. For example, antidepressant medication and a form of psychotherapy such as cognitive behavioral therapy (CBT) have been shown to each be effective in comparison to a placebo treatment (DeRubeis, Siegle, & Hollon, 2008).
In Figure 15-5, you can see that an antidepressant medication shows greater progress in reducing symptoms of depression at eight weeks of therapy as compared to CBT. Both medication and CBT are better than a placebo pill. It should also be noted that giving individuals with depression a placebo that is described as fast-acting will itself cause brain changes associated with a reduction in depression (Peciña et al., 2015). After 16 weeks of treatment, CBT and medication show equal effectiveness.
Figure 15-5 Cognitive behavioral therapy (CBT) and antidepressant medication (ADM) have comparable short-term effects.
Source: DeRubeis et al. (2008, p. 781).
With equal effectiveness of CBT and an antidepressant medication, what do you think would happen if they were both discontinued? What happened was that in both groups symptoms of depression began to reappear. However, there were fewer symptoms of depression in the CBT condition than in the drug condition. Thus, what was learned in CBT could continue to be effective although the therapy itself had been stopped. The medication on the other hand showed no lingering positive effects when it was no longer given. Other studies have shown that the combination of CBT with an antidepressant medication is more effective than either alone. Thus, although medication may initially be more effective for the treatment of depression, CBT shows more long-term effects. Of course, both together will give you the most effective treatment.
Thought Question: Write a brief explanation to give one of your friends if she asked you why a treatment for depression that combined medication and psychotherapy was more effective than providing either one alone.
Psychological Treatments for Depression
All of the three major psychological therapy approaches—dynamic, cognitive behavioral, and existential-humanistic—have empirically supported therapies for the treatment of depression. Emotion-focused therapy for depression, which is based on existential-humanistic techniques, has been shown to be useful for someone with mild to moderate depression (Greenberg & Watson, 2006). As noted previously, whereas the dynamic approach focuses on insight, the cognitive behavioral approach emphasizes the importance of action. That is to say, in dynamic approaches interpersonal difficulties are examined, with some focus on where thoughts and behaviors that did not work in the past came from. This often leads to discussion of early and significant relationships. Cognitive behavioral approaches, on the other hand, spend less time on past relationships and more on how to deal effectively with events in the future. The session itself is more of an educational process in which the client is helped to consider alternative explanations and learn how to cope. In CBT, there is little discussion of the relationship between the therapist and the client as there would be in dynamic approaches. Both approaches examine the manner in which individuals with depression distort and misperceive events in their lives. A number of studies have shown similar changes in depressive symptoms with either a dynamic or CBT approach (Goldfried et al., 1997; Shapiro et al., 1994).
Cognitive Therapy for Depression
Aaron Beck created a cognitive therapy for depression in the early 1960s (Beck, 1967; 2019; Beck & Alford, 2009; Hollon & Beck, 2013; see also Judith Beck, 2011, for an overview and update). The cognitive therapy model suggests that dysfunctional thinking and negative information processing maintain depression. Cognitive therapy for depression is structured and problem focused. By learning in therapy how to understand one’s thinking, it is possible to change the way one thinks as well as one’s emotional state and behaviors. Thus, the therapy process helps the individual with depression to evaluate the validity and utility of her thoughts. For example, if a person says, “It is all my fault,” or “No one will ever hire me,” the therapist would help the client consider ways to test these ideas empirically. Having a person fill out a log of her activities would help someone who says, “I never do anything,” determine the validity of the statement. The client might also be assigned homework to move beyond inertia and create potentially positive experiences.
The cognitive model is described in terms of a cognitive triad related to depression. The first component of the triad is the individual’s negative view of self. This is when the individual attributes unpleasant experiences to her own mental, physical, and moral defects. When something negative happens, the person says this is my fault. In therapy, clients can become aware of the content of their thinking. The second component is the individual’s tendency to interpret experiences in a negative manner. That is, the person tailors the facts to fit negative conclusions. The basic idea is that thinking influences emotion and behavior. The third component is that the person regards the future in a negative way. She envisions a life of only hardships and anticipates failure in all tasks. In therapy, the basic idea is that individuals can modify their cognitive and behavioral responses. Overall, the therapy is directed at the automatic thoughts in relation to catastrophizing—believing that nothing will work out; personalization—believing that everything relates to you; overgeneralization—believing that one event is how it always is; and dichotomous thinking—believing that things are either good or bad.
A number of researchers and clinicians have further developed the classic approaches of Aaron Beck and others. These cognitive behavioral treatments are referred to as “new wave” or “third wave” approaches (Cristea, Montgomery, Szamoskozi, & David, 2013; Hayes, 2004). These new wave approaches focus less on changing the contents of a person’s thoughts and more on the person’s relationship to them and how they influence the person’s functioning. The goals of these new wave therapies include creating flexibility and a willingness to experience one’s thoughts and emotions rather than avoiding them. It is assumed that this experiential avoidance lies at the heart of psychological difficulties. Some examples of these new wave treatment approaches are acceptance and commitment therapy (ACT) and mindfulness-based cognitive therapy (MBCT), which have been shown to be effective for the treatment of depression (Kuyken et al., 2016). In other studies, it has been suggested that mindfulness meditation works through the default mode network to help regulate emotional reactions (Barnhofer, Huntenburg, Lifshitz, Wild, Antonova, & Margulies, 2016).
Emotion-Focused Therapy for Depression
Emotion-focused therapy (EFT) for depression is an empirically supported therapy developed by Leslie Greenberg and his colleagues (Greenberg & Watson, 2006). EFT promotes the individual experiencing and processing emotional aspects of his experience. This may involve bringing past emotional experiences and memories into the present. As part of therapy, the client is able to identify his maladaptive emotions and understand emotional needs in the present. This, in turn, allows the person to discover new ways of satisfying his current needs.
In terms of depression, the treatment begins with the person experiencing the weak or bad sense of self, which lies at the core of depression. Often a sense of shame and fear is associated with this maladaptive sense of self. In EFT, the client must do more than just name the maladaptive sense of self. They must fully experience it so change can take place. The role of the therapist is to empathetically be with the person and help the person regulate these negative emotional states without the fear of being overwhelmed. Thus, EFT works on the level of emotionality rather than the cognitive level as seen in CBT, although they both emphasize the meaning a client gives to his or her experiences. Like dynamic therapy, EFT would also consider the relationship between the therapist and the client on an emotional level. Further, where CBT may be seen as helping the person develop a logic and intelligence for dealing with his thoughts, EFT seeks to develop emotional intelligence.
In their empirical research to study the efficacy of EFT (see Greenberg & Watson, 2006, for an overview), Greenberg and his colleagues found that it worked best in individuals with depression who were not completely immobile. The clients that it worked best with were those who were able to parent, work, or go to school, although all of these individuals reported difficulty and found little satisfaction in their activities. EFT emphasizes tailoring the therapy to the client since depression can manifest on a number of levels. Although all of the clients in the study were diagnosed with depression according to DSM, their depression symptoms differed. Some were highly critical and felt like failures while others had lost relationships and felt abandoned and sad. Still others felt empty, confused, and aimless. Their interpersonal relationships with the therapist also differed greatly. In testing the effects of EFT against other therapies, EFT was shown to be effective in reducing the symptoms of depression.
Psychodynamic Therapy for Depression
One important aspect of dynamic therapy is the search for insight. One focus would be an understanding of how the depressive symptoms developed. Do they relate to the experience of losses in one’s life? Do they relate to previous negative relationships, including critical parents who leave the child with little ability to accomplish life’s goals? Do they relate to confusions concerning one’s role in a job or relationship? Most short-term psychodynamic therapy would then focus on this theme.
In addition to past experiences, an additional focus would be on current relationships, including the relationship with the therapist. Like the Strupp and Binder (1984) approach, most psychodynamic approaches in relation to depression would begin with an understanding of the client’s behavior and relationships and how these contribute to the continuation of the depressive symptoms. Some common themes with depression include a feeling of being helpless and the dependent feeling associated with this, an overdeveloped sense of responsibility, and a feeling of anger for one’s situation, which becomes internalized.
The therapeutic relationship between the client and the therapist offers an opportunity to see disturbed relationships in a safe environment. Transference is an important mechanism in which the client tends to see the therapist in terms of significant others in his life. As the client talks with the therapist, he will replay prior conflicts and enact maladaptive patterns. For example, if one of his parents was very critical of his ideas, then he may initially find it difficult to tell the therapist feelings or thoughts that are very important to him or related to how he sees himself. Another situation would be one in which a parent never allowed him to engage in tasks that he could fail at or would save him whenever he encountered problems. These past situations would leave him with unrealistic expectations as to what to expect from the world and from others. In these situations, the person has never really learned what the world has to offer and may act as a child expecting someone to protect him and thus miss out on new experiences and learning. By understanding one’s life, it is possible to gain insight into how to avoid moving into old, unhealthy patterns in new situations, which would maintain depressive symptoms.
Medications for Depression
The first effective medications for depression were introduced in the 1950s and 1960s (Gitlin, 2009; Hantsoo & Mathews, 2019). Two of these were imipramine (Tofranil), a tri-cyclic antidepressant, and iproniazid (Marsilid, Rivivol, Euphozid, Iprazid, Ipronid, Ipronin), a monoamine oxidase (MAO) inhibitor. The term tricyclic refers to the three-ring chemical structure of the drug. MAO inhibitor refers to the focus of action at the synapse. One problem with these initial medications was side effects such as weight gain, sleep problems, and irregular cardiovascular functioning. Additionally, MAO inhibitors can interact with certain foods, such as cheese, that contain the amino acid tyramine to increase blood pressure to dangerous levels.
In the late 1980s, a second generation of medications was released with fewer side effects. One of the most well-known was fluoxetine (Prozac). Prozac became an instant hit and was given to a large number of individuals worldwide, although the popular press suggested it was overprescribed. One problem with Prozac is that it is connected with thoughts of suicide in those under 18 years of age. It has also been associated with less sexual desire and symptoms such as headache and joint pain. Prozac is one of a number of drugs referred to as selective serotonin reuptake inhibitors (SSRIs) because of their effects at the synapse. SSRIs prevent the presynaptic reuptake of serotonin, which in turn increases the level of serotonin at the synapse. Newer antidepressant medications alter the central nervous system by influencing serotonin or norepinephrine or both. These are referred to as SNRIs. It general, it takes more than four weeks for antidepressant medications to have an effect.
One faster acting medication for depression that is being researched is Ketamine (Andrade, 2017; Hirota & Lambert, 2018; Nemeroff, 2018). It is generally administered as a slow intravenous infusion, although in 2019 a nasal spray related to Ketamine was approved by the FDA, which also must be administered in a medical setting. With Ketamine, changes in depression are seen within hours but decrease after 3 to 12 days. It has also been shown to reduce suicidal tendencies in individuals with major depressive disorder.
Overall, the effectiveness of antidepressant medication is found to be about 50% in clinical trials with adults (Fava, 2003). There have been a number of concerns when antidepressant medication is used with children and adolescents. In particular, some studies have suggested, as noted above, a risk for increased suicide among adolescents on these medications (Bridge et al., 2007). In children, these drugs may interact with normal processes such as exercise to lead to problems. However, for millions of Americans, a range of antidepressant medications have provided significant relief from depression.
Treatment for Bipolar Disorder
Until the middle of the last century, there was no effective treatment for bipolar disorder. Even today, it remains a complex disorder to treat. The main treatment goals are to optimize function and minimize symptoms and to establish mood stability. There is no accepted treatment for bipolar disorder that does not involve some form of medication. Because its symptoms may vary from depression to mania and this occurs in an irregular manner, there are fewer medications available for bipolar disorder. Further, a large number of individuals with bipolar disorder report a history of being misdiagnosed. This is partly because it is difficult to diagnose bipolar disorder without a clear picture of its course. Young adults who first show the symptoms in college, for example, may experience the symptoms as part of their lifestyle. It is often during a treatment for a depressive episode when mania appears that it is realized that bipolar disorder is the correct diagnosis.
Even with treatment, as just noted, those individuals with bipolar disorder who live in a negative emotional environment are more likely to relapse. Further, some people with bipolar disorder will discontinue their medication on their own, which leads to relapse. They may discontinue the medication because they miss the “highs” they experienced during mania, or want a wider range of emotional experience. Thus, most professionals recommend a combination of medication and psychotherapy and other types of support including family involvement for those with bipolar disorder. The nature of the disorder and the various psychosocial factors experienced by the person with bipolar disorder make performing research on a single medication or psychotherapy difficult.
Psychological Treatments for Bipolar Disorder
Most psychological therapies that have been used with bipolar disorders focus on both an educational and a psychological perspective. Specifically, techniques related to stress reduction and ways to reduce negative interactions with others are emphasized. Additionally, the client is also taught about bipolar disorder, its symptoms, the manner in which it may occur over time, and the importance of the use of medication. Family members and significant others in the client’s life may also be involved in the education and stress-reduction aspects of therapy.
Monica Basco and John Rush (2005) have developed a 20-session CBT for use with individuals with bipolar disorder. The initial therapy sessions focus on the symptoms of bipolar disorder and the medications that are used to treat them. The next sessions focus on the client’s particular symptoms, how to systematically monitor them, and factors related to treatment compliance. Following this, sessions are devoted to understanding one’s cognitions including biased thinking and acting in both mania and depression. The final sessions emphasize an understanding of social relationships and ways to problem solve and resolve difficult situations.
Medications for Bipolar Disorder
It is important to keep in mind that there are different stages of treatment that require different processes (Goodwin & Jamison, 2007). These can be described as acute treatment, continuation treatment, and maintenance treatment. Acute treatment refers to the period from the beginning of a manic or depressive episode to remission of the symptoms. This period usually lasts from 6 to 12 weeks. Continuation treatment is the period from the remission of the symptoms to the time that they would not be expected to recur. This time has been determined from noting spontaneous recovery times in individuals who have not been treated. This period is about 6 months for a depressive episode and 4 months for a manic episode. Maintenance treatment is designed to prevent or reduce future episodes of mania and depression.
Psychopharmacological treatments for bipolar disorder involve a treatment for episodes of depression, a treatment for episodes of mania, and drugs to reduce relapse (Rosenblat & McIntyre, 2019; Thase & Denko, 2008). Lithium (Eskalith, Lithobid) is the most common treatment for bipolar disorder. Lithium is a salt found in nature. It was first used in the 1800s to treat mental disorders, although real interest in its use for the treatment of bipolar disorder began in the 1950s (Malhi, 2009). Lithium is more effective for the mania aspect of bipolar than the depressive aspect, and it is seen as a mood stabilizer. Although lithium has been used for a number of years, a major review suggested it is not as effective as commonly believed (Geddes, Burgess, Hawton, Jamison, & Goodwin, 2004). However, this review suggests its use is warranted in those individuals who respond to the drug. One group of individuals who do not respond to lithium are those who show rapid cycling.
Because lithium is not useful with certain groups, drugs referred to as anticonvulsants have been tried and shown to be effective such as lamotrigine (Lamictal). Another two of these anticonvulsants are sodium valproate (Depalote, Epival) and carbamazepine (Tegretol, Carbartol). Other classes of drugs such as antipsychotics have also been used in the treatment of bipolar disorder. One might think that antidepressants would work, but in some individuals these cause a switch to mania and rapid cycling.
Treatment for Dissociative Disorders
Although some dissociative disorders such as dissociative amnesia may resolve on their own, others such as dissociative identity disorder (DID) require long-term treatment. The basic procedure for treating DID is typically long-term psychotherapy. In therapy, a focus on the relationship between the client and the therapist is important. The emphasis is on developing a safe place where individuals can experience and integrate the various parts of themselves. At present, there are no empirically supported principles that have been tested in terms of dissociation. However, techniques from cognitive behavioral therapy (CBT), existential-humanistic, and dynamic approaches have been used in various combinations (see Ross, 1997). There are also no established medications directed solely for DID.
Treatment for Schizophrenia
Until about the 1960s, individuals with schizophrenia were placed in mental hospitals, often with little real treatment other than controlling them. With the advent of medications in the middle of the past century, it became possible for individuals with schizophrenia to live within community or home settings. In fact, individuals with schizophrenia tend to show more positive mental health behaviors when living within a community. In some cultures, small towns saw it as their duty to take care of these individuals. Today, after initial hospitalizations to gain control over symptoms, many individuals with schizophrenia return to their family. Other individuals continue their education or work. Some individuals are able to be productive and succeed in high-level jobs with appropriate support. However, some individuals with schizophrenia become homeless and are at the mercy of their community. In many communities, it becomes the role of the police and others to help protect these individuals.
Over the past 100 years, there has been a shift in viewing schizophrenia as a disorder with inevitable deterioration to one in which recovery is possible (see Frese, Knight, & Saks, 2009, for an overview). Recovery includes having a career. Living with schizophrenia depends on the resources of the individual in terms of intellectual abilities, coping techniques, and willingness to accept the advice of professionals.
Treatment for schizophrenia involves addressing the specific stage of the illness. These stages include the premorbid (before onset), prodromal (initial symptoms), first psychotic symptoms, a possible relapse even with treatment, and recovery. One major focus of treatment and research is the manner in which early intervention at each stage can reduce the severity of that stage. There are studies currently underway that are seeking to identify reliable indicators as to who will develop schizophrenia later in life (for example, Dixon, Goldman, Srihari, & Kane, 2018). However, at this point the research is not definitive. Thus, knowing with whom and how to intervene remains a future possibility, although a number of programs are testing this possibility. Once signs of schizophrenia develop, early intervention becomes important. With signs of a psychotic episode, antipsychotic medication and psychological treatments become important. Following this, supportive mechanisms such as family therapy and the creation of living and work conditions that help to reduce relapse are critical.
The Internet offers access to local and national groups that offer support for those with schizophrenia as well as the caregivers who offer support. In order to help individuals with schizophrenia cope in the community, a number of support procedures have been developed. These include antipsychotic medications as well as educational procedures to help the individual with schizophrenia and his or her family understand the course of the illness and the types of support necessary. As with other mental health disorders, specific psychotherapies for the person himself have been developed. Research suggests that the most effective treatment of schizophrenia should involve both medication and psychological approaches (Beck & Rector, 2005; Kane et al., 2015).
Psychological Interventions for Schizophrenia
Psychosocial factors play an important role in the overall treatment of individuals with schizophrenia. It has been estimated that more than 60% of people with a first episode of a major mental illness return to live with relatives. Thus, families play an important role in supporting these individuals. In fact, family interventions for schizophrenia reduce relapse and hospitalizations. A number of meta-analyses looked at evidence supporting family interventions (see Barrowclough & Lobban, 2008, for an overview). In general, family interventions involve the following key components:
1. Provide practical emotional support to family members.
2. Provide information about schizophrenia, what mental health services are available in the community, and nationwide support services (such as those found on the Internet).
3. Help the family develop a model of schizophrenia (including not blaming themselves).
4. Modify beliefs about schizophrenia that are unhelpful or inaccurate.
5. Increase coping for all family members.
6. Enhance problem-solving skills.
7. Enhance positive communications.
8. Involve everyone in a relapse-prevention plan.
A number of manuals involving cognitive behavioral therapy (CBT) approaches to schizophrenia are available (for example, Kingdon & Turkington, 1994; Smith, Nathan, Juniper, Kingsep, & Lim, 2003). The basic model suggests that what is important is the manner in which individuals interpret psychotic phenomena (see Beck & Rector, 2005; A. Morrison, 2008, for overviews). The overall model suggests that neurocognitive impairment in the premorbid state makes the individual vulnerable to difficulties in school or work, which lead to nonfunctional beliefs such as “I am inferior,” maladaptive cognitive appraisals, and in turn nonfunctional behavior such as social withdrawal (Beck & Rector, 2005). The cognitive approach is aimed at helping the client understand the psychotic experience as well as cope with the experience and reduce distress. One key feature of schizophrenia is the disruption of thought processes, and one part of the treatment is directed at these illogical associations. Another focus of the treatment is directed at interpersonal relationships and success at work. This approach may also involve skills training such as self-monitoring and activity scheduling. Since individuals with schizophrenia may also show mood and anxiety problems, CBT aimed at these processes can also be utilized. The key features of CBT for schizophrenia can be summarized as follows (Beck & Rector, 2005; Turkington, Kingdon, & Weiden, 2006):
1. Develop a therapeutic alliance based on the client’s perspective.
2. Understand the client’s interpretation of past and present events.
3. Develop alternative explanations of schizophrenia symptoms.
4. Normalize and reduce the impact of positive and negative symptoms.
5. Educate the client in terms of the role of stress.
6. Teach the client about the cognitive model, including the role between thoughts, feelings, and behaviors.
7. Offer alternatives to the medical model to address medication adherence.
Developing a therapeutic alliance, that is, a relationship between the therapist and client who helps the work of therapy, is an initial task of therapy. Part of this may include talking with the client about his delusional beliefs. For example, if a client says that he invented a machine to solve the world’s problems, then the therapist might ask when the person had this idea and what he has done to create the machine. The therapist might also ask him about others who had helped him with his ideas. As with CBT for other disorders, the basic idea is to look for inconsistent thoughts and conclusions that do not follow logically. For example, if no one would help the person with his machine, it does not follow logically that everyone is out to get him.
Another major task of therapy is helping the individual develop an alternative understanding of his or her symptoms. For example, some individuals with schizophrenia experience the voices that they hear as coming from outside of them. One goal of therapy would be to help the client reinterpret the source of the voices. Part of this may also include a cognitive assessment of alternatives to obeying the voices.
The role of stress in increasing symptoms of schizophrenia is an important concept for clients to understand. It is also important for them to understand the problems associated with not taking medication to control the symptoms of schizophrenia. Keeping individuals with schizophrenia on their medications is a difficult problem. In studies involving active medication alone versus a placebo alone, the relapse rates are about one half with medication compared with a placebo (32% versus 72%) (Hogarty & Goldberg, 1973). Based on current studies, treating individuals with schizophrenia with both CBT and psychotropic medication appears to be the most effective approach (see Beck & Rector, 2005, for outcome studies).
In the 1950s, George Brown in London, England sought to understand why some individuals with schizophrenia were readmitted soon after their hospital discharge with their symptoms reoccurring (see Brown, 1985 for an overview). What was found was that one important factor was the emotional environment in the home. This came to be referred to as expressed emotion. That is, homes in which the person experienced critical comments, hostility, and angry arguments were associated with relapse, whereas homes with warmth and positive remarks were not. Since that time, a number of intervention programs have been developed involving caregivers and others who live with those with schizophrenia (Amaresha & Venkatasubramanian, 2012).
A new approach is being tried in the treatment of schizophrenia—early intervention (see Fisher, Loewy, Hardy, Schlosser, & Vinogradov, 2013, for an overview). This approach seeks individuals who are at high risk for developing schizophrenia. The basic approach is to help these individuals develop cognitive skills as a way to increase attention, memory, executive control, and other cognitive processes. In addition, cognitive therapy is being used to reduce the reactivity to stress seen in the period prior to the development of psychosis and to better understand their thoughts and feelings. Although some success has been reported, this approach for the prevention of schizophrenia is still early in its development.
Another new approach referred to as NAVIGATE has been designed for the treatment of first-episode psychosis (Kane et al., 2015). NAVIGATE is a multidisciplinary, team-based approach that emphasizes low-dose antipsychotic medications, cognitive-behavioral psychotherapy, family education and support, and vocational and educational support. The program also helps the person engage in his or her community. One advantage of this approach is that the individual with first-episode psychosis receives all of these different treatment approaches. In a randomized control study involving 34 community mental health centers in 21 US states, the NAVIGATE program was shown to be more effective than the standard care found in the community health center. Further, the earlier the person entered treatment after the first psychotic episode, the better his or her outcome measures were. Based on these types of results, the National Institute of Mental Health has announced the Early Psychosis Intervention Network (EPINET) (http://www.nimh.nih.gov/ and search for EPINET).
Many professionals involved in the treatment of schizophrenia have come to realize that people are more likely to accept treatment and follow directions if they are involved in their own treatment. A number of states have coordinated treatment approaches such as NAVIGATE that use a multidisciplinary team as well as input from the person with schizophrenia. This is critical since many youths in the early stages of schizophrenia drop out of conventional medication-alone treatment.
A variety of medications have been used in the treatment of schizophrenia (see Gopalakrishna, Ithman, & Lauriello, 2016; Hyman & Cohen, 2013; Kutscher, 2008; Minzenberg, Yoon, & Carter, 2010; Serper & Wang, 2019, for overviews). The treatment of schizophrenia changed drastically in 1954 with the discovery of chlorpromazine (Thorazine). When effective, this drug reduces agitation, hostility, and aggression. It also reduces the positive symptoms such as hallucinations and delusions and increases the time between hospitalizations associated with schizophrenia. However, negative symptoms and cognitive deficits are not changed by the drug.
One problem of this and other initial drugs were side effects such as tardive dyskinesia, which is a movement disorder resulting in involuntary movement of the lower face and at times the limbs. These purposeless movements include sucking, smacking the lips, and making tongue movements. These and other movement side effects are difficult to reverse if the medication was given over a period of time. Weight gain is also seen with antipsychotic medications. In subsequent years, new and different classes of neuroleptic medications have been developed with different or fewer side effects (Gopalakrishna, Ithman, & Lauriello, 2016). These newer drugs tend to reduce the positive symptoms of schizophrenia such as hallucinations and delusions. They also help the individual think more clearly and remain calmer. Not all medications work for all individuals. There is also some suggestion that different ethnic groups respond differently to neuroleptics, although it is less clear whether it is genetic factors or diet that influences these differences.
Overall, medications for schizophrenia have been referred to as first-generation or second-generation antipsychotics. Second-generation antipsychotics are also known as atypical antipsychotics. First-generation antipsychotics influence dopamine receptors (D2), although the exact mechanism by which they work is still being studied. One example of a first-generation antipsychotic medication is haloperidol, which has a number of trade names worldwide, one being Haldol. Second-generation or atypical antipsychotic medications influence the dopamine receptors differently. Both first-and second-generation antipsychotics are successful in treating the positive symptoms seen in schizophrenia. One advantage of the second-generation antipsychotics is that they are also able to treat the negative symptoms. Initially, it was thought that the second-generation antipsychotics had fewer motor side effects, although this has not always been shown to be the case (Peluso, Lewis, Barnes, & Jones, 2012). In fact, large-scale studies suggest that second-generation drugs are no more effective than the older ones (Hyman & Cohen, 2013).
One large-scale study of effectiveness of antipsychotic medication was conducted at 57 clinical sites in the United States in the early 2000s involving almost 1,500 individuals with schizophrenia (see Lieberman & Stroup, 2011, for an overview and update). This is referred to as the CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) study. Individuals with schizophrenia were randomly assigned to one of five antipsychotic medications—olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), ziprasidone (Geodon) and perphenazine (Trilafon)—and followed for 18 months. One important aspect of the study was to compare first-and second-generation antipsychotic medications. One surprising result was that the second-generation medications did not show greater effectiveness than the first-generation medication, perphenazine. This included greater effectiveness in terms of negative symptoms and cognitive impairment. These results had implications not only for treatment effectiveness, but also for economic considerations since first-generation medications are less expensive. The CATIE study brought forth much controversy in the years following its publication (Lieberman & Stroup, 2011).
Treatment for Personality Disorders
Personality disorders are difficult to treat. This is in part related to the fact that one individual with a personality disorder may show different signs and symptoms than another. Additionally, individuals with personality disorders find it difficult to maintain a close intimate relationship with their therapist. Because of this, psychotherapy for personality disorders is more individual focused than that for other disorders. At this point, research studies have shown that treatments based on both cognitive behavioral and dynamic perspectives have been effective. Medications have not been used as a direct treatment, but only as an adjunct (Bateman, Gunderson, & Mulder, 2015).
Although psychosocial treatment approaches come from different traditions, the effective approaches show many common factors (Bateman, Gunderson, & Mulder, 2015; Cuijers, Reijnders, & Huibers, 2019). Borderline personality disorder (BPD) has been the focus of most empirical treatment studies. The common factors seen in the treatment of BPD are:
1. A structured manualized approach is used that focuses on the commonly seen problems.
2. Clients are encouraged to assume control of themselves.
3. The therapist helps the clients to understand the connections of their feelings to events and actions. The therapist helps the client to consider the situation rather than just experiencing anxiety.
4. Therapists are active, responsive, and validating.
5. Therapists are willing to discuss their own reactions in the therapy session. For example, the therapist might say, “I misunderstood.”
Let us now discuss specific treatment approaches.
Dialectical Behavior Therapy
One of the first researched treatment approaches for BPD is dialectical behavior therapy (DBT). DBT was developed by Marsha Linehan, based on her work with suicidal clients and then expanded to those with BPD (Linehan, 1993; Linehan & Dexter-Mazza, 2008). Numerous studies have shown DBT to be effective in reducing suicide and increasing positive changes. This is especially true when a group skills training component is included (Linehan et al., 2015).
DBT therapy begins with the acceptance of the fact that individuals with BPD experience extreme emotional reactions and are particularly sensitive to changes in the environment. Anger toward the therapist is not uncommon. Individuals with BPD take longer to return to baseline conditions after their emotional reactivity. They may be impulsive. Suicidal considerations are common. This makes these clients difficult to work with and therapy sessions are often very challenging.
DBT is described by Marsha Linehan and her colleagues as a blend of behavioral science, dialectical philosophy, and Zen practice. The cornerstone of DBT is based on problem solving and acceptance of the experience of the moment. That is, the therapist acknowledges and accepts that a person felt rejected at the moment but not that the response to the rejection would be to hurt herself. The therapy itself is conceptualized in terms of a number of stages.
The pretreatment stage is a time when the client and the therapist arrive at a mutually informed decision to work together. This includes an understanding of the person’s history and decisions concerning which processes should receive high priority. This pre-treatment stage also includes a discussion concerning what can reasonably be expected from therapy and the roles of the therapist and the client. One emphasis is on the therapist and the client as a team, whose goal it is to help the client create a life worth living. In the service of creating a productive life, the individual will develop problem-solving skills for her own life.
The first stage of therapy is directed at helping the client develop a stable life. This includes reducing suicide-related behaviors and other behaviors that interfere with therapy and life. This stage typically lasts for one year. During this stage, dialectical thinking encourages clients to see reality as complex and not something that can be reduced to a single idea. This includes developing the ability to experience thoughts and feelings, which are experienced as contradictory. This is a difficult task for those with BPD. Four specific goals of Stage 1 include reducing suicidal ideation, reducing behavior that interferes with therapy, achieving a stable lifestyle, and developing skills in emotional regulation such as mindfulness. Stage 1 has been most researched in terms of empirically supported procedures.
The second stage of therapy moves to processing previously experienced traumatic events. One approach is to have the person re-experience prior trauma inside the therapy session. This stage can only occur once the person’s life is stable and her emotional responding is under her control. The four specific goals of this stage include remembering and accepting the facts of earlier trauma, reducing any self-blame involving the earlier trauma, reducing the intrusive material associated with the earlier trauma as well as any denial associated with it, and resolving dialectical tensions associated with blame for the trauma.
The third stage of therapy is directed at helping the person develop a sense of self that allows her to live independently. The goal is to help the person experience both happiness and unhappiness with the ability to trust in her experiences. The fourth and final stage of therapy focuses on the ability to sustain joy and be part of an ever-changing world.
Other Effective Therapies for Treating Borderline Personality Disorder
In addition to DBT, there are also a number of dynamic-oriented therapies that are empirically supported. One of these is dynamic deconstructive psychotherapy (DDP). DDP was developed for clients who find therapy difficult, as well as for those who may also have substance abuse problems (Gregory & Remen, 2008). This approach is partly based on neuroscience research, which shows that individuals with BPD show difficulties with memory, emotional regulation, and decision making. This is seen as preventing these individuals from building a coherent self-system independent of other people. DDP is designed to help individuals with BPD develop a coherent sense of self.
DDP is divided into four distinct stages. The first stage is for the client and the therapist together to identify the client’s difficulties and establish a series of goals and tasks for working on these difficulties. They also create an agreement as to how the client will keep himself safe. By the end of this stage, the relationship between the therapist and client should be stable and give the client comfort. This stage is similar in both dynamic and cognitive behavioral approaches.
The second stage involves the development of the client’s ability to maintain complex ideas related to his relationships with others. For example, when a relationship with another ended, he would be able to say, “I felt both horrified and relieved.” As this stage ends, the client begins to give up an idealized image of himself. As his idealized image of himself and his abilities is given up, there can be a better understanding of self-limitations, which is the focus of the third stage. During this third stage, the client can learn to verbalize his or her disappointments and experience the loss associated with this. This can also lead to fears of personal incompetence. The fourth and final stage moves to the relationship between the client and therapist and how the person will experience the termination of therapy.
Another empirically supported therapy is transference-focused psychotherapy (TFP). This is a twice-weekly therapy based on Otto Kernberg’s object relations model (Clarkin, Yeomans, & Kernberg, 2006; see also Levy & Scala, 2012). As with other approaches, TFP seeks to reduce symptoms of BPD, especially self-destructive behaviors. The technique involves an exploration of how the person views herself and may combine her identity with that of another. That is, she does not have a stable view of self. During the first year of treatment, behaviors involved with self-harm are limited and a therapy contract is developed. In the sessions, the therapist follows the affect that the client brings to the session. The emphasis is on the relationship between the client and therapist. Questions of whether this relationship can also be seen in the client’s other relationships can be addressed. Many of these techniques are similar to those of Hans Strupp described previously.
Treatment of Other Personality Disorders
Most of our knowledge of the treatment of personality disorders other than BPD is based on the experience of health care professionals, case studies, or simple descriptions of treatments. These include treatment approaches described in terms of borderline personality disorder. The individuals with other personality disorders about whom we have information present problems with their self and in their behavior toward—or relationships with—others in a number of different ways. This requires the mental health professional to pay attention to the specific way in which an individual is interacting with his or her world. Thus, manualized, empirically validated treatments for disorders other than BPD are less available.
Treatment for Neurodevelopment Disorders
As noted in the last chapter, neurodevelopmental disorders are those disorders that begin early in a child’s life. These can include problems in the development of language, cognitive, emotional, and motor problems. Much of the treatment of these disorders takes place in the school that the child attends. In addition to programs in the school, both psychological treatments and medications have been used with two of these disorders, which are autism spectrum disorder and attention deficit hyperactivity disorder (ADHD).
Treatment for Autism Spectrum Disorder
Since autism spectrum disorder appears early in a child’s life, parents turn to a number of different professionals for help. Depending on the initial problems of development noted, these professionals can include kindergarten teachers, special education teachers, speech pathologists, child clinical psychologists and psychiatrists, and pediatricians.
The first empirically supported treatments were developed by Lovaas and his colleagues in the 1960s (Lovaas & Smith, 2003). This approach, which was based on behavioral principles, was referred to as the UCLA Young Autism Project. This project has reported about 50% “recovery” rates for young children with autism, and these principles have been supported in other studies (Rogers & Vismara, 2008). Besides the success with individual children, this approach helped the field to understand that children with autism can learn important new skills.
The UCLA Project accepts children with autism under 4 years of age with the average age being 2 years 10 months. These children also need not to show major medical problems such as hearing or vision loss. These children then receive 40 hours a week of one-to-one interventions. This treatment lasts for about three years, depending on the individual child. Based on behavioral principles, the treatment was designed to maximize positive outcomes and reduce failure experiences. This includes giving the child short and clear instructions and immediate reinforcement for each correct response. Parents are also an important part of the process.
There are five major stages of treatment in the Lovaas treatment program. The first is establishing a teaching relationship, which lasts from two to four weeks. Since many of these children have previously avoided situations through tantrums and other means, the therapist works with the child in following simple directions. The second stage, which lasts from one to four months, involves teaching foundational skills related to following directions, imitating behaviors, and identifying objects. The third stage lasts for about six months and focuses on beginning communication. This includes initial speech processes and identifying objects and actions. The fourth stage, which lasts for about a year, continues communication processes such as labeling colors and shapes and developing the basic concepts of language. The fifth stage, which also lasts about a year, is designed to continue communication processes and help the child adjust to school situations, including peer interactions. The program ends as the child becomes part of a school situation.
In addition to psychosocial treatment approaches, medications have been used to address specific disruptive behaviors seen in ASD. These behaviors include hyperactivity, inattention, repetitive thoughts and behaviors, and aggressive behaviors against others and the self. Medications include antidepressants, stimulants, and antipsychotic medications. These medications are typically given to older rather than younger children with ASD. Those randomized control trials that do exist suggest improvement in irritability and hyperactivity resulting from a number of different medications (Friedman, Politte, Nowinski, & McDougle, 2015). At this point, there are no US Food and Drug Administration (FDA) approved drugs that have demonstrated significant changes in the core autism spectrum symptoms (Matson & Burns, 2019).
Treatment for ADHD
The major treatment for ADHD is medications that are stimulants. The benefit of stimulants for this purpose was found by accident in the last century. Although initially given to children as a treatment for headaches following an invasive brain X-ray technique, the stimulant amphetamine was also shown to help the children in the hospital to be calmer and more organized in their thinking (Adler et al., 2015). Although it may seem paradoxical to give a stimulant to a person who is hyperactive, these medications have been shown to be effective (Bidwell, McClernon, & Kolins, 2011; Fredriksen, Halmøy, Faraone, & Haavik, 2013). Stimulants appear to improve functioning by changing neurotransmitters in the brain.
The most common medications used in ADHD treatment are methylphenidates, which include the trade name Ritalin, and amphetamines including dextroamphetamine, which are known as Adderall and Dexedrine. These drugs reduce the symptoms of ADHD, such as disruptive and noncompliant behavior. They also increase the ability to focus attention. These medications may also improve physical coordination. It has been estimated that 70% of children with ADHD will show symptom reduction with stimulant medications.
Psychosocial methods are also used for the treatment of ADHD. These are often used in combination with medication, with the best treatment results seen with a combination of both (Hoza, Kaiser, & Hurt, 2008; Newcorn, Ivanov, & Chacko, 2015). Reviews of the treatment literature show that psychosocial interventions can have a positive impact beyond that of the medication alone (Watson, Richels, Michalek, & Raymer, 2015). With older adolescents and adults, psychological therapies may be useful in allowing the person to talk about the experience of having ADHD and to create cognitive and behavioral strategies for managing his or her environment. For example, reducing distraction allows the person to function more effectively.
1. What is the importance of the concept of empirically based treatments or empirically based principles to the treatment of mental disorders?
2. What medications and psychological therapies are recommended for treating generalized anxiety disorder (GAD)? What aspects of GAD does each type of treatment target?
3. What do we know about how specific phobias are treated?
4. What medication and psychological approaches are available for the treatment of panic disorders? Is there one approach that is the most effective?
5. If a friend or family member asked you for a recommendation of the best treatment for OCD, what would you include in your answer?
6. Currently, what are the primary classes of antidepressant medications? How does each work? What are the advantages and disadvantages of each?
7. All of the three psychological therapy approaches—cognitive behavioral, existential-humanistic, and dynamic—described previously have empirically supported therapies for the treatment of depression. Considering each of these approaches, what is the primary focus of the therapy in regard to depression and what course does the therapy typically follow in providing an effective treatment?
8. What is currently available for the assessment and treatment of individuals with dissociative disorders?
9. What are three critical shifts in the past 60 years that have transformed the treatment of schizophrenia from one that was institution-based to one that is community-based?
10. A variety of classes of medications have been used in the treatment of schizophrenia. What are they, and what are the advantages and disadvantages of each?
11. What is it about personality disorders that makes them difficult to treat? What factors do effective treatments have in common to address those difficulties?
12. What are the major treatments for autism spectrum disorder and ADHD?
Learning Objective 1: Discuss the history of psychopathology and its treatments.
Although the Greek and Roman periods saw individuals who attempted to understand psychopathology in a more humane way, this disappeared as their civilizations declined. As the Middle Ages approached, disease and especially mental illness was seen from the standpoint of a religious perspective with the devil being a major player. In 1330, a convent of the order of St. Mary of Bethlehem became the first institution for the mentally ill in England. Two hundred years later, King Henry VIII gave the institution a royal charter.
In the 1800s, there was a campaign in England to change the conditions of the patients, which led to the establishment of the Committee on Madhouses in 1815. This issued in a period of concern for the patients rather than seeing them as objects of curiosity as in the previous century. Treatment for patients during the 1800s brought new practices, including the therapeutic value of work. During this period, there was a spirit throughout the world to adopt a “moral treatment of the insane.” Three important individuals were Benjamin Rush (1745—1813) in the United States, Philippe Pinel (1745—1826) in France, and Vincenzo Chiarugi (1759—1820) in Italy. In the United States, Rush, who had signed the Declaration of Independence, is often seen as the father of American psychiatry and saw mental illness as a problem of the mind.
William Tuke (1732—1822) was a Quaker philanthropist. In 1796, near York, England, he created a Retreat for Persons Afflicted with Disorders of the Mind. This Quaker retreat carried with it the idea that the individuals who were there should be given respect as well as good food and exercise. Another individual who contributed to the American mental health movement was Dorothea Dix (1802—1887). She encouraged the American congress to give federal land to the states to establish mental hospitals in the same way they created land grant colleges in the 1860s. Although this bill was not passed, it is estimated that her work led to the establishment of some 40 mental hospitals in the US and Europe.
Learning Objective 2: Describe the psychological treatment perspectives for the treatment of mental disorders.
There are three approaches for the psychological treatment of mental disorders: psychodynamic approach, existential-humanistic approach, and the cognitive behavioral approach.
The psychodynamic perspective is based on the idea that psychological problems are manifestations of inner mental conflicts and that conscious awareness of those conflicts is a key to recovery. Historically, Sigmund Freud laid the foundation for this perspective. By the beginning of the 20th century, there was an understanding that psychological processes were an important source of information concerning mental illness. Psychodynamic therapy is based on Freud’s ideas and psychoanalysis was the first psychodynamic therapy to develop. Psychoanalysis treatment was based on the search for ideas and emotions that are in conflict and the manner in which an individual has relationships with other people. His specific treatment came to be called psychoanalysis.
The existential-humanistic perspective focuses on three themes: The first is an emphasis on human growth and the need for a positive psychology that moves beyond the discussion of stress and neurosis seen in the psychodynamic approaches. A second emphasis is that psychological health is more than just the absence of pathology. Not having a problem is not the same as finding meaning in one’s life. The third theme stresses the importance of not only considering the external world and a person’s relationship to it but also the internal world.
With the emphasis on experience, one well-known humanistic therapy is client-centered therapy.
Carl Rogers brought the humanistic movement to the forefront by creating client-centered therapy, also referred to as person-centered therapy. He was also one of the first psychologists to record therapy sessions so that they could be used for research. Rogers emphasized the relationship between the therapist and client as a critical key to effective therapy. There are three key characteristics of the client-centered approach: (1) empathic understanding, (2) unconditional positive regard, and (3) for the therapist to show genuineness and congruence.
The cognitive behavioral movement seeks to understand how cognitions are disordered or disrupted in mental disorders. Whereas humanistic therapies emphasize emotional processing, cognitive behavioral approaches emphasize thoughts and the manner in which a person thinks about her life and experiences. The basic idea is that psychological disturbances often involve errors in thinking. One real value of many cognitive behavioral approaches is that they have been tested empirically and presented in books and manuals that describe the steps involved in therapy. Cognitive behavioral therapy (CBT) has been developed for a variety of disorders. Overall, behavioral therapy focused on changing behaviors through conditioning principles, whereas cognitive behavioral therapy examined the manner in which thoughts influence behaviors. The behavioral perspective, as the name implies, has focused on the level of actions and behaviors.
Learning Objective 3: Summarize the biological approaches to treating mental disorders.
Medication plays an important role in the treatment of mental illness. In addition to medication, there are other treatment approaches that seek to directly change the physiological processes. These treatments range from the widespread prescribing of drugs to deal with psychological disorders to the less-often used but significant measures involving shock or electrical stimulation of the brain to the rarer use of neurosurgery.
Psychotropic Medications. Drugs that came to be called antidepressants for the treatment of depression such as monoamine oxidase inhibitors (MAOIs) and the tricyclic anti-depressants (TCAs) were discovered by serendipity in the 1950s. SSRIs (selective serotonin re-uptake inhibitors) such as Prozac were developed later. These are typically used for the treatment of mood disorders. Benzodiazepines such as Valium have been used for the treatment of anxiety for at least 50 years. One significant event came in 1952 when a French naval surgeon was attempting to find medications to give before an operation to reduce stress. What he discovered was that an antihistamine substance, called chlorpromazine, left individuals feeling indifferent about their operation. Noticing its calming effect, he suggested that this might be useful in treatment of mental disorders. In particular, it was discovered that chlorpromazine (Thorazine) helped to reduce the symptoms of schizophrenia and became an important antipsychotic medication.
Electroconvulsive Therapy. Other current treatment approaches seek to influence the individual’s brain by changing the underlying electrical activity. Some of these treatments are seen as noninvasive. That is, there is no requirement that electrodes or other devices be placed inside the brain itself. The oldest of these techniques is electroconvulsive therapy (ECT) in which electrical activity disrupts the normal brain activity and produces convulsions. This electrical activity triggers a brief seizure of less than a minute, which most likely influences changes in brain chemistry and specific networks of the cortex. ECT has changed over the years with a reduction in motor convulsions and a reduction in the number of brain areas affected. It is seen as an effective treatment for those with severe depression that does not respond to other types of medication or psychotherapy.
Brain Stimulation. An alternative to ECT, referred to as transcranial magnetic stimulation (TMS), disrupts the brain activity using magnetic stimulation to treat mental disorders, including depression. It has been known for a long time that electromagnetic activity can induce electrical changes in various materials.
Learning Objective 4: Summarize the effective treatment options for mental disorders.
Anxiety is a common experience of many individuals that they may report to many types of health professionals. These individuals are often given medications such as benzodiazepines or offered one of the types of psychotherapy described previously. Studies using psycho-dynamic, existential-humanistic, and cognitive behavioral approaches have all reported reductions in anxiety. At this point, both medications and psychological treatments show similar reductions in generalized anxiety disorder (GAD) in the short term.
Social Anxiety Disorder. There are a number of psychological therapies that have been developed for treating social anxiety disorder (SAD). These therapies include CBT, exposure therapy, social skills training, and group CBT. These different approaches may also be combined in different ways. Both CBT-type therapies and medication have been shown to be effective with SAD. CBT-type therapies show larger changes with fewer side effects than medications. Medications appear to show a faster reduction in anxiety initially. However, following treatment when no additional medication or psychotherapy is offered, there is a greater relapse with medication treatment than with CBT therapy.
Specific Phobias. It is commonly accepted that phobias are best treated by exposure to the feared object. Lars Öst has shown in a number of studies that a phobia such as fear of snakes or spiders can be significantly reduced after a single three-hour session, although similar results are found in a larger number of shorter sessions. During the session, the therapist would bring the feared object closer to the person until she was able to touch it with reduced fear.
Panic Disorder. The currently preferred medication treatments for panic disorder are SSRIs, which have been shown to be more effective than placebo treatments. Benzodiazepines have also been shown to be effective. The best-studied psychological treatment for panic disorder is CBT, which has been shown to be effective.
Obsessive-Compulsive Disorder. Both psychopharmacological and behavioral therapies have been shown to be effective for OCD. The most common medications are SSRIs and the tricyclic antidepressant clomipramine.
Depression. Both medication and a number of different psychological approaches have been shown to be effective. Additionally, the combination of both is also very effective.
Bipolar Disorder. The main treatment goals are to optimize function and minimize symptoms and to establish mood stability. There is no accepted treatment for bipolar disorder that does not involve some form of medication. Because its symptoms may vary from depression to mania and this occurs in an irregular manner, there are fewer medications available for bipolar disorder. Most professionals recommend a combination of medication and psychotherapy and other types of support, including family involvement, for those with bipolar disorder.
Dissociative Disorders. Although some dissociative disorders such as dissociative amnesia may resolve on their own, others such as dissociative identity disorder (DID) require long-term treatment. The basic procedure for treating DID is typically long-term psychotherapy. In therapy, a focus on the relationship between the client and the therapist is important. Cognitive behavioral therapy (CBT), existential-humanistic, and dynamic approaches have been used in various combinations.
Schizophrenia. Until about the 1960s, individuals with schizophrenia were placed in mental hospitals, often with little real treatment other than controlling them. With the advent of medications in the middle of the past century, it became possible for individuals with schizophrenia to live within community or home settings. In fact, individuals with schizophrenia tend to show more positive mental health behaviors when living within a community. Today, after initial hospitalizations to gain control over symptoms, many individuals with schizophrenia return to their family. Other individuals continue their education or work. Some individuals are able to be productive and succeed in high-level jobs with appropriate support. However, some individuals with schizophrenia become homeless and are at the mercy of their community. In many communities, it becomes the role of the police and others to help protect these individuals.
Personality Disorders. Personality disorders are difficult to treat. This is in part related to the fact that one individual with a personality disorder may show different signs and symptoms than another. Additionally, individuals with personality disorders find it difficult to maintain a close intimate relationship with their therapist. Because of this, psychotherapy for personality disorders is more individual focused than that for other disorders. At this point, research studies have shown that treatments based on both cognitive behavioral and dynamic perspectives have been effective. Medications have not been used as a direct treatment, but only as an adjunct.
1. “During the current historical period, we have also come to see those with mental illness as whole people with both abilities and difficulties.” How does viewing mental illness from the perspective of the individual change our views of appropriate treatment?
2. This chapter introduced three primary psychological treatment perspectives—dynamic, existential-humanistic, and behavioral and cognitive behavioral. For each perspective, describe:
a. Its historical understanding
b. Its broad principles
c. Examples of specific treatments that have been tested in a scientific manner
3. Many current therapy approaches represent an integration of the three primary psychological treatment perspectives—dynamic, existential-humanistic, and behavioral and cognitive behavioral—as well as from other perspectives. Describe two examples that illustrate this integration, including the perspectives from which it draws.
4. What are the respective roles of therapist and client in each of these treatment approaches based on the three primary psychological treatment perspectives—dynamic, existential-humanistic, and behavioral and cognitive behavioral:
a. Psychoanalysis, the dynamic treatment approach developed by Sigmund Freud?
b. The dynamic treatment approach developed by Hans Strupp and colleagues?
c. Client-centered or person-centered therapy, an existential-humanistic treatment approach developed by Carl Rogers?
d. Emotion-focused or process experiential therapy, a humanistic-experiential treatment approach developed by Leslie Greenberg and colleagues?
e. Cognitive triad for depression model, a cognitive behavioral approach developed by Aaron Beck?
5. In what ways are generalized anxiety disorder (GAD), social anxiety disorder (SAD), specific phobias, and panic disorder similar in terms of their treatment? How are they different?
6. What are three examples of effective treatment approaches for borderline personality disorder (BPD)? What is the overall approach of each therapy as well as the goals for each of the therapy’s stages? How are the therapies similar, and how are they different?
7. Construct a table that lists all of the specific disorders included in this chapter on treatment of mental disorders. For each disorder, make a column for its empirically supported biological and medication treatments and psychological treatments.
b. What are two or three insights on the current state of treatment for psychological disorders that this analysis gives you?
✵ Elyn Saks—https://www.ted.com/talks/elyn_saks_seeing_mental_illness
✵ Deep brain treatment of OCD—https://www.npr.org/2019/03/28/707639854/the-remote-control-brain
✵ Treatment APA—https://div12.org/psychological-treatments/
✵ SAMHSA substance abuse interventions—https://www.samhsa.gov/find-treatment
✵ Effective treatments for children and adolescents—http://effectivechildtherapy.com/
✵ Early Psychosis Intervention Network (EPINET)—https://www.nimh.nih.gov/index.shtml
Key Terms and Concepts
client-centered therapy or person-centered therapy
cognitive behavioral perspective
cognitive behavioral therapy (CBT)
deep brain stimulation (DBS)
electroconvulsive therapy (ECT)
emotion-focused therapy (ETF)
empirically based treatments or empirically based principles
process experiential therapy
transcranial magnetic stimulation (TMS)