Introduction to Psychology: Australian Edition
Introduction to Psychology: Australian Edition

Introduction to Psychology: Australian Edition

Lead Author(s): Meaghan Altman, Dawn Darlaston-Jones, Maddie Boe, Pat Dudgeon

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Introduction to Psychology: Australian Edition presents material such as methods, memory and states of consciousness in an engaging way. As a result, students will be able to understand and synthesise the content better. This book is written with the principles that underlie learning and memory - the goal is to provide an exciting experience for students to help them retain information in the long term. The Australian edition features newly developed Indigenous Content and has been edited by our team of Australian editors.

Chapter 15: Treatment of Psychological Disorders

Figure 15.1: The treatment of psychological disorders is complex and there are multiple approaches. [1]

​15.1 Introduction to Treatment of Psychological Disorders

Many people define psychology as the practice of ‘helping people.’ Now that you have reached the final chapter of Introduction to Psychology, you know that the field of psychology is so much more complex than that. However, helping people is still an important and admirable goal. There are many ways to help people manage psychological disorders, and in this chapter, we will group this variety of strategies under the term treatment.

One practicing mental health professional describes her desire to treat psychological disorders:

Before becoming a counselling psychologist, I knew that I wanted to “help people” through being a “therapist.” Most of how I knew that was based on unrealistic perspectives of abnormal psychology and therapy. For example, I watched movies and television shows that depicted different patient-therapist scenarios. Some were more directive, some were less than ethical, and few were accurate to what I know therapy to be today.

The treatment of psychological disorders is complicated, and as the counselling psychologist suggests above, ideas about what treatment actually is are often off-base. For example, popular culture tends to portray psychological treatment in misleading ways:

TV’s Dr. Phil (who is actually trained as a psychologist) tends to lecture and offer instant answers to guests on his show. Other TV shows like Hoarders and Intervention, which feature actual mental health professionals, also depict treatment in a ‘quick-fix’ light. In reality, however, therapy takes longer than one 60-minute session, and patients are often guided to be reflective and introspective in order to find their own answers.

In the movie Analyze This, a psychiatrist becomes intimately involved in a patient’s life, even interrupting his own wedding to have a session. In Prince of Tides, the psychiatrist enters into a romantic and sexual relationship with the brother of her patient. In reality, therapists maintain professional boundaries which often include interaction only during scheduled appointments. Of course, exceptions may be made for crisis situations. Mental health providers also abide by ethics codes which strictly prohibit sexual relationships with patients. 

Figure 15.2: Even though the relationship between mental health provider and patient may seem personal, it is actually a professional relationship. [2]

​These media portrayals can give the wrong idea about what to expect from treatment or may even make individuals fearful of seeking out mental health care. Popular culture also tends to oversimplify the treatment of psychological disorders. Mental health professionals have obtained specialised training and must engage in ongoing learning (i.e., continuing education), which differentiates treatment from talking to a good friend or seeking advice from a family member. Mental health treatment requires objectivity, which is more difficult to provide when a clinician has a personal connection to someone. Furthermore, treatment providers are regulated by Psychologists Registration Board (PsyBA) under the auspices of the Australian Health Practitioner Regulation Agency (AHPRA) to ensure ethical practices and to protect consumers.

15.1.1 What Counts as Treatment?

It is important to define what actually counts as treatment. When discussing treatment of psychological disorders, the term therapy will inevitably be brought up. Therapy literally means to cure or heal, and in a broader sense, to reduce distress and improve individuals’ ability to function in daily life. Therapy is not limited to addressing mental health concerns. For example, physical therapy helps people to improve the movement of their bodies and speech therapy addresses communication difficulties. However, when included as the root word of pharmacotherapy or psychotherapy, the connection to medication or psychological treatment, respectively, becomes clearer.

Pharmacotherapy involves prescription and management of medication, and more specifically, psychopharmacotherapy is the administration of psychotropic medications to treat psychological disorders. It is important to note that psychopharmacotherapy alone may not be sufficient for treating psychological disorders. Psychotherapy, commonly referred to as talk therapy, employs a variety of psychological techniques to help individuals identify and change troublesome thoughts, feelings, or behaviours (National Institute of Mental Health, 2016). Psychotherapy also aims to improve relationships, social skills, and overall wellbeing as well as promote personal growth (Frank, 1985; Wolberg, 1967). A common misconception is that psychotherapy only involves talking. However, psychotherapists use a variety of other techniques, including relaxation exercises, role-play simulations, and homework assignments.

Figure 15.3: Psychopharmacotheray can play an important role in the treatment and maintenance of psychological disorders, but are often insufficient for treatment without psychotherapy. [3]

​15.1.2 Who Provides Treatment?

The treatment of psychological disorders is not one-size-fits-all. Rather, treatment comes in many different forms. Mental health providers work with individuals, families, and groups in a number of settings, including hospitals, community mental health clinics, private practices, and schools. What follows are some of the mental health professionals who may provide psychological treatment:

Psychiatrists are medical doctors who have specialised in the assessment and treatment of psychological disorders. As physicians, psychiatrists pay special attention to how physical conditions affect mental health, and often prescribe medications to address mental health concerns. Although they are trained to provide psychotherapy (i.e., talk therapy), many psychiatrists prescribe and manage medications and refer to other mental health providers for psychotherapy. Psychiatric nurse practitioners are nurses with advanced training and education (i.e., master’s or doctorate degree) who,  are able to prescribe and manage psychiatric medications.

Psychologists have a doctoral degree (Ph.D. or Psy.D.) in psychology and are qualified to diagnose and treat disorders of behaviour, emotion, and thought. Psychologists are ‘scientist-practitioners’, meaning that that they are trained to conduct and consume research as well as provide psychotherapy.  In Australia there are nine specialisations of psychology: Counselling, Clinical, Community, Health, Sport, Organisational,  Neuro-clinical and Forensic. Each specialised field requires advanced training at Master's and/or Doctoral level. Community psychologists are focused on supporting individuals while simultaneously identifying and shifting structural barriers that have caused them psychological distress. They have a strong sense of human rights and social justice underpinning their practice and often work with marginalised persons and groups. Sport psychologists often work with athletes and support the multiple demands faced by individuals in elite roles (dancers, tennis players, etc.). They also emphasise that wellbeing for persons and groups can often be derived from engagement in some form of sporting activity. Clinical psychologists have advanced training in identifying and treating serious mental health issues, and finally, counselling psychologists tend to work with those individuals who currently find it difficult to cope with and adjust to life crises and stressors. 

Therapist/psychotherapist is a broad term that can describe a number of practitioners, not all of whom have completed advanced (or in some cases any) training in mental health. It is critical to ensure that the practitioner you consult is registered with AHPRA and their specific registration board. If you cannot find the practitioner listed in either of these registries, it means that they are not licensed to practice or to call themselves by those specialised descriptors.    

Question 15.01

Zahara and Nia are twins, and both treat psychological disorders. Zahara received her M.D. and often prescribes medications while Nia received a Ph.D. and practices therapy. It is most likely that:

A

Zahara is a clinical psychologist and Nia is a psychiatrist.

B

Zahara is a psychiatrist and Nia is a social worker.

C

Zahara is a psychiatrist and Nia is a psychologist.

D

Zahara is a psychologist and Nia is a therapist.

Question 15.02

Eliza is a community psychologist who spend her time:

A

Working with local communities to provide support to individuals and providing access to resources offered by other agencies

B

Prescribing medications to individuals with psychological problems.

C

Diagnosing abnormal behaviour.

D

Collaborating with teachers to help teenagers cope with the demands of school.

15.1.3 History of Mental Health Treatment

The treatment of psychological disorders has a complicated and controversial history that continues to the present day. This history has a lot to do with how people have understood psychological disorders over time and is helpful for understanding the variety of treatment options currently available today.

For much of history, mental illness or ‘madness’ was explained by witchcraft and deals made with the devil (Szasz, 1960). When individuals were accused of being under the influence of witchcraft or some other evil influence, they were often hanged or burned at the stake (Fabrega, 1991). Another widespread explanation of mental illness was possession by evil spirits, and treatment often aimed to cure the patient by releasing the demons. Prayers, incantations, and even exorcism were common methods to treat madness, and in extreme cases, some individuals underwent trepanation. Dating back to 5000 BCE, this method entailed drilling holes into an individual’s skull in order to release the demons that were causing mental illness. Even though trepanation was considered a treatment, most people died as a result of this procedure.

Figure 15.4: Trepanation entailed drilling holes into an individual’s skull in order to release the demons that were thought to cause mental illness. [4]​
Figure 15.5: Demonic possession was considered a perfectly reasonable explanation for abnormal behaviour until fairly recently. [5]​

​Inhumane treatment of mental illness continued into the 18th century with a movement towards institutionalisation, or separating individuals with psychological disorders from the rest of society. Such institutions were called asylums, and conditions for patients were often horrible. Bethlehem Hospital, located in London, was one of the first such institutions dedicated to the treatment of mental illness. Originally founded to provide medical care to the poor, the focus shifted over time to management of psychological disorders. As the number of patients grew, living and treatment conditions deteriorated. Patients were crowded into rooms where they slept on piles of straw and had no access to restrooms, and many suffered from starvation due to inadequate food. According to historical accounts, patients with violent symptoms were shackled to walls in public view while those deemed to be harmless were sent out to beg for money. Psychological treatments included isolation, physical restraints, beatings, bloodletting (withdrawal of blood), and hydrotherapy (submersion in hot or cold water) (Foerschner, 2010). Bedlam, a nickname for Bethlehem Hospital, came to be synonymous with chaos, confusion, and insanity.

Figure 15.6: Bethlehem Hospital in London was among the first institutions dedicated to the treatment of mental health. [6]​

​Reformers like Philippe Pinel and Dorothea Dix argued for more humane and dignified treatment for patients with mental illness. Instead of being locked away and mistreated, they advocated that the ultimate goal of treatment should be improvement of psychological symptoms that would allow individuals to return to their lives outside of an institution.

Along with advances in medical knowledge, researchers attempted to understand mental illness in the same way other medical conditions were understood. This is known as the medical model. Just as diabetes reflects an interruption in normal physiological processes that can be addressed with medical intervention, perhaps psychological disorders could be treated and cured. This shift in thinking was an important step in how mental health challenges were understood and led to more concrete definitions of psychological disorders that could be researched more effectively.

The introduction of psychiatric medications drastically changed the treatment of psychological disorders, and in many ways offered an alternative to mandatory institutionalisation. Of course, applying the medical model to the treatment of psychological disorders has several drawbacks as well as advantages. While medications may improve psychological symptoms, they do not address environmental factors that may contribute to mental illness. For example, an individual diagnosed with an alcohol related disorder should likely not continue to hang out with friends at the bar. Additionally, the medical model is not always sensitive to cultural differences, which influence how we perceive thoughts, feelings, and behaviours as normal or abnormal.

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Question 15.04

The practice of separating individuals with psychological disorders from the rest of society is known as:

A

Institutionalisation

B

Therapy

C

Psychotherapy

D

Commitment

​15.1.4 Importance of Evidence-Based Mental Health Treatment

​For much of history, attempts to treat mental health concerns were based on spirituality and fear. With the shift to more scientific efforts to treat psychological disorders, it has become important to demonstrate evidence of what actually works. When you take a medication prescribed by a physician, you assume that it has been scientifically proven to work – and you hope it has been scientifically tested so the risks and side effects of that medication are well known. These standards are demanded by consumers as well as federal regulating bodies, medical insurance companies, and licensing boards (APA Presidential Task Force on Evidence-Based Practice, 2006). Mental health professionals are also expected to show that the treatments they use are scientifically proven to work.

Evidence-based mental health treatments have undergone research and been shown to consistently improve patient outcomes (Drake et al., 2001). The efficacy of a treatment shows that therapy to work under strictly controlled (laboratory) conditions while the effectiveness of a treatment shows that therapy to work in the real world (Ernst & Pittler, 2006). The training of psychologists is accredited by the Australian Psychology Accreditation Council, and approved by The Psychologists Registration Board to ensure that future mental health providers are trained to practice evidence-based treatments. Once they are qualified and registered, PsyBA requires annual re-registration and to meet the criteria practitioners have to demonstrate currency through compulsory professional development processes. The next section of this chapter describes several evidence-based methods for treating psychological disorders.

Question 15.05

Match the term with the setting that the treatment will work in.

Premise
Response
1

Efficacy

A

Therapy works in the real world.

2

Effectiveness

B

A given treatment works under laboratory conditions.

Question 15.06

Which of the following statements is/are true about Bethlehem Hospital?

A

Treatments often included bloodletting, hydrotherapy, and isolation.

B

Patients were often abused and neglected.

C

The hospital became known as Bedlam.

D

A, B, & C are true.

E

Only A & B are true.

15.2 Differing Approaches to Treatment

​The biopsychosocial model (Engel, 1980), introduced in Chapter 14 of this textbook, suggests that the intricate interactions of an individual’s biological makeup, psychological experiences, and social environment determine their risk for a psychological disorder. The same framework is helpful in discussing the many options that have been developed to treat psychological disorders. Mental health is complex and a treatment that is effective for one person may not be at all helpful for another. Many people find that they need to try many treatment approaches before they start to experience improvement. The types of treatments offered depend on many factors, including the type of provider and their training background.

Biological treatments tend to fall under the scope of psychiatrists, neuro-psychologists, and psychiatric nurse practitioners while psychological interventions tend to be offered by psychologists. Community psychologists have the added advantage of being able to understand the complexities and intersectionality of the social environment and therefore offer a holistic approach.  

​15.2.1 Biological Approaches – Treating the Brain

Figure 15.7: Medical models seek to understand mental illness from a biological perspective and treatment focuses on the brain. [7]​

​As previously discussed, the medical model seeks to understand mental illness from a biological perspective. As such, psychiatrists, neuro-psychologists, and psychiatric nurse practitioners are trained in the anatomy and physiology of the brain, and their interventions focus on brain dysfunction that may contribute to mental illness. These providers may use both pharmacological (drug-based) and non-pharmacological (not drug-based) techniques to treat psychological disorders. The majority of psychopharmacological interventions target brain chemicals called neurotransmitters (discussed in Chapter 3).

15.2.1.1 Psychopharmacotherapy (psycho = of the mind; pharmaco = drug; therapy = treatment)

Today, prescribing psychotropic medications is a common practice of treating psychological disorders. In fact, there are numerous prescription drugs that are used to treat specific mental health disorders. While some of these medications have been developed specifically for psychiatric treatments, the history of psychopharmacology was much less intentional.

In the 1800’s, syphilis was a major public health issue. Early stages of this sexually transmitted infection are marked by skin lesions and sores. However, because there was no cure at this time, people who contracted syphilis typically lived with the disease for their whole lives. Left untreated, the disease can go dormant in the body for decades. When it resurfaces, it attacks the brain, resulting in distorted thinking, hallucinations, paralysis, and eventually death. Interestingly, there were cases reported of people with late-stage syphilis who recovered and experienced mental stabilisation – after contracting and surviving malaria. The explanation was that the intense fever that accompanied malaria destroyed the syphilis bacteria (Nicol, 1933).

Similar accidental discoveries in medical settings can be tracked throughout the 1900’s. For example, in the late 1920’s a psychiatrist discovered that high-dose insulin injections caused seizures (Sakel, 1958). Insulin was occasionally used to stimulate the appetites of psychotic patients and even had a calming effect. When high doses of insulin were used to trigger seizures, Sakel observed that patients experienced temporary relief from their schizophrenia symptoms. Russell Crowe does an on-screen rendition of what insulin shock therapy may have looked like in the film A Beautiful Mind (Howard, 2001).

In a parallel line of research in the 1920s, two Italian researchers, Ugo Cerletti and Lucio Bini, successfully demonstrated that they could trigger seizures by passing electric current through a patient’s head. Another name for seizures is convulsions, and their discovery was the precursor of what is now called electroconvulsive therapy (ECT) (Hunt, 1980).

Figure 15.8. Electroconvulsive therapy (ECT) delivers electric currents to the brain to trigger brief seizures that may provide relief for psychological disorders.​ [8]

In perhaps the greatest advance of psychopharmacotherapy, a French pharmaceutical company researching antihistamine medications produced a new drug that, in addition to relieving allergy symptoms, had a strong sedative effect. This means that the drug could make people feel more calm and peaceful. These findings were the foundation for the development of chlorpromazine, the first antipsychotic drug which was introduced in 1950.

Antipsychotic Drugs

As you may recall from Chapter 14, psychosis is the prominent feature of schizophrenia spectrum disorders. Psychosis includes delusions, hallucinations, and disorganised thinking, and as the name implies, antipsychotic drugs are used to reduce these symptoms. As researchers continued to explore the connection between seizures and symptoms of schizophrenia, it was soon realised that there were serious side-effects (e.g. death) that came along with administering large doses of insulin to trigger seizures. At the time, ECT was not much safer, so a less dangerous alternative was needed.

Typical Antipsychotics

After discovering the sedative effects of chlorpromazine (also known by brand names: Thorazine and Largactil), the drug was used as anaesthesia during surgery. The tranquillising effects were then trialled with psychiatric patients and found to effectively manage psychotic behaviours (Pieters, 2011). Other antipsychotic drugs soon followed, introducing medications like haloperidol (brand name: Haldol). This first generation of medications to treat psychological disorders is known as typical antipsychotics, and work by blocking dopamine receptors in the brain. Dopamine is a neurotransmitter associated with pleasure, motivation, and motor control; too much or too little dopamine in the brain can be a problem. Typical antipsychotics reduce the activity of dopamine in the brain.

The role of dopamine in producing symptoms similar to those of psychosis was already being studied. Stimulant drugs like cocaine and amphetamine increase the amount of dopamine available in the brain, and can lead to anxiety, agitation, delusions, and hallucinations (Ghodse, 2010). Researchers realised that reducing dopamine activity should have the opposite effect.

Figure 15.9: Antipsychotic drugs work by reducing dopamine in the brain. This reduces positive symptoms of schizophrenia, like hallucinations, delusions, and agitation. [9]​

​As with any drug, there are a number of side-effects associated with use of typical antipsychotics. Mild or moderate side-effects include dry mouth, blurred vision, drowsiness, and dizziness. With long-term use, this class of drugs can cause extrapyramidal symptoms – disruption in an individual’s ability to consciously control their body movements (e.g. involuntary body tremors or rigidity). The most serious of these symptoms is tardive dyskinesia, which consists of involuntary and unwanted movements in the face, tongue, or arms. Often, tardive dyskinesia persists even when administration of the typical antipsychotic is stopped (Patterson, Albala, McCahill, & Edwards, 2010).

Atypical Antipsychotics

Due to concern for extrapyramidal symptoms, a second generation of medications was developed: atypical antipsychotics. While still acting on dopamine pathways in the brain, these medications tend to act on serotonin as well (serotonin is a neurotransmitter that helps to regulate mood and energy expenditure). The first drug of this class to be introduced was clozapine (brand name: Clozaril) (Hippius, 1989). Other atypical antipsychotics that are commonly prescribed include risperidone (brand name: Risperdal), olanzapine (brand name: Zyprexa) and aripiprazole (brand name: Abilify).

Despite the term ‘atypical’, which was used to indicate the absence of extrapyramidal symptoms, tardive dyskinesia is still a common side effect of clozapine. The medication can also decrease an individual’s white blood cell count, making them more susceptible to infection. Other side-effects of atypical antipsychotics include difficulty with concentration, weight gain, and excessive grogginess. These side-effects are cited as barriers to patients taking their medication as prescribed (Pratt et al., 2006).

Antidepressant Medications

During the same timeframe as the development of typical antipsychotics to treat schizophrenia, researchers were also working to develop antidepressants – medicinal treatments for depression. While amphetamine and opioids had been used successfully to improve mood, the side effects, along with the addictive nature of these medications, necessitated alternative treatment options (Weber & Emrich, 1988; Heal et al., 2013).

Since the 1950’s, several different types, or classes, of antidepressants have been developed. The prevailing theory is that depression is a result of an imbalance of specific brain chemicals, known collectively as monoamine neurotransmitters. The monoamines include serotonin, norepinephrine, and dopamine, and each class of antidepressant acts on these neurotransmitters in slightly different ways. Three major classes of antidepressants are described below: monoamine oxidase inhibitors, tricyclic antidepressants, and selective serotonin reuptake inhibitors.

Figure 15.10: The discovery of antidepressants, although accidental, has resulted in a lot of relief for individuals experiencing depression. [10]​

Monoamine Oxidase Inhibitors

Similar to the discovery of typical antipsychotics, the first antidepressants were coincidental findings. Researchers studying medication for tuberculosis noted a stimulating side-effect, and these drugs were soon trialled with patients diagnosed with depression. Upon further study, these drugs were found to inhibit an enzyme called monoamine oxidase. The role of this enzyme is to chemically break down monoamines in the synapse, thereby disposing of serotonin, norepinephrine, and dopamine. By inhibiting this enzyme, monoamine oxidase inhibitors (MAOIs) allow these mood-influencing neurotransmitters to remain in the synapse for longer periods of time.

Currently, MAOIs such as phenelzine (brand name: Nardil), tranylcypromine (brand name: Parnate), and isocarboxazid (brand name: Marplan) are prescribed as a last resort, after other classes of antidepressants have failed to reduce depressive symptoms (Mayo Clinic, 2017). This is due to dangerous (or even lethal) food and drug interactions. Individuals prescribed MAOIs must avoid thymine, a substance present in cheese, red wine, pickles, decongestants, and birth control pills.

Tricyclic Antidepressants

Tricyclic antidepressants (TCAs), named for their 3-ring chemical structure, were developed soon after MAOIs. This class of drugs has its fair share of side-effects (e.g., low blood pressure, weight gain, reduced sexual interest), though the food and drug interactions associated with MAOIs are absent (Patterson, Albala, McCahill, & Edwards, 2010). TCAs such as imipramine (brand name: Tofranil), amitriptyline (brand name: Elavil), and nortriptyline (brand name: Pamelor) were the first widely accepted medications for treating depression and were the most commonly prescribed antidepressants for many years (Gitlin, 2009).

TCAs affect brain chemistry by inhibiting reuptake of serotonin and norepinephrine. Another way to say this is that TCAs are serotonin-norepinephrine reuptake inhibitors (SNRIs). As mentioned in Chapter 3 of this textbook, reuptake is a kind of neurotransmitter recycling process. When reuptake is inhibited, serotonin and norepinephrine are more available in the synapse.

Selective Serotonin Reuptake Inhibitors

The most commonly prescribed antidepressants are selective serotonin reuptake inhibitors (SSRIs). In fact, due to their high rates of effectiveness and lower risk of side-effects (Patterson, Albala, McCahill, & Edwards, 2010), many prescribing mental health providers choose an SSRI as the initial attempt at treating depression. This is called a first-line treatment. SSRIs include fluoxetine (brand name: Prozac), citalopram (brand name: Celexa), escitalopram (brand name: Lexapro), and sertraline (brand name: Zoloft). Prozac has become a household name for treatment of depression, and with good reason. According to the Australian Bureau of Statisitcs (ABS, 2016) SSRIs are the most commonly used antidepressants (https://www.healthdirect.gov.au/antidepressant-medicines).

SSRIs function in a fashion very similar to TCAs. As the name implies, SSRIs target serotonin and have very little effect on norepinephrine and dopamine. By inhibiting reuptake of serotonin in the synapse, the concentration of serotonin is enhanced.

Question 15.07

Match the antidepressant with the best description.

Premise
Response
1

Monoamine Oxidase Inhibitors

A

The first antidepressant (discovered by accident) and can have potentially lethal interactions with certain foods.

2

Tricyclic Antidepressants

B

Named for three ring chemical structure¸works by stopping the reuptake of both Serotonin and Nerepinephrine.

3

Selective Serotonin Reuptake Inhibitors

C

The most commonly prescribed and most recent antidepressants¸effective enough to be considered a first line treatment.

Effectiveness of Antidepressants

Despite the years of research and clinical trials on antidepressants, it is still unclear exactly how or why these drugs influence mood. New research from the past 10 years shows that approximately 50% of people with depression experience some relief from their symptoms using SSRIs, but only 20-30% experience complete relief (Trivedi et al., 2006; Kirsch, 2008). Antidepressants appear most effective for individuals with severe depression. However, in cases of mild or moderate depression, much of the improvement from antidepressant medications can best be attributed to placebo effect (Kirsch, 2002). A common rebuttal is that SSRIs appear less effective because it takes, on average, 4-6 weeks for the medications to build up to an active level in the brain (Penn & Tracy, 2012).

Figure 15.11: Approximately 50% of people experience relief from depressive symptoms using SSRIs. [11]​

​Currently, alternatives to SSRIs are being sought. The most promising appears to be ketamine, which focuses on a different neurotransmitter, glutamate (Kirby, 2015). Glutamate is an excitatory neurotransmitter, meaning it increases all manner of brain activity. Furthermore, glutamate accounts for more than 90% of all synapses in the human brain, making it the most prevalent of all neurotransmitters. Although the psychopharmacotherapeutic effect of ketamine is still in its experimental stages, many are excited about the possibility of finding a medication that helps relieve symptoms of depression more than 50% of the time.

Antidepressants are not perfect at managing depression. While strong efficacy and effectiveness have been demonstrated in reducing symptoms, antidepressant medications are not as effective for one of the most critical goals in treating depression: preventing the next depressive episode (Insel, 2006; Thase, 2009). It is not surprising that when people start to feel better, they often stop taking their medication, not realising that depression often reoccurs within 5 years. Psychological strategies, such as those provided in psychotherapy, can strengthen lifestyle changes that support longer-term remission of symptoms. Interestingly, psychotherapy (Stewart & Strunk, 2006, Kaslow et al., 2009) and regular exercise (Babyak, 2000) have demonstrated similar effectiveness to antidepressant drug trials.

Question 15.08

On average, ______ of the people who experience symptoms associated with depression experience some relief when taking SSRIs, but only ______ experience complete relief.

A

100%; 75%

B

75%; 45-50%

C

58%; 50%

D

50%; 20-30%

Question 15.09

SSRIs target ________; while ketamine targets the neurotransmitter ________.

A

dopamine; serotonin

B

GABA; serotonin

C

serotonin; dopamine

D

glutamate; serotonin

E

serotonin; glutamate

Anxiolytics

Anxiolytics, sometimes called anti-anxiety medications, are prescribed to treat the sensations of arousal and tension associated with disorders of anxiety. Like antipsychotic and antidepressant medications, anxiolytics achieve their desired effect by acting on neurotransmitters in the brain. Because the desired effect of these drugs is to create a state of calm and relaxation, anxiolytics are considered to be a class of sedatives.

Benzodiazepines

The neurotransmitter gamma-aminobutyric acid (GABA) is the main inhibitor of the central nervous system, meaning that its major responsibility is to calm the brain. As such, drugs that increase the amount of GABA available in the synapse are effective treatments for symptoms of anxiety. Barbiturates such as phenobarbital were used for years to treat anxiety, but quickly fell out of favour when less toxic options were introduced. The revolutionary discovery of benzodiazepines (also known as benzos), which enhance the effect of GABA, was another fortuitous mistake.

The first benzo developed was chlordiazepoxide (brand name: Librium). Leo Sternbach, the scientist credited with its creation originally considered the drug to be a failure and abandoned the project. Two years later, while cleaning the lab, Sternbach decided to test the drug and discovered that it had anxiety reducing effects. Chlordiazepoxide was a commercial success, and Sternbach went on to develop one of the most prescribed psychotropic medications ever sold: diazepam (brand name: Valium).

Figure 15.12. Anxiolytics, sometimes called anti-anxiety medications, are prescribed to treat the sensations of arousal and tension associated with disorders of anxiety. [12]​

​Benzodiazepines were so well-received because of their fast-acting effect. Individuals report anxiety symptom relief within 20-40 minutes after they are taken, and even quicker when taken sublingually (i.e., under the tongue). Unfortunately, the quick-acting quality of these drugs makes them highly addictive. As people use benzodiazepines, they develop a tolerance for the drugs, and can become chemically dependent on them. Furthermore, while benzodiazepines are safe for short-term use, long-term use is associated with aggression, agitation, and panic. This is called a paradoxical effect, because the drug is actually causing symptoms it is intended to treat.

To address the potential for abuse of benzodiazepines, pharmaceutical companies developed extended-release forms to slow down the effects (Patterson, Albala, McCahill, & Edwards, 2010). However, these variations were easy to crush up or alter in other ways to experience the effects faster. For this reason, benzodiazepines such as alprazolam (brand name: Xanax) and lorazepam (brand name: Ativan) are not prescribed as frequently as they used to be. However, benzodiazepines remain the most widely used class of drug for treating anxiety (Bruce et al., 2003).

Other Anxiolytics

GABA is not the only neurotransmitter associated with symptoms of anxiety. Medications that act on other neurotransmitter pathways have also demonstrated efficacy and effectiveness in treating anxiety-related disorders. For example, individuals who experience panic attacks or obsessions and/or compulsions show benefits from taking SSRIs (Barlow & Craske, 2009; Stewart, Jenike, & Jenike, 2009), and individuals diagnosed with social anxiety have experienced symptom reduction when prescribed TCAs (Stein et al., 1998). Buspirone (brand name: Buspar), used primarily to treat generalised anxiety disorder, achieves its anxiolytic affect by decreasing serotonin levels while increasing levels of norepinephrine and dopamine in the brain (Loane & Politis, 2012). Other promising psychopharmacotherapies for anxiety include the use of beta blockers, which are medications originally developed to treat irregular heart rhythms and high blood pressure (Giles, 2005).

Mood-Stabilising Medications

Bipolar disorder is characterised by shifts in mood – from mania to depression, or vice versa. As such, medication management of bipolar disorder aims to level or stabilise these shifts in mood. These psychopharmacological agents are classified as moods stabilisers. Recall from Chapter 14 that the true marker of bipolar disorder is mania; mood stabilisers are highly effective for managing the excessive euphoria, reduced need for sleep, and grandiose thinking typical of a manic episode. These medications are also affective for reducing aggression and agitation.

Lithium, a naturally occurring mineral, is the most efficacious and most commonly prescribed mood stabiliser. Even after years of research on this agent, the reason lithium works is still not clear. Some hypotheses are that lithium increases production of serotonin and enhances neural plasticity, which allows the brain to be more flexible. What is well known is the toxicity of lithium to the body. Potential side effects from taking too much lithium include reduced thyroid function, substantial weight gain, and organ damage. However, taking too little lithium will not produce the desired therapeutic effect. For this reason, individuals prescribed lithium must undergo regular blood testing in order to monitor levels of the drug in the body (Patterson, Albala, McCahill, & Edwards, 2010).

Figure 15.13: Lithium, the most commonly prescribed mood stabiliser, is particularly effective in the treatment of bipolar disorder. [13]​

​Despite its effectiveness, the dangerous side-effects associated with lithium have prompted scientists to research alternative mood stabilising medications. Anticonvulsant medications, also known as anti-seisure medications, show great promise. Valporate (brand name: Depakote) and lamotrigine (brand name: Lamictal), both of which enhance the availability of GABA, are effective in managing manic episodes with much lower risk of side-effects. However, comparative studies of these treatments show that lithium is still more effective in reducing bipolar-related suicidal behaviour, psychosis, and aggression (Thase & Denko, 2008).

15.2.1.2 Pros and Cons of Psychopharmacotherapy

Psychopharmacotherapy is certainly a major player in the treatment of psychological disorders. However, it is not the only player. It is important to keep in mind that psychotropic medications do not necessarily cure psychological disorders; instead, they provide relief of symptoms. When medications are discontinued, symptoms often return. Furthermore, psychopharmacotherapy is not really intended to be the one and only long-term solution for psychological disorders. Individuals taking medications over the long-term must be carefully monitored and medications must be adjusted as body chemistry changes over time. It is also important to consider the risk of physiological and/or psychological addiction. Finally, another important consideration is cost. While most are readily available on the Pharmaceutical Benefits Scheme (PBS) some of the newer drugs take time to be added and therefore are not as accessible as practitioners might like. 

Medically stabilising a patient might assist them to achieve mastery over their mental health and make progress toward recovery. Medications can dramatically alter a person’s quality of life, often for the better, allowing them to be productive members of society. Unfortunately, however, not all psychological concerns are responsive to medication and not all medications are effective for all people. 

As such, the general consensus among mental health professionals is that ideal treatment for psychological disorders often includes a combination of psychopharmacotherapy and psychotherapy (Cuijpers et al., 2014; de Jonghe, 2001; Seligman, 1995). As discussed, medications address the biological aspect of psychological disorders while psychotherapy addresses the psychological and social aspects. Psychotherapy can help people build coping skills and more adaptive patterns of thinking and behaving as well as identify triggers in their environments that can make mental health difficulties worse.

Question 15.10

Match the items on the left with its correct description on the right.

Premise
Response
1

Chlorpromazine

A

The first antidepressants.

2

Atypical Antipsychotics

B

The first line treatment for depression.

3

Monomine Oxidase Inhibitors

C

Serotonin-norepinephrine reuptake inhibitors.

4

Tricyclici Antidepressants

D

Act on both dopamine and serotonin pathways.

5

Selective Serotonin Reuptake Inhibitors

E

Enhance the effect of GABA.

6

Benzodiazepines

F

The first antipsychotic drug - introduced in 1950.

Question 15.11

Which of the following drugs acts to block or slow down the use of dopamine within the brain?

A

Chlorpromazine

B

Benzodiazepines

C

Lithium carbonate

D

All of the above

Question 15.12

Which of the following drugs is used to treat the symptoms of bipolar disorder?

A

Chlorpromazine

B

Haloperidol

C

Benzodiazepines

D

Lithium carbonate

Question 15.13

Tricyclics are used to treat which psychological disorder?

A

Anxiety

B

Schizophrenia

C

Depression

D

Antisocial personality disorder

E

Paranoid personality disorder

Question 15.14

Juan has just started taking antidepressant medication. He should expect relief from his symptoms of depression:

A

Within 2-3 hours of taking the drug for the first time.

B

Within 24 hours of taking the drug for the first time.

C

After 3-4 days of taking the prescribed amount of the drug.

D

After several weeks of taking the prescribed amount of the drug.

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Let’s talk about...Well-being

Mainstream diagnostic and therapy approaches to mental ill-health and psychological distress are not always effective when working with Indigenous communities. Because of this, different approaches to the training and education of mental health professionals is needed (Walker, Schultz & Sonn, 2014). In Australia, the development of the Social and Emotional Well-being Model by Indigenous researchers, practitioners, and educators has contributed to a different lens being applied at all stages of the diagnostic and therapy cycle. 

The framework, developed by Gee and colleagues, is grounded in a collectivist approach to well-being that situates the person at the centre of, and inextricably linked and connected to, family and community. This places equal emphasis on the connection to culture, tradition, and country while simultaneously examining and critiquing social systems and practices in the broader society that undermine this sense of connection (Gee, Schultz, Hart & Kelly, 2013).

Understanding this model and how the separation from or fragmentation of these connections can contribute to mental health issues is a ground-breaking step forward in the mental health movement – specifically because it moves away from a victim-blaming approach to diagnosis and care. It is also significant because it is applicable to non-Indigenous populations and communities, too. Therefore, it represents a moment in psychological history where mainstream theory is informed by Indigenous knowledges. The framework is particularly useful in training mental health practitioners and should be embedded in the training of all psychologists across all levels of education (Prilleltensky, 2014) as it allows for a nuanced understanding of intergenerational trauma as a result of colonisation, as well as the effects of living in a toxic environment. It also helps to unpack the use of substances as a form of self-medication to help manage the pain on dislocation and trauma. By viewing strong cultural links as a protective and remediating factor in therapeutic contexts, rather than as a variable to be controlled and moderated (a positivist stance), social and emotional wellbeing, provides a therapeutic framework of healing that transcends cultural boundaries (Dudgeon, Bray & Darlaston-Jones, 2016). 

Non-Indigenous frameworks of well-being (Fox, Prilleltensky, & Austin, 2009; Prilleltensky & Nelson,2002; Prilleltensky & Prilleltensky, 2006) similarly outline the importance of interconnectedness beyond the person, and the complexities and intersectionality of systems that support or impede well-being. In their model, Prilleltensky and Nelson articulate the levels of connection between the person, their relational lives (family, school, work, neighbourhood etc.) and the collective (the political, social, cultural, economic) aspects of society, which are transmitted through socialisation and acculturation (Berry, 1980, 2016). Making connections between mainstream psychological thought and practice and Indigenous knowledges is the way forward for the evolution of psychology as a discipline and profession. Valuing the interconnectedness of western and Indigenous theories, ways of being and knowing can only enhance our understanding of self and others and how this connects with mental health. It is the way forward for a new generation of practitioners, academics, and researchers that values and respects diverse traditions and consequently enacts the vision that Berry had when he developed his acculturation model. Whereby, both groups benefit and grow by virtue of their contact and interaction (Dudgeon, Darlaston-Jones, Nikora, Waitoki, Pe-Pua, Nhat Tran, & Rouhani, 2016).

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15.2.1.3 Nonpharmacological Interventions

Medication management of psychological disorders has seen vast advancements over the years. However, the brain is such a complex organ, and medication is not always successful in treating symptoms of mental illness. In cases of treatment-resistant psychological disorders that have not responded to multiple trials of psychotropic medications,  practitioners might recommend other biological treatments.

Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT) is used in cases of treatment-resistant depression and schizophrenia. This treatment involves the use of electrical currents delivered to the brain to induce seizures. The premise is the same as that behind insulin shock therapy. While ECT may seem scary or even barbaric, technological improvements have made ECT a safe and effective treatment for severe psychological disorders.

When ECT was first introduced in the 1930s, the procedure was used without much thought to the experiences of the patient. It was not uncommon for people to experience injuries, including broken bones and teeth, from the seizure. The classic movie One Flew Over the Cuckoo's Nest (Forman, 1975) offers a depiction of the procedure.

Currently, ECT is administered over the course of several sessions. Patients are typically sedated during the procedure while a low voltage electrical current is administered (Peterchev, et al., 2015). When administered effectively, controlled research studies have found that ECT is effective in alleviating depressive symptoms in 50-70% of cases (Carney et al., 2003). Unfortunately, the relapse rate of severe depression is rather high. Thus, it is highly probable that if ECT is needed once, it will most likely need to be used again when the symptoms reappear. Also, ECT is not without side-effects. Mental confusion and short-term memory loss are not uncommon, but they usually go away after 7-14 days.   In the following video, physician Sherwin Nuland describes the development of ECT and shares his personal experiences with the treatment.

Transcranial Magnetic Stimulation (TMS)

Figure 15.14: TMS is a non-invasive procedure that can create temporary lesions in the brain. [14]​

Transcranial Magnetic Stimulation (TMS) is a non-invasive procedure that uses electromagnetic currents to stimulate portions of the brain. The TMS device produces small magnetic pulses that feel like light taps on the head. These pulses pass through the skull and go about two and half centimetres into the brain where they can increase or decrease neuronal activity. When the pulses are delivered in quick succession, the procedure is called repetitive TMS (rTMS), it has evidenced longer lasting changes to brain activity (George et al., 2010). Common side-effects of TMS include mild headache, fainting, scalp pain, and in rare instances, seizure activity. The magnetic pulses are loud and the device is often positioned close to the ears, so many people find it helpful to wear earphones or earplugs while undergoing treatment. Click this link to view an interesting video about TMS.

Psychosurgery

As the name implies, psychosurgery is an operation in which psychological disorders are addressed using surgical procedures. Psychiatrists are not typically trained in surgical techniques, so they collaborate with neurosurgeons (i.e., physicians who specialise in conditions affecting the nervous system) to conduct psychosurgery.

Trepanation was one of the earliest forms of psychosurgery. Many years later, the prefrontal lobotomy was developed to treat severe cases of psychosis. The procedure severs the connections between the prefrontal lobe and the rest of the brain (Money, 1951). The purpose of the operation was to reduce the severity of symptoms associated with mental disorders, and from this perspective, the surgery was often a success. In fact, the developer of the lobotomy was awarded the Nobel prize in 1949. Other forms of psychosurgery remove or destroy small pieces of the brain thought to be causing mental dysfunction. As with any invasive procedure, there are considerable risks associated with psychosurgery. Side-effects include seizures, cognitive deficit, and death.

Figure 15.15: Deep brain stimulation, a modern form of psychosurgery, is significantly safer and more precise than historical procedures. [15]​

Deep brain stimulation (DBS) is a more modern form of psychosurgery. This invasive technique involves implanting electrodes into the brain in order to electrically stimulate certain areas. The neurostimulator operates via a battery and is similar to a cardiac pacemaker. The electrical current can help to prevent signals that cause psychiatric symptoms. As with the other non-pharmacological interventions discussed, DBS is reserved for treatment-resistant cases of mental illness.

Question 15.15

Match the psychosurgery with the correct description.

Premise
Response
1

Electroconvulsive Therapy

A

Severs the connections between the prefrontal lobe and the rest of the brain.

2

Deep Brain Stimulation

B

Use of electrical currents delivered to the brain to induce seizures.

3

Prefrontal lobotomy

C

A non-invasive procedure that uses electromagnetic currents to stimulate portions of the brain.

4

Transcranial Stimulation

D

Implanting electrodes into the brain to stimulate certain regions.

Question 15.16

Research suggests that electroconvulsive shock therapy (ECT) is:

A

Successful 10%-15% of the time in reducing the symptoms of depression.

B

Not safe in any way for any disease.

C

Not an effective treatment for any known psychological disorders.

D

Successful in 50-70% of cases of paranoid schizophrenia.

E

Successful 50%-70% of the time in reducing the symptoms of depression.

​15.2.2 Psychological Approaches – Treating the Mind

Psychotherapy is a psychological approach to helping individuals identify, change, and overcome problematic thoughts, feelings, or behaviours (National Institute of Mental Health, 2016). Psychotherapy is commonly referred to as talk therapy and is often presented as a non-medical approach to treating psychological disorders. Unfortunately, these views of psychotherapy may suggest that psychological approaches are not based in scientific research and can take away from the rigour of these treatment options. However, the examples of psychotherapy presented in this section are all evidence-based mental health treatments.

In general, psychotherapy focuses on changing individuals’ internal experiences, including how they think and feel. Psychotherapy also focuses on making adjustments to how individuals show or express their internal experience through behaviour (i.e. how they act). In addition to this internal work, psychotherapy can also guide individuals to change the systems in which they are embedded. In other words, they may be encouraged to address problems within their household, workplace, or social environment in order to improve their psychological functioning.

Psychotherapy can take many forms. For example, individual therapy is a collaborative treatment that is based on the relationship formed between an individual and their therapist (APA, 2018). This relationship is a professional one, marked by boundaries and ethics. Therapists are legally required to protect the confidentiality of their patients, meaning that they must not share what they hear from their patients with anyone. The exception to this rule includes learning that an individual plans to harm themselves or another person. The psychotherapeutic relationship is also marked by rapport (the ‘t’ is silent), which describes an individual’s comfort and willingness to engage with their therapist.

In addition to individual therapy, there are also forms of psychotherapy that involve multiple individuals being treated together. These treatments share a philosophy that individuals do not function in isolation and that as social beings, focusing on interpersonal relationships can lead to better treatment outcomes.

15.2.2.1 Group Therapy

Group therapy is a treatment option in which a therapist works at once with several individuals. In many instances, the group shares a common theme, such as anxiety or anger. Other times, the group is less focused on a particular mental health concern, and group members spend time sharing and exploring their current thoughts and feelings. Because each patient in a group brings different experiences and viewpoints, treatment in group therapy is also thought to be influenced by the group dynamic, or how individuals in the group relate and interact with each other (Yalom & Leszcz, 2005). 

Figure 15.16: In group therapy, members spend sessions sharing and exploring problematic thoughts, feelings, and behaviours. [16]​

​A variant of group therapy is the mutual-help group (Kelly & Yeterian, 2011), which are peer-run groups made up of members who share a common experience such as bereavement, a specific mental health problem, or a form of addiction. These support groups are often economically more feasible than group therapy led by a trained professional, and many of these groups specify anonymity, allowing members to be helpful to one another without the need to be a patient in a treatment setting. Among the most well-known mutual-help groups are 12-step recovery groups, including Alcoholics Anonymous (AA). Members of these groups follow a pre-established set of recovery steps in order to maintain behaviour change, such as stopping alcohol use (Tonigan, Connors, & Miller, 2003). It is important to note that due to the intentionally informal nature of mutual-help groups, efficacy of these types of programs is not well studied and can vary from group to group (Kelly, Humphreys, & Ferri, 2017).

15.2.2.2 Couple’s and Family Therapy

Oftentimes, an individual’s psychological problems affect the people around them; psychological problems can also be influenced by the people with whom an individual interacts. Couple’s and family therapy (CFT) is a form of psychotherapy that addresses the thoughts, feelings, and behaviours of all members of a relationship unit (e.g., romantic couple, family) and how these thoughts, feelings, and behaviours affect individual members as well as the relationship unit as a whole. CFT was traditionally referred to as marriage and family therapy; the updated term acknowledges the array of human relationships that may not be fit underneath the umbrella of marriage. Other names for CFT include marital therapy, couple’s counselling, relationship counselling, and family therapy.

Couple’s therapy involves a couple meeting with a therapist to help resolve difficulties within their relationship, which may include problems with infidelity, communication, or sexual dysfunction. It is important to note that the goal of couple’s therapy is not always to “save the relationship” but rather to facilitate communication between the two individuals so that they can move ahead in a way that is most healthy for all involved. 

​As the name implies, family therapy seeks to address interpersonal difficulties within the family unit, which may consist of nuclear and/or extended family members (e.g., grandparents, aunts, uncles, in-laws). Specific issues addressed in family therapy might include conflict between parent and child, planning to co-parent following a divorce, or coping with the care of a terminally ill family member. Treatment tends to focus on the importance of shared responsibility for problematic interactions within the family unit – one individual is not to blame.

15.2.2.3 Schools of Psychotherapy

Over the years, a number of evidence-based psychotherapies have been developed and implemented. These psychotherapies are typically rooted in scientific theory, with treatment techniques evolving with new scientific discoveries (Lambert, 1992). The science and practice of psychotherapy has progressed in large movements, and at present, the field has seen four major movements of psychotherapy: insight therapy, behaviour therapy, humanistic therapy, and cognitive therapy.

The success of treatment for psychological disorders depends on many different factors, and similar to psychopharmacotherapy, it is sometimes necessary to try several types to psychotherapy before finding the best fit for an individual’s unique needs.

Figure 15.17: The relationship between therapist and patient is a critical aspect of psychotherapy. [17]​

Insight Therapy

Sigmund Freud is considered by many to be the father of modern psychotherapy, and many current psychotherapy techniques have roots in his methods. A major focus of Freud’s style of psychotherapy was helping people to understand why they think, feel, and behave the way they do – he wanted people to have more insight, but argued that the reasons for human thoughts, feelings, and behaviours lie outside of conscious awareness. Insight therapy uses a variety of techniques to help people gain more awareness of their unconscious thoughts, feelings, and behaviours.

Psychoanalysis

Figure 15.18. Sigmund Freud, often referred to as the father of modern psychotherapy.​ [18]

An insight therapist’s job is to closely examine or analyse an individual’s unconscious processes (e.g., fantasies, dreams, sexual desires) in order to bring them to conscious awareness – thus the term psychoanalysis. Psychoanalysis is an intensive form of psychotherapy that can involve multiple sessions each week over the course of many months or years. Consistent with popular media, a patient of psychoanalysis may lie on a couch with the therapist sitting to the side or behind, out of sight. In session, the patient is encouraged to engage in free association, saying everything that comes to mind, without censoring themselves. The therapist listens carefully, taking notes on reoccurring themes, metaphors, and memories, all of which are thought to provide insight into the unconscious. Even specific word choices are analysed for unconscious content. The term Freudian slip refers to an error in speech, memory, or action that is thought to reveal an unconscious thought, feeling, or belief. A classic example is an employee responding to unexpectedly seeing her boss in the elevator with, “I’m mad to see you” instead of “I’m glad to see you.”

During the process of free association, the content of dreams often comes up. Freud called dreams “the royal road to the unconscious.” As such, dream analysis is another important tool of psychoanalysis. Dream analysis involves the exploration of manifest content (aspects of dreams that the patient remembers) in the hopes of uncovering latent content (parts of dreams that reveal deeper insight into the patient’s thoughts, feelings, and behaviours).

Figure 15.19: The process of dream analysis involves the exploration of manifest content and latent content of the dream for the patient. [19]​

​In addition to listening and interpreting what the patient shares during free association and dream analysis, the therapist also pays attention to behaviours. As the therapist and patient approach the root of specific problems, the unconscious mind creates roadblocks to resist therapy. Resistance occurs when a patient stops cooperating in psychoanalysis. Resistance may take the form of missed appointments or forgotten dreams (repression), insistence that they have recovered and no longer need therapy (denial), or expressing the desire to return to previously resolved problems (regression).

Although resistance is a normal part of psychoanalysis, it can present a serious challenge to progress. One clue that a 'breakthrough' is about to occur is a specific form of resistance known as transference. Transference occurs when the patient expresses feelings (such as love or anger) for another person to the therapist. Although quite difficult (and often uncomfortable) to navigate, transference indicates that the patient’s hidden memories and conflicts are getting close to conscious awareness. It is important for both the patient and therapist to understand that these feelings, although quite intense, are not really about the therapist. Through the course of psychoanalysis, the therapist can help the patient navigate these emotions and uncover the meaning of them. In fact, analysing transference can help to clarify childhood relationships that the patient had with important adult figures in the past.

While psychoanalysis is the term Freud used to describe his school of thought, he was not the sole contributor. Freud collaborated with several scholars who extended and expanded upon his theory of psychotherapy into what become known as psychodynamic psychology. Among these collaborators were Carl Jung, Alfred Adler, and Sigmund Freud's daughter, Anna Freud. In contrast to psychoanalysis, psychodynamic therapy is less time-intensive and more focused on specific psychological disorders (Fonagy, 2003).

Question 15.17

Lina has been seeing a psychoanalyst for several months. She is convinced that she has fallen madly in love with her therapist. Her therapist has assured her that this is a sign that her conflicts are getting closer to the surface. It is probable that Lina is experiencing:

A

Transference

B

Resistance

C

Free association

D

Reaction formation

Question 15.18

Sidra has been seeing a psychoanalyist for several months. She suddenly starts forgetting to attend appointments and arguing with her therapist when she does see her. It is likely Sidra is experiencing:

A

Transference

B

Resistance

C

Free association

D

Reaction formation

Question 15.19

Psychoanalysis is based on the assumption that the therapist’s job is to:

A

Understand the patient's conscious thoughts.

B

Understand which environmental conditions are causing poor behaviour.

C

Help a patient find the best medication for their disorder.

D

Bring unconscious impulses and memories into conscious awareness.

Question 15.20

During free association, patients:

A

Relax and express thoughts and feelings as they come to mind.

B

Express feelings toward the therapist that represent repressed feelings for other people in their life.

C

Discuss the content of dreams.

D

Confront their negative thoughts and irrational beliefs.

Behaviour Therapy

Behaviour therapy is strongly rooted in learning theory, which was covered in Chapter 7 of this textbook. Human behaviour can be defined as what we do or how we act, and according to learning theory, whether we continue or discontinue certain behaviours is influenced by the feedback we get from our environment. While insight therapy focuses on how unconscious processes influence behaviour, behaviour therapy focuses on behaviour modification, the process of changing problematic behaviours.

Figure 15.20: Behaviour therapy is an effective treatment for changing maladaptive behaviours, and even works well with young children. [20]​

​Largely, behaviour therapy is based on the work of three scientists who were simultaneously doing very similar work in different parts of the world (Yates, 1970): B.F. Skinner in the United States, Joseph Wolpe in South Africa, and Hans Eysenck in the United Kingdom. Skinner’s work applied techniques associated with operant conditioning while Wolpe’s work was informed by classical conditioning. Eysenck’s contributions to behaviour therapy were based on the interplay of personality characteristics, the environment, and behaviour.

Operant Conditioning Therapies

As a reminder, operant conditioning describes learning that is based on the consequences of behaviour. By implementing rewards and punishments, a behaviour therapist attempts to modify maladaptive behaviour. Specifically, desirable behaviours are rewarded (i.e., reinforced) and undesirable behaviours are punished. A common technique used in behaviour therapy is contingency management, which involves the use of tangible rewards to reinforce positive behaviours (National Institute on Drug Abuse, 2018).

Figure 15.21: A token economy uses objects, such as poker chips, to reinforce good behaviour. Once a certain number of tokens is collected, they can be traded for other desirable objects. ​[21]

​A token economy uses objects or symbols that are earned in response to a desired behaviour; the tokens can then be exchanged for some larger reinforcer of value. For example, a behaviour therapist working with a toddler on potty training may give a sticker for each time the child puts uses the toilet. Once the child earns five stickers, they gets to pick out a new toy. Contingency management has also been used effectively to treat addiction-based disorders (Lussier et al., 2006). Voucher-Based Reinforcement provides patients a voucher for every drug-free urine sample they provide; vouchers have monetary value, and the value increases with the number of drug-free urine samples (Budney et al., 2006).

Similar in theory to the token economy, behavioural activation is one of the most effective treatments for depression and is found to demonstrate similar outcomes to medication (Elkers et al., 2014). Behavioural activation uses principles of operant conditioning through scheduling to encourage individuals with depression to engage in enjoyable activities. The schedule is important, because it forces individuals to be more intentional about doing something they may not want or have energy to do. The theory behind behavioural activation is that enjoyable activities are rewarding, and when a behaviour is rewarded, we keep doing it.

Applied Behaviour Analysis

One of Skinner’s biggest contributions to behaviour therapy was the concept of applied behaviour analysis (ABA) therapy. The aim of ABA therapy is to reduce inappropriate behaviours and increase effective communication, adaptive learning, and appropriate social behaviours (Wong et al., 2015). This is accomplished through the consistent use of positive reinforcement and rewards. For instance, an ABA therapist working with an adolescent on social skills may give a high five every time the teen greets a new person with a smile and handshake.

While ABA therapy is used to treat a number of psychological disorders, it is most commonly used as an intervention for individuals with autism spectrum disorder. There is strong evidence that when implemented intensively (i.e., more than 20 hours per week) and early in life (i.e., prior to the age of 4 years), ABA therapy is associated with large developmental gains and reduced need for special services later in life (Reichow, 2012).

Classical Conditioning Therapies

Classical conditioning involves learning that is based on the association of behaviours and environmental stimuli. A behaviour therapist employing classical conditioning techniques attempts to teach their patient about the predictive properties in the environment. The basic premise of these therapies is that learned behaviours are sometimes maladaptive, and this is when psychotherapy may be helpful.

In behaviour therapy, classical conditioning is a commonly applied treatment approach for fears and phobias. For example, an individual diagnosed with arachnophobia may experience uncomfortable physiological symptoms (e.g., sweating, racing heart) when confronted with a spider. A behaviour therapist may apply counterconditioning, a technique used to replace undesirable behaviours with more adaptive, desirable actions. Instead of wanting to run away when seeing a spider, the patient may learn to take deep breaths or repeat a calming mantra like, “spiders are not a big deal.”

Systematic Desensitisation

A specific counterconditioning technique that has been particularly effective is systematic desensitisation. Developed by Wolpe, systematic desensitisation is used by behaviour therapists to treat patients whose experience of anxiety is so overwhelming that it interferes with day-to-day life. An individual who is fearful of having peanut butter stuck to the roof of their mouth (arachibutyrophobia) can likely navigate life without having to lick a spoon of peanut butter or eat a peanut butter sandwich. However, a college student experiencing crippling test anxiety is far more likely to need intervention.

12526922203_6f193348b0_n.jpg
Figure 15.22: Systematic desensitisation is a therapeutic technique that can help patients manage their anxiety and phobias. [22]

​The first step in applying systematic desensitisation is teaching relaxation skills in the absence of the anxiety-provoking stimulus. For instance, a behaviour therapist may spend early sessions guiding their patient through deep breathing exercises or progressive muscle relaxation. Once the patient becomes proficient at relaxing at will – and it does take some practice –the next step is to establish a fear hierarchy. This chart ranks anxiety-inducing stimuli from least to most distressing. Once stimuli are identified, they are given a rating between 1-100, known as Subjective Units of Distress Scale (SUDS)  (Wolpe, 1969).

Ratings near the bottom of the SUDS produce little to no distress while a stimulus receiving a rating of 100 is likely to create a sense of extreme anxiety; for many people, even the thought of these stimuli creates sensations of distress. Once this hierarchy has been established, the therapist and patient practice relaxation in the presence of the low-SUDS stimuli. As the patient becomes more comfortable, the therapist works up through the hierarchy.

Figure 15.23: For someone with an intense fear of spiders, even looking at an image can cause extreme anxiety. [23]​

Example Fear Hierarchy:

 Stimulus

 SUDS Rating

  Think about a spider

 10

  Look at cartoon picture of a spider

 15

  Look at photograph of a spider

 25

  Look at a toy spider

 35

  Hold a toy spider in hands

 40

  Look at a real spider in a jar

 50

  Look at a real spider crawling on floor

 70

  Allow a real spider to crawl on clothing

 90

  Hold a real spider in hands

 100

​Consider the earlier example of a student experiencing test anxiety. Once the student has learned and practiced relaxation skills, fear-inducing stimuli would be placed on the fear hierarchy. A short attendance quiz may receive a rating of 20 SUDS, a midterm in a difficult course might receive a score of 75 SUDS, and a final exam worth 100% of the course grade would most likely receive 100 subjective units of distress. The first step would be to encourage the student to visualise sitting in a classroom taking a low-stakes quiz and then practice relaxing. Visualisation or imaginal exposure creates vivid, but safe, imagined experiences of stressful events. Creating an imagined event allows the behaviour therapist to assist with early confrontation of the threatening stimulus. Ideally, visualised quizzes become less anxiety-provoking and the student can confront real quizzes paired with relaxation techniques mastered in therapy. Thus, the purpose of this technique replaces the learned anxiety with a pleasurable sensation of calm. As the quiz becomes less anxiety-provoking, the student advances to visualising a midterm and relaxing, then taking an actual midterm while focusing on deep breathing and muscle relaxation. Ideally, it is possible to work up through the hierarchy to the final exam (although a final exam worth 100% of your overall grade would be rather anxiety-provoking for anyone).

Unfortunately, systematic desensitisation can take many months as the patient progresses through the hierarchy. A technique known as flooding uses extinction to reduce responding in the presence of anxiety-producing stimuli. Under carefully controlled conditions, a patient is placed in the highest rated anxiety-provoking situation, (safely) encouraged to confront their fear, and not permitted to escape. The initial reaction can be quite extreme, but over the course of several minutes (or hours) of exposure to the scary object or situation without consequences, the patient is able to relax. Although this approach may seem intense, it can be highly successful in confronting several different anxiety disorders.

Figure 15.24: Flooding uses the principle of extinction. A person faces their fear in a controlled environment until they are able to relax. [24]​

​Consider a person with a crippling fear of snakes (ophiophobia) who needs to recover quickly because she wants to be a veterinarian in a zoo. If her therapist to employ flooding, our future vet would sit in a room with several harmless snakes. Although she may feel completely panicked when the exercise begins, as the harmless snakes slither about the room over time and no negative consequences occur, her fear should be extinguished.

Question 15.21

Elsa is a 5 year old in a pre-Kindergarten program. Every week Elsa is assigned specific chores to complete, for every chore she does correctly, she gets a star. At the end of the week, she can trade her stars for books, toys, or games from the class 'store'. It would appear that Elsa’s teacher is using:

A

Token economy

B

Applied behaviour analysis

C

Counterconditioning

D

Extinction techniques

Question 15.22

Kamal is experiencing crippling test anxiety. His school therapist suggests he try learning relaxation skills and then practice relaxing when he thinks of quizzes, during quizzes, when he thinks of exams, and then finally during exams. Kamal's therapist is suggesting a technique known as:

A

Insight therapy

B

Transference

C

Systematic desensitisation

D

Behavioural activation

Question 15.23

Match the concept with its correct description.

Premise
Response
1

Voucher-Based Reinforcement

A

Patients are reinforced by engaging in enjoyable activities.

2

Behavioural Activation

B

Uses extinction to reduce responding in the presence of anxiety producing stimuli.

3

Applied Behaviour Analysis

C

Provides patients with a voucher for desired behaviours. These can be exchanged for something of value later.

4

Flooding

D

Reduce inappropriate behaviours and increase appropriate behaviours through consistent use of positive reinforcement.

Question 15.24

When Xander was three years old, there was a thunderstorm one night. When the storm was particularly close, the thunder became quite loud. As an adult, she is still terrified of thunderstorms. Based on classical conditioning, a behavioural therapist would suggest that the initial experience of thunder served as:

A

An unconditioned response

B

A conditioned stimulus.

C

A conditioned response.

D

An unconditioned stimulus.

Question 15.25

The therapeutic technique that increases adaptive behaviours using reinforcers is:

A

Systematic desensitisation

B

Aversion therapy

C

Social skills training

D

Use of a token economy

Humanistic Therapy

Figure 15.25. Carl Rogers is a major proponent of humanistic psychotherapy, which seeks to help individuals reach their full potential in life. ​[25]

​As psychology continued to progress as a profession and a science, limitations in existing psychotherapeutic approaches became more apparent. With its strong focus on the unconscious and past experiences, insight therapies were time-intensive and not necessarily focused on solutions to current problems. Behaviour therapies, on the other hand, were focused on very specific problems and did not address personal growth. Furthermore, behaviour theory is founded on nonhuman animal experimentation. Humanistic therapy developed as a means of better understanding and addressing problems unique to the human experience.

Humanism is a philosophy that suggests that individuals are all unique, that we all have a contribution to make, and that psychological health is found when we each reach our full potential for growth. As such, the primary goal of humanistic therapy is to help patients develop a stronger, healthier sense of identity to better understand the meaning of life (Kirk et al., 2015). Many consider humanistic therapy to be a more positive approach to the treatment of psychological disorders than earlier schools of psychotherapy.

The major proponent of humanistic therapy was Carl Rogers. Like many psychologists of his time, Rogers was trained psychoanalytically and valued the role of the unconscious. However, Rogers’ theories placed larger emphasis on the conscious aspects of human experience. As you might recall from his personality theory (see Chapter 7), Rogers (1959) distinguished between a real self and ideal self, which contributes to personality development (and sometimes maladjustment). The real self is constituted by how we view ourselves, our capabilities, and characteristics while the ideal self is how we think we should be – often based on external and societal expectations. When the real and ideal selves do not match, the result is psychological maladjustment. 

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Question 15.28

Idris has been struggling lately and has started seeing a Humanistic therapist. Idris has been struggling with his advanced physics class, he reports that even though he thinks he should be able to do well in the class and studies for hours at a time, he cannot pass the class. In this case it is most likely that Idris' therapist would say:

A

His unconscious anxiety is causing problems in class.

B

He needs to be properly rewarded for good behaviour.

C

There is a mismatch between his ideal self and real self.

D

The best treatment would be systematic sensitisation.

Person-Centred Therapy

Humanistic therapy can be applied to treat a number of psychological disorders, including anxiety, depression, personality disorders, and substance-related disorders. The overarching goal of this treatment approach is to guide an individual’s self-actualising tendency, which Rogers (1961) described as humans’ natural inclination to reach their full potential. With this strong focus on the patient’s own role in their treatment, Roger’s termed his model of humanistic therapy person-centred therapy (Hazler, 2016). However, the therapist providing this treatment has some very specific responsibilities. Person-centred therapy is founded on three basic conditions (Seligman, 2006):

Figure 15.26: Unconditional positive regard, empathy, and congruence are the keystones to Person-Centred Therapy. [26]​
  • Unconditional positive regard: the therapist is accepting, respectful, and caring towards the patient. Even when the therapist does not agree with the patient’s views or behaviours, they should demonstrate that they believe the patient is doing the best that they can.
  • Empathy: the therapist shows an understanding of the patient’s problems and emotions. This is different from sympathy, which is feeling sorry for the patient.
  • Congruence: the therapist is genuine and authentic. It is important that body language matches the words the therapist says. For example, saying “I’m sorry to hear that” while smiling is incongruent.

​In summary, a person-centred therapist is supportive, understanding, and nonjudgmental. There is also no hierarchy in humanistic therapy – the patient and therapist are peers. Finally, person-centred therapy is nondirective, meaning that the therapist follows the patient’s lead rather than forcing their own agenda. This implies, however, that person-centred therapy is a more effective option for patients who are self-motivated to make change.

Question 15.29

Match the term on the left with its definition on the right.

Premise
Response
1

Unconditional Positive Regard

A

Therapist is accepting¸ respectful and caring toward the patient.

2

Empathy

B

The therapist is genuine and authentic.

3

Congruence

C

The therapist shows an understanding of the patient’s problems and emotions.

Question 15.30

You are researching different therapists, one that you are particularly interested in states that she was highly influenced by the work of Carl Rogers. This therapist will likely:

A

Use systematic desensitisation to reduce specific fears.

B

Spend time trying to get unconscious conflicts into conscious awareness.

C

Use humanistic therapy for treatment

D

Prescribe medication to regulate brain chemistry.

Question 15.31

Samir is a therapist, in his practice, he is totally accepting and respectful of the patient. Samir is displaying the quality of:

A

Clarification

B

Congruence

C

Incongruence

D

Empathy

E

Unconditional positive regard

Gestalt Therapy

Another variation on humanistic therapy is based on gestalt theory, which asserts that “the whole is more than the sum of its parts.” Fritz Perls, founder of gestalt therapy, believed that sometimes the most important parts of ourselves are hidden from us (Perls, 1969). Gestalt therapy helps the patient to uncover these hidden elements of self that were suppressed because of external disapproval. Once these parts are discovered in a present-focused, genuine exploration of emotions and problems, the patient is then challenged by the therapist to re-own them.

Like other forms of humanistic therapy, gestalt therapy focused on the “here and now.” However, unlike person-centred therapy, the approach of gestalt therapists tends to be more direct and far less gentle. Patients are encouraged and sometimes actively pushed to express their feelings openly. The central tenet is that by understanding and expressing oneself as a whole person, the patient can then take responsibility for their feelings and discover the capacity to change.

Techniques of the Gestalt therapist can be rather creative. One famous technique is known as “the empty chair.” In this exercise, the patient imagines an individual or a problem sitting in an empty chair. They are encouraged to express their feelings and thoughts to the chair. The idea is that through 'talking it out', the patient can become aware of underlying conflicts. At times, the therapist will sometimes place the patient  in the 'hot seat' and even provoke strong emotions such as anger in the hopes of helping patients access their genuine feelings (Perls, 1969).

Figure 15.27: Cognitive therapy focuses on changing an individual’s maladaptive thoughts and beliefs. ​[27]
Question 15.32

Dr. Yun is a psychotherapist who encourages her patients to express their current feelings. Sometimes, she has patients talk through their feelings onto an empty chair. Dr. Yun is most likely:

A

A Gestalt therapist

B

A rational-emotive therapist

C

A psychoanalyst

D

A therapist who uses Beck's cognitive approach

Cognitive Therapy

The human mind is very powerful, and cognitive therapy capitalises on the strength of the mind. From a cognitive perspective, the way we think about things influences how we see our world, thereby influencing our emotions and behaviours. For example, reflecting on a sad memory can make us feel down and cry while thinking happy thoughts can make us feel good and smile. Cognitive therapy differs from the previously discussed schools of psychotherapy in that it focuses on thinking, specifically maladaptive thoughts. Essentially, cognitive therapy treats psychological disorders by teaching thought-management techniques to dispel negative thinking patterns.

Figure 15.28: Cognitive therapy focuses on changing an individual's maladaptive thoughts and beliefs. ​[28]

​During the 1950’s, psychologist Albert Ellis introduced Rational-Emotive Therapy, a psychotherapy strongly influenced by cognitive theory. In this modality, patients were taught the A-B-C approach (Ellis, 1994):

A – Adverse event: a situation or event that triggers a negative emotional or behavioural response.

B – Beliefs: the core beliefs associated with the activating event.

C – Consequences: the emotional or behavioural outcome due to beliefs about the activating event (the psychological problem).

When facing an adverse event (A), an individual’s beliefs (B) about that event will influence their response and lead to emotional or behavioural consequences (C). While we all hold certain beliefs about events in our lives, Ellis argued that it is the irrational or inflexible beliefs (e.g., I must be loved to be valuable, I must be the smartest in the class) that are consequential (Dryden & Neenan, 2003).

Consider this example of Hendrick, a man recently diagnosed with major depressive disorder. Hendrick reported that he started to feel down after breaking up with his romantic partner. His cognitive therapist argued that it was not the breakup that has him down, but rather his beliefs about the breakup. Hendrick acknowledged that he had been telling himself that he is not worthy of love and that no one will ever love him again, and that over time, these beliefs became automatic and involuntary.

Ellis believed the role of the cognitive therapist is to directly, and sometimes aggressively, challenge irrational maladaptive beliefs until they are surrendered. The central tenet of rational-emotive therapy is that the therapist attacks the maladaptive thinking with the goal of illustrating that the belief is fundamentally irrational.

Building upon the ideals of rational-emotive therapy, a psychiatrist named Aaron Beck introduced cognitive therapy as a treatment for depression. Similar to rational-emotive therapy, Beck’s model of intervention addresses dysfunctional thinking by focusing on the connections between how an individual evaluates events and the resulting emotions (Chambless & Ollendick, 2001). Patients are trained to identify negative forms of thinking, and they are encouraged to reevaluate these beliefs.  To facilitate this process, Beck developed the thought record, in which patients write out their thoughts with the goal of finding healthier ways of thinking.

In developing cognitive therapy, Beck identified several patterns of automatic negative thoughts that he termed cognitive distortions. Cognitive distortions tend to be exaggerations or misperceptions of actual life events. Some examples include:

  • ​All-or-Nothing Thinking (also known as black and white thinking or dichotomous thinking) – an individual sees a situation in only two categories instead of along a continuum. ​Example: “If I don’t earn all A’s, I’m a failure.”
  • Discounting the Positive – an individual believes that positive attributes and experiences do not count. ​Example: “I was only hired for this job because I got lucky.”
  • Catastrophising – an individual makes negative predictions about the future without considering other, more likely possibilities. Example: “I will never be able to learn all this material before my exam.”

Once cognitive distortions are identified, a cognitive therapist works with patients to retrain how they think about their daily lives. Keeping a thought record can be very useful in this process. During therapy sessions, the therapist and patient evaluate the distorted thinking and discuss more adaptive ways to think about life events.

Question 15.33

Rational-emotive therapy is designed to help the patient by:

A

Identify negative forms of thinking

B

Challenge irrational beliefs through aggressive interactions.

C

Treat the patient with unconditional positive regard.

D

Help the patient uncover hidden desires embedded in the unconscious.

Question 15.34

Cognitive therapies are based on the assumption that:

A

Psychological disorders result from unconscious anxiety.

B

Each person has all the tools needed to achieve mental health.

C

Disorder results from irrational beliefs and maladaptive thoughts.

D

Therapists should be unconditionally accepting of their patient.

Question 15.35

Dr. Samuels is a psychotherapist who often becomes confrontational with her patients. She often encourages them to think about things from a different perspective. She tries to get them to confront their irrational beliefs and maladaptive thoughts. Dr. Samuels is most likely:

A

A person-centred therapist

B

A therapist who uses Beck's cognitive approach

C

A psychodynamic therapist

D

A rational-emotive therapist

E

A behavioural therapist

Question 15.36

Dr. Khislavsky requests that her patients keep extensive records of intrusive thoughts and emotions. They work together to come up with solutions to these thoughts. This form of psychotherapy is:

A

Rational emotive therpay

B

Person-centred therapy

C

Beck's cognitive therapy

D

None of the above

Cognitive Behavioural Therapy

Figure15.29.jpg
Figure 15.29. A model that depicts the intersection of cognitive and behavioural therapy, including the internal thoughts, feelings, and beliefs of the individual interfacing with behaviour.​

Cognitive Behavioural Therapy (CBT) is a model of psychotherapy that combines the basic tenets of behavioural and cognitive therapies. As discussed, the rise of behaviour therapy was a drastic departure from insight therapies. In fact, behaviour therapy is now considered to be a distinct era of psychotherapy and is often referred to as the first wave of psychotherapy (Hayes & Hofmann, 2017). CBT, referred to as the second wave, focuses on information processing, and specifically how emotions and behaviours are influenced by maladaptive thought patterns. CBT employs techniques to identify and change those patterns.

As a school of psychotherapy, CBT is short-term, action-oriented, and problem-focused. Furthermore, in comparison to the exploration of the unconscious in insight therapy and the self-actualisation goals of humanistic therapy, CBT is intended to treat specific psychological disorders. Just like behaviour and cognitive therapies, CBT is based on the view that problematic behavioural and thinking patterns play a key role in development of psychological disorders, and that effective treatment of psychological disorders must include more adaptive behaviours and thoughts (Beck & Dozois, 2011).

Figure 15.30: Cognitive behavioural therapy combines elements of both of cognitive therapies and behavioural therapies. [29]​

​While Beck referred to his contributions to psychotherapy as cognitive therapy, he is also considered to be a founder of CBT. Beck’s cognitive triad represents an individual’s belief system about the self, the world, and the future that can make them more or less susceptible to depression. Treatment addresses automatic or spontaneous negative thoughts regarding aspects of this system. An example of this therapeutic process is cognitive restructuring, in which patients learn to identify their cognitive distortions, dispute their negative thoughts, and develop alternate, more positive and rational thoughts.

Psychotherapy has come a long way since Freud introduced psychoanalysis, and CBT is now the most widely used form of evidence-based psychotherapy (Field, Beeson, & Jones, 2015). CBT has demonstrated efficacy in the treatment of depression, bipolar disorder, anxiety disorders, somatic disorders, eating disorders, substance use disorders, schizophrenia and other psychotic disorders, insomnia, personality disorders, anger and aggression, criminal behaviours, general stress, distress due to general medical conditions, chronic pain and fatigue, and distress related to pregnancy complications, (Hofmann et al., 2012). As practitioners refine this efficacious treatment model, a third wave of psychotherapy has been ushered in (Hayes & Hofmann, 2017).

The third wave of psychotherapy emphasises mindfulness, acceptance, and individual values and goals (Kahl, Winter, & Schweiger, 2012). Treatments include acceptance and commitment therapy, dialectical behaviour therapy, and mindfulness-based cognitive therapy. Although these modes of psychotherapy have not been around as long as CBT, efficacy and effectiveness trials have shown strong evidence for these third wave treatments (Ost, 2008). While there is no evidence that third wave psychotherapy performs better than CBT, it seems that patients may be more accepting of mindfulness-based treatments, as shown by better retention rates in treatment (Kahl et al., 2012).

Question 15.37

Match the term with its appropriate explanation.

Premise
Response
1

Cognitive triad

A

Represents an individual’s belief system about the self¸ world¸ and future.

2

Cognitive restructuring

B

Patients learn to identify their cognitive distortions.

Question 15.38

The most widely used form of evidence-based therapy used today is:

A

Cognitive therapy

B

Behavioural therapy

C

Psychoanalysis

D

Cognitive-behavioural therapy

Question 15.39

What do the letters A, B, and C stand for in rational emotive therapy?

A

A is adverse event; B is beliefs; C is consequences

B

A is adaptability; B is beliefs; C is cognitive appraisal

C

A is adverse event; B is benefit; C is cognitive

D

A is adaptability; B is benefit; C is contagion

Question 15.40

Beck’s cognitive triad represents an individual’s belief system about:

A

The past, present, and the future.

B

Their worth, their creativity, and their ability to accomplish goals.

C

The self, the world, and the future.

D

The self, the other, and the interaction with the environment.

​15.2.3 Social Approaches – Addressing the Environment

The statement that individuals are products of their environment means that we are influenced by the people and things around us. This statement certainly holds true for the development, maintenance, and treatment of psychological disorders. According to the biopsychosocial model (Engel, 1980), it is the interaction of biological makeup, psychological experiences, and social environment that determine risk as well as treatment success. The previous sections of this chapter have examined biological and psychological approaches to treatment, and it is now time to turn to social approaches.

Figure 15.31: Sometimes, treatment requires addressing the environment to promote patient's success. [30]​

​The social environment is broad and complex, and treatment of psychological disorders occurs within the social environment. Malsow’s hierarchy of needs (see Chapter 12) proposes that individuals must meet basic needs before they are able to address higher-order needs. In terms of psychological treatment, it is hard to imagine that a patient can participate fully in psychotherapy when they are hungry or have no safe place to sleep. Similarly, a psychiatrist prescribing an antidepressant may assume that the patient has access to healthcare insurance to cover costs, although this is not always the case.

Many times, a treatment plan must go beyond interactions with a mental health provider. Some patients may benefit from connection with community resources and government agencies, such as food banks, employment initiatives, child-care services, and housing resources. Social workers specialise in connecting patients with such resources (Bureau of Labor Statistics). While trained to provide psychotherapy, social workers have additional training in advocacy and problem solving techniques. Such a holistic view to the treatment of psychological disorders is likely to demonstrate improvements in mental health outcomes (Prince et al., 2007).

15.3 Conclusion

​There is no shortage of ways to help people who experience psychological disorders. In fact, the field of mental health care continues to expand to find new and improved models of alleviating the distress associated with mental illness. In 1952, Hans Eyesenck published, “The Effects of Psychotherapy: An Evaluation.” In this report, he concluded that psychotherapy works just as well as doing nothing. He went on to report that spontaneous remission, or improvement in mental health, that occurs without any particular form of treatment happens in about 72% of the population. Despite these uninspiring results, psychological treatment grew and flourished over the years, and in another classic study, Smith, Glass, and Miller (1980) aggregated data from 475 research studies and revealed that the average psychotherapy patient had better outcomes than 80% of untreated patients. More recent research continues to demonstrate that mental health intervention is effective. As our world continues to evolve, it will be important that the treatment of psychological disorders keeps up with the pace of this evolution in order to continue helping those in need.

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