Topic 14: Therapies

Historical Approaches to Mental Health Treatment

The history of psychological therapies reveals evolving attitudes and practices toward mental illness. Early institutions were often characterized by harsh conditions and ineffective treatments, while later decades saw the development of medications and deinstitutionalization.

• 1400s: First institutions for the mentally ill were established, often with brutal conditions.

• Late 1800s: Overcrowded asylums and ineffective treatments such as cold water submersion and electroshock therapy.

• 1960s: Discovery of antipsychotic medication, deinstitutionalization, and emergence of residential treatment centers.

Example: Deinstitutionalization led to many mentally ill individuals becoming homeless or involved with the justice system.

Mental Health & Homelessness in Canada

Mental health issues are prevalent among homeless populations, with youth and Indigenous individuals experiencing higher rates of mental health and substance use challenges.

• 85% of homeless individuals report at least one health challenge.

• Youth (13-24) have the highest prevalence of mental health issues (67%).

• Indigenous respondents report higher rates of substance use (69%) compared to non-Indigenous (57%).

• Former youth in care have significantly higher rates of mental health and substance use issues (59% vs. 41%).

The Courts & Mental Health

The legal system may mandate treatment for individuals with severe mental health issues, including community treatment orders and involuntary hospitalization.

• Community treatment orders require individuals to live in the community under legally mandated treatment conditions.

• Highly erratic or disturbing behavior may lead to court-ordered treatment.

• Controversial due to concerns about individual rights and resource shortages.

Students & Mental Health

University students face increasing rates of depression and mental health challenges, with counseling centers often experiencing high demand and long waiting lists.

• 15-20% of university students exhibit symptoms of depression.

• 50% increase in prevalence over the past two decades.

• Counseling centers vary by size and funding, often with waiting lists.

Mental Health Treatment Today

Modern mental health treatment includes psychiatric hospitals, community hospitals, and a range of professionals. Hospitalization is typically reserved for imminent threats to self or others, with legal protections for involuntary admissions.

• Psychiatric hospitals focus on short-term care.

• Involuntary admission requires risk of serious harm or inability to care for oneself.

• Legal representation and review boards are available to challenge detention.

Sources of Psychological Treatment

Individuals can seek mental health help from various sources, each with distinct roles and qualifications.

• Family doctors & primary care clinics: Initial assessments, medication, referrals.

• Psychiatrists: Medical doctors, can prescribe medication, treat severe disorders.

• Private psychologists & therapists: Provide therapy and assessments, cannot prescribe medication.

• Community mental health services: Offer low-cost support, therapy, crisis intervention.

• Crisis & emergency services: Immediate support for acute mental health crises.

Types of Therapists

Different professionals provide psychological treatment, each with specific training and scope of practice.

• Clinical Psychologists: PhD or PsyD, specialize in assessment and treatment.

• Counselling Psychologists: PhD, EdD, or master's, focus on adjustment problems.

• Psychiatrists: MDs, can prescribe medication, treat severe disorders.

• Psychoanalysts: Specialize in psychoanalysis, often MDs or psychologists.

• Registered Psychotherapists: Certified professionals, provide therapy for a range of issues.

• Licensed Professional Counsellors: Master's degree, certified, provide therapy to individuals, couples, families.

• Clinical/Psychiatric Social Workers: Master's degree, specialized training, focus on family and personal problems.

Barriers to Psychological Treatment

Several factors can impede access to mental health care, including stigma, cultural attitudes, and financial constraints.

• Ambiguity of disorders

• Stigma about mental illness

• Attitudes toward treatment

• Gender roles

• Culture

• Geographical barriers

• Financial barriers

Cultural Barriers to Therapy

Cultural background influences willingness to seek therapy. Individualistic cultures are more accepting of therapy, while collectivist cultures may view it less favorably.

• Asian Canadians and Indigenous people are less likely to seek treatment than Canadians of European background.

• Therapy is more popular in Canada and the US than in countries like Israel, Hungary, Japan, Korea.

Men & Mental Health

Men face unique barriers to seeking mental health treatment, including masculinity norms, symptom recognition, attitudinal barriers, stigma, and service fit.

• Masculinity Norms: Emotional disclosure seen as weakness.

• Symptom Recognition: Depression may manifest as anger or substance use.

• Attitudinal Barriers: Preference for self-reliance, discomfort with vulnerability.

• Stigma: Fear of judgment from peers, family, workplace.

• Service Fit: Services may not be tailored to men's communication styles.

Types of Psychological Therapies

Insight Therapies

Insight therapies involve dialogue between client and therapist to gain awareness and understanding of psychological problems. Psychodynamic therapies emphasize uncovering unconscious conflicts.

• Psychoanalysis: Developed by Freud, aims to release unconscious thoughts and feelings.

• Techniques: Free association, dream analysis.

• Resistance: Unwillingness to discuss certain memories or thoughts.

• Transference: Transfer of feelings to the therapist.

Psychodynamic Therapy

Modern psychodynamic therapy is shorter in duration and focuses on early childhood experiences and emotional attachments. It is partially empirically supported for certain disorders.

• Object relations therapy: Focuses on childhood experiences and emotional attachments.

• Evaluation: Promising for panic disorder, opiate addiction, and borderline personality disorder.

Person-Centered Therapy

Person-centered therapy emphasizes the therapeutic relationship, self-actualization, and empathy. It is a non-directive, humanistic approach.

• Core conditions: Congruence, unconditional positive regard, empathy.

• Therapeutic alliance: Strong predictor of successful therapy.

Behavioral Approaches

Behavioral therapies apply principles of learning to change undesirable behaviors. Classical and operant conditioning techniques are commonly used.

• Aversive conditioning: Uses unpleasant stimuli to stop unwanted behaviors.

• Systematic desensitization: Gradual exposure to anxiety-provoking stimuli paired with relaxation.

• Flooding: Rapid exposure to anxiety-provoking stimuli.

• Operant conditioning: Rewards desirable behaviors, extinguishes negative behaviors.

• Observational learning: Modeling appropriate behaviors.

Cognitive-Behavioural Therapies (CBT)

CBT addresses negative thoughts and behaviors, helping clients find more logical and positive ways to interpret situations. It is effective for a range of disorders.

• Cognitive restructuring: Rethink negative beliefs.

• Exposure: Face avoided situations.

• Relaxation: Regain emotional control.

• Homework and practice: Client and therapist work intensively.

Dialectical Behavioural Therapy (DBT)

DBT focuses on acceptance, behavioral skills, distress tolerance, and mindfulness. It is especially effective for some personality disorders.

• Distress tolerance: Negative emotions are inevitable but temporary.

• Mindfulness training: Attention to present experiences without judgment.

Interoceptive Exposure Therapy

Used to treat panic disorder by exposing clients to normal physical sensations associated with panic attacks, helping them perceive these sensations as harmless.

• Examples: Spinning in a chair, breathing through a straw, stair climbing, hyperventilating.

Mindfulness-Based Cognitive Therapy

This approach combines mindfulness meditation with CBT tools, encouraging decentering and objective self-observation.

• Decentering: Step back from normal consciousness and observe oneself objectively.

Evaluating Cognitive-Behavioural Therapies

• Advantages: Effective for anxiety, depression, substance abuse, eating disorders.

• Disadvantages: May not acknowledge irrational aspects of life; logical thinking is not always helpful.

Group and Family Therapies

Group therapy provides support and advice in a group setting, while family therapy aims to adopt new roles and patterns of behavior. Self-help groups are also common.

• Economical: Group therapy is cost-effective.

• Types: Self-help groups (e.g., AA), family therapy.

Does Therapy Work?

Psychotherapy is effective for most people, but not all. Different treatments are suited to different problems, and therapists often use an eclectic approach.

Biomedical Therapies

Antipsychotic Drugs

Antipsychotic drugs temporarily reduce psychotic symptoms by blocking dopamine receptors. Newer antipsychotics may increase dopamine in certain brain areas.

• Example: Clozapine increases dopamine in planning and goal-directed areas.

Antianxiety Drugs

Benzodiazepines (e.g., Xanax, Valium, Ativan) reduce excitability and increase well-being by affecting GABA activity. There are concerns about dependence and lethality with alcohol.

Antidepressant Drugs

Antidepressants improve well-being and are used for anxiety disorders. Types include tricyclics, MAO inhibitors, and SSRIs.

• Tricyclics: Increase norepinephrine.

• MAO inhibitors: Prevent breakdown of neurotransmitters.

• SSRIs: Target serotonin, allow it to linger at synapse (e.g., Prozac, Zoloft).

Herbal Remedies

St. John’s Wort is a supplement shown to reduce depression, but quality is not standardized and it can interact with other medications.

New Directions in Psychopharmacology

• Ketamine therapy: Blocks NDMA receptor, affects glutamate, promising for treatment-resistant depression.

• Side effects: Cognitive impairment, increased depressive symptoms, addiction concerns.

Transcranial Magnetic Stimulation (TMS)

TMS uses magnetic pulses to activate specific brain areas, effective for depression but may cause seizures.

Electroconvulsive Therapy (ECT)

ECT is used for severe depression, involves brief electric currents, and is controversial due to potential side effects like memory loss.

Psychosurgery

Historically involved lobotomies and lesions; now a last resort for severe OCD, depression, and bipolar disorder.

Biomedical Therapies in Perspective

• Revolutionized mental health treatment.

• Allows more outpatient care.

• Not a cure-all; may only provide temporary relief and can have serious side effects.

Eye Movement Desensitization & Reprocessing (EMDR)

EMDR involves recalling traumatic events while performing rapid eye movements. It is controversial due to limited evidence and unclear mechanisms.

On Being Sane in Insane Places (Rosenhan, 1970s)

Rosenhan's study demonstrated the challenges of psychiatric diagnosis, as sane individuals were admitted to hospitals and treated as schizophrenics, highlighting issues of depersonalization and misdiagnosis.