Therapies in Psychology

Historical Approaches to Mental Health Treatment

The treatment of mental illness has evolved significantly over the centuries, reflecting changes in societal attitudes, scientific understanding, and available resources.

• 1400s: The first institutions for the mentally ill were established, often characterized by harsh and inhumane conditions.

• Late 1800s: Overcrowded asylums became common, with ineffective and sometimes brutal treatments such as cold water submersion and early forms of electroshock therapy.

• 1960s: The discovery of antipsychotic medications led to deinstitutionalization, shifting care from asylums to community-based settings and residential treatment centers.

Example: Deinstitutionalization resulted in many individuals with mental illness living in the community, but also contributed to increased rates of homelessness and justice involvement among this population.

Mental Health and Homelessness in Canada

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

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

• Youth (ages 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%).

Additional info: Deinstitutionalization, while intended to improve care, has left many mentally ill individuals without adequate support, leading to increased interactions with the justice system.

The Courts and Mental Health

The legal system sometimes mandates mental health treatment for individuals whose behavior is highly erratic or disturbing. Community treatment orders require individuals to live in the community under legally mandated treatment conditions, such as taking medication or attending psychiatric appointments. This is a controversial issue, balancing public safety and individual rights.

Modern Mental Health Treatment Settings

Today, mental health treatment is provided in a variety of settings, with a focus on short-term care and community integration.

• Psychiatric hospitals and local community hospitals focus on short-term care, usually for individuals who are an imminent threat to themselves or others.

• Involuntary admission (e.g., Form 1 in Ontario) is used when there is a risk of serious harm or inability to care for oneself. Legal rights include access to legal representation and review boards.

• Sources of treatment: Family doctors, psychiatrists, private psychologists/therapists, community mental health services, and crisis/emergency services.

Types of Therapists

There are several types of mental health professionals, each with different qualifications and roles:

• Clinical Psychologists: Hold a PhD or PsyD, specialize in assessment and treatment of psychological difficulties.

• Counselling Psychologists: Typically treat day-to-day adjustment problems.

• Psychiatrists: Medical doctors who can prescribe medication and treat severe psychological disorders.

• Psychoanalysts: Specialize in psychoanalysis, often with medical or psychology backgrounds.

• Registered Psychotherapists: Provide therapy for a range of issues, with varying educational backgrounds.

• Licensed Professional Counsellors/Clinical Mental Health Counsellors: Hold a master’s degree and certification.

• Clinical or Psychiatric Social Workers: Hold a master’s degree and provide therapy for common family and personal problems.

Barriers to Psychological Treatment

Many factors can prevent individuals from seeking or receiving effective mental health care:

• Ambiguity of disorders

• Stigma about mental illness

• Attitudes toward treatment

• Gender roles and cultural expectations

• Geographical and financial barriers

Cultural Barriers to Therapy

Cultural background influences attitudes toward therapy. In Canada, Asian Canadians and Indigenous people are less likely to seek mental health treatment than Canadians of European background. Therapy is more widely accepted in individualistic cultures and less so in collectivist cultures.

Men and 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, or workplace.

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

Insight Therapies

Psychoanalysis

Psychoanalysis, developed by Freud, aims to release unconscious thoughts and feelings to reduce their influence on behavior. Techniques include free association and dream analysis. Resistance and transference are common phenomena in psychoanalysis.

• Resistance: Inability or unwillingness to discuss certain memories or motivations.

• Transference: Transfer of feelings toward 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, especially for panic disorder, opiate addiction, and borderline personality disorder (BPD).

Person-Centered Therapy

This humanistic approach emphasizes the importance of the therapeutic relationship, self-actualization, and empathy. A strong therapeutic alliance is a good predictor of successful therapy outcomes.

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

Behavioral Approaches

Classical Conditioning Techniques

Behavioral therapies apply principles of learning to change undesirable behaviors. Classical conditioning techniques include:

• Aversive Conditioning: Pairing an unpleasant stimulus with an unwanted behavior (e.g., Antabuse for alcohol use disorder).

• Systematic Desensitization: Gradual exposure to anxiety-provoking stimuli paired with relaxation techniques to extinguish the anxiety response. Used for phobias and anxiety disorders.

• Flooding: Rapid and intense exposure to the feared stimulus until the anxiety diminishes. Newer forms use VR technology.

Operant Conditioning Techniques

Operant conditioning techniques reinforce desirable behaviors and extinguish negative ones through rewards, ignoring, or punishment. Examples include token systems, contingency contracting, and observational learning (e.g., Fearless Peer).

Evaluation of Behavior Therapy

• Advantages: Effective for phobias, compulsions, impulse control, and social skills training.

• Disadvantages: Does not address underlying thoughts or severe disorders like deep depression.

Cognitive-Behavioral Therapies (CBT)

Principles and Techniques

CBT, developed by Aaron Beck, assumes that negative emotions stem from faulty thinking. It helps clients identify and restructure negative beliefs, face avoided situations, and practice relaxation techniques.

• Cognitive restructuring – Rethinking negative beliefs.

• Exposure – Facing avoided situations.

• Relaxation – Regaining emotional control.

Dysfunctional Thinking Patterns in Depression

• Internal attributions: "It's all my fault."

• Stable attributions: "It's never going to change."

• Global events: "My whole life is ruined."

Dialectical Behavioral Therapy (DBT)

DBT focuses on acceptance and change, teaching behavioral skills for emotional regulation, distress tolerance, mindfulness, and interpersonal effectiveness. It is especially effective for some personality disorders.

Interoceptive Exposure Therapy

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

Mindfulness-Based Cognitive Therapy (MBCT)

MBCT combines mindfulness meditation with CBT tools, encouraging clients to "decenter" and observe their thoughts and feelings objectively.

Evaluation of CBT

• Advantages: Effective for anxiety, depression, substance abuse, and eating disorders. Can be combined with other approaches.

• Disadvantages: May not address irrational aspects of life or be helpful in all cases.

Group and Family Therapies

Group therapy provides support and advice in a group setting, while family therapy focuses on improving family dynamics. Self-help groups (e.g., Alcoholics Anonymous) are also common.

Effectiveness of Therapy

Psychotherapy is generally effective for most people, though not universally so. Different treatments are suited to different problems, and therapists often use an eclectic approach.

Biomedical Therapies

Antipsychotic Drugs

Antipsychotic drugs reduce psychotic symptoms by blocking dopamine receptors. Newer antipsychotics may increase dopamine in certain brain regions. They are not a cure-all and can have serious side effects.

Antianxiety Drugs

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

Antidepressant Drugs

Antidepressants improve well-being and are used for depression and anxiety disorders. Types include tricyclics, MAO inhibitors, and selective serotonin reuptake inhibitors (SSRIs) such as Prozac and Zoloft. Not effective for everyone and may have side effects.

Herbal Remedies

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

New Directions in Psychopharmacology

• Ketamine therapy: Blocks NMDA receptors, promising for treatment-resistant depression but with side effects and addiction concerns.

Transcranial Magnetic Stimulation (TMS)

TMS uses magnetic pulses to activate specific brain regions, effective for depression but with risks such as seizures.

Electroconvulsive Therapy (ECT)

ECT is used for severe depression, involving brief electrical currents to the brain. It is controversial due to potential side effects like memory loss, and its mechanism is not fully understood.

Psychosurgery

Historically, procedures like lobotomies were common. Modern psychosurgery is a last resort for severe cases and uses more precise techniques.

Biomedical Therapies in Perspective

Biomedical therapies have revolutionized mental health treatment, allowing more outpatient care. However, they often provide only temporary symptom relief and may not address underlying problems.

Controversial and Alternative Therapies

Eye Movement Desensitization and Reprocessing (EMDR)

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

On Being Sane in Insane Places (Rosenhan Study)

Rosenhan’s study involved "sane" individuals gaining admission to psychiatric hospitals by feigning hallucinations. The study highlighted issues of depersonalization and the challenges of psychiatric diagnosis.