– [Voiceover] Hello, this is Jeff Luzel, I’ve already provided some
lectures on psychopathology covering chapters 14 in your textbook. Today I’m going to be covering chapter 15, which deals specifically
with the treatment of psychological disorders. Let’s start by asking the
question, “Who seeks treatment?” And I want to provide you
with some general points to help anchor your
understanding of the answer to this question. So, approximately 15% of the
population of the United States seeks some form of mental
health treatment each year. That’s a significant number,
but one of the things that we know for sure is that this
is a gross under estimation of the number of people both who need, would benefit from
psychological treatment, but also who could use treatment
at any given point in time. We also know that more women
than men seek treatment. And we could ask the
question why might that be? Typically, those with medical
insurance are the ones who avail themselves, who have
psychotherapy at any moment in time. But we also know that a lot
of people without insurance are getting psychological treatment, often through emergency medicine services. Those with higher levels
of education are also more likely to seek mental health services. And in terms of disorders,
depression and anxiety are the most commonly treated
disorders in the United States. This gives you a little bit
of an overview of who seeks treatment for mental health problems. Let’s take a slightly more
fine grain look at that. So, as you see from this graph here, what I’ve done is provided
data that breaks down, basically, what I’ve just reviewed. Looking at issues like medical insurance, marital status, divorce,
separated, married, single, for instance. Levels of education, age, and gender. And this gives you a bit of a picture of the data that went into
some of the points that I just made. So take a second and look at this and see what comes to mind for you. Now, turning to our next slide,
what you see here graphed is the proportion of people
who are seeking or obtaining treatment based on the type
of psychological disorder that they might have. And here, again, take a look at this one. One of the things you’ll
see is that, perhaps, major depression and anxiety
are the most commonly treated disorders. Certainly the DSM disorders. But you see that a lot of
the other disorders are being treated at about the same rate. Now, who provides treatment? Who provides mental health
treatment to the kinds of demographics that you you’ve
just seen on the previous slides or based on the kind
of psychological disorder that somebody might be struggling with. In the United States, and I
think this is fairly typical in most modern industrialized
first world countries around the world, clinical
psychologists or psychiatrists are the two leading providers
of mental health services. Clinical psychologists
include people with PhDs, or research degrees, or
PsyDs who are more treatment focused degrees. Counseling psychologists also
with PhDs or with masters are common providers of
mental health services. But then, I think psychiatry
is likely to be one of the two larger professional
degrees that provides mental health treatment. And again, the major
distinction between psychiatry, individuals with an MD, and
psychologists and counseling psychologists with PhDs is
that Mds have been trained to provide medication, whereas
psychologists are generally providing talking therapies
and other kinds of cognitive and behavioral therapies that
I’ll be reviewing in a bit. Additionally, we have
clinical social workers, which is a large and very
common class of professionals who are providing treatment. Clinical social workers
often with masters degrees are not involved in providing medications, but part of their training
is to be very alert to or aware of somebody who
might benefit from medication and to provide referrals to psychiatrists. We have psychiatric nurses
working in tandem with psychiatry or clinical
psychology, and often those are individuals who are working
at hospital settings or in-patient mental
health treatment settings. They work in combination
with psychologists and psychiatrists. And then, finally, a large
class of, or catch all class, would be referred to as paraprofessionals, and these are individuals with
not necessarily additional formal educational training
in the provision of mental health treatment, but who
probably, by experience and based on their own professions
have acquired a good understanding of how to
help other individuals. And often we find that
different socio-cultural or cultural and ethnic groups
will favor paraprofessionals. For instance, priests and
faith workers, teachers, educators are often in this role. So you can think of a whole
class of individuals who, while not trained in mental
health treatment provision, by virtue of who they are
and what their profession is, they’re often working closely
with individuals who are struggling with mental
health treatment problems. Okay, now, let’s focus now on the basic approaches to the
treatment of psychological disorders. And organizing this section
I want to ask the question, “How do we treat psychological disorders?” So we’ve talked a little
bit already about who seeks treatment and who provides treatment. Now let’s actually dig in
and look at the types of psychological disorders that
we’ve reviewed in chapter 14 and ask the question of how
do we actually treat these? I think the easiest way to
approach this question is to organize the basic psychological
treatments into two major classes. Those that are biologically
based and those that are really focusing on
psychological processes. And I’ll start with biologically
based interventions. And as you probably can
appreciate, these approaches to treating mental illness
reflect medical ideas of what constitutes psycho-pathology
or what constitutes mental disorders and diseases. The other major class
would be psychologically based interventions, or
what we call psychotherapy. And these are, although
they may have a belief that the kind of disorder you’re
treating is biologically rooted or is affected by your biology, the major goals or aims of
psycho therapy is to change patterns of thought and
behavior through other kinds of psychological mechanisms. Not addressing underlying
biology, but addressing cognitive processes, emotional processes, and behavioral processes. So these are the two large
classes of treatment for psychological disorders. Let’s now take a look at these
a little bit more carefully. Now, a lot of you probably
have either firsthand or secondhand experience with
biological approaches to treating mental health issues. This is, perhaps, one of the most common, if not the most common approach. It’s often thought to be
the frontline approach for dealing with mental health problems. And it takes the form of
what we call pharmacotherapy, or the prescription of medication. So psychotropic medications
are medications that are prescribed for psychological problems. Are a class of, or different
classes of drugs that, really, are geared at changing
brain neuro chemistry. And in the process affecting
mental processes and even behavioral processes. You know, there are many
different kinds of pharmacotherapy medications used to treat
different kinds of disorders. And they all operate in
the brain differently. For instance, a number of
them would be geared or developed to inhibit the
way certain kinds of areas of the brain are functioning. Inhibit neuro chemistry,
inhibit neuro firing. Others are designed to
increase or even decrease the activation of different
kinds of neurotransmitters. So if you remember back to
our chapters on the brain and how brain chemistry
is really what drives psychological processes, you
can think about medications that are being developed to
target neurotransmission. Either by increasing or
decreasing the availability of a range of different kind
of neurotransmitters. So psychotropic medications
are really operating on different waves, but have some
of the same outcomes in mind. Changing thought processes,
emotional processes, and ultimately behavior by
regulating neuro chemistry. We, when we look at the
kinds of, or classes of, pharmacotherapy that’s
available right now, we see largely three
types of drug categories. Modern day drugs targeting
major psychological disorders fall into categories such
as anti-anxiety psychotropic medications, antidepressants,
and antipsychotics medicines. These three classes are
operating and sometimes similarly, but at the core
they’re really targeting different areas of the brain
and their usage reflects different understanding of what might be causing psychopathology for somebody. Alright, so let’s look
at anti-anxiety drugs. So, in general, these are
medications that have a tranquilizing effect. And commonly these are
referred to as tranquilizers. So a drug such as Xanax,
which is a commonly used term in popular media, etc. It’s a drug that’s targeting
areas of the brain that lead to elevated mood, increased
nervousness and arousal, and by tranquilizing or
calming these circuits in the brain, we generally think
that we can lower symptoms of anxiety. Benzodiazepines, which is
the formal medical name for these kinds of anti-anxiety medications. For instance, Xanax, have
as their action increasing the activity of certain
kinds of neurotransmitters. Something like GABA, which
is a neurotransmitter in the brain that’s involved in
regulating mood and arousal. And by increasing
neurotransmission of something like GABA and other neurotransmitters,
what we believe and what this drug reflects
is the theory that anxiety is a deficit of a
neurotransmitter like GABA. The absence of sufficient
GABA in the brain increases arousal, increases nervousness,
increases feelings and states of anxiety. And by bringing these levels
to what we would consider to be normal typical
levels, the theory is that Benzodiazepines such as
Xanax, by increasing GABA, would lower symptoms of anxiety. Now, as you’re going to see
or hear in the next couple of minutes, and hopefully
you’ve read in chapter 15, any kind of medication that
we might prescribe to deal, treat mental health problems,
are going to have positives, but importantly, are
often carry side effects, or what we call cons and negatives. And the use and prescription
of any kind of drug, we need to think carefully
about both of these. So, the pros for
anti-anxiety medications is, we would hope, is that it
reduces anxiety and through tranquilization processes,
promotes relaxation. But the cons, especially
if you don’t have the right dosage level, or may have
prescribed anti-anxiety disorder that doesn’t really
work well with a particular persons neuro chemistry
can lead to things like, you know, heavy sedation,
drowsiness, and there’s been shown through research
one of the biggest cons of anti-anxiety medications is
the likelihood of forming an addiction to these
kinds of medications. So, you know, as you’ve
probably seen in media, films, etc, tranquilizers are
highly addictive and this is one of the serious cons. Alright, now looking at anti-depressant. You know, as the term suggests
these are used primarily to treat depression, but
because, as you know, theoretically and conceptually,
depression and anxiety share a lot of common
features and implicate similar brain areas. Antidepressants are often used
to treat anxiety, as well. Today there’s two primary
antidepressants that are used to treat depression. Or what I mean, there’s two
classes of drugs that operate in different areas of the
brain with the goal of treating depression. The first of these are what
we call MAO inhibitors, or monoamino oxidase inhibitors. And what these medications
do is they inhibit symptoms of depression by working in
the synapse of the brain to make more serotonin, or
neurotransmitters like serotonin available to the brain. One of the things that
MAOs do is they also raise levels of norepinephrine and dopamine. And these are, in addition to serotonin, two other kinds of
neurotransmitters that have been implicated in depression. Now, one of the things that
we know about MAOs is that they have a fairly significant
side effect profile. And so they’re used much
more cautiously than SSRI’s, which I’ll talk about in a second. So, these are generally types of drugs. MAO medications are often used
only for those individuals who aren’t responding to other, other kinds of antidepressants. So again, MAOs work to break
down serotonin in the synapse and ideally raising the
availability of certain kinds of neurotransmitters. Now, selective serotonin
inhibitors, or what are called SSRIs are perhaps the most
commonly used antidepressants today and these include
medications that are generically known as Zoloft, Prozac, etc. And what these class of drugs
do is, rather than breaking down and altering the way MAOs
do the supply of serotonin, norepinephrine, dopamine,
they work to alter or adjust the rate at which the
brain utilizes serotonin. And one of the things that
serotonin inhibitors do is that it targets the, what
we call, the post-synaptic neuron and makes it less
receptive to serotonin. Which essentially means
that there’s more serotonin circulating in the brain. And what we believe is that
it’s a deficit of serotonin in the brain that is
related to depression. So these kinds of SSRIs,
whether it’s Zoloft or Prozac, operate in somewhat different
ways, but the net effect of these is that they’re
allowing the brain to have more circulating serotonin,
which we believe is critical to lowering symptoms of depression. Alright, now turning to antipsychotics, the third class of pharmacotherapies. Antipsychotics, as you
probably can appreciate, are used to treat mental
health disorders that have psychotic symptoms to them. Or psychotics features, and
perhaps most commonly this would be just sort of schizophrenia. Anytime somebody’s dealing
with a major mental disorder that might not be schizophrenia,
but carries with it some kind of psychotic feature. For instance, bipolar disorder. When somebody’s in the manic
phase of their cycling, we might use an
antipsychotic to treat this. Somebody who is deeply
clinically depressed and has strong agitated features
might sometimes present with psychotic symptoms. We might use anti psychotics. So it’s not just limited to schizophrenia. This is the number one class
of drug to treat a disorder like schizophrenia. Now, you remember back to your
reading and the presentation about, say, schizophrenia and
what the types of symptoms are positive and negative symptoms. Antipsychotic medications
are generally treating the positive symptoms. So they’re targeting the
reduction of hallucinations and delusions, excuse me. So these are the positive
symptoms of schizophrenia and antipsychotics are attempting
to lower the likelihood that someone is going to be
experiencing hallucinations. Lowering the likelihood
that somebody’s going to experience delusions. And the way that antipsychotics
generally work is by targeting the dopamine system. And by blocking the effects of dopamine. So one of the things we
know is that it’s a surplus of dopamine or the way in
which dopamine is acting on vulnerable circuits in
the brain that seems to be driving hallucinations and delusions. So, antipsychotic medications
are generally trying to block the effects of dopamine. One of the things about
antipsychotics that is very important to understand
is that they are either non-effective in many cases,
although they’re still our frontline way of
treating active psychosis. But they also have a number
of potentially irreversible side effects. Individuals who are on
antipsychotic medications for a long time might develop
side effects such as tardive dyskinesia, which is
a form of a mental tremor, a neurological tremor
that expresses itself both behaviorally in the
forms of tremoring limbs, or sometimes it expresses
itself in terms of stuttering speech. These are really significant side effects. Now, the other thing about
antipsychotics is that, while they might be effective
in treating the positive symptoms, they themselves
are not very effective at treating the negative symptoms. Things like social withdrawal,
apathy, depressed mood, and often what psychiatry
will do is use combinations of medications, such as
antipsychotics and antidepressants to treat both the positive
and the negative symptoms. We’ve, because combinations
of drugs increase or double the likelihood of side effects,
developers of medications have been trying to target
combination drugs that, in one, will address both
positive and negative symptoms. So, neuro antipsychotic
medications such as Clozapine act on the dopamine system,
but also have properties that act on other
neurotransmitters in the brain, such as serotonin and norepinephrine. So these newer classes of
antipsychotics are showing to be more effective at
treating the areas of the brain that seem to be involved in schizophrenia. But because it’s a newer
class of drug and we still don’t have as extensive
research as we would need, oftentimes, these newer
drugs are used only for those who aren’t responding
to other better studied antipsychotics. So, this slide shows you
what we call the psychotropic mechanisms of action. And this is a schema, a
schematic, if you will, that is not specific to
any one of the medications, the psychotropic medications
that I’ve just described. But is a review of the way
in which different kinds of psychotropic drugs can alter
behavior by interacting with the brain’s
neurotransmission systems. So, again, depending on
the class of drug and what neurotransmission system it’s targeting, these drugs may operate
to release or increase the release of certain kinds
of transmitters into that synaptic region, that synaptic cleft. Which is where a lot of the
action in the brain happens. Or it may be targeting the
receiving neuron and block the reuptake. So it’s dampening the utility
of the neurotransmissions, and etc. You see some other ideas here. So what I encourage you to
do is be re-familiarized with the way in which these kinds
of drugs might be operating in the neurons in the brain. And this is exactly when
we treat different kinds of psychopathologies. What we’re trying to do
when we use medications. Okay, now drugs are not the
only biological treatment options that psychiatry
and clinical psychology has at it’s disposal. We also have, potentially,
some more drastic approaches. In some instances these may
be the only options we have when people haven’t responded
to different kinds of drugs. So, surgery is still a
biological option and it’s, often though, the court of
last resort when it comes to treating serious mental disturbances. So, things like lobotomies
that have been, you know, demonized and popularized
in different kinds of media is a form of psycho-surgery
that would be used when somebody hasn’t been
responsive to any of the other kinds of drug or talking therapies. Also, historically, ECT or
what’s called electroconvulsive therapy has been a commonly
used biological approach to treatment. And it’s often used, for
instance, in treating cases of depression that are highly
unresponsive to our, essentially non-responsive,
to any other kinds of biological interventions. And essentially ECT as the name of it, electroconvulsive therapy
suggests is an administration of an electrical current
into the brain and, essentially, causing micro
seizures in areas that we think are probably not
functioning optimally. And it really is designed
to try and reset, reset homeostatic levels of
different neurotransmitters. So by creating these micro
seizures in areas of the brain that are, we believe,
functioning inappropriately. The seizure essentially
serves to reset these homeostatic balances and gives
the brain a chance to start functioning the way it would normally do. Now, again, it’s used to
treat very severe cases of, for instance, depression. And like any of these other
medications that I’ve reviewed, would carry certain side effects. However, for individuals
who have been completely unresponsive, some of the
research suggests that this is, perhaps, one of the most
effective ways of improving the likelihood that somebody
might be responsive to a medicine and a talking
therapy going forward. Some additional alternative
biological treatments also include what we call TMS, or transcranial magnetic stimulation. This is a little less
drastic of approach compared to ECT, but it works on
the same principle that, by introducing mild electrical
currents into the brain, we might be able to induce
alterations in neuro circuits that might be malfunctioning. The way TMS, or transcranial
magnetic stimulation works is that it, it
interrupts neuro functioning in really targeted regions
and it’s this disruption that might alter certain symptoms. Again, like ECT, it’s
often used to treat severe vegetative and non-responsive depression. Another newer, much newer,
biological approach is what’s called DBS, or deep brain stimulation. And this is a combination of
both surgical implantation of electrical diodes, if
you will, into the brain, and this concept of introducing
electrical currents. And essentially what happens
is that we surgically implant these electrodes into the
brain and into areas of the brain that we know to be
involved in certain kind of mental health and neurological disorders. And this that this slow
and steady introduction of electrical current into
the brain stimulates, stimulates normal functioning
in these areas that might be deficient. And a nice analogy of this is
that a deep brain stimulator is very similar to a pacemaker,
which essentially operates to help the heart continue
to function normally. Deep brain stimulation
has been used in a variety of different kinds of psychopathology’s. For instance, again it
might be very effective in treating depression that
hasn’t responded to medications and some certain other approaches. It’s also been shown to be
effective in treating OCD or obsessive compulsive disorder. But increasingly it’s being
used later in life for neurological and degenerative
disorders, like Parkinsons. And one of the things we found is that, that is has both fewer side
effects than some of the heavy duty drugs that are
used to treat Parkinsons and also has some unintended effects. That, for instance, it
reduces some of the tremoring problems that comes with
Parkinsons in addition to trying to affect some of the memory
and cognitive functions that are features of Parkinsons. So these would be the host
of alternative biological approaches that would be used today. Probably mostly by
psychiatry that is, again, very much rooted in the biomedical
model of psychopathology. Alright, let’s turn now away
from the biomedical model and turn more towards the
psychological model or approach to treating mental health problems. And that would be a class of
treatments that are called psychotherapy. These are, you know,
let’s call them for now, the talking therapies. So as an overview, when we
just say that there’s been a lot of research done, both
on biomedical interventions and to treating psychopathology
but also a great deal of research that’s looked
at the effectiveness of psychotherapies, talking therapies. And one of the things we know
now after well over about 100 years of research on
different types of psychotherapies is that some of them have
been shown to be effective, and some of those have been
shown to be less effective. And so what you have here in this graph, or this table, is examples
of psychotherapies that, either are very difficult
to study through research, or when studied have shown
limited effectiveness verses those that continue, through
repeated analysis and investigation, have shown
themselves to be our most effective talking therapy. So, you know, historically
Freudian type approaches to treating psychopathology in
the form of psychodynamic therapies or other kinds of
approaches, such as hypnosis, or more commonly, crystal
therpies which are popular in certain parts of the country. The research that has been done
on these type of approaches to dealing with mental
health problems have shown that they have limited
or no positive benefit. While they may still be popular,
the scientific literature doesn’t provide a great deal
of evidence that they’re effective. In contrast, we have both
a lot of research evidence as well as research evidence
that suggests that a variety of other kinds of therapies are effective. And these would include thins
like cognitive therapies, or more commonly, cognitive
behavioral therapies, CBT. And some newer examples of
psychotherapies that would include things like dialectical
behavior therapy, DBT, ACT, acceptance and commitment
therapy and mindfulness based cognitive therapy. These would be considered
the set of psychotherapies that have the strongest
research evidence behind them. And consequently, these are
the ones that are most used to treat different kinds
of psychopathologies. And what I want to do for the
next few minutes is talk about those with a strong research support. Alright, let’s start and
look at cognitive therapy. Cognitive therapies have
evolved, primarily to treat depression. Again, if you remember back
to that first graph and what you know about
psychopathology, depression is one of the most prevalent
disorders and consequently a lot of the treatments
that have been developed and tested are geared
to treating depression. And the major theory behind
cognitive therapy reflects the major theory of what depression is. And that is that depression
results from distorted thoughts. And so the theory of
cognitive therapy is that, through the treatment of
distorted thoughts that produce maladaptive behaviors
and emotions we can alter depressive symptoms. So the goal is to identify
those problematic cognitive or thought patterns and
to modify them through, you know, a variety of
different types of interventions and to change problematic
and negative thought patterns to more adaptive and
positive and positive thought processes. This is, within cognitive
therapy, what’s called cognitive restructuring. You know, in terms of the
length of this kind of therapy, you know, it’s probably
a typical length therapy, lasting anywhere from 10 to 20 sessions. Sometimes longer, sometimes less. But typically and on average
it’s somewhere in that 10 to 20 session range. So you can accomplish a
fair amount in a reasonable amount of time. So just to give you an example
of how cognitive therapy might work, somebody’s
depression might be defined by maladaptive cognitive
patterns that really suggest somebody’s very hyper
sensitive to feedback. And the response is that
you’re constantly getting negative critical feedback,
even if somebody might not be intending to be negative. But in this example that I have here, imagine somebody’s boss or a
parent is critical with them and the distorted thought
process is that that negative feedback that they’re
getting really translates into self esteem issues. Feelings of worthlessness
and it’s the feeling of worthlessness that translates
into or can contribute to the onset of depressive symptoms. So cognitive therapy’s goal
would be to cognitively restructure the meaning of
what it is to have somebody become cross or provide negative feedback, or a parent yells or becomes
negative with somebody, the goal of cognitive
therapy would be to say, “This isn’t about me, this
is probably something about “this person.” So, this person might be
having a bad day and to not internalize it and make it
something about one’s self. And the thought is that by
altering these cognitive, distorted cognitive thoughts,
this is going to make it less likely that somebody
who’s struggling with symptoms of depression. Alright, now let’s look at
cognitive behavioral therapy, and this is clearly an
extension of cognitive therapy and research on cognitive
therapy has show that, while this can be effective
in treating disorders like depression and other
disorders like anxiety. The lack of focus on some
of the behavioral aspects of disorders like depression
and anxiety has made a lot of clinicians feel that a
treatment approach such as cognitive behavioral
therapy is more effective. Again, cognitive behavioral
therapy has been used to treat a variety of
disorders, but in general, when you look at the research
literature and you look a at the way in which different
professionals use it, it’s primarily used to
treat depression an anxiety. And at the core, the theory of CBT, cognitive behavioral
therapy is that, again, we have distorted or maladaptive
thoughts and, consequently feelings and that these
distorted thoughts and feelings play a critical role in
shaping the kind of behavior that becomes problematic for somebody. So the goal of cognitive
behavioral therapy, like cognitive therapy is to
first identify and to change those distorted, destructive
or disturbing thought patterns. And to try and ensure
that those negatively, they do not negatively
influence feelings of behavior. And so when it’s working
well for somebody, it’s a combination of focus
on both the thoughts and feelings, but also behaviors. And I’ll try to make that clear. Like cognitive therapy, CBT,
cognitive behavioral therapy we think of generally as
a short lasting therapy. Somewhere in the neighborhood
of 10 to 20 sessions, 10 to 18 sessions. So again, a lot can be
accomplished in a very structured or manualized approach to
dealing with thoughts and behaviors. So let’s look at an example
here of out CBT might work with social phobia. So again, CBT is focusing
on thoughts, emotions, and behavior and what you
might see from this slide here is that somebody’s
distorted thoughts might include things like the fear that
people are judging you or that one is worthless
because they can’t function in social situations. And so the ultimate result
of those feelings is, because they engender negative emotions, such as nervousness and sadness. That those thoughts and those
feelings are going to lead to behaviors such as avoiding
or escaping or leaving social situations. Which is essentially going to
produce this self-fulfilling prophecy which creates this
negative spiral of events. So once you begin to engage
in less social activities or escape and avoid social
situations that’s going to increase the feeling
that you’re worthless, socially inept, which increases
negative and sad emotions. So this cognitive spiral
would be the target of CBT. So how would CBT address
something like social phobia? So what are the tools available? So, again, the first
target would be cognitive restructuring and trying
to address those inaccurate thoughts about ones worthlessness. Or the idea that everybody
is looking at you and judging you. The next major goal or
tool within the CBT toolbox would be to deal with the
emotions that those distorted thought processes create. So putting people in
situations where they actually see that they can manage
the emotions that those distorted thought processes might create. And then, finally, by using
certain kinds of behavioral strategies that create more
pleasurable or positive experiences. So I’ve provided you a
link here to a really good example of what’s called
exposure therapy for social anxiety, or this case, it’s a phobia. And it would work similarly
for social anxiety and other kinds of anxieties about
certain situations. And what you see from the
example is that the goal is to address both the distorted
thoughts, the emotions that get created in certain
situations by those distorted thought, and to create new actions, new action goals that would
address the core symptoms of something like a phobia. And this is a really nice
example, video example, of how we would use exposure
therapy to deal with a particular kind of anxiety disorder. And these are all examples
of how cognitive behavioral therapies, by focusing
our thoughts, emotions, and behavior might reduce
something like phobia could be used similarly
for addressing depression. Alright, let’s move beyond
cognitive and cognitive behavioral therapies and
look at newer classes of psychotherapies. Perhaps one of the newest,
but also one of the most popular in psychotherapy and
is getting a lot of attention. Both professionally and by
the scientific communities, a therapy called ACT or
Acceptance and Commitment therapy. A lot of people believe
that this is the new wave and a very promising
future for the treatment of psychopathologies. And we’re probably going to
see in the next five to 20 years therapies like CBT
incorporating aspects of ACT because it’s really showing
itself to be very effective. ACT is very effective in
treating a wide variety of conditions. So whereas we’re finding that
CBT, cognitive behavioral therapy is really effective
at treating depression and anxiety. Acceptance and commitment
therapy is used to treat depression and anxiety,
but it’s also being used in the treatment of a whole
variety of other kinds of disorders, including
substance abuse problems, etc. So what is ACT? Theoretically the idea behind
ACT is that individuals are suffering psychologically
and that this suffering increases because we’re
trying to control what is bothering us. And it’s this struggle to
control the symptoms and the negative emotions that get
generated by problems that lead to different kinds of
clinical psychopathologies. And essentially at the core
of ACT is this idea that psychological suffering
is really a normal part of the human condition. That, you know, at different
points in our lives we’re going to experience
psychological disturbance. We’re going to experience
symptoms of depression, we’re going to experience
symptoms of anxiety. That this is really an
inevitable aspect of being a human being, operating
in a complex world. And what ACT is trying to
do is to normalize that, to lower the need to fight or resist it, and to increase the way
in which we can think about those things as a
normal part of living. And hopefully those don’t
cause us the same levels of distress and disturbance
that they might when we’re resisting them and
seeing them as abnormal and distorted. So the goals of ACT are really three fold. One is what we call
acceptance, as the name of the treatment suggests and
by increasing acceptance we’re emphasizing or
supporting that individual’s willingness to tolerate
unwanted thoughts and feelings and experiences. So in other words, to create
the space in your life we want to make room for
them and to see them as a natural part of the human experience. One of the ways in which that
acceptance can be achieved is by being very present focused
and encouraging individuals to really, not be trying
to escape these feelings by retreating to the past,
glorifying the past. “I was really great
then and healthy then.” Or to look to the future, but
really to try and emphasize the importance of being
present in the here and now. To being conscious of what’s going on. And so I’ll talk about in a
minute, this is an exercise that is now being thought of
as, or called mindfulness. And being mindful about where
you are and really living in the here and now has been
shown to be highly effective in reducing things like
depression and anxiety. And the third piece of ACT
or acceptance and commitment therapy is what we call
value focused interventions. And this is where we’re
encouraging individuals to set goals that reflect what
you want for yourself, what you value in your
life, and to take positive steps towards achieving those goals. Not to be critical when you
fall short of those goals, but again, to have a sense
of goals and value focused objectives and through
acceptance processes and being present to slowly work
to achieve those goals. These would be the positive
behavioral aspects of one’s life that lower the
feeling that your life is a struggle, life is difficult. And by achieving these
goals that are aligned with your values, ACT believes
that this will help to reduce some of the core symptoms
of psychopathologies like depression and anxiety,
reduce the need to use substances to manage some
of the suffering that goes along with being a human being. Now I said when I was talking
a second ago about ACT that one of the core tools is mindfulness. And there’s been a lot of
research in the last 10 to 15 years, or even more recently
than that really focusing on that very specific aspect
of ACT because it’s not limited to just acceptance
and commitment therapy, but mindfulness is potentially
a tool that can be useful to improving positive functioning
in all aspects of life regardless of whether somebody
is dealing with a major form of psychopathology. One of the ways to think
about mindfulness practices is that it may operate
as a preventative for the development of psychopathology
by reducing the effects that stress and stressful
circumstances might have on our psychological well being. So the practice of mindfulness
is this idea of purposely focusing your attention
on the present moment. And, like ACT, accepting
without judgement what’s going on for you. And it’s this repeated
practice of mindfully being present in the moment and
not being judgmental that we think lowers the likelihood
that certain kinds of mental health problems are going
to take root in our brains and then slowly but surely develop. So mindfulness research has
shown that it has a lot of physical benefits. Being mindful through
practices such as meditation or just quiet breathing,
focused breathing, has been shown to relieve
stress, lower blood pressure, been effective at dealing
with cardiac problems. It’s been effective in
treating pain and, importantly, this process of relaxation
improves the ability to sleep at night. So, mindfulness has been shown
to have a profound effect on a variety of physical
symptoms, but it’s also been shown to have important
psychological benefits. Now I have a link that the
bottom here to, perhaps, one of the most important
originators of mindfulness practices. Both in forms of mediation and other ways. A gentleman by the name of Jon Kabat-Zinn, who’s probably developed
the most important approach to stress reduction through
mindfulness practices. So I encourage you to watch
this youtube and what you’re going to see here is Dr.
Kabat-Zinn providing a structured guided approach to paced breathing. Where you’re really just
reflecting on the here and now trying to clear your mind
of distracting feelings. And, you know, it’s really not
designed to be a treatment, but rather it’s designed
to give you a feeling of, or the flavor of what mindfulness
practices might comprise. So the practices of
mindfulness have been so effective that they’re now
being incorporated into more traditional therapies
and so we have an even newer class of psychotherapies
that are called mindfulness based cognitive
therapies and cognitive behavioral therapy. So cognitive therapy, CT
and CBT have incorporated mindfulness as an important
tool in addition to some of the other aspects. And as you see here on the
slide, the goal is to help individuals become more aware
of their negative thoughts and behaviors. Especially when these thoughts
and behaviors might manifest and make them vulnerable. And to use mindfulness
practices, meditation, being present in the here and
now, to disengage individuals from these negative cognitive cycles. And through the practice and
mindfulness and mindfulness meditation on a regular
basis to lower the likelihood that those distorted thoughts
and behaviors are going to interfere with normal functioning. So, a lot of, as I suggested
at the outset of my discussion about mindfulness and some
of these newer practices that include meditation, I
think what we’re going to see in the next 10 to 20 years is
mindfulness based practices becoming an important facet
of all types of psychotherapy. Okay, what I want to do now
for the next couple minutes is jump back by linking the
chapter 14 discussion of certain kinds of specific
forms of psychopathologies with chapter 15’s focus on treatment. And just quickly run
through what the science and research of psychotherapy
shows us to be the best treatments for these
different kinds of disorders. So I spent a bit of time
talking about anxiety and what we know to be the
best treatments really depends on the type of anxiety that
somebody is dealing with. So, for phobias, exposure
therapy, the kind that you saw in the video, is a form of
CBT that has been highly effective in treating phobias. Both claustrophobia, social phobias, etc. So this idea of exposing,
incrementally exposing individuals to what’s
creating fear and showing that an individual can manage
that fear is an important approach to dealing with phobias. In terms of obsessive
compulsive disorders, OCD, we’ve got both the talking
therapies and the biological psychotropic medications like SSRIs. So these have both shown to be effective. For disorders such as panic
disorder, you see here therapies that are really
targeting the distorted thoughts and behaviors seem
to be highly effective. In general, treatments
that focus on both behavior and cognition through
CBT are really, perhaps, our most effective,
especially for the long term. And I’ll come back to
this idea in a minute. Are the most effective ways
of dealing with anxiety disorders. The issue with medications
is that they’re very helpful, especially in the short
term, but again it’s these, the long term maintenance
of treatment affects as well as the side effects
that make long term use of medicines to be more problematic. And I’ll come back to this in a second. In terms of depression,
and again, CBT is perhaps the most effective of the treatments. Especially long term. I want to introduce one of
the thoughts that I’m going to come back to when I summarize in a minute. And that is that long term,
one of the things we know is that talking therapy, such
as CBT may be more effective than psychotropic medical interventions. And, in fact, it might be
that medical interventions that use drugs such as
serotonin inhibitors, MAOs, those may be especially
important in the short term when somebody may be at
their most acute and severe levels of a disturbance like depression. But that long term, really
what we need are talking therapies to really alter
in a fundamental way the distorted thoughts and behaviors
that underlie depression. So, the research has shown
that CBT and psychotheraputic interventions that include medicines, they tend to be comparably effective. But the critical question
that we want to ask when we compare talking therapies
with biological interventions is what’s the long term picture
look like for individuals who are using one or these
other kinds of treatments? And I’ll, again, I’ll come
back to that in a second. But in terms of depression,
we know that CBT is highly effective and perhaps just as effective, certainly in the short
term, as treating depression that serotonin inhibitors might be. So it isn’t that talking
therapies are always going to be the best. In fact, when we look at schizophrenia, what’s become very clear,
abundantly clear to us, is that pharmacotherapy is
probably our best line of defense against the most
difficult aspects of schizophrenia and the positive symptoms of
hallucinations, delusions, etc. And especially bringing people
out of actively psychotic episodes really can only be
accomplished with pharmaco interventions. But, what we also know to be
important about schizophrenia is that, long term,
psychotropic pharmacological interventions alone are not
going to help an individual. Given how devastating this
disorder is and the way it impacts an individual
in all areas of their life, we really need to start
thinking of what we call combination therapies. And again, this is going
to be another point that I come back to in a minute. So one of the things we
know, and you can see this in terms of this relapse
graph, is that long term, medicines alone are not going
to guard against relapse. They might be very effective
in the short term in dealing with active psychotic
symptomatology, but long term, we need to combine
pharmacotherapy with other kinds of treatments, like social
skills, therapy, family therapy, or even combinations of all these. What you see here is a graph
that shows the relapse, the longer term relapse if
you just use medication, if you combine medical
interventions with skills training, and or family therapies. Then there’s a certain
amount of relapse that comes with those, but when you
follow individuals long term in this particular study,
the relapse when you combine psycho pharmacological
interventions with social skills, support, as well as family
therapy targeting what we call the expressed
emotion and the difficulties that families experience,
the relapse rates tend to be close to zero. Now, long term, this might
be a short term look at combo therapies and what they do. But what we know to be the
case is that combination therapies have the best
promise for long term outcomes. Alright? Now let’s look, also, at
ADHA, a childhood disorder. And, again, two principles hold here. One is that combination
therapies show the best improvement over time and in
terms of long term prognosis it’s likely to be combination
therapies, those that combine medical interventions with
biological interventions. Such as psychostimulants with
social skills and behavioral interventions. It showed the best long
term prognosis for children and adolescents using depression. So what you see here is
some of the data that comes form the MTA study, the
Multimodal Treatment of ADHD which was the largest
clinical trial treatment trial studying different kinds
of approaches to treating ADHD. And what was found here
14 months after the end of the treatment study,
that a combination of a psycho-stimulant with
behavioral therapies, which included family therapy,
peer social skills treatment of the children, that this
showed the best long term improvement. Psycho-stimulants alone
looked pretty good too, certainly compared to
behavioral treatments alone, or what we call the
community as usual approach. Which generally is a hodge
podge of different ways of treating ADHD. It’s really this combination
treatment that shows the long term prognosis. And these data now, or the
MTA study has extended it’s analysis of these different
approaches to treating ADHD. Three and five and seven years
beyond the treatment trial. And even stronger than these
data combination treatments long term seem to be the best approach. So, kind of like schizophrenia
and the combination of antipsychotic medications
with different kinds of psychotherapies, it’s these
combination approaches that probably are our best
hope for treating difficult disorders in the long term. Alright, so I want to summarize
what I’ve just been talking about with some basic general
principles that really derive some of the research on
what constitutes effective and efficacious treatments
for mental health problems. These are the thoughts that I
would want to leave you with in terms of the major takeaways. The big picture takeaways from chapter 15. One thing that I haven’t
talked about, but maybe becomes evident to you when you think
about what I have covered is that a lot of these
different therapies, whether it’s biological
or talking therapy, have what we call, at
their core, common factors. And one of the things that
we’ve found through the study of different kinds of
psychotherapies and biological therapies is that there are
important elements that are similar across these different therapies. So, you know, even contact
with your psychiatrist, who’s primary way of treating
you or supporting you is through the prescription
of medications. We know that there’s
something important about that human contact. That may, in fact, be one
of the things that enables medications to work long term. This belief that the
professional you’re working with has your best interests
at heart and is using effectively studied tools,
this belief in the human contact is an example of
a common factor that is characteristic of both
the prescription medicines as well as psychotherapies
such as CBT, acceptance and commitment therapy. So one of the things that I
want you to think about is, what makes a treatment
effective may be the same thing that makes another treatment effective. And it may include things
such as human contact or this belief that the treatment
effect is going to be helpful to you. Another thing that we now
know is that therapies, although they’re based on
the theory of what underlies or is contributing to a specific
form of psychopathology. We know that psychotherapies,
whether they’re targeting biological mechanisms or
cognitive behavioral mechanisms have both specific as well
as non-specific effects. So treatments may lead to
changes in the targeted symptoms that we’re trying to address, but sometimes they
often have non-intended, non-targeted biological effects. And these can be both
positive and negative. So, for instance, in
terms of positive effects, drugs such as Ritalin,
which is a psycho-stimulant used to treat ADHD, targets
the ability of a child to pay attention, to regulate attention. But one of the side effects,
or one of the positive benefits that comes along
with treating attention is that it improves an
individuals ability to regulate their emotion. So this would be a positive
non-specific effect. We also have what are called
the unintended consequences. So, a term that you’ve read
in the chapter and you know from earlier readings,
unintended negative consequences are often called iatrogenic effects. And these are the negative
effects of using a positive or a therapeutic intervention. So drug side effects is an
example of an iatrogenic effect. A classic example from the
psychotherapy literature of an iatorgenic effect is
the use of group therapies treating adolescents who have
contact behavior problems. We find that when we put
groups of teenagers who are dealing with conduct disorder
and anti-social personality characteristics and we put
them into the same treatment group, the iatrogenic effect
is that serves to positively reinforce these negative behaviors. So, one of the other things
we’ve learned about therapeutic interventions through
research is that they often have both non-specific positive effects, but they also have negative
or iatrogenic effects. A couple of final points
that aren’t listed on this slide, but I was just talking
about in the last couple of minutes is that we now know that, certainly with more severe
forms of psychopathology, long term it’s going to be
combinations of therapies that are targeting both
biological aspects of a disorder as well as the cognitive
social, emotional, and behavioral aspects that
are going to have the best long term prognosis. Okay, that ends chapter 15
from the lecture point of view. Thank you very much.

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