Chapter 17: Treatment of Mental Disorders
Chapter Summary
- BIOMEDICAL THERAPIES
- Many mental disorders are treated with drugs. For example, classical antipsychotics are helpful in holding in check the major positive symptoms of schizophrenia, and new antipsychotics show promise in treating negative symptoms as well.
- Drug treatments have allowed a movement toward deinstitutionalization of individuals with mental disorders. However, this movement has been only a partial success, in part because of a lack of support services outside mental hospitals.
- Classical antidepressants such as the MAO inhibitors and tricyclics counteract depression. However, these antidepressants all have many undesirable side effects, which have led to a search for better medications. The last few decades have seen the advent of the so-called designer drugs, engineered specifically to enhanceor inhibit certain neurotransmitters but not others. Of these the best known is Prozac, which belongs to the group of selective serotonin reuptake inhibitors (SSRIs). The newer drugs have fewer side effects and are as effective as the older ones in treating depression and obsessive-compulsive disorder.
- Lithium carbonate is useful in cases of bipolar disorder, especially in forestalling or reducing the intensity of manic episodes. In addition, anxiolytics have proved effective for the treatment of anxiety disorders.
- Other biological therapies include psychosurgery and electroconvulsive therapy (ECT), which is markedly effective in cases of severe and potentially suicidal depression.
- PSYCHOTHERAPIES
- A different approach to the treatment of mental disorder, psychotherapy, relies on efforts to change the patient’s thinking and behavior directly, usually by some form of discussion, instruction, or training.
- Classical psychoanalysis seeks to help a patient gain insight into his own hidden conflicts and wishes. The person must “work through” the conflicts, so that the insights are not merely intellectual, and this working through depends crucially on the process of transference. Psychodynamic therapy still preserves many insights from psychoanalysis, but puts as much emphasis on conscious thoughts as on unconscious conflicts, and emphasizes the ways in which a patient’s pattern of interaction in childhood can influence (and distort) current social relationships.
- Interpersonal therapy (IPT) places its emphasis squarely on social relationships, and seeks to help a patient learn new and more beneficial ways of interacting and communicating. Humanistic-experiential therapy seeks to create a genuinely empathic and accepting atmosphere in therapy, but also seeks to deepen the patient’s experience.
- Behavior therapy seeks to change a patient’s behavior directly, drawing on principles of classical and instrumental conditioning. One example is systematic desensitization; another is aversion therapy, in which undesirable behaviors, thoughts, and desires are coupled with unpleasant stimuli. Therapies based on principles of operant conditioning include the use of token economies, in which patients are systematically reinforced for showing desirable behaviors. Yet another behavioral technique is modeling.
- Cognitive therapy seeks to change a person’s beliefs and mode of thinking. One example is stress-inoculation therapy, which seeks to prepare people to deal with the stresses they encounter in everyday life. A different example is Aaron Beck’s therapy for depression, which tries to help patients identify their automatic thoughts and reactions, and to substitute more beneficial reactions.
- Although these therapies differ in many regards, they all benefit from relationship effects, including the therapeutic alliance. Other shared benefits include interpersonal learning, emotional defusing, and a prospect for gaining self-knowledge. In addition, the distinctions among therapies are being blurred by the broad trend toward multimodal therapy, in which therapists draw on several of the traditions we have named, and combine psychotherapy with drug treatment.
- The last few decades have seen an enormous extension of psychotherapy. One such extension involves the increasing use of therapy with children. Another concerns group therapy, in which patients are treated in groups rather than individually. Yet another example is family (and couples) therapy, whose practitioners believe that family distress is not in the pathology of any one individual, but in the relationships within the family system. Practitioners therefore try to rectify these faulty relationships.
- Another extension concerns the therapeutic goals. While the original purpose of psychotherapy was to cure pathology, some practitioners have gradually broadened this goal to include treatment for individuals with subsyndromal problems.
- Therapy is also being broadened to reach out to other groups, including members of different cultures and different socioeconomic classes. This broadening requires cultural competence, and also an openness to the possibility that Western ways of dealing with mental disorder may not be optimal.
- EVALUATING THERAPEUTIC OUTCOME
- There is no question that psychotherapy works in many cases, although more so with some individuals, and some diagnoses, than with others. Therapy appears to be particularly effective when patients feel they have a strong sense of alliance with their therapists, and also when patients are optimistic about their chances of recovery. An increasing emphasis on evidence-based practice (EBP), however, has called for closer scrutiny of whether, when, and why therapy is effective.
- If people are better off after therapy than before, this might be the result of spontaneous improvement. To address this concern, a group receiving therapy should be compared with a matched group that receives no therapy, and the two groups should be uniform in their disorder at the start of therapy. When testing a new drug, it is also crucial to control for placebo effects. It is not clear, however, how to control for such effects when testing a form of psychotherapy.
- Randomized clinical trials (RCTs) are often used to assess the efficacy of therapy, but the conditions of these trials are often different from those in actual clinical practice. One difference lies in the use of manualized therapy; another lies in the focus on patients with a single diagnosis and no comorbidity. For these reasons, it is important to combine data from randomized clinical trials with other forms of data collection.
- One assessment of psychotherapy relies on a statistical technique called meta-analysis, by means of which the results of many different studies can be combined. The results of such analyses indicate that the various psychotherapies are effective, butsurprisinglythe meta-analyses also suggest that very different forms of therapy can be equally effective, a result often referred to as the dodo bird verdict.
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