Chapter 16 - Treatment of Psychological Disorders
Section 1 - Psychotherapy: Psychodynamic, Behavioral, and Cognitive Approaches to Treatment
MAIN IDEA QUESTIONS
What are the goals of psychologically and biologically based treatment approaches?
What are the psychodynamic, behavioral, and cognitive approaches to treatment?
VOCABULARY
psychodynamic therapy - Therapy that seeks to bring unresolved past conflicts and unacceptable impulses from the unconscious into the conscious, where patients may deal with the problems more effectively
psychoanalysis - Freudian psychotherapy in which the goal is to release hidden unconscious thoughts and feelings in order to reduce their power in controlling behavior
transference - The transfer or feelings to a psychoanalyst of love or anger that had been originally directed to a patient's parents or other authority figures
behavioral treatment approaches - Treatment approaches that build on the basic processes of learning, such as reinforcement and extinction, and assume that normal and abnormal behavior are both learned
aversive conditioning - A form of therapy that reduces the frequency of undesired behavior by pairing an aversive, unpleasant stimulus with undesired behavior
systematic desensitization - A behavioral technique in which gradual exposure to an anxiety-producing stimulus is paired with relaxation to extinguish the response of anxiety
exposure - A behavioral treatment for anxiety in which people are confronted either suddenly or gradually with a stimulus that they fear
dialectical behavior therapy - A form of treatment in which the focus is on getting people to accept who they are regardless of whether it matches their ideal
cognitive treatment approaches - Treatment approaches that teach people to think in more adaptive ways by changing their dysfunctional cognitions about the world and themselves
cognitive-behavioral approach - A treatment approach that incorporates basic principles of learning to change the way people think
rational-emotional behavior therapy - A form of therapy that attempts to restructure a person's belief system into a more realistic, rational, and logical set of views by challenging dysfunctional beliefs that maintain irrational behavior
Therapists use some 400 different varieties of psychotherapy, approaches to therapy that focus on psychological factors. The people who provide therapy vary considerably in educational background and training. Many have doctoral degrees in psychology. Therapy is also provided by fields allied with psychology, such as psychiatry and social work. Almost all psychotherapists employ one of the four major approaches to therapy: psychodynamic, behavioral, cognitive, and humanistic treatments.
PSYCHODYNAMIC APPROACHES TO THERAPY
Psychodynamic therapy seeks to bring unresolved past conflicts and unacceptable impulses from the unconscious into the conscious, where patients may deal with the problems more effectively. This is based on Freud's psychodynamic approach to personality and the use of defense mechanisms.
The most common defense mechanism is repression, which pushes threatening conflicts and impulses back into the unconscious. Since these impulses and conflicts can never be completely buried, some of the anxiety associated with them can produce abnormal behavior in the form of what Freud called neurotic symptoms.
A psychodynamic therapist, then, faces the challenge of finding a way to assist patients' attempts to explore and understand the unconscious. The technique basically consists of guiding patients to consider and discuss their past experiences in explicit detail from the time of their first memories. This process assumes that patients will eventually stumble upon long-hidden crises, trauma, and conflicts that are producing anxiety in their adult lives. They will then be able to "work through" - understand and rectify - those difficulties.
Psychoanalysis: Freud's Therapy
The therapy of psychoanalysis tends to be a lengthy and expensive affair. Psychoanalysis is Freudian psychotherapy in which the goal is to release hidden unconscious thoughts and feelings in order to reduce their power in controlling behavior.
Patients may meet with a therapist with considerable frequency, sometimes as much as 50 minutes a day, four to five days a week, for several years. In the sessions, they often use free association, telling patients to say aloud whatever comes to mind, regardless of irrelevance or senselessness, and the analysts attempt to make connections between what is said and the unconscious. Therapists also use dream interpretation, examining dreams to find clues to unconscious conflicts and problems.
These methods do not always move forward easily. Unconscious forces may keep past difficulties out of the conscious mind, which produces resistance. Resistance is the inability or unwillingness to discuss or reveal particular memories, thoughts, or motivations.
Relationships between patient and therapist often become emotionally charged. Patients may sometimes think of the analyst as a symbol of a significant other in their past, perhaps a parent or lover, and apply some of their feelings for that person to the analyst - a phenomenon known as transference.
Contemporary Psychodynamic Approaches
Few people have the time, money, or patience for years of traditional psychoanalysis. Today, psychodynamic therapy is of shorter duration and usually lasts no longer than 3 months or 20 sessions. There is more control and directness on the part of the therapist, putting less emphasis on a patient's past history and childhood, instead focusing on and individual's current relationship and specific complaints.
Evaluating Psychodynamic Therapy
Psychodynamic therapy has its critics. It can be time consuming and expensive, especially when compared with other forms of psychotherapy, such as behavioral and cognitive approaches. Less articulate patients may not do as well as more articulate ones.
The most important question is whether it works, and there is no simple answer. There is difficulty in determining whether patients have improved, which is left to the subjective view of the patient or therapist and may be open to bias. Others critics maintain that the constructs of the unconscious have not been confirmed scientifically. Still, psychodynamic treatment has remained viable.
BEHAVIORAL APPROACHES TO THERAPY
Behavioral treatment approaches make this fundamental assumption: Both abnormal behavior and normal behavior are learned. People who act abnormally have either failed to learn the skills they need to cope with the problems of everyday living or have acquired faulty skills and patterns that are being maintained through some form of reinforcement. Proponents maintain that patients must learn new behavior to replace the faulty skills they have developed and unlearn their maladaptive behavior.
Behavioral psychologists do not dig into the patient's past or psyche. The goal of therapy is to change people's behavior to allow them to function more effectively. If you can change the behavior, treatment was successful.
Classical Conditioning Treatments
Aversive Conditioning. Some behavior therapists use aversive conditioning, a form of therapy that reduces the frequency of undesired behavior by pairing an aversive, unpleasant stimulus with undesired behavior. For example, a therapist may pair alcohol with a drug that causes nausea and vomiting. After the two have been paired a few times, the person associates the alcohol alone with vomiting and finds alcohol less appealing.
Although this approach is most useful with substance abuse issues, critics question its long-term effectiveness. Ethical questions exist about employing such potent stimuli as electric shock (which is used in extreme cases such as self-mutilation).
Systematic Desensitization. In systematic desensitization, gradual exposure to an anxiety-producing stimulus is paired with relaxation to extinguish the response of anxiety. First, a patient is trained in relaxation techniques by a therapist, allowing them to relax their body fully - a highly pleasant state. The next step would involve constructing a hierarchy of fears - a list in order of increasing severity of the things the patient would associate with his/her fears. Finally, the patient would learn to associate the two sets of responses. The therapist may ask the patient to put himself/herself in a relaxed state and then imagine themselves in the first situation identified in their hierarchy. Once considering the situation in a relaxed state, the patient moves through the hierarchy.
Exposure Treatments. Although successful, systematic desensitization today is often replaced with a less complicated for of treatment called exposure. Exposure is a behavioral treatment for anxiety in which people are confronted either suddenly or gradually with a stimulus that they fear. Relaxation training is omitted.
In most cases, therapists use graded exposure in which patients are exposed to a feared stimulus in gradual steps. For example, a patient who is afraid of dogs might view a video of dogs. Gradually the exposure escalates to seeing a live, leashed dog across the room and then actually petting and touching the dog.
Exposure has proven to be an effective treatment for a number of problems, including phobias, anxiety disorders, and even impotence and fear of sexual contact.
Operant Conditioning Techniques
These approaches are based on the notion that we should reward people for carrying out desirable behavior and extinguish undesirable behavior by either ignoring it or punishing it.
One example is the token system, which rewards a person for desired behavior with a token such as a poker chip or some kind of play money. The system resembles what parents do when they give their children money for being well behaved - money that the children can later exchange for something they want. The desired behavior could range from keeping one's room neat to personal grooming and interacting with other people. In institutions, patients can exchange tokens for some object or activity, such as snacks, new clothes, or, in extreme cases, sleeping in one's own bed rather than in a sleeping bag on the floor.
Contingency contracting, a variant of the token system, has proved quite effective in producing behavior modification. In contingency contracting, the therapist and client (or teacher and student or parent and child) draw up a written agreement. The contract states a series of behavioral goals the client hopes to achieve. It also specifies the positive consequences for the client if the client reaches goals - usually an explicit reward such as money or additional privileges. There are frequently negative consequences if the client does not reach the stated goals, such as having to write a check for a cause they have no interest in supporting (such as the National Rifle Association if they are strong supporters of gun control).
Behavioral therapists also use observational learning, the process in which the behavior of other people is modeled, to systematically teach people new skills and ways of handling their fears and anxieties. Examples include maintaining eye contact during conversation or acting assertively. Children with a phobia of dogs could view another child - the "Fearless Peer" - repeatedly walk up to a dog, touch it, pet it, and finally play with it.
Dialectical Behavior Therapy
In dialectical behavior therapy, the focus is on getting people to accept who they are regardless of whether it matches their ideal. Even if their childhood has been dysfunctional or they have ruined relationships with others, that's in the past. What matters is who they wish to become.
The therapy is an outgrowth of behavioral approaches, but also includes components of other perspectives. Patients are taught to realize that they have two choices: Either they remain unhappy, or they change. Once patients agree to change, it is up to them to modify their behavior. They are taught that even if they experience unhappiness, anger, or any other negative emotion, it doesn't need to rule their behavior. It's their behavior that counts - not their inner life.
Evaluating Behavior Therapy
Behavior therapy works especially well for eliminating anxiety disorders, treating phobias and compulsions, establishing control over impulses, and learning complex social skills to replace maladaptive behavior.
Critics believe that because it focuses on changing external behavior, people do not necessarily gain insight into thoughts and expectations that may be fostering their maladaptive behavior. Research has shown, however, that actual changes in brain functioning can occur as a result of treatment.
COGNITIVE APPROACHES TO THERAPY
Cognitive treatment approaches teach people to think in more adaptive ways by changing their dysfunctional cognitions about the world and themselves. Therapists attempt to change the way people think as well as their behavior. Because they employ principles of learning, the approach is often referred to as the cognitive-behavioral approach.
All cognitive approaches share the assumption that anxiety, depression, and negative emotions develop from maladaptive thinking. Cognitive treatments seek to change thought patterns that lead to getting "stuck" in dysfunctional ways of thinking. Therapists teach their clients to systematically challenge their assumptions and adopt new approaches to old problems.
The therapy is relatively short and lasts a maximum of 20 sessions. It is highly structured and focused on concrete problems. A good example of cognitive treatment is rational-emotive behavior therapy, an attempt to restructure a person's belief system into a more realistic, rational, and logical set of views. According to psychologist Albert Ellis, many people lead unhappy lives and suffer from psychological disorders because they harbor irrational, unrealistic ideas such as these:
We need the love or approval or virtually every significant other person for everything we do.
We should be thoroughly competent, adequate, and successful in all possible respects in order to consider ourselves worthwhile.
It is horrible when things don't turn out the way we want them to.
Such irrational believes trigger negative emotions, which in turn support the irrational beliefs and lead to a self-defeating cycle. To change thinking, therapists take an active, directive role during therapy and openly challenge patterns of thought that appear to be dysfunctional.
Another influential form of therapy was developed by Aaron Beck, aiming to change people's illogical thoughts about themselves and the world. Instead of therapists arguing with their clients, they more often play the role of teacher. Therapists urge clients to obtain information on their own that will lead them to discard their inaccurate thinking through a process of cognitive appraisal. In cognitive appraisal, clients are asked to evaluate situations, themselves, and others in terms of their memories, values, beliefs, thoughts, and expectations. Therapists help clients discover ways of thinking more appropriately about themselves and others.
Evaluating Cognitive Approaches To Therapy
These approaches have proved successful in dealing with a broad range of disorders, including anxiety disorders, depression, substance abuse, and eating disorders. At the same time, critics have pointed out that helping people to think more rationally ignores the fact that life is sometimes irrational. Changing one's assumptions to make them more reasonable and logical thus may not always be helpful - even assuming it is possible to bring about true cognitive change. Still, the success of these approaches has made it one of the most frequently employed therapies.
Section 2 - Psychotherapy: Humanistic, Interpersonal, and Group Approaches to Treatment
MAIN IDEA QUESTIONS
What are the humanistic approaches to treatment?
What is interpersonal therapy?
How does group therapy differ from individual types of therapy?
How effective is psychotherapy, and which kind of psychotherapy works best in a given situation?
VOCABULARY
humanistic therapy - Therapy in which the underlying rationale is that people have control of their behavior, can make choices about their lives, and are essentially responsible for solving their own problems
person-centered therapy - Therapy in which the goal is to reach one's potential for self-actualization
interpersonal therapy (IPT) - Short-term therapy that focuses on the context of current social relationships
group therapy - Therapy in which people meet in a group with a therapist to discuss problems
family therapy - An approach that focuses on the family and its dynamics
spontaneous remission - Recovery without treatment
HUMANISTIC THERAPY
Humanistic therapy draws on the philosophical perspective of self-responsibility in developing treatment techniques. The rationale of this treatment: We have control of our own behavior, we can make choices about the kind of lives we want to live, and it is up to us to solve the difficulties we encounter in our daily lives. Humanistic psychologists believe people naturally are motivated to strive for self-actualization.
Humanist therapists merely view themselves as guides or facilitators. The psychological disorders in their patients result from the inability to find meaning in life and from feelings of loneliness and a lack of connection to others. The techniques used seek to help people understand themselves and find ways to come closer to the ideal they hold for themselves.
Person-Centered Therapy
In this therapy, the therapist does not answer or interpret questions the client has raised; instead, the therapist clarifies or reflects back what the client has said. Person-centered therapy aims to enable people to reach their potential for self-actualization. Therapists create a warm and accepting environment hoping to motivate their clients to air their problems and feelings.
Therapists provide unconditional positive regard, always expressing acceptance and understanding. In such an environment, therapists hope clients can come to more rational decisions that can improve their lives.
This therapy is rarely used today in its purest form. Contemporary approaches are more directive as therapists nudge clients toward insights rather than merely reflecting back their statements.
Evaluating Humanistic Approaches To Therapy
The approach appeals philosophically to many people, and clients find an unusually supportive environment for therapy allowing them to more easily find solutions. However, the approach lacks specificity. It is the least scientifically and theoretically developed treatment.
INTERPERSONAL THERAPY
Interpersonal therapy (IPT) considers therapy in the context of social relationships. It focuses on interpersonal issues such as conflicts with others, social skills issues, role transitions (such as divorce), or grief. The therapy branches from psychodynamic therapy.
This therapy is more active and directive that traditional psychodynamic approaches, and sessions are more structured. The approach makes no assumptions about the underlying causes of psychological disorders but focuses on the interpersonal context in which a disorder is developed and maintained. Treatment typically lasts 12-16 weeks. During those sessions, therapists make concrete suggestions on improving relations with others and offer recommendations and advice. Interpersonal therapy is especially effective in dealing with depression, anxiety, addictions, and eating disorders.
GROUP THERAPY, FAMILY THERAPY, AND SELF-HELP GROUPS
Some forms of therapy involve groups of people seeking treatment. In group therapy, several unrelated people meet with a therapist to discuss some aspect of their psychological functioning. People typically discuss with the group their problems, which often center on a common difficulty, such as alcoholism or a lack of social skills. Other members of the group provide emotional support and dispense advice on the ways they have coped effectively with similar problems.
There are psychoanalytic groups, humanistic groups, and groups corresponding to the other approaches. Because several people are being treated, it is a much more economical form of treatment than psychotherapy. On the other hand, critics argue that group settings lack the individual attention inherent in one-to-one therapy and that especially shy and withdrawn individuals may not receive the attention they need.
Family Therapy
One specialized form of group therapy is family therapy, which involves two or more family members, one (or more) of whose problems led to treatment. Family therapists consider the family as a unit rather than focusing on the one who initiated the problem. Therapists try to understand how the family interacts with one another.
Therapists view the family as a "system" and assume that individuals in the family cannot improve without understanding the conflicts found in interactions among family members. The therapist expects each member to contribute to the resolution of the problem being addressed. Many therapists believe that family members fall into rigid roles or set patterns of behavior with one person acting as the scapegoat, another as a bully, and so forth. Such a system perpetuates family disturbances. One goal of the therapy is to get the family to adopt new, more constructive roles and patterns of behavior.
Self-Help Therapy
In some cases, people with similar problems get together to discuss their shared feelings and experiences. For example, a bereavement support group would be for people who recently experienced the death of a spouse, whereas college students may get together to discuss their adjustment to college.
One of the best-known self-help groups is Alcoholics Anonymous (AA), designed to help members deal with alcohol related problems. AA prescribes 12 steps that alcoholics must pass on their road to recovery, beginning with an admission that they are alcoholics and powerless over alcohol. Other 12-step programs, such as Narcotics Anonymous can be successful in treating other substance-abuse problems.
EVALUATING PSYCHOTHERAPY: DOES THERAPY WORK?
Many individuals who need help are fairly skeptical about the process of therapy - even know they need some help. Furthermore, many do not know of the different therapies or which one works best.
Is Therapy Effective?
Identifying the single most important form of treatment is controversial and still unresolved for psychologists specializing in psychological disorders. Until the 1950s, most people assumed that therapy in any form was effective. In a study challenging that assumption, psychologist Hans Eysenck concluded that people would go into spontaneous remission, recovery without treatment, if they were simply left alone - certainly a simpler and cheaper process.
Other psychologists quickly challenged Eysenck's conclusions, however, his study produced a continuing stream of better controlled, more carefully crafted studies on the effectiveness of psychotherapy. Today most psychologists agree: Therapy does work. Therapy brings about greater improvement than no treatment at all, according to many studies, with the rate of spontaneous remission being fairly low.
Which Kind Of Therapy Works Best?
The question of whether any specific form of treatment is superior to any other has not been answered definitively. Several studies show behavioral and cognitive approaches to be slightly more successful, but that result may have been due to differences in severity of the cases treated. Other research, which relies on meta-analysis in which data from a large number of studies are statistically combined, yields similar general conclusions.
A large survey of 186,000 individuals found that respondents felt they had benefited substantially from psychotherapy. However, there was little difference in "consumer satisfaction" on the basis of the specific type of treatment they had received.
In short, converging evidence allows us to draw several conclusions about the effectiveness of psychotherapy;
For most people, psychotherapy is effective.
On the other hand, psychotherapy doesn't work for everyone.
No single form of therapy works best for every problem, and certain specific types of treatment are better, although not invariably, for specific types of problems.
Most therapies share several basic similar elements.
There is no single, definitive answer to the broad question, "Which therapy works best?" because of the complexity in sorting out the various factors that enter into successful therapy. Evidence-based psychotherapy practice seeks to use research findings to determine the best practices for treating a specific disorder. Researchers use clinical interviews, client self-reports of improvement in quality of life, reductions in symptoms, observations of behavior, and other outcomes to compare different therapies.
In an eclectic approach to therapy, therapists use a variety of techniques, thus integrating several perspectives, to treat a person's problems. By employing more than one approach, therapists can choose the appropriate mix of evidence-based treatments to match the individual's specific needs. Other factors to consider include the personality of the therapist and even the racial and ethnic factors of the treatment.
Section 3 - Biomedical Therapy: Biological Approaches to Treatment
MAIN IDEA QUESTION
How are drug, electroconvulsive, and psychosurgical techniques used today in the treatment of psychological disorders?
VOCABULARY
drug therapy - Control of psychological disorders through the use of drugs
antipsychotic drugs - Drugs that temporarily reduce psychotic symptoms such as agitation, hallucinations, and delusions
antidepressant drugs - Medications that improve a severely depressed patient's mood and feeling of well-being
mood stabilizers - Drugs used to treat mood disorders that prevent manic episodes of bipolar disorder
antianxiety drugs - Drugs that reduce the level of anxiety a person experiences essentially by reducing excitability and increasing feelings feelings of well-being
electroconvulsive therapy (ECT) - A procedure used in the treatment of severe depression in which an electric current of 70-150 volts is briefly administered to a patient's head
transcranial magnetic stimulation (TMS) - A depression treatment in which a precise magnetic pulse is directed to a specific area of the brain
psychosurgery - Brain surgery once used to reduce the symptoms of mental disorder but rarely used today
community psychology - A branch of psychology that focuses on the prevention and minimization of psychological disorders in the community
deinstitutionalization - The transfer of former mental patients from institutions to the community
Could an approach that focuses on the body's physiology be effective for psychological disorders? According to biological approaches to treatment, the answer is yes. Rather than focusing on a patient's psychological conflicts, past traumas, or environmental factors that may produce abnormal behavior, the treatment is focused on brain chemistry and other neurological factors.
DRUG THERAPY
Drug therapy, the control of psychological disorders through drugs, works by altering the operation of neurotransmitters and neurons in the brain. Some drugs inhibit neurotransmitters at particular synapses while other drugs to just the opposite, increasing the activity of certain neurotransmitters or neurons.
Antipsychotic Drugs
Perhaps the greatest change for mental hospitals came in the mid-1950s with the successful introduction of antipsychotic drugs - drugs used to reduce severe symptoms of disturbance, such as loss of touch with reality and agitation.
The dramatic change came about through the introduction of the drug chlorpromazine. It rapidly became the most popular and most successful treatment for schizophrenia. Today drug therapy is the preferred treatment for most cases of severely abnormal behavior and is used for most patients hospitalized with psychological disorders. The newest generation of antipsychotics, referred to as atypical antipsychotics, have had fewer side effects.
Most of the drugs block dopamine receptors at the brain's synapses. They affect both serotonin and dopamine levels in certain parts of the brain, such as those related to planning and goal-directed activity. Despite their effectiveness, they do not produce a "cure" in the same way that, say, penicillin cures an infection. Most of the time, the symptoms reappear when the drug is withdrawn. Furthermore, such drugs can have long-term side effects, such as dryness of the mouth and throat, dizziness, and sometimes tremors and loss of muscle control, which may continue after drug treatments are stopped.
Antidepressant Drugs
As the name suggests, antidepressant drugs are a class of medications used in cases of severe depression to improve the patient's mood and feeling of well-being. They are also sometimes used for other disorders, such as anxiety disorders and bulimia.
Most of these drugs work by changing the concentration of specific neurotransmitters in the brain. For example, tricyclic drugs increase the availability of norepinephrine at the synapses of neurons, whereas MAO inhibitors prevent the enzyme monoamine oxidase (MAO) from breaking down neurotransmitters. Newer antidepressants - such as Lexapro - are selective serotonin reuptake inhibitors (SSRIs). SSRIs target the neurotransmitter serotonin and permit it to linger in the synapse.
Finally, there are newer drugs on the horizon. Scientists have found that the anesthetic ketamine blocks the neural receptor NMDA, which affects the neurotransmitter glutamate. Glutamate plays an important role in mood regulation and the ability to experience pleasure.
The overall success rate of antidepressant drugs is good. These drugs can produce lasting, long-term recovery from depression. In many cases, even after users stop taking the drug, their depression does not return. However, there may be side effects such as drowsiness and faintness, and there is evidence that SSRI antidepressants can increase the risk of suicide in children and adolescents.
Consumers spend billions of dollars each year on antidepressant drugs. In particular, the antidepressant Fluoxetine, sold under the trade name Prozac, has been highlighted on magazine covers and has been the topic of best-sellers. The drug is effective and has relatively few side effects. On the other hand, some 20-30% of users report experiencing nausea and diarrhea, and a smaller number report sexual dysfunctions.
Another substance receiving a great deal of publicity is St. John's wort, an herb that some have called a "natural" antidepressant. It is available without a prescription since the U.S. Food and Drug Administration has classified it as a dietary supplement. Despite it's popularity, definitive clinical tests have found that the herb is ineffective in the treatment of depression.
Mood Stabilizers
Mood stabilizers are used to treat mood disorders. The drug lithium, for example, is a form of mineral salts that has been used very successfully in patients with bipolar disorders. While effectively reducing manic episodes, they do not effectively treat the depressive phases of bipolar disorder.
One quality which sets lithium and similar drugs apart from other drug treatments is that they can be a preventive treatment that blocks future episodes of manic depression. By taking a daily dose of lithium you can prevent episodes from occurring, while most other drugs are useful only when the symptoms of a psychological disturbance occur.
Antianxiety Drugs
As the name implies, antianxiety drugs reduce the level of anxiety a person experiences and increases feelings of well-being. These drugs, such as Xanax and Valium, are among the medications physicians most frequently prescribe. They reduce general tension in people who are experiencing temporary difficulties but can also aid in the treatment of more serious anxiety disorders.
Despite there popularity, they may produce serious side effects. One side effect is fatigue, and long-term use can lead to dependence. When taken in combination with alcohol, some of these drugs can be lethal. A further criticism is that anxiety merely masks deeper problems, and use of these drugs may simply be hiding other difficulties rather than treating them.
ELECTROCONVULSIVE THERAPY (ECT)
First introduced in the 1930s, electroconvulsive therapy (ECT), is a procedure used in the treatment of severe depression. In the procedure, an electric current of 70-150 volts is briefly administered to a patient's head, which causes a loss of consciousness and often causes seizures. Typically, patients are sedated with muscle relaxants before the current is administered. The typical patient receives about 10 ECT treatments in the course of a month, but some continue with maintenance treatments for months afterward.
ECT is a controversial technique, not only for evoking images of execution, but there are also frequent side effects including disorientation, confusion, and sometimes memory loss that may remain for months. ECT often does not produce long-term improvement. Finally, even when ECT does work, we do not know why, and some critics believe it may cause permanent brain damage.
Knowing the controversy and drawbacks, why do therapists use ECT? Basically, they use it because in many severe cases of depression, it offers the only quickly effective treatment. It may prevent depressed, suicidal individuals from committing suicide and can act more quickly than antidepressant drugs. The use of ECT has risen in the last decade, with over 100,000 people undergoing it each year. Still, it only tends to be used when other treatments have proven ineffective.
One new alternate technique to ECT is transcranial magnetic stimulation (TMS). TMS creates a precise magnetic pulse in a specific area of the brain. By activating particular neurons, TMS has been effective in relieving the symptoms of major depression in a number of controlled experiments. However, the therapy can produce side effects, such as seizures and convulsions, and it is still considered experimental.
PSYCHOSURGERY
If ECT strikes you as a questionable procedure, the use of psychosurgery - brain surgery in which the object is to reduce symptoms of mental disorder - probably appears even more dubious. Rarely used today, psychosurgery was introduced as a "treatment of last resort."
The initial form of psychosurgery, a prefrontal lobotomy, consisted of surgically destroying or removing parts of a patient's frontal lobes, which surgeons thought controlled emotionality. In the 1930s and 1940s, surgeons performed the procedure on thousands of patients often with little precision. In one common technique, a surgeon literally would jab an ice pick under a patient's eyeball and swivel it back and forth.
Psychosurgery often did improve a patient's behavior - but not without drastic side effects. Patients sometimes experienced personality changes and became bland, colorless, and unemotional. In other cases, patients became aggressive and unable to control their impulses. In the worst cases, treatment resulted in death.
With the introductions of drug treatment, psychosurgery became nearly obsolete. It is still used in very rare cases when all other procedures have failed and the patient's behavior presents a high risk to the patient and others. Occasionally, dying patients with severe, uncontrollable pain also receive psychosurgery. Still, even these cases raise important ethical issues, and psychosurgery remains a highly controversial treatment.
BIOMEDICAL THERAPIES IN PERSPECTIVE
In some respects, no greater revolution has occurred in the field of mental health than biological approaches to treatment. As previously violent, uncontrollable patients have been calmed by the use of drugs, mental hospitals have been able to concentrate more on actually helping patients and less on custodial functions. Patients whose lives have been disrupted by depression or bipolar disorder have been able to function normally.
The use of biomedical therapy for everyday problems is rising. One study found that from 1989 to 2001, the number of college students who were taking medication for psychological disorders increased from 10% to 25%.
New forms of biomedical therapy are promising. The newest therapy - which is still experimental - is gene therapy. Genes may be introduced to particular regions of the brain. These genes have the potential to reverse or even prevent biochemical events that give rise to psychological disorders.
Despite their promise, biomedical therapies do not represent a cure-all for psychological disorders. Critics charge that such therapies only provide a relief of the symptoms of psychological disorder; as soon as the drugs are withdrawn, the symptoms return. Biomedical therapies can also produce side effects that range from minor to serious physical reactions to the development of new symptoms of abnormal behavior. Finally, an overreliance on biomedical therapies may lead therapists to overlook alternative forms of treatment that may be helpful.
Still, biomedical therapies have permitted millions of people to function more effectively. Although biomedical therapy and psychotherapy appear distinct, research shows that biomedical therapies ultimately may not be as different from talk therapies as one might imagine, at least in terms of their consequences.
COMMUNITY PSYCHOLOGY: FOCUS ON PREVENTION
Each of the treatments we have covered has a common element: It is a "restorative" treatment aimed at alleviating psychological difficulties that already exist. However, an approach known as community psychology has a different aim: to prevent or minimize the incidence of psychological disorders. This form of psychology came of age in the 1960s, when mental health professionals developed plans for a nationwide network of community mental health services. The population of mental hospital plunged as drug treatments made physical restraint of patients unnecessary.
This transfer of former mental patients out of institutions and into the community - a process known as deinstitutionalization - was encouraged by the growth of the community psychology movement.
The promise of such an approach has not been met largely because insufficient resources are provided to deinstitutionalized patients. Former patients of mental hospitals had been dumped into the community without any real support. Many became homeless - between 15-35% of all homeless adults are thought to have a major psychological disorder - and some became involved in illegal acts caused by their disorders. In short, many people who need treatment do not get it.
On the other hand, the community psychology movement has had some positive outcomes, including telephone "hot lines" and college and high school crisis centers.