Chapter 17: Treatment of Mental Disorders
TREATMENTS PAST AND PRESENT
- Early treatments for mental disorders were frequently harsh and rarely effective. Over the centuries, reformers have succeeded in eliminating many of the worst practices.
- Contemporary treatments target different aspects of the network of interrelated biological and environmental factors that give rise to mental disorders. For convenience, researchers make a distinction between psychological and biomedical treatments. However, the boundaries between psychological and biological aspects of treatments are by no means clear-cut; many treatments emphasize both aspects.
- A wide range of professionals provide treatments for mental disorders, including clinical psychologists; psychiatrists; psychiatric nurses; marriage, family, and child counselors; school and vocational counselors; mental health counselors; and clinical social workers. Cultural competence refers to taking into account a patient’s cultural beliefs, values, and expectations.
- Psychological treatments involve efforts to change the patient’s thinking and behavior directly, usually by some form of discussion, instruction, or training.
- Psychodynamic approaches to therapy have their origins in the classical psychoanalytic method developed by Sigmund Freud. The goal of this therapy is to have the patient “work through” psychological conflicts. Transformative insights are not merely intellectual, and this working through depends crucially on the process of transference, which illuminates the ways in which a patient’s pattern of interaction in childhood can influence (and distort) current social relationships.
- Humanistic approaches have in common the idea that people must take responsibility for their lives and their actions, and live fully in the present. Carl Rogers’s client-centered therapy stresses genuineness, unconditional positive regard, and empathic understanding. Fritz Perls’s gestalt therapy uses a variety of techniques to help his patients integrate previously disparate aspects of self.
- Behavioral approaches seek to change a patient’s behavior directly, drawing on principles of classical and operant conditioning as well as observational learning. One classical conditioning technique is exposure therapy. One operant conditioning technique is the use of token economies.One observational learning technique is modeling.
- Cognitive-behavioral approaches seek to change a person’s beliefs and mode of thinking. One example is Albert Ellis’s rational-emotive behavioral therapy, which challenges irrational beliefs. A second example is Aaron Beck’s cognitive therapy, which helps patients identify their automatic thoughts and reactions, and substitute more beneficial reactions.
- Therapists often practice eclecticism, which weaves together various approaches. The last few decades have also seen extensions beyond one-on-one therapy. These include shared problem groups, therapy groups, and couple and family therapy.
- Biomedical treatments are designed to alleviate mental disorders by directly altering the brain’s functioning.
- Pharmacological treatments involve the administration of psychotropic drugs. Classical antipsychotics are helpful in treating the major positive symptoms of schizophrenia; newer antipsychotics show promise in treating negative symptoms. Antidepressants, such as the selective serotonin reuptake inhibitors (SSRIs), influence one or more neurotransmitter systems and offer relief from the symptoms of depression and other mental disorders. Anxiolytics decrease feelings of anxiety associated with the anxiety disorders.
- Drug treatments provide substantial symptom relief for many people with mental disorders. Drug therapy has not been an unqualified success, however, because of the prevalence of side effects and because it is difficult to determine which drug an individual should take—and in what quantity—for a given mental disorder. For example, the widespread use of medications for developmental disorders such as attentiondeficit/ hyperactivity disorder continues to be controversial.
- Nonpharmacological treatments for mental disorders include psychosurgery and electroconvulsive therapy, as well as newer treatments such as vagal nerve stimulation, deep brain stimulation, and repetitive transcranial magnetic stimulation (rTMS).
COMMON FACTORS AND COMBINED TREATMENTS
- Although the various psychological and biomedical therapies differ in many regards, they all benefit from relationship effects, including the therapeutic alliance. Other shared benefits include hope and learning new ways of thinking, feeling, and behaving.
- The empirically supported treatments movement calls for identifying treatments that are based on solid research. Outcome research is more difficult than it appears. For example, 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.
- 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. When testing a new drug, it is also crucial to control for the placebo effect. It is not as clear, however, how to control for this effect when testing a form of psychotherapy.
- One tool for assessing therapies is meta-analysis, by means of which the results of many different studies can be combined. The results of such analyses indicate that many of the various psychological and biomedical treatments are effective. Surprisingly, meta-analyses suggest that very different forms of therapy can be equally effective, a result often referred to as the dodo bird verdict.