How can psychopathology be treated? - Chapter 4

What is the nature and function of psychopathology treatments?

Treatments for psychopathology usually entail providing clients with relief from the distress, insight to their problems and self-awareness, acquisition of coping and problem-solving skills and identification and resolving of the causes of psychopathology. The palliative effect occurs when a form of treatment does not provide the client with insight into their problems and only reduces the severity of symptoms. The theoretical orientation and a therapist's training together with the nature of the psychopathology determine the treatment approach. Therapists take part in continuing professional development (CPD) to update their knowledge of recent developments in treatment techniques.

Which theoretical approaches to treatment are there?

What are psychodynamic approaches?

The psychodynamic approach works with the assumption that an individual develops unconscious conflicts early in life. This approach tries to uncover these events. The therapist will work out strategies with the client for change by bringing these conflicts into conscious awareness through acknowledgment. Sigmund Freud (1856-1939) introduced the form of psychodynamic therapy called psychoanalysis, in which the therapist works with free association, dream interpretation and transference analysis to uncover the client's unconscious conflicts. For the client to call conflicts into awareness, to understand the source of the conflicts and to help the individual gain control over behavior, feelings and attitudes, psychoanalysts make use of these techniques:

• Free association: Any thoughts, feelings, or images that the client has in mind are verbalized
• Transference: The therapist becomes a representative for an important person in the client's life, and thus any emotional responses or behaviors targeted towards that person are acted out on the therapist. This helps the client understand his feelings towards that person
• Dream analysis: Dreams represent unconscious conflicts in a symbolic form
• Interpretation: The information from all three sources is interpreted and ways of conflict solving are developed

Psychoanalysis treatment takes long (3-7 years) to yield benefits and is based on the acquisition of self-knowledge.

What is behavior therapy?

Behavior therapy uses objective knowledge to create a therapy approach. The approach is built on the principles of classical and operant conditioning. Earlier it was thought that psychological disorders came from faulty learning, in which pathological responses are learned. If psychological problems can be learned, then it should be possible to 'unlearn' them. From this idea the behavior analysis or behavior modification approach evolved, which uses the principles of operant conditioning, and the behavior therapy approach, which is based on principles of classical conditioning.

Wolpe (1958) postulated that through the classical conditioning principle of extinction emotional disorders could be cured. Associations between the situation and the threat are in that way 'unlearned'. Popular techniques used for extinction are flooding, counterconditioning and systematic desensitization, which are all termed exposure therapies. Another principle of Wolpe is reciprocal inhibition, in which an anxiety-incompatible response is attached to the cue that induces the emotion. These techniques are utilized for a wide range of disorders. Aversion therapy tries to condition an individual to feel aversion towards a stimulus that they are wrongly attracted to (e.g., addictive behaviour, distressing sexual activities).

Influencing the frequency of a behavior is the target of operant conditioning. Rewards or reinforcing consequences following a behavior increase the frequency and punishment or negative consequences following a behavior decrease the frequency. Three principles are used in therapy: 1) functional analysis 2) establishment of appropriate behaviors by using reinforcers or rewards 3) eliminating problematic behavior by using punishment and negative consequences. Functional analysis looks at consistencies between problematic behaviors and their consequences, such as a reward that follows a problematic behavior thereby maintaining it. Another intervention is the token approach, in which tokens are distributed for the desired behavior and can later be exchanged for a fancied item or activity (e.g., cinema visit). With the response shaping procedure, the frequency of new and desired behaviors is increased, thereby developing new behaviours. A behavior that occurs already frequently serves as an approximation to the frequency in which the new behavior should ultimately occur, and reinforcement is given to approximations that come closer to this model. With behavioral self-control, an individual can make personal use of the operant conditioning principles to bring about change in his or her own behaviour. A good example of this is the program developed by Stuart (1967) to prevent overeating. and reinforcement is given to approximations that come closer to this model. With behavioral self-control, an individual can make personal use of the operant conditioning principles to bring about change in his or her own behaviour

What are cognitive therapies?

Dysfunctional ways of thinking or processing and interpreting incoming information can cause psychopathology. Cognitive therapy tries to identify and change these faulty ways of thinking about the world. Beck's cognitive therapy and rational emotive therapy (RET) represent two early approaches to cognitive therapy. Rational emotive therapy, by Albert Ellis (1962) focuses on how people construct themselves, their life and the world, and how this creates their feelings. This approach tries to free individuals from irrational and unrealistic beliefs, by which they judge themselves and others, and set more attainable life goals. The aim is to replace these implicit assumptions that the individual carries around with more rational beliefs. Beck's cognitive therapy for depression requires the individual to provide evidence for the biased views held of the world, helping him or her to come to the conclusion that the existing schemas are irrational. From these approaches, the approach of cognitive behavior therapy (CBT) was born, which aims to change both thought and behaviour.

The following points are usually part of this therapy:

• The client writes a diary, writing down important events and associated feelings.
• The therapist helps the client identify and challenge dysfunctional beliefs.
• Clients do homework, which allows them to see that their assumptions are irrational.
• For situations eliciting their psychopathology, clients practice new ways of thinking, behaving and reacting.

New forms of cognitive behavior therapy are developed over time, and these different forms of CBT are described as waves. The first wave of CBT was represented mostly by behavior therapy based on conditioning and learning. The second wave focuses more on our cognitions, so the way we think. This was also the wave out of which Beck's therapy developed. The third (and current) wave being developed focuses more on the mindfulness and acceptance of our cognitions. Mindfulness-based cognitive therapy (MBCT) attempts to improve one's emotional well-being by increasing the awareness of how our automatic responses to thoughts, sensations and emotions can be distressing. This is done by achieving a mental state with a focus on the present-moment while maintaining a non-judgmental attitude. MBCT has been shown to have a positive effect on reducing many symptoms, among which are anxiety and depression symptoms. Another third wave variant of cognitive behavioral therapy is acceptance and commitment therapy (ACT). ACT teaches one to 'simply' accept any thought or feelings a person might experience, compared to traditional CBT which focuses on changing these thoughts. When someone applies ACT and accepts their thoughts and feelings, they are not distressed by the negative valence they give to these thoughts, and therefore they might be more successful in clarifying their values ​​and taking action on them. ACT teaches one to 'simply' accept any thought or feelings a person might experience, compared to traditional CBT which focuses on changing these thoughts.

What are humanistic therapies?

Humanistic therapies place emphasis on the client as a 'whole' person, such as in holistic therapies, and focus primarily on the individual and his feelings. The therapy should be built on a good client-therapist relationship that allows cooperation and should enable the client to feel in control of solving his own problems. The most successful therapy of this approach is the client-centered therapy, in which the therapist demonstrates empathy and unconditional positive regard to help the client develop into a well-adjusted, happy individual. The therapist takes the role of the listener and thereby helps the client to grow and move from one phenomenological state to another.

What are family and systemic therapies?

The family therapy is helpful if psychopathology is caused by communication and specific conflicts between family members. The systems theory attempts to re-mold the relationships within a family, especially the relationship between the two parents, so it can function well again. In therapy it is explored how the problem affects functioning of the family and usually the emphasis does not lie on the cause of the problem but rather why it is maintained. The goal is to identify patterns of interaction in the family that are unknown to the members. The therapist will then offer them other ways of responding to each other that are more effective.

What is drug treatment?

As a common first line treatment, drug treatments come in various forms. Antidepressant drugs are prescribed against depression and mood disorders, anxiolytic drugs treat symptoms of anxiety and stress, and antipsychotic drugs deal with symptoms of psychosis and schizophrenia. The first drug against depression, which increased the amount of norepinephrine and serotonin available for synaptic transmission, was called tricyclic antidepressants. This was around the year 1960, and other antidepressants that came on the market during that time were the monoamine oxidase (MAO) inhibitors. If a patient with major depression has not responded to any medication, MAOIs can be effective for some. Bipolar depression and panic disorder can also be treated effectively with MAOIs. Newer types of drugs that have developed (e.g., against depression), such as fluoxetine, sertraline, paroxetine and citalopram, are collectively referred to as selective serotonin reuptake inhibitors or SSRIs. They affect the uptake of only serotonin and produce fewer side effects than for example tricyclic antidepressants that yield the same effects in reducing symptoms of depression. Recent studies have suggested that antidepressants are only more effective than placebos for those suffering from major depression, and that they are not more effective than placebos for people suffering from milder versions of depression. Prevalent disorders of anxiety, such as specific phobias, obsessive-compulsive disorder, panic disorder, generalized anxiety disorder (GAD), and post-traumatic stress disorder, can be treated with benzodiazepines.

Due to the development of antipsychotic drugs the prognosis and view of sufferers of schizophrenia has changed a lot with the time spent in psychiatric institutions having come down to 2 months, when before the introduction of the drug in 1980 the patients spent most of their lives in a psychiatric institution. Antipsychotic drugs, reducing high levels of dopamine in the brain, can target the major positive symptoms but also the major negative symptoms, but also have side effects (e.g., blurred vision, muscles spasms) that lead the patient to stop taking the drug often times. Even though drug treatment is mostly effective, they give an individual the constant feeling of having a disease and being dependent on the drug to alleviate symptoms. There is also evidence that holds that drug treatment worsens a disorder seen over long-term and increases likelihood of relapse. Drug treatment paired with psychological treatment yields most effective results.

What are different modes of treatment delivery?

What is group therapy?

Group therapy is a form of therapy that is useful if an individual benefits from comfort provided by the other members and from the presence of other people that share the same problem and that can help to treat certain psychopathologies in which being surrounded by people plays a role. Different forms of group therapy are experimental groups and encounter groups in which self-growth is fostered through disclosure and interaction and self-help groups in which a common problem is the basis and members support each other through the sharing of information.

What is counselling?

Counseling provides the opportunity for personal-growth and productivity of an individual. This approach has become popular in the last 20-30 years, also because of the greater demand of support and treatment. Counseling can also help in resolving problems of underlying psychopathology. Counselors differ in approaches they use and also specialize in specific areas. This gives the names to counselors such as mental health counselor, marriage counselor or student counselor, and often there is direct service provided for people with specific medical conditions and their caretakers.

What about digital technologies such as computerised CBT, e-therapy, and virtual reality exposure?

Computerised CBT works with software packages that can be used independently by clients. Two CCBT packages are recommended by the UK Department of Health, Beating the Blues for moderate to mild depression, and Fear Fighter for managing panic and phobia. Beating the Blues was found to be more effective than a GP treatment for depression and anxiety.

With the rise of the internet, e-therapy has evolved into an effective add-on to conventional therapy. Treatment can be continued over distance; the client's behaviour can be monitored daily, and family members of the client can communicate that way with the therapist as well. Furthermore, the client can initiate contact with the therapist easier, which is especially good if the client is shy in personal interviews or lives in a remote area. Drawbacks of online communication are miscommunication, effective intervention when a client is experiencing a crisis and difficulty to ensure confidentiality.

Finally, in the last 20 years, the use of virtual reality environments to assess and treat a range of mental health problems has become significantly more widespread. Virtual reality refers to an interactive computer environment that allows the user to experience a particular environment and also interact with that environment. Virtual reality exposure (VRE) is useful in helping the therapist to identify environmental factors that may trigger symptoms and is predominantly used as a safe form of exposure therapy.

Mental health problems not only affect the people suffering from it, but also the economy. Much money is spent on mental health care and lost because of individuals suffering from mental problems. Because of this, many countries are now working hard to supply better access to therapies such as CBT, which has proven its efficacy. Improving Access to Psychological Therapies is a program by NHS which provides services across the UK for people suffering from anxiety or depression disorders. In order to do this, they:

• Train many practitioners therapies such as CBT, and these people get known as psychological well-being practitioners (PWPs)
• Improve the access to treatment and reducing its waiting times
• Increase the client choice and satisfaction

The money that is spend on programs like these are thought to be well returned by the money saved because of people gaining more access to therapy, which results in more people returning back to work.

How is treatment evaluated?

Evaluating treatment is not as easy as it sounds, as one has to take into consideration that different approaches judge differently of what a successful therapy is and what characterizes that success. A therapy in that sense is effective if it was helpful to the client. Nevertheless, objective criteria to assess success of therapies are sought, because the aim is to provide the most effective support for clients and to determine how long-lived the effects of a therapy are and prevention of relapse.

Which factors affect evaluation of treatment?

A client's rating that therapy was effective does not mean that there has been a therapeutic gain, and if there has been a therapeutic gain it does not mean that this was an outcome of the specific type of therapy used. A treatment high in internal validity means the treatment is effective due to the principles it contains. There are several factors that can influence the effectiveness of a treatment, such as spontaneous remission, placebo effects, and unstructured attention, understanding, and caring.

What is spontaneous remission?

Spontaneous remission can be a confounding factor when assessing the effectiveness of a treatment, because it means that over time the people with disorders will get better anyways, without structured treatment. The rate of remission is currently 30%.

What are placebo effects?

When individuals expect to get better by taking a medication for example, they simply get better just by the expectation of improvement. When this happens the placebo effect occurs, but it only holds for a short time and actual psychotherapies show more improvement.

What about unstructured attention, understanding, and caring?

Befriending is a way how to compare effects of structured therapy with the effects of simple social support (attention, understanding and caring) to see if it is the principles contained in the structured therapy that produce improvement. Befriending acts as a control condition in which the therapist applies social support but does not directly target symptoms. Topics of the interview are usually neutral (e.g., hobbies).

Which methods can be used to examine what treatments are effective?

Some forms of therapy do not start with the assumption that the success can be quantitatively or objectively measured, because they focus on the reconstruction of the client's world. Nevertheless, being able to assess treatment is important to provide some sort of a benchmark measure. There are several ways in which the effectiveness of treatments can be assessed, such as randomized controlled trials, and meta-analyses and reviews.

What are randomized controlled trials?

Randomized controlled trials (RCTs) use a variety of control conditions and possibly also other forms of treatment to see how they compare to the treatment being assessed. Random assignment is used to place participants into a control group, either a no treatment or a waiting-list control group, an expectancy and relationship control group and, a comparative treatment group. A therapy is said to possess internal validity and be effective if it is more effective than groups 1 and 2 and at least as effective as group 3 named above.

Limitations:

• Dropouts are common, especially in no treatment conditions.
• RCTs take a lot of time and are expensive.
• Some participants may like some types of therapy better than others, and in random assignment this is not controlled for.
• Objectivity is hard to obtain in RCTs, and there is often explicit or implicit bias.

What are meta-analyses?

The question of whether psychotherapy treatment is more effective than no treatment at all has been investigated by meta-analysis and results of a large-scale study reveal that psychotherapies indeed show greater effectiveness than not treating an individual at all. Yet, the types of psychotherapies did not differ in their effectiveness.

What can be concluded about the effectiveness of treatments?

Most contemporary, accepted therapies seem to be more effective than no therapy, but when compared to each other, no therapy is significantly better than the other. This is also known as the Dodo Bird Verdict, an expression from Alice's Adventures in Wonderland.

Characteristics that can be commonly found in successful therapists include giving good feedback, helping clients gain self-efficacy and autonomy and supporting clients so they can understand their own thoughts and further their relationships. In a large-scale study where clients were asked to rate their satisfaction of the psychotherapy, they reported:

• Significant benefit from the therapy
• There was no difference with psychotherapy plus medication
• The types of therapists were equally effective and
• The longer the treatment was the more they gained from it