General Psychology An Introduction Chapter 14 Therapy

Chapter 14 Therapy 26 Therapeutic Hannah , Stefan Wu In the past century , a number of psychotherapeutic have gained popularity for treating mental illnesses . This module outlines some of the therapeutic approaches and explains the history , techniques , advantages , and disadvantages associated with each . The most effective modern approach is cognitive behavioral therapy ( We also discuss psychoanalytic therapy , therapy , and approaches . emerging new treatment strategies will also be briefly explored . Learning Objectives Become familiar with the most widely practiced approaches to psychotherapy . For each therapeutic approach , consider history , goals , key techniques , and empirical support . Consider the impact of emerging treatment strategies in mental health . Introduction The history of mental illness can be traced as far back as 1500 , when the ancient Egyptians noted cases of distorted concentration and emotional distress in the heart or mind ( lives , and mental health problems affect more than population in year ( Kessler et , 2005 ) Fortunately , a range of exist to treat mental illnesses . This module provides an overview of some of the schools in

Therapeutic 467 psychotherapy . Currently , the most effective approach is called Cognitive Behavioral Therapy ( however , other approaches , such as psychoanalytic therapy , therapy , and therapies are also the effectiveness of these treatments are as clear as they are for . Throughout this module , note the advantages and disadvantages of each approach , paying special attention to their support by empirical research . is an approach to treating mental illness that involves work with a therapist as well as homework assignments between sessions . It has proven to be vew effective for virtually all Psychoanalysis and psychiatric illnesses . Research Report Series Therapy Therapeutic Commons The earliest organized therapy for mental disorders was psychoanalysis . Made famous in the century ofthe , Sigmund Freud , this approach stresses that mental health problems are rooted in unconscious conflicts and desires . In order to resolve the mental illness , then , these unconscious struggles must be identified and addressed . Psychoanalysis often does this through exploring one early childhood experiences that may have continuing repercussions on one mental health in the present and later in life . Psychoanalysis is an intensive , approach in which patients and therapists may meet multiple times per week , often for many years . History of Psychoanalytic Therapy Freud initially suggested that mental health problems arise from efforts to push inappropriate sexual urges out of conscious awareness ( Later , Freud suggested more generally that psychiatric problems are the result of tension between different parts of the mind the id , the superego , and the ego . In Freud , the id represents driven unconscious urges ( our animalistic desires for sex and aggression ) while the superego is the part of the mind where morals and societal judgment are internalized ( the part ofyou that automatically knows how society expects you to behave ) The partly between the id and superego . Freud believed that bringing unconscious struggles like these ( where the id demands one thing and the superego

Therapeutic 468 another ) into conscious awareness would relieve the stress ofthe conflict ( Freud , 955 ) became the goal of psychoanalytic therapy . Although psychoanalysis is still practiced today , it has largely been replaced by the more broadly defined psychodynamic therapy . This latter approach has the same basic tenets as psychoanalysis , but is briefer , makes more of an effort to put clients in their social and interpersonal context , and focuses more on relieving psychological distress than on changing the person . Techniques in Psychoanalysis Psychoanalysts and psychodynamic therapists patients unconscious mind . One common technique is called free association . Here , the patient mind , without attempting to organize or censor them in any way . For example , if you took a pen and paper and just wrote down whatever came into your head , letting one thought lead to the next without allowing conscious criticism to shape what you were writing , you would be doing free association . The analyst then uses his or her expertise to discern underlying meaning in the patient thoughts . patterns Oi Sometimes , free association exercises are applied childhood recollections . Building on the work and others , Sigmund Freud developed psychotherapeutic theories and techniques that became widely known as psychoanalysis or psychoanalytic therapy . Photo Psychology Pictures That is , psychoanalysts believe a childhood relationships with caregivers often determine the way that person relates to others , and predicts later psychiatric difficulties . Thus , exploring these childhood memories , through free association or otherwise , can provide therapists with insights into a patient psychological makeup . Because we do always have the ability to consciously recall these deep memories ,

Therapeutic 469 psychoanalysts also discuss their patients dreams . In Freudian theory , dreams contain not only manifest ( or literal ) content , but also latent ( or symbolic ) content ( i ) For example , someone may have a dream that teeth are falling manifest or actual content of the dream . However , dreaming that one teeth are falling out could be a reflection ofthe person unconscious concern about losing his or her physical latent or metaphorical content of the dream . It is the therapist job to help discover the latent content underlying one manifest content through dream analysis . In psychoanalytic and psychodynamic therapy , the therapist plays a receptive interpreting the patient thoughts and behavior based on clinical experience and psychoanalytic theory . For example , if during therapy a patient begins to express unjustified anger toward the therapist , the therapist may recognize this as an act of transference . That is , the patient may be displacing feelings for people in his or her life ( anger toward a parent ) onto the therapist . At the same time , though , the therapist has to be aware of his or her own thoughts and emotions , for , in a related process , called countertransference , the therapist may displace own emotions onto the patient . The key to psychoanalytic theory is to have patients uncover the buried , conflicting content oftheir mind , and therapists use various as seating patients to face away from promote a freer . And , as a therapist spends more time with a patient , the therapist can come to view his or her relationship with the patient as another reflection of the patient mind . Advantages and Disadvantages of Psychoanalytic Therapy Psychoanalysis was once the only type of psychotherapy available , but presently the number of therapists practicing this approach is decreasing around the world . Psychoanalysis is not appropriate for some types of patients , including those with severe psychopathology or mental retardation . Further , psychoanalysis is often expensive because treatment usually lasts many years . Still , some patients and therapists find the prolonged and detailed analysis very rewarding . Perhaps the greatest disadvantage of psychoanalysis and related approaches is the lack of empirical support for their effectiveness . The limited research that has been conducted on these treatments suggests that they do not reliably lead to better mental health outcomes ( et , 2010 ) And , although there are some reviews that seem to indicate that other researchers have questioned the validity ofthese reviews . Nevertheless , psychoanalytic

Therapeutic 470 theory was history first attempt at formal treatment of mental illness , setting the stage for the more modern approaches used today . Humanistic and Therapy One of the next developments in therapy for mental illness , which arrived in the century , is called humanistic or therapy ( Here , the belief is that mental health problems result from an inconsistency between patients behavior and their true personal identity . Thus , the goal of is to create conditions under which patients can , and behavior to better reflect this identity . History of Therapy developed bya psychologist named Carl Rogers , during a time of significant growth in the movements of humanistic theory and human potential . These perspectives were based on the idea that humans have an inherent drive to realize and express their own capabilities and creativity . Rogers , in particular , believed that all people have the potential to change and improve , and that the role of therapists is to foster understanding in an environment where adaptive change is most likely to occur ( Rogers suggested that the therapist and patient must engage in a genuine , egalitarian relationship in which the therapist is and empathetic . In , the patient should experience both a vulnerability to anxiety , which motivates the desire to change , and an appreciation for the therapist support . Carl Rogers , the father of Person Centered Therapy ( at commons Techniques in Therapy Humanistic and therapy , like psychoanalysis , involves a largely unstructured conversation between the patient . Unlike psychoanalysis , though , using takes a passive role , guiding the patient toward his or her own . Rogers original name for was therapy , and this notion is reflected in the

Therapeutic 471 flexibility found in . Therapists do not tryto change patients thoughts or behaviors directly . Rather , their role is to provide the therapeutic relationship as a platform for personal growth . In these kinds of sessions , the therapist tends only to ask questions and does provide any judgment or interpretation ofwhat the patient says . Instead , the therapist is provide a safe and encouraging environment for the person to explore these issues for or herself . An important aspect ofthe relationship is the therapist unconditional positive regard for the patient feelings and behaviors . That is , the therapist is never to condemn or criticize the patient for what has done or thought the therapist is only to express warmth and empathy . This creates an environment free of approval or disapproval , where patients come to appreciate their value and to behave in ways that are congruent with their own identity . Advantages and Disadvantages of Therapy One key advantage of therapy is that it is highly acceptable to patients . In other words , people tend to find the supportive , flexible environment of this approach very rewarding . Furthermore , some of the themes of translate well to other therapeutic approaches . For example , most therapists ofany orientation find that clients respond well to being treated with empathy . The main disadvantage to , however , is that findings about its effectiveness are mixed . One possibility for this could be that the treatment is primarily based on unspecific treatment factors . That is , rather than using therapeutic techniques that are specific to the patient and the mental problem ( specific treatment factors ) the therapy focuses on techniques that can be applied to anyone ( establishing a good With the patient ) 97 ) Similar to how does really fit every person , uses the same practices for everyone , which may work for some people but not others . Further research is necessary to evaluate its utility as a therapeutic approach . Cognitive Behavioral Therapy Although both psychoanalysis and are still used today , another therapy , behavioral therapy ( has gained more widespread support and practice . refers to a family of therapeutic approaches whose goal is to alleviate psychological symptoms by changing their underlying and behaviors . The premise of is that thoughts , behaviors , and emotions interact and contribute to various mental disorders . For example , let consider how a therapist would view a patient who compulsively washes her hands for hours every day . First , the therapist would identify the patient thought If I do wash my hands like this , I will get a disease and The therapist then identifies how

Therapeutic 472 this thought leads to a emotion the feeling of anxiety when her hands are being washed . And finally , this emotion leads to the behavior the patient washing her hands for hours every day . is a therapy ( focused on the now rather than causes from the past , such as childhood relationships ) that uses behavioral goals to improve one mental illness . Often , these behavioral goals involve homework assignments . For example , the therapist may give the patient a worksheet to take home on this worksheet , the woman is to write down every time she feels the urge to wash her hands , how she deals with the urge , and what behavior she replaces that urge with . When the patient has her next therapy session , she and the therapist review her homework together . is a relatively brief intervention of 12 to 16 weekly sessions , closely tailored to the nature of the psychopathology and treatment of the specific mental disorder . And , as the empirical data shows , has proven to be highly efficacious for virtually all psychiatric illnesses ( Sawyer , Fang , 2012 ) Thoughts create feelings Behaviors reinforce thoughts Feelings create behaviors Pattern of thoughts , feelings , and behaviors addressed through behavioral therapy . History of Cognitive Behavioral Therapy developed from clinical work conducted in the century by Beck , a

Therapeutic 473 psychiatrist , and Albert Ellis , a psychologist . Beck used the term automatic thoughts to refer to the thoughts depressed patients report experiencing spontaneously . He observed that these thoughts arise from three belief systems , or beliefs about the self , beliefs about the world , and beliefs about the future . In treatment , therapy initially focuses on identifying automatic thoughts ( If I do wash my hands constantly , I get a disease ) testing their validity , and replacing thoughts with more adaptive thoughts ( Washing my hands three times a day is sufficient to prevent a disease ) In later stages of treatment , the patient are examined and modified . Ellis ( took a comparable approach , in what he called therapy ( which also encourages patients to evaluate their own thoughts about situations . Techniques in Beck and Ellis strove to help patients identify appraisals , or the and evaluations of certain thoughts . For example , if it your first time meeting new people , you may have the automatic thought , These people wo like me because I have nothing interesting to share . That thought itself is not what troublesome the appraisal ( or evaluation ) that it might have merit is Pioneers Dialectical behavior therapy ( lynch , 2012 ) and The central notion of ( ET is the idea that a person behavioral and emotional responses are causally by one thinking . The stoic Greek philosopher is quoted as are not moved by things , but by the view they take of Meaning , it is not the event per se , but rather one assumptions ( including interpretations and perceptions ) of the event that are responsible for one emotional response to it . Beck calls these assumptions about events and situations automatic thoughts ( Beck , whereas Ellis ( 1962 ) refers to these assumptions as . The cognitive model assumes that these cognitive processes cause the emotional and behavioral responses to events or stimuli . This causal chain is illustrated in Ellis ABC model , in which A stands for the antecedent event , for belief , and stands for consequence . During , the person is encouraged to carefully observe the sequence of events and the response to them , and then explore the validity of the underlying beliefs through behavioral experiments and reasoning , much like a detective or scientist . what troublesome . The goal is to help people make adaptive , instead of , appraisals ( I do know interesting ) This technique of reappraisal , or cognitive restructuring , is a fundamental aspect of . With cognitive restructuring , it is the job to help point out when a person has an inaccurate or , so that the patient can either eliminate it or modify it to be more adaptive . In addition to thoughts , though , another important treatment target of is behavior . Every time a person engages in behavior ( never speaking to someone in new situations ) he or she reinforces the validity ofthe thought , thus

Therapeutic 474 maintaining or perpetuating the psychological illness . In treatment , the therapist and patient work together to develop healthy behavioral habits ( often tracked with homework ) so that the patient can break this cycle of thoughts and behaviors . For many mental health problems , especially anxiety disorders , incorporates what is known as exposure therapy . During exposure therapy , a patient confronts a problematic situation and fully engages in the experience instead of avoiding it . For example , imagine a man who is terrified of spiders . Whenever he encounters one , he immediately screams and panics . In exposure therapy , the man would be forced to confront and interact with spiders , rather than simply avoiding them as he usually does . The goal is to reduce the fear associated with the situation through extinction learning , a neurobiological and cognitive process by which the patient the irrational fear . For example , exposure of spiders might begin with him looking at a cartoon of a spider , followed by him looking at pictures of real spiders , and later , him plastic spider . After weeks ofthis incremental exposure , the patient may even be able to hold a live spider . After repeated exposure ( starting small and building one way up ) the patient experiences less physiological fear and thoughts about spiders , breaking his tendency for anxiety and subsequent avoidance . Advantages and Disadvantages of interventions tend to be relatively brief , making them for the average consumer . In addition , is an intuitive treatment that makes logical sense to patients . It can also be adapted to suit the needs of many different populations . One disadvantage , however , is that does involve significant effort on the patient part , because the patient is an active participant in treatment . Therapists often assign homework ( worksheets for recording one thoughts and behaviors ) between sessions to maintain the cognitive and behavioral habits the patient is working on . The greatest strength of is the abundance of empirical support for its effectiveness . Studies have consistently found to be equally or more effective than other forms of treatment , including medication and other therapies ( Butler , Chapman , Forman , Beck , 2006 et , 2012 ) For this reason , is considered a treatment for many mental disorders . Acceptance and Approaches Unlike the preceding therapies , which were developed in the century , this next one was born out of Buddhist and yoga practices . Mindfulness , or a process that tries to cultivate a , yet attentive , mental state , is a therapy that focuses on ones

Therapeutic 475 awareness of bodily sensations , thoughts , and the outside environment . Whereas other therapies work to modify or eliminate these sensations and thoughts , mindfulness focuses on accepting them ( For example , whereas may actively confront and work to change a thought , mindfulness therapy acknowledge and , spontaneous and not what the person truly believes . There are two important components of mindfulness ( of attention , and ( orientation toward the present moment ( Bishop et , past and future stressors , encourages acceptance of troubling thoughts and feelings , and promotes physical relaxation . Techniques in Therapy Psychologists have adapted the practice of mindfulness as a form of psychotherapy , generally called therapy ( Several types have become recent years , including stress reduction ( 1982 ) and uses meditation , yoga , and attention to physical experiences to reduce stress . The hope is that reducing a person overall stress will allow that person to more objectively evaluate his or . In , ratherthan reducing one general stress to address a specific problem , attention is focused on ones thoughts and their associated emotions . For example , helps prevent relapses in depression by encouraging patients to evaluate their own thoughts objectively and without value judgment ( may seem similar to this , it focuses on pushing out the thought , whereas cognitive therapy focuses on One ofthe most important advantages getting caught up in it . The treatments used based therapy is its level of accessibility to patients . in have been used to address a Wide range , including depression , anxiety , chronic pain , coronary artery disease , and ( Sawyer , Oh , 2010 )

Therapeutic 476 Mindfulness and addition to being therapies in their own also been used as in other therapies , particularly in dialectical behavior therapy ( i , often used in the treatment of borderline personality disorder , focuses on skills training . That is , it often employs mindfulness and cognitive behavioral therapy practices , but it also works to teach its patients skills they can use to correct tendencies . For example , one skill teaches patients is called distress , ways to cope with thoughts and emotions in the moment . For example , people who feel an urge to cut themselves may be taught to snap their arm with a rubber band instead . The primary difference between and is that employs techniques that address the symptoms of the problem ( cutting oneself ) rather than the problem itself ( understanding the psychological motivation to cut oneself ) does not teach such skills training because of the concern that the though they may help in the be harmful in the , by maintaining thoughts and behaviors . is founded on the perspective ofa dialectical worldview . That is , rather than thinking of the world as black and white , or only good and only bad , it focuses on accepting that some things can have characteristics of both good and So , in a case involving thoughts , instead of teaching that a thought is entirely bad , tries to help patients be less judgmental of their thoughts ( as with therapy ) and encourages change through therapeutic progress , using techniques as well as mindfulness exercises . Another form of treatment that also uses mindfulness techniques is acceptance and commitment therapy ( ACT ) Hayes , Wilson , 1999 ) In this treatment , patients are encourages patients not to attempt to change or avoid thoughts and emotions they observe in themselves , but to recognize which are beneficial and which are harmful . However , the differences among ACT , and other treatments are a topic of controversy in the current literature . Advantages and Disadvantages of Therapy Two key advantages of therapies are their acceptability and accessibility to patients . Because yoga and meditation are already widely known in popular culture , consumers healthcare are often interested in trying related psychological therapies . Currently , psychologists have not come to a consensus on the efficacy of , though growing evidence supports its effectiveness for treating mood and anxiety disorders . For example ,

Therapeutic 477 one review of studies for anxiety and depression found that interventions generally led to moderate symptom improvement ( et , 2010 ) Emerging Treatment Strategies With growth in research and technology , psychologists have been able to develop new treatment strategies in recent years . Often , these approaches focus on enhancing existing treatments , such as therapies , through the use of technological advances . For example , and therapies make psychological treatments more available , through smartphones and online access . online modules allow patients to Recent improvements in video chat technology along with the access home important for patients with less geographic or socioeconomic access to traditional treatments . Furthermore , smartphones help extend therapy to patients daily lives , allowing for symptom tracking , homework reminders , and more frequent therapist contact . Another benefit of technology is cognitive bias modification . Here , patients are given exercises , often through the use games , aimed at changing their problematic thought processes . For example , researchers might use a mobile app to train alcohol abusers to avoid stimuli related to alcohol . One version ofthis game flashes four pictures on the alcohol cues ( a can of beer , the front ofa bar ) and one image ( someone drinking water ) The goal is for the patient to tap the healthy picture as fast as can . Games like these aim to target patients automatic , subconscious thoughts that may be difficult to direct through conscious effort . That is , by repeatedly tapping the healthy image , the patient learns to ignore the alcohol cues , so when those cues are encountered in the environment , they will be less trigger the urge to drink . Approaches like these are promising because of their accessibility , however they require further research to establish their effectiveness . Yet another emerging treatment employs pharmaceutical agents . drugs used to improve the effects interventions . Based on research from animal

Therapeutic 478 experiments , researchers have found that certain drugs influence the biological processes known to be involved in learning . Thus , if people take these drugs while going through psychotherapy , they are better able to learn the techniques for improvement . For example , the antibiotic improves treatment for anxiety disorders by facilitating the learning processes that occur during exposure therapy . Ongoing research in this exciting area may prove to be quite fruitful . Pharmacological Treatments Up until this point , all the therapies we have discussed have been or meditative practices . However , psychiatric medications are also frequently used to treat mental disorders , bipolar disorder , depression , and . Psychiatric drugs are commonly used , in part , because they can be prescribed by general medical practitioners , whereas only trained psychologists are qualified to deliver effective psychotherapy . While drugs and therapies tend to be almost equally effective , choosing the best intervention depends on the disorder and individual being treated , as well as other as treatment availability and ( having multiple mental or physical disorders at once ) Although many new drugs have been introduced in recent decades , there is still much we do not understand about their mechanism in the brain . Further research is needed to refine our understanding of both pharmacological and behavioral treatments before we can make firm claims about their effectiveness . Integrative and Eclectic Psychotherapy In discussing therapeutic , it is important to note that some incorporate techniques from multiple approaches , a practice known as integrative or eclectic psychotherapy . For example , a therapist may employ distress tolerance skills from ( to resolve problems ) cognitive reappraisal from ( to address issues ) and meditation from ( to reduce overall stress ) And , in fact , between 13 and 42 of therapists have identified their own approaches as integrative or eclectic ( 2005 ) Conclusion Throughout human history we have had to deal with mental illness in one form or another . Over time , several schools of thought have emerged for treating these problems . Although various therapies have been shown to work for specific individuals , cognitive behavioral

Therapeutic 479 therapy is currently the treatment most widely supported by empirical research . Still , practices like psychodynamic therapies , therapy , treatments , and acceptance and commitment therapy have also shown success . And , with recent advances in research and technology , are able to enhance these and other therapies to treat more patients more effectively than ever before . However , what is important in the end is that people actually seek out mental health specialists to help them with their problems . One of the biggest to doing so is that people do understand what psychotherapy really entails . Through understanding how current practices work , not only can we better educate people about how to get the help they need , but we can continue to advance our treatments to be more effective in the future .

Therapeutic 480 Discussion Questions . Psychoanalytic theory is no longer the dominant therapeutic approach , because it lacks empirical support . Yet many consumers continue to seek psychoanalytic or psychodynamic treatments . Do you think psychoanalysis still has a place in mental health treatment ?

why ?

What might be some advantages and disadvantages of technological advances in psychological treatment ?

What will psychotherapy look like 100 years from now ?

Some people have argued that all therapies are about equally effective , and that they all affect change through common factors such as the involvement ofa supportive therapist . Does this claim sound reasonable to you ?

Why or why not ?

When choosing a psychological treatment for a specific patient , what factors besides the treatment demonstrated efficacy should be taken into account ?

Therapeutic 481 Vocabulary Acceptance and commitment therapy A therapeutic approach designed to foster observation of ones own mental processes . Automatic thoughts Thoughts that occur spontaneously often used to describe problematic thoughts that maintain mental disorders . Cognitive bias modification Using exercises ( computer games ) to change problematic thinking habits . therapy ( A family of approaches with the goal of changing the thoughts and behaviors that influence psychopathology . Describes a state of having more than one psychological or physical disorder at a given time . Dialectical behavior therapy ( A treatment often used for borderline personality disorder that incorporates both behavioral and mindfulness elements . Dialectical worldview A perspective in that emphasizes thejoint importance of change and acceptance . Exposure therapy A form of intervention in which the patient engages with a problematic ( usually feared ) situation without avoidance or escape . Free association In psychodynamic therapy , a process in which the patient reports all thoughts that come to mind without censorship , and these thoughts are interpreted by the therapist . Integrative or eclectic psychotherapy Also called integrative psychotherapy , this term refers to approaches combining multiple ( with psychoanalytic elements )

Therapeutic 482 Integrative or eclectic psychotherapy Also called integrative psychotherapy , this term refers to approaches combining multiple ( with psychoanalytic elements ) Mindfulness A process that reflects a , yet attentive , mental state . therapy A form of psychotherapy grounded in mindfulness theory and practice , often involving meditation , yoga , body scan , and other features of mindfulness exercises . therapy A therapeutic approach focused on creating a supportive environment for . Psychoanalytic therapy Sigmund Freud therapeutic approach focusing on resolving unconscious conflicts . Psychodynamic therapy Treatment applying psychoanalytic principles in a briefer , more individualized format . Reappraisal , or Cognitive restructuring The process of identifying , evaluating , and changing thoughts in psychotherapy . Schema A mental representation or set of beliefs about something . Unconditional positive regard In therapy , an attitude , empathy and acceptance adopted by the therapist in order to foster feelings of inherent worth in the patient .

Therapeutic 483 References , 2003 ) Mindfulness training as a clinical intervention A conceptual and empirical review . Clinical Psychology Science and Practice , 10 , Bishop , Lau , Shapiro , Anderson , Carmody , Abbey , 2004 ) A proposed operational definition . Clinical Psychology Science and Practice , 11 , Butler , Chapman , Forman , Beck , 2006 ) The empirical status behavioral therapy A review of . Clinical Psychology Review , 26 , van , Barth , 2012 ) The efficacy of supportive therapy for adult depression A . Clinical Psychology Review , 32 , de , A . 2010 ) The efficacy psychodynamic psychotherapy for depression A . Clinical Psychology Review , 30 , Ellis , A . 1957 ) Rational psychotherapy and individual psychology . journal of Individual Psychology , 13 , Freud , 955 ) Studies on hysteria . London , UK Hogarth Press ( Original work published 1895 ) Freud , 1955 ) The interpretation of dreams . London , UK Hogarth Press ( Original work published 1900 ) Freud . 1955 ) Beyond the pleasure principle . London , UK Hogarth Press ( Original work published 1920 ) King , Lloyd , 1997 ) Randomized controlled assessment of psychotherapy versus routine care . Lancet , 350 , 1665 . Hayes , Wilson , 1999 ) Acceptance and Commitment Therapy . NY Press . Sawyer , Fang , A . 2012 ) The efficacy of cognitive behavioral therapy A review of . Cognitive Therapy and Research , 36 , Sawyer , Oh , 201 ) The effect therapy on anxiety and depression A review . journal of Consulting and Clinical Psychology , 78 , 2003 ) interventions in context Past , present , and future . Clinical Psychology Science and Practice , 10 ,

Therapeutic 484 , 982 ) An outpatient program in behavioral medicine for chronic pain on the practice of mindfulness meditation Theoretical considerations and preliminary results . General Hospital Psychiatry , Kessler , Jin , 2005 ) Lifetime prevalence and age of onset distribution of disorders in the National Survey Replication . Archives of General Psychiatry , 62 , 2008 ) Effectiveness of psychodynamic psychotherapy A . Suarez , Heard , 1991 ) behavioral treatment of chronically suicidal borderline patients . Archives of General Psychiatry , 48 , 1987 ) Psychiatry in ancient Egypt . Bulletin of the Royal College , 11 , 2005 ) Handbook Psychotherapy Integration . New York , NY Oxford University Press . Rogers , 1951 ) Therapy . Cambridge , MA Riverside Press . Williams , 2002 ) Cognitive Depression A New Approach to Preventing Relapse . New York , NY Press .

27 Susan is the study of how drugs affect behavior . If a drug changes your perception , or the way you feel or think , the drug exerts effects on your brain and nervous system . We call drugs that change the way you think or feel psychoactive or psychotropic drugs , and almost everyone has used a psychoactive drug at some point ( yes , caffeine counts ) Understanding some ofthe basics about can help us better understand a wide range of things that interest psychologists and others . For example , the pharmacological treatment neurodegenerative diseases such as disease tells us something about the disease itself . The pharmacological treatments used to treat psychiatric conditions such as schizophrenia or depression have undergone amazing development since the 19505 , and the drugs used to treat these disorders tell us something about what is happening in the brain of individuals with these conditions . Finally , understanding something about the actions of drugs of abuse and their routes of administration can help us understand why some psychoactive drugs are so addictive . In this module , we will provide an overview of some ofthese topics as well as discuss some current controversial areas in the field of . Learning Objectives How do the majority of psychoactive drugs work in the brain ?

How does the route of administration affect how rewarding a drug might be ?

Why is grapefruit dangerous to consume with many psychotropic medications ?

Why might individualized drug doses based on genetic screening be helpful for treating conditions like depression ?

Why is there controversy regarding pharmacotherapy for children , adolescents , and the elderly ?

486 Introduction , the study of how drugs affect the brain and behavior , is a relatively new science , although people have probably been taking drugs to change how from early in human history ( consider the of eating fermented fruit , ancient beer recipes , chewing on the leaves of the cocaine plant for stimulant properties as just some examples ) The word us that this is a field that bridges our understanding ( and brain ) and pharmacology , and the range of topics included within this field is extremely broad . changes the wayyou feel how with each other . Neurons ( morethan 100 billion in your nervous system ) communicate with each other by releasing a chemical ( neurotransmitter ) across a tiny space between two neurons ( the synapse ) When the neurotransmitter crosses the synapse , it binds to a postsynaptic receptor ( protein ) on the receiving neuron and the message may then be transmitted onward . Obviously , is far more Drugs that alter our feelings and behavior do so by Complicated than this links at the end of this affecting the communication between neurons in the module can provide some useful background if brain , Perry you want more detail but the first step is understanding that virtually all psychoactive drugs interfere with or alter how neurons communicate with each other . There are many neurotransmitters . Some of the most important in terms of treatment and drugs are outlined in Table . The neurons that release these neurotransmitters , for the most part , are localized within specific circuits ofthe brain that mediate these behaviors . Psychoactive drugs can either increase activity at the synapse ( these are called ) or reduce activity at the synapse ( antagonists ) Different drugs do this by different mechanisms , and some examples of and antagonists are presented in Table . For each example , the drug trade name , which is the name of the drug provided by the drug company , and generic name ( in parentheses ) are provided . A very useful link at the end of this module shows the various steps involved in

487 , Behaviors or Diseases Related to Neurotransmitter Abbreviation . These Neurotransmitter Learning and Acetylcholine ACh disease muscle movement in the peripheral nervous system , DA Reward circuits Motor circuits involved in disease Schizophrenia Norepinephrine NE Arousal Depression Serotonin Depression Aggression Schizophrenia Glutamate Learning Major excitatory neurotransmitter in the brain Anxiety disorders Epilepsy Major inhibitory neurotransmitter in the brain , Endorphins , Endogenous Pain . Analgesia , Reward Table and some ways drugs can alter this . Mechanism Increase synthesis of DA disease Agonist for DA ( Increase release of DA , NE Agonist for DA , NE salts amphetamine ) Ritalin Blocks removal of DA . NE . and . lesser ( from synapse for DA NE ( Blocks re from disease Agonist for ACh Blocks removal of from Depression . obsessive compulsive Prozac ( Synapse disorder Agonist ( Blocks DA and receptors Schizophrenia , bipolar disorder Antagonist for DA Blocks ( naltrexone ) receptors Alcoholism , addiction Antagonist ( for opioids ) Table

488 Table provides examples of drugs and their primary mechanism of action , but it is very important to realize that drugs also have effects on other neurotransmitters . This contributes to the kinds of side effects that are observed when someone takes a particular drug . The reality is that no drugs currently available work only exactly where we would like in the brain or only on a specific neurotransmitter . In many cases , individuals are sometimes prescribed one psychotropic drug but then may also have to take additional drugs to reduce the side effects caused by the initial drug . Sometimes individuals stop taking medication because the side effects can be so profound . What Is It Why Is It Important ?

While this section may sound more like pharmacology , it is realize how important can be when considering psychoactive drugs . refers to how the body handles a drug that we take . As mentioned earlier , psychoactive drugs exert their effects on behavior by altering neuronal communication in the brain , and the majority of drugs reach the brain by traveling in the blood . The acronym is often used with A standing for absorption ( how the drug gets into the blood ) Distribution ( how the drug gets to the organ in this module , that is the brain ) Metabolism ( howthe drug is broken down so it no longer exerts its psychoactive effects ) and Excretion ( how the drug leaves the body ) We will talk about a couple of these to show their importance for considering psychoactive drugs . Drug Administration There are many ways to take drugs , and these routes administration can have a significant impact on how quickly that drug reaches brain . The most common route is oral administration , which is relatively slow and perhaps surprisingly often the most variable and complex route of administration . Drugs enter the stomach and then get absorbed by the blood capillaries the brain small intestine . The rate of absorption is taken orally . While rapid delivery has advantages , there are also can be affected by a Variety of factors risks involved with IV administration . Photo Bart the quantity and the type of

489 food in the stomach ( fats proteins ) This is why the medicine label for some drugs ( like antibiotics ) may specifically state foods that you should or should NOT consume within an hour of taking the drug because they can affect the rate . Two of the most rapid routes of administration include inhalation ( smoking or gaseous anesthesia ) and intravenous ( IV ) in which the drug is injected directly into the vein and hence the blood supply . Both of these routes of administration can get the drug to brain in less than 10 seconds . IV administration also has the distinction of being the most dangerous because if there is an adverse drug reaction , there is very little time to administer any antidote , as in the case of an IV heroin overdose . Why might how quickly a drug gets to the brain be important ?

If a drug activates the reward circuits in the brain AND it reaches the brain very quickly , the drug has a high risk for abuse and addiction . like amphetamine or cocaine are examples of drugs that have high risk for abuse because they are at DA neurons involved in reward AND because these drugs exist in forms that can be either smoked or injected intravenously . Some argue that cigarette smoking is one of the hardest addictions to quit , and although part of the reason for this may be that smoking gets the nicotine into the brain very quickly ( and indirectly acts on DA neurons ) it is a more complicated story . For drugs that reach the brain very quickly , not only is the drug very addictive , but so are the cues associated with the drug ( See , a , Crack Use this be the pipe that they use to smoke the drug . For a cigarette smoker , however , it could be something as normal as finishing dinner or waking up in the morning ( if that is when the smoker usually has a cigarette ) For both the crack user and the cigarette smoker , the cues associated with the drug may actually cause craving that is alleviated by ( you guessed it ) lighting a cigarette or using crack ( relapse ) This is one ofthe reasons individuals that enroll in drug treatment programs , especially programs , are at significant risk of relapse if they later find themselves in old haunts , friends , etc . But this is much more difficult for a cigarette smoker . How can someone avoid eating ?

Or avoid waking up in the morning , etc . These examples help you begin to understand how important the route of administration can be for psychoactive drugs . Drug Metabolism Metabolism involves the breakdown of psychoactive drugs , and this occurs primarily in the liver . The liver produces enzymes ( proteins that speed up a chemical reaction ) and these enzymes help catalyze a chemical reaction that breaks down psychoactive drugs . Enzymes exist in families , and many psychoactive drugs are broken down by the same family of enzymes , the cytochrome superfamily . There is not a unique enzyme for each drug

490 rather , certain enzymes can break down a wide variety of drugs . Tolerance to the effects of many drugs can occur with repeated exposure that is , the drug produces less of an effect over time , so more of the drug is needed to get the same effect . This is particularly true for sedative drugs like alcohol or painkillers . Metabolic tolerance is one kind of tolerance and it takes place in the liver . Some drugs ( like alcohol ) cause enzyme induction an increase in the enzymes produced by the liver . For example , chronic drinking results in alcohol being broken down more quickly , so the alcoholic needs to drink more to get the same effect of course , until so much alcohol is consumed that it damages the liver ( alcohol can cause fatty liver or cirrhosis ) Recent Issues Related to Psychotropic Drugs and Metabolism and Metabolism Certain types in the stomach can alter the rate absorption , and other foods can also alter the rate metabolism . The most well known is grapefruit juice . Grapefruit juice suppresses cytochrome enzymes in the liver , and these liver enzymes normally break down a large variety of drugs ( including some of the psychotropic drugs ) If the enzymes are suppressed , drug levels can build up to potentially toxic levels . In this case , the effects can persist for extended periods oftime after the consumption . As , there are at least 85 drugs shown to adversely interact Grapefruit can interfere with enzymes in the liver that with grapefruit juice ( Bailey Dresser Arnold help the body to process certain drugs . Photo 2013 ) Some psychotropic drugs that are likely to interact with grapefruit juice include ( prescribed for bipolar disorder diazepam ( Valium ) used to treat anxiety , alcohol withdrawal , and muscle spasms and ( used to treat obsessive compulsive disorder and depression . A link at the end ofthis module gives the latest list reported to have this unusual interaction . Individualized Therapy , Metabolic Differences , and Potential Prescribing Approaches for the Future

491 Mental illnesses contribute to more disability in western countries than all other illnesses including cancer and heart disease . Depression alone is predicted to be the second largest contributor to disease burden by 2020 ( The numbers of people affected by mental health issues are pretty astonishing , with estimates that 25 of adults experience a mental health issue in any given year , and this affects not only the individual but their friends and family . One in 17 adults experiences a serious mental illness ( Newer antidepressants are probably the most frequently prescribed drugs for treating mental health issues , although there is no magic bullet for treating depression or other conditions . Pharmacotherapy with psychological therapy may be the most beneficial treatment approach for many psychiatric conditions , but there are still many unanswered questions . For example , why does one antidepressant help one individual yet have no effect for another ?

Antidepressants can take to weeks to start improving depressive symptoms , and we do really understand why . Many people do not respond to the first antidepressant prescribed and may have to try different drugs before . Other antidepressants ( 2008 ) As we better understand why individuals differ , the easier and more rapidly we will be able to help people in distress . One area that has received interest recently has to do with an individualized treatment approach . We now know that there are genetic differences in some of the cytochrome enzymes and their ability to break down drugs . The general population falls into the following categories ) break down certain drugs ( like some ofthe current antidepressants ) very , very quickly , extensive are also able to break down drugs fairly quickly , intermediate break down drugs more slowly than either of the two above groups , and finally ) poor break down drugs much more slowly than all ofthe other groups . Now consider someone prescription foran what would the consequences be ifthey were either an or a poor ?

The would be given antidepressants and told it will probably take to weeks to begin working ( this is true ) but they metabolize the medication so quickly that it will never be effective for them . In contrast , the poor given the same daily dose of the same antidepressant may build up such high levels in their blood ( because they are not breaking the drug down ) that they will have a wide range effects and feel really badly also not a positive outcome . What instead prior to prescribing an antidepressant , the doctor could take a blood sample and determine which type of a patient actually was ?

They could then make a much more informed decision about the best dose to prescribe . There are new genetic tests now available to better individualize treatment in just this way . A blood sample can determine ( at least for some drugs ) which category an individual fits into , but we need data to determine ifthis actually is effective for treating depression or other mental illnesses ( Zhou , 2009 ) Currently , this genetic

492 test is expensive and not many health insurance plans cover this screen , but this may be an important component in the future of . Other Controversial Issues Juveniles and A recent Centers for Disease Control ( report has suggested that as many as in children between the ages of and 17 may have some type of mental disorder ( autism , anxiety , depression ) 201 ) The incidence disorder in children and adolescents There is no single answer to this important question . Some believe that greater public awareness has contributed to increased teacher and parent referrals . Others argue that the increase stems from changes in criterion currently used for diagnosing . Still others suggest environmental factors , either prenatally or , have contributed to this upsurge . We do not have an answer , but the question does bring up an additional controversy related to how we should treat this population of children and adolescents . Many psychotropic drugs used for treating psychiatric disorders have been tested in adults , but few have been tested for safety or children . The established psychotropics prescribed for children and adolescents are the drugs used for treating attention deficit hyperactivity disorder ( and there are clinical data on how effective these drugs are . However , we know far less about the safety and efficacy in young populations ofthe prescribed anxiety , depression , or other psychiatric disorders . The young brain continues to mature until after age 20 , so some scientists are concerned that drugs that alter neuronal activity in the developing There are Concerns about both the Safety and brain could have significant consequences . There efficacy like children and teens . is an obvious need for clinical trials in children and Photo

493 adolescents to test the safety and effectiveness of many ofthese drugs , which also brings up a variety of ethical questions about who decides what children and adolescents will participate in these clinical trials , who can give consent , who receives , etc . The Elderly and Another population that has not typically been included in clinical trials to determine the safety or effectiveness of psychotropic drugs is the elderly . Currently , there is very little quality evidence to guide prescribing for older people clinical trials often exclude people with multiple ( other diseases , conditions , etc . which are typical for elderly ( See , This is Serious issue because the elderly consume a disproportionate number of the prescription meds prescribed . The term polypharmacy refers to the use drugs , which is very common in elderly populations in the United States . As our population ages , some estimate that the proportion of people 65 or older will reach 20 ofthe population by 2030 , with this group consuming 40 of the prescribed medications . As shown in Table ( from Schwartz and effectiveness of psychotropic drugs can be problematic if we try to interpret these results for an elderly population . Clinical Trial Subjects Aged Patients Who Receive Drug Therapies One drug Drug of interest and medications Single does Chronic administration disease Multiple diseases No alcohol , tobacco , drugs , alcohol , tobacco , and drugs . other years ( years ) years Caucasians and minorities Selection bias All basis Over the counter Table . Characteristics if clinical trial subjects actual patients . Reprinted by permission from Schwartz , 2008 .

494 Metabolism of drugs is often slowed considerably for elderly populations , so less drug can produce the same effect ( or all too often , too much drug can result in a variety effects ) One of the greatest risk factors for elderly populations is falling ( and breaking bones ) which can happen ifthe elderly person gets dizzy from too much ofa drug . There is also evidence that psychotropic medications can reduce bone density ( thus worsening the consequences if someone falls ) Although we are gaining an awareness about some of the issues facing pharmacotherapy in older populations , this is a very complex area with many medical and ethical questions . This module provided an introduction of some of the important areas in the field of . It should be apparent that this touched on a number of topics included in this field . It should also be apparent that understanding more about is important to anyone interested in understanding behavior and that our understanding of issues in this field has important implications for society .

495 Outside Resources Video ?

Web Description of how some drugs work and the brain areas involved Web Description of how some drugs work and the brain areas involved Web Information about how neurons communicate and the reward pathways Web National Institute of Alcohol Abuse and Alcoholism Web National Institute of Drug Abuse Web National Institute of Mental Health Web Web Report of the Working Group on Psychotropic Medications for Children and Adolescents , Psychosocial , and Combined Interventions for Childhood Disorders Evidence Base , Contextual Factors , and Future Directions ( 2008 ) Web Ways drugs can alter Discussion Questions . What are some of the issues surrounding prescribing medications for children and

496 adolescents ?

How might this be improved ?

What are some of the factors that can affect relapse to an addictive drug ?

How might prescribing medications for depression be improved in the future to increase the likelihood that a drug would work and minimize side effects ?

497 Vocabulary A drug that increases or enhances a neurotransmitter effect . Antagonist A drug that blocks a neurotransmitter effect . Enzyme A protein produced by a living organism that allows or helps a chemical reaction to occur . Enzyme induction Process through which a drug can enhance the production ofan enzyme . Metabolism Breakdown of substances . Neurotransmitter substance produced bya neuron that is used for communication between neurons . The action of a drug through the body , including absorption , distribution , metabolism , and excretion . Polypharmacy The use of many medications . Psychoactive drugs A drug that changes mood or the way someone feels . Psychotropic drug A drug that changes mood or emotion , usually used when talking about drugs prescribed for various mental conditions ( depression , anxiety , schizophrenia , Synapse The tiny space separating neurons .

498 References Bailey , Dresser , Arnold ( 2013 ) interactions forbidden fruit or avoidable consequences ?

Canadian Medical , 185 , Brown , 201 ) Brains , bones , and aging psychotropic medications and bone health among older adults . Current Osteoporosis Reports , 10 , Centers for Disease Control and Prevention ( 201 ) Prevalence spectrum disorders autism and developmental disabilities monitoring network , 14 sites , United States , 2008 . Morbidity and Mortality Weekly Report 61 ( Centers for Disease Control and Prevention . 2013 ) Mental health surveillance among children United States , Morbidity and Mortality Weekly Report 62 , 2008 ) The effects of polypharmacy in older adults . Clinical Pharmacology Therapeutics , 85 , A . 2008 ) Effectiveness of antidepressants an evidence myth constructed from a thousand randomized trials ?

Philosophy , Ethics and Humanities in Medicine , Kessler , Chiu , Walters , 2005 ) Prevalence , severity , and of disorders in the National Survey Replication ( Archives of General Psychiatry , 62 , Moreno , Blanco , Jiang , Schmidt , A . 2007 ) National trends in the outpatient diagnosis and treatment of bipolar disorder in youth . Archives General Psychiatry , 64 ( Pollock , 2008 ) The critical role of clinical pharmacology in geriatric . Clinical Pharmacology Therapeutics , 85 , 990 ) Cue reactivity in addictive behaviors Theoretical and treatment implications . International journal of Addiction , 25 , Schwartz , 2008 ) Aging and medications Past , present , future . Clinical Pharmacology Therapeutics , 85 , World Health Organization . 2004 ) Promoting mental health concepts , emerging evidence , practice ( Summary Report ) Geneva , Switzerland Author . Retrieved from Zhou , 2009 ) Polymorphism of human cytochrome and its clinical significance Part II . Clinical , 48 ,