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In this article we will discuss about how to treat mental disorders using therapies.
A. Psychotherapies:
Say the word psychotherapy, and many people quickly imagine a scene in which a patient lies on a couch in a dimly lit room while a therapist sits in the background. The therapist urges the patient to reveal the deepest secrets of her or his mind hidden urges, traumatic early experiences, and especially anything relating to sex! As these painful thoughts and images are dredged out of the unconscious, the patient suffers emotional turmoil, but also moves toward improved mental health.
Actually, this popular image has little to do with many modern forms of psychotherapy. In fact, it applies primarily to only one type, an approach developed by Freud that is rarely used by psychologists and is even fading rapidly from psychiatry, in which it was a mainstay for many years.
Psychotherapy, as it is currently practiced by psychologists and other professionals, actually takes many different forms, uses a tremendously varied range of procedures, and can be conducted with groups as well as with individuals. Let’s take a closer look at several important forms of psychotherapy including, of course, the methods used by Freud.
1. Psychodynamic Therapies: From Repression to Insight:
Psychodynamic therapies are based on the idea that mental disorders stem primarily from the kind of hidden inner conflicts first described by Freud—for instance, conflicts between our primitive sexual and aggressive urges (id impulses) and the ego.
More specifically, psychodynamic therapies assume that mental disorders occur because something has gone seriously wrong in the balance between these inner forces. Several forms of therapy are based on these assumptions, but the most famous is psychoanalysis, the approach developed by Freud.
Freud believed that personality consists of three major parts: id, ego, and superego, which correspond roughly to desire, reason, and conscience. Freud believed that mental disorders stem from the fact that many impulses of the id are unacceptable to the ego or the superego and are therefore repressed driven into the depths of the unconscious.
There these urges persist, and individuals must devote a considerable portion of their psychic energy to keeping them in check and out of consciousness. In fact, people often use various defense mechanisms to protect the ego from feelings of anxiety generated by these inner conflicts and clashes.
How can such problems be relieved? Freud felt that the crucial task was for people to overcome repression and recognize and confront their hidden feelings and impulses. Having gained such insight, he believed, they would experience a release of emotion known as abreaction, then, with their energies at last freed from the task of repression, they could direct these energies into healthy growth.
These ideas concerning the causes and cure of mental illness are reflected in psychoanalysis, the type of therapy developed by Freud. As popular images suggest, the patient undergoing psychoanalysis lies on a couch in a partly darkened room and engages in free association he or she reports everything that passes through his or her mind. Freud believed that the repressed impulses and inner conflicts present in the unconscious would ultimately be revealed by these mental wanderings, at least to the trained ear of the analyst.
Freud felt that dreams were especially useful in this respect; because they often represented inner conflicts and hidden impulses in disguised form. But everyday events, too, could be revealing. Slips of the tongue (such as “I hurt you” rather than “I heard you”) and seemingly accidental events (e.g., spilling a drink on someone or dropping papers into the mud) could aid the analyst in making interpretations concerning the patient’s hidden inner conflicts.
Freud noted that during psychoanalysis several intriguing events often occur. The first of these is resistance a patient’s stubborn refusal to report certain thoughts, motives, and experiences or overt rejection of the analyst’s interpretations. Presumably, resistance occurs because patients wish to avoid the anxiety they experience as threatening or painful thoughts come closer and closer to consciousness.
Another aspect of psychoanalysis is transference intense feelings of love or hate toward the analyst on the part of the patient. Often, patients react toward their analyst as they did to someone who played a crucial role in their early lives for example, one of their parents.
Freud believed that transference could be an important tool for helping individuals work through conflicts regarding their parents, this time in a setting where the harm done by disordered early relationships could be effectively countered. As patients’ insight increased, Freud believed, transference would gradually fade away.
Psychoanalysis: An Evaluation:
Psychoanalysis is probably the most famous form of psychotherapy. What accounts for its fame? Certainly not its proven effectiveness. It is fair to say that the reputation of psychoanalysis far exceeds its success in alleviating mental disorders. In the form proposed by Freud, psychoanalysis suffers from several major and obvious weaknesses that lessen its value.
First, it is a costly and time-consuming process. Several years and large amounts of money are usually required for its completion; assuming it ever ends.
Second, psychoanalysis is based largely on Freud’s theories of personality and psychosexual development. These theories are provocative but difficult to test scientifically, so psychoanalysis rests on shaky scientific ground.
Third, Freud designed psychoanalysis for use with highly educated persons with impressive verbal skills-persons who could describe their inner thoughts and feelings with ease. Finally, and perhaps most important, psychoanalysis has often adopted the posture of a closed logical system. You don’t believe in psychoanalysis? That’s a clear sign that you are showing resistance or are suffering from serious mental disorders that prevent you from seeing the truth!
Finally, this theory’s major assumption that once insight is acquired, mental health will follow automatically is contradicted by research findings. Over and over again, psychologists have found that insight into one’s thoughts and feelings does not necessarily change those thoughts or feelings or prevent them from influencing behavior.
Beyond Psychoanalysis: Psychodynamic Therapy Today:
Because of such problems, classical psychoanalysis is rarely practiced today. However, modified (and less lengthy) versions introduced by Freud’s students and disciples, including the neo-Freudians, are used more frequently. For instance, in psychoanalytically oriented psychotherapy, client and therapist sit facing each other, and conversations focus on current problems rather than on the distant past. The therapist attempts to help the client re-experience old conflicts so that they can be resolved in a more adaptive manner.
Alfred Adler, one famous Neo-Freudian, emphasized the importance of feelings of inferiority in mental disorders. He believed that people often show basic mistakes in their thinking false beliefs that interfere with their mental health, such as “Life is very dangerous” or “I have to please everybody”. Adler developed procedures for changing these beliefs that are similar in some ways to more modern forms of therapy.
A third example of alternative forms of psychodynamic therapy is the type devised by Henry Stack Sullivan. Sullivan felt that mental disorders stem not from unconscious conflicts but rather from disturbances in interpersonal relationships problems that develop out of early interactions between children and their parents or peers.
Sullivan’s approach to therapy focuses on helping the client identify his or her maladaptive interpersonal styles actions that provoke others into treating the person in ways that reinforce maladaptive behaviors. In sum, psychoanalysis is just one of several types of psychodynamic therapy, and today it is practiced by a relatively small number of therapists, primarily psychiatrists.
2. Phenomenological/Experiential Therapies: Emphasizing the Positive:
Freud was something of a pessimist about basic human nature. He felt that we must struggle constantly with primitive impulses from the id. However, many psychologists reject this view. They contend that people are basically good and that our strivings for growth, dignity, and self-control are just as strong as the powerful aggressive and sexual urges Freud described. According to such psychologists, mental disorders do not stem from unresolved inner conflicts. Rather, they arise because the environment we live in somehow interferes with personal growth and fulfillment.
The phenomenological/experiential therapies (often known as humanistic therapies) are based on this view and on the following three principles:
(1) Understanding other people requires trying to see the world through their eyes (a phenomenological approach);
(2) Clients should be treated as equals; and
(3) The therapeutic relationship with the client is central to the benefits of therapy.
The goal of phenomenological/experiential therapy is to help clients (not “patients”) to become more truly themselves to find meaning in their lives and to live in ways truly consistent with their own traits and values. Unlike psychoanalysts, humanistic therapists believe that clients, not they, must take essential responsibility for the success of therapy. The therapist is mainly a guide and facilitator, not the one who runs the show. Let’s take a closer look at two forms of humanistic therapy.
i. Client-Centered Therapy: The Benefits of Being Accepted:
Perhaps the most influential humanistic approach is client-centered therapy, developed by Carl Rogers (1970, 1980). Rogers strongly rejected Freud’s view that mental disorders stem from conflicts over the expression of primitive, instinctive urges. On the contrary, he argued, such problems arise mainly because clients’ efforts to attain self-actualization growth and development are thwarted early in life by judgments and ideas imposed by other people.
According to Rogers, these judgments lead individuals to acquire what he terms unrealistic conditions of worth. That is, they learn that they must be something other than what they really are in order to be loved and accepted to be worthwhile as a person.
For example, children may come to believe that they will be rejected by their parents if they are not always neat and submissive or if they do not live up to various parental ideals. Such beliefs block people from recognizing large portions of their experience and emotions. This, in turn, interferes with normal development of the self and causes people to experience maladjustment.
Client-centered therapy focuses on eliminating such unrealistic conditions of worth through creation of a psychological climate in which clients feel valued as persons. Client-centered therapists offer unconditional positive regard, or unconditional acceptance, of the client and her or his feelings; a high level of empathetic understanding, and accurate reflection of the client’s feelings and perceptions. In this warm, caring environment, freed from the threat of rejection, individuals can come to understand their own feelings and accept even previously unwanted aspects of their own personalities.
As a result, they come to see themselves as unique human beings with many desirable characteristics. To the extent such changes occur, Rogers suggests, many mental disorders disappear and individuals can resume their normal progress toward self-fulfillment.
ii. Gestalt Therapy: Becoming Whole:
The theme of incomplete self-awareness especially of gaps in clients’ awareness of their genuine feelings is echoed in a second humanistic approach, Gestalt therapy. According to Fritz Perls, originator of this type of therapy, many people have difficulties in directly experiencing and expressing emotions such as anger or the need for love.
As a result, they develop manipulative social games or phony roles to try (usually without success) to satisfy their needs indirectly. Playing these games, in turn, leads people to believe that they are not responsible for their own behavior; they blame others and come to feel powerless. Gestalt therapy, therefore, aims to help clients to become aware of the feelings and needs they have disowned, to recognize that these are a genuine part of themselves, and so to attain psychological “wholeness” (the meaning of Gestalt).
How can clients reach these goals? Only by re-experiencing old hurts jealousies, fears, and resentments. To help clients do this, Gestalt therapists often use the empty chair technique.
The client imagines that an important person from his or her past a parent, child, and spouse is sitting in the chair; then, perhaps for the first time, the client expresses his or her true feelings to this person (feelings about the imaginary person or about events or conflicts in which this person played a part). As a result, clients gain insight into their true feelings. This may actually help to reduce the emotional turmoil that brought clients to therapy in the first place an important benefit in itself.
Humanistic Therapies: An Overview:
Phenomenological/experiential therapies certainly have a much more optimistic flavor than psychoanalysis; they don’t assume that human beings must constantly struggle to control dark internal forces. In this sense, they cast bright sunshine into the shadowy world envisioned by psychoanalysis. In addition, several techniques devised by humanistic therapists are now widely used, even by psychologists who do not share this perspective.
For instance, Carl Rogers was one of the first therapists to tape-record therapy sessions so that therapists could study the tapes at a later time. This tactic not only helps therapists to assist their clients; it also provides information about which techniques are most effective during therapy. Finally, some of the assumptions underlying humanistic therapies have been subjected to scientific test and found to be valid.
For instance, research findings tend to confirm Rogers’s view that the gap between an individual’s self-image and his or her “ideal self” plays a crucial role in maladjustment. In these ways, then, humanistic therapies have made lasting contributions to the practice of psychotherapy.
On the other side of the coin, such therapies have been criticized for their lack of a unified theoretical base and for being vague about precisely what is supposed to happen between clients and therapists. So although they are more widely used at present than psychoanalysis, they are subject to important criticisms.
3. Behavior Therapies: Mental Disorders and Faulty Learning:
Although psychodynamic and phenomenological/experiential therapies differ in many ways, they both place importance on early events in clients’ lives as a key source of current disturbances. In contrast, another major group of therapies, known collectively as behavior therapies, focus primarily on individuals’ current behavior. These therapies are based on the belief that many mental disorders stem from faulty learning.
Either the persons involved have failed to acquire the skills and behaviors they need for coping with the problems of daily life, or they have acquired maladaptive habits and reactions.
The key task for therapy is to change current behavior, not to correct faulty self-concepts or to resolve inner conflicts. What kinds of learning play a role in behavior therapy? There are several basic kinds of learning. Reflecting this fact, behavior therapies employ techniques based on three major kinds of learning.
i. Therapies Based on Classical Conditioning:
Classical conditioning, as you will remember, is a process in which organisms learn that the occurrence of one stimulus will soon be followed by the occurrence of another. As a result, reactions that are at first produced only by the second stimulus gradually come to be evoked by the first as well.
What does classical conditioning have to do with mental disorders? According to behavior therapists, quite a bit. Behavior therapists suggest, for example, that many phobias are acquired in this manner. Stimuli that happen to be present when real dangers occur may acquire the capacity to evoke intense fear because of this association. As a result, individuals experience intense fears in response to these conditioned stimuli, even though they pose no threat to their well-being.
To eliminate such reactions, behavior therapists sometimes use the technique of flooding. This involves exposure to the feared stimuli, or to mental representations of them, under conditions in which the person with the phobias can’t escape from them. These procedures encourage extinction of such fears; the phobias may soon fade away.
Another technique based in part on principles of classical conditioning is known as systematic desensitization. In systematic desensitization, individuals first learn how to induce a relaxed state in their own bodies often by learning how to relax their muscles. Then, while in a relaxed state, they are exposed to stimuli that elicit fear. Because they are now experiencing relaxation, which is incompatible with fear, the conditioned link between these stimuli and fear is weakened.
ii. Therapies Based on Operant Conditioning:
Behavior is often shaped by the consequences it produces; actions are repeated if they yield positive outcomes or if they permit individuals to avoid or escape from negative ones. In contrast, actions that lead to negative results are suppressed. These basic principles of learning are incorporated in several forms of therapy based on operant conditioning.
These therapies differ considerably in their details, but all include the following steps:
(1) Clear identification of undesirable or maladaptive behaviors currently shown by individuals,
(2) Identification of events that reinforce and maintain such responses, and
(3) Efforts to change the environment so that these maladaptive behaviors are no longer followed by reinforcement.
Operant principles have sometimes been used in hospital settings, where a large degree of control over patients’ reinforcements is possible. Several projects have involved the establishment of token economies—systems under which patients earn tokens they can exchange for various rewards, such as television-watching privileges, candy, or trips to town.
These tokens are awarded for various forms of adaptive behavior, such as keeping one’s room neat, participating in group meetings or therapy sessions, coming to meals on time, and eating neatly. The results have often been impressive. When individuals learn that they can acquire rewards by behaving in adaptive ways, they often do so, with important benefits to them as well as to hospital staff.
Observational Learning: Benefiting from Exposure to Others:
Many people who come to psychologists for help appear to be lacking in basic social skills—they don’t know how to interact with others in an effective manner. They don’t know how to make a request without sounding pushy, or how to refuse one without making the requester angry. They don’t know how to express their feelings clearly, how to hold their temper in check, or how to hold an ordinary conversation with others.
As a result, such individuals experience difficulties in forming friendships or intimate relationships, and they encounter problems in many everyday situations. These difficulties, in turn, can leave them feeling helpless, depressed, anxious, and resentful.
Behavior therapists have developed techniques for helping people improve their social skills through observational learning. These often involve modeling—showing individuals live demonstrations or videotapes of how people with good social skills behave in many situations.
For instance, modeling (as well as other techniques) is often used in assertiveness training, which focuses on helping clients learn how to express their feelings and desires more clearly and effectively. Being assertive doesn’t mean being aggressive; rather, it means being able to state one’s preferences and needs rather than simply surrendering to those of others.
Modeling techniques have also been used, with impressive success, in the treatment of phobias. Many studies indicate that individuals who experience intense fear of relatively harmless objects can be helped to overcome these fears through exposure to appropriate social models who demonstrate lack of fear and show that no harm occurs as a result of contact with these objects.
Such procedures have been found to be effective in reducing a wide range of phobias excessive fears of dogs, snakes, and spiders, to mention just a few. In sum, behavioral therapies have been shown to be useful in alleviating many types of mental disorders.
4. Cognitive Therapies: Changing Disordered Thought:
At several points, cognitive processes often exert powerful effects on emotions and behavior. In other words, what we think strongly influences how we feel and what we do. This principle underlies another major group of approaches to psychotherapy, cognitive therapies.
The basic idea behind all cognitive therapies is this: Many mental disorders stem from faulty or distorted modes of thought. Change these, and the disorders, too, can be alleviated. Let’s examine several forms of therapy based on this reasoning.
i. Rational-Emotive Therapy: Overcoming Irrational Beliefs:
Everyone I meet should like me.
I should be perfect (or darn near perfect) in every way.
Because something once affected my life, it will always affect it.
I can’t bear it when things are not the way I would like them to be.
I can’t help feeling the way I do about certain things or in certain situations.
Be honest- Do such views ever influence your thinking? While you may strongly protest that they do not, I one psychologist, Albert Ellis (1987), believes that they probably do influence your thinking to some extent. Moreover, he contends that such irrational thoughts often play a key role in many mental disorders. According to Ellis, the process goes something like this.
Individuals experience activating events things that happen to them that can potentially trigger upsetting emotional reactions. If they actually experience these strong emotional reactions, then mental disorders such as anxiety or depression may develop. The key factor determining whether this happens, however, is the way people think about the activating events. If people allow irrational beliefs to shape their thoughts, they are at serious risk for experiencing psychological problems.
Here’s an example: Suppose that one day, your current romantic partner dumps you. This is certainly an unpleasant event—but does it undermine your self-esteem and cause you to become deeply depressed? Ellis argues that this depends on how you think about it. If you fall prey to irrational beliefs such as “Everyone must love me!” or “I can’t control my emotions I must feel totally crushed by this rejection!” you may well become depressed.
If, instead, you reject these modes of thought and think, instead, “Some people will love me and others won’t, and love itself isn’t always constant,” or “I can deal with this it’s painful, but not the end of the world” then you will bounce back and will not experience depression.
In essence, Ellis is saying this- You can’t always change the world or what happens to you, but you can change the ways in which you think about your experiences. You can decide whether, and how much, to be bothered or upset by being dumped by a romantic partner, losing a job, getting a lower-than-expected grade on a test, and so on.
To help people combat the negative effects of irrational thinking, Ellis developed rational-emotive therapy (RET). During RET, the therapist first attempts to identify irrational thoughts and then tries to persuade clients to recognize them for what they are. By challenging the irrationality of their clients’ beliefs, therapists practicing RET get them to see how ridiculous and unrealistic some of their ideas are; in this way, they can help them stop being their own worst enemies.
ii. Beck’s Cognitive Behavior Therapy for Depression:
This therapy is extremely common but serious mental disorder has an important cognitive component. It stems, at least in part, from distorted and often self-defeating modes of thought. Recognizing this important fact, Aaron Beck (1985) devised a cognitive behavior therapy for alleviating depression. Like Ellis, Beck assumes that depressed individuals engage in illogical thinking and that this underlies their difficulties.
Such individuals hold unrealistically negative beliefs and assumptions about themselves, the future, and the world (e.g., “I’m a worthless person no one could ever love,” “If good things happen to me, it’s just blind luck,” “My life is a mess and will never improve”). Moreover, Beck contends, people cling to these illogical ideas and assumptions no matter what happens.
According to Beck, such distorted thinking leads individuals to have negative moods; which, in turn, increase the probability of more negative thinking. In other words, Beck emphasizes the importance of mood-dependent memory how our current moods influence what we remember and what we think about.
How can this vicious circle be broken? In contrast to rational—emotive therapy, Beck’s cognitive approach does not attempt to disprove the ideas held by depressed persons. Rather, the therapist and client work together to identify the individual’s assumptions, beliefs, and expectations and to formulate ways of testing them. For example, if a client states that she is a total failure, the therapist may ask how she defines failure, and whether some experiences she defines this way may actually be only partial failures.
If that’s so, the therapist inquires, aren’t they also partial successes? Continuing in this manner, the therapist might then ask the client whether there are any areas of her life in which she does experience success and has succeeded in reaching goals.
Research findings indicate that as a result of these procedures, individuals learn to reinterpret negative events in ways that help them cope with such outcomes without becoming depressed. So although the specific techniques used are different from those used in RET, the major goal is much the same; helping people to recognize, and reject, the false assumptions that are central to their difficulties.
Cognitive Therapies: An Evaluation:
An essential question about any form of therapy is “Does it work?” Cognitive therapies pass this test with flying colors. Many studies indicate that changing or eliminating irrational beliefs can be very effective in countering depression and other personal difficulties. Similarly, the procedures outlined by Beck have been found to be highly effective in treating depression.
Perhaps even more important, the effects of cognitive therapy tend to be longer-lasting than those produced by other forms of therapy for depression—for instance, antidepressant drugs. For instance, consider a study conducted by Segal, Gemar, and Williams (1999).
These psychologists exposed two groups of persons who had recently recovered from depression to procedures designed to induce negative moods: Participants listened to sad music and were also asked to remember a time in their lives when they had felt sad. One of the groups had recovered from depression as a result of cognitive therapy, whereas the other had been treated only with drugs.
Both groups of participants completed measures of the kinds of cognitions that often accompany depression (the kinds of negative self-evaluations highlighted by Beck and others as playing a key role in depression) on two separate occasions: before the negative mood induction and after it.
The researchers predicted that persons who had recovered from depression as a result of cognitive behavior therapy would show lower levels of dysfunctional (i.e., depression-inducing) thoughts than would those who had recovered as a result of drug therapy.
This is precisely what happened. Moreover, follow-up research over a four-year period indicated that the kind of dysfunctional thinking shown by the drug-treated group was indeed predictive of a recurrence of depression. Findings such as these suggest that not only is cognitive therapy for depression effective it may offer longer-lasting protection against the recurrence of this serious psychological disorder than other forms of therapy.
B. Biological Therapies:
Development of effective drugs for treating serious mental disorders led to a sharp drop in the number of patients in public mental hospitals. What are these drugs, how do they work, and just how effective are they? We’ll examine these questions here; forms of therapy that attempt to alleviate mental disorders through biological means. Efforts along these lines have continued for hundreds, perhaps thousands of years.
Indeed, skulls from early civilizations often show neatly drilled holes, suggesting that some persons, at least, may have received surgery on their brains as a means of eliminating mental disorders; presumably, the holes were intended to provide an escape route for the causes of such disorders (e.g., evil spirits). Even in the nineteenth century, many physicians used devices, which delivered electric shocks, to treat a wide range of “nervous disorders.”
Both brain surgery and the use of electric shock continue today. But by far the most popular form of biologically based therapy involves the use of various psychoactive drugs—drugs that alter feelings, thoughts, and behavior.
1. Drug Therapy: The Pharmacological Revolution:
In 1955, almost 600,000 persons were full-time resident patients in psychiatric hospitals in the United States. Twenty years later, this number had dropped below 175,000. Was the U.S. population achieving mental health at a dizzying pace? Absolutely not. What happened in those years was the advent of drug therapy: A wide range of drugs effective in treating mental disorders were developed and put to use.
Such use has continued to increase, rising from 27 percent of patients in 1977 to more than 90 percent at present. This trend isn’t due solely to the effectiveness of the drugs; it also reflects the fact that treating mental disorders with drugs is often less expensive than other forms of therapy and changes in health care (e.g., the growth of managed care and HMOs) have made cost a primary consideration. Let’s now take a closer look at these drugs and their effects.
If you had visited the wards of a psychiatric hospital for seriously disturbed persons before 1955, you would have witnessed some pretty wild scenes—screaming, bizarre actions, nudity. If you had returned a few years later, however, you would have seen a dramatic change- peace, relative tranquility, and many patients now capable of direct, sensible communication.
These startling changes were largely the result of the development of antipsychotic drugs, sometimes known as the major tranquilizers or neuroleptics. These drugs were highly effective in reducing the positive symptoms shown by schizophrenics (e.g., hallucinations, delusions), although they were less effective in reducing negative symptoms (e.g., withdrawal, lack of affect).
The most important group of antipsychotic drugs, phenothiazines, was discovered by accident. In the early 1950s a French surgeon, Henri Laborit, used a drug in this chemical family, Thorazine (chlorpromazine) to try to reduce blood pressure in patients before surgery. He found that their blood pressure didn’t drop, but that they became much less anxious.
French psychiatrists tried the drug with their patients, and found that it worked. It reduced anxiety and, even more important, it also reduced hallucinations and delusions among schizophrenic patients. Chemists quickly analyzed chlorpromazine and developed many other drugs that are related to it but are even more effective in reducing psychotic symptoms (e.g., clozapine, haloperidol).
How do the antipsychotics produce such effects? Some block the action of the neurotransmitter dopamine on certain receptors in the brain (D2 receptors). The presence of an excess of this neurotransmitter, or increased sensitivity to it, may play a role in schizophrenia.
Other antipsychotics especially the newest, such as Novartis and Zeneca influence many different chemicals in the brain: neurotransmitters and other compounds as well. In sum, many different antipsychotic drugs exist, and they do not all operate in the same way. Whatever the precise mechanism involved, however, it is clear that antipsychotic drugs are very helpful in reducing the bizarre symptoms of schizophrenia.
The use of these drugs, however, is not without drawbacks. They often produce side effects such as blurred vision and dry mouth. In addition, they produce more serious side effects known as extrapyramidal symptoms for instance, fine tremor of the hands, muscular weakness, and rigidity. Additional and even more serious effects can involve uncontrollable contractions of muscles in the neck, head, tongue, and back, or uncontrollable restlessness and agitation.
The most serious side effect of all, however, is tardive dyskinesia. After receiving antipsychotic drugs for prolonged periods of time, many patients develop this side effect, which involves loss of motor control, especially in the face. As a result, they show involuntary muscle movements of the tongue, lips, and jaw. Unfortunately, these effects don’t occur until after patients have taken neuroleptics for several years, and at this point the disorder is irreversible.
Schizophrenics often take antipsychotic drugs throughout life, and as a result they stand a very good chance of developing this side effect. One relatively new antipsychotic drug, Clozaril (clozapine), appears to be effective without producing tardive dyskinesia. However, clozapine has its own side effects, the most serious of which is agranulocytosis—a fatal blood disease. Additional antipsychotic drugs are under development (e.g., olanzapine), and it is hoped that they will cause even fewer side effects.
Although the antipsychotic drugs are clearly of great value and do reduce the most bizarre symptoms of schizophrenia, it should be emphasized that they do not cure this disorder. In the past, such drugs were more effective in reducing the positive symptoms of schizophrenia than in treating the negative symptoms. Thus, persons receiving them tended to remain somewhat withdrawn and to show the low levels of affect that are often part of schizophrenia.
Newer drugs, however, do seem more successful in treating these negative symptoms. Such drugs are sometimes termed atypicals, because they influence many different chemicals in the brain rather than only one. In any case, although drugs for treating schizophrenia are improving, the likelihood that individuals with schizophrenia will regain normal functioning and be able to live on their own is increased when they receive psychotherapy too.
Shortly after the development of chlorpromazine, drugs effective in reducing depression made their appearance. There are three basic types of such compounds, tricyclics, selective serotonin reuptake inhibitors (SSRIs), and MAO inhibitors. Again, as is true with virtually all drugs used to treat mental disorders, antidepressants seem to exert their effects by influencing neurotransmitters, especially serotonin and norepinephrine.
Among the SSRIs, Prozac (fluoxetine) is by far the most famous and also the most commonly prescribed. More than 1.5 million prescriptions for it are written every month in the United States alone. Depressed persons taking this drug often report that they feel better than they have in their entire lives. However, Prozac, like other antidepressant drugs, appears to have serious side effects. About 30 percent of patients taking it report nervousness, insomnia, joint pain, weight loss, and sexual dysfunction.
A small number report suicidal thoughts. In contrast, MAO inhibitors can produce more dangerous side effects. They seem to virtually eliminate REM sleep; and if consumed with food containing tyramine (e.g., aged cheeses, beer, red wine), MAO inhibitors can cause a sudden extreme rise in blood pressure, thus putting patients at risk for strokes.
For these reasons, these drugs are used less often than the other two types of antidepressants. Tricyclics also produce side effects, such as disturbances in sleep and appetite, but these tend to decrease within a few weeks. Widely prescribed tricyclics include Elavil (amitriptyline) and Tofranil (imipramine).
iii. Lithium:
An entirely different kind of antidepressant drug is lithium (usually administered as lithium chloride). This drug has been found to be quite effective in treating people with bipolar (manic—depressive) disorders, and is successful with 60 to 70 percent of these persons.
Because such persons are often quite agitated and even psychotic, lithium is generally administered along with antipsychotic or antidepressant medications. Unfortunately, lithium has serious side effects; excessive doses can cause delirium and even death.
Thus, it has a very small “therapeutic window” or dose level that is effective without being dangerous. Exactly how lithium exerts its effects is not known; one possibility is that it influences the effects of secondary messengers, changes that occur in neurons after they have initially been stimulated by a neurotransmitter. Another possibility is that lithium affects electrolyte balances in the neurons. Whatever its mechanism, it is one of the few drugs effective in treating manic-depressive disorders, so its continued use seems likely.
Alcohol, a substance used by many people to combat anxiety, has been available for thousands of years. Needless to say, however, it has important negative side effects. Synthetic drugs with antianxiety effects sometimes known as minor tranquilizers have been manufactured for several decades. The most widely prescribed of these at present are the benzodiazepines. This group includes drugs- Valium, Ativan, Xanax, and Librium.
The most common use for antianxiety drugs, at least ostensibly, is as an aid to sleep. They are safer for this purpose than barbiturates, being less addicting. However, substances derived from the benzodiazepines remain in the body for longer periods of time than those from barbiturates and can cumulate until they reach toxic levels. Thus, long-term use of these drugs can be quite dangerous. In addition, when they are taken with alcohol, their effects may be magnified; this is definitely a combination to avoid.
Finally, the benzodiazepines tend to produce dependency; individuals experience withdrawal symptoms when they are abruptly stopped. These drugs seem to produce their effects by facilitating the postsynaptic binding of central nervous system neurotransmitters such as GABA, the brain’s major inhibitor. Thus, the drugs seem to serve as a kind of braking system, reducing activity in the nervous system that would otherwise result in anxiety and tension.
While benzodiazepines are effective persons who take them report being calmer and less worried they have potentially serious side effects: drowsiness, dizziness, fatigue, and reduced motor coordination. These can prove fatal to motorists or people operating dangerous machinery.
Fortunately, such effects are much smaller for an additional antianxiety drug that is not related to the benzodiazepines-: BuSpar (buspirone). In fact, BuSpar produces little or no drowsiness and no more body sway than an inactive placebo. There is a lag of one to three weeks before BuSpar produces its antianxiety effects. However, it does seem to be a useful alternative to the benzodiazepines.
In sum, many drugs are effective in treating serious mental disorders, and these drugs are being prescribed in ever increasing quantities. Some of these drugs are fairly new, however, so their long-term effects remain unknown. Moreover, as with all drugs, the benefits of these medications are offset, to a degree, by potentially serious side effects. Should society be more cautious in using drug therapy? This is a complex issue, but many psychologists feel that greater caution may be justified.
Ethnic differences in reactions to psychoactive drugs also exist. Asians seem to require only half the doses of some antidepressant drugs than persons of European descent. Similarly, persons of African descent seem to require smaller doses than Europeans: They accumulate these drugs more quickly in their system and experience faster and stronger responses to them.
The effects of neuroleptics, too, vary with patients’ ethnic background. Asians show higher blood concentrations of drugs such as haloperidol than do persons of European descent after receiving a standard dose. This finding implies that Asians require lower doses of such drugs than Europeans.
In view of these and related findings, it is clear that important ethnic and gender differences exist with respect to reactions to drugs used to treat many mental disorders. Failure to pay careful attention to such differences can reduce the effectiveness of such drugs or even put patients at serious risk.
2. Electroconvulsive Therapy:
In electroconvulsive therapy (ECT), physicians place electrodes on the patient’s temples and deliver shocks of 70 to 130 volts for brief intervals (approximately one second).
These shocks are continued until the patient has a seizure, a muscle contraction of the entire body, lasting at least twenty to twenty-five seconds. In order to prevent broken bones and other injuries, a muscle relaxant and a mild anesthetic are usually administered before the start of the shocks. Patients typically receive three treatments a week for several weeks.
Surprisingly, ECT seems to work, at least for some disorders. It reduces severe depression, especially with persons who have failed to respond to other forms of therapy. The American Psychiatric Association recommends ECT for use with patients who are severely suicidal or psychotically depressed (e.g., refusing to eat, in a stupor).
Unfortunately, there are important risks connected with ECT. It is designed to alter the brain and it does, producing loss of episodic memory in many patients; that is, they forget events they have personally experienced. In some cases ECT does irreversible damage to portions of the brain.
Further, although the shocks themselves are painless, many patients find the procedures frightening. These facts have led some researchers to criticize the use of ECT and to call for its elimination as a form of therapy. However, the fact that ECT works for some severely depressed persons who have not responded to other forms of therapy has encouraged its continued use.
3. Psychosurgery:
In 1935 a Portuguese psychiatrist, Egas Moniz, attempted to reduce aggressive behavior in psychotic patients by severing neural connections between the prefrontal lobes and the remainder of the brain. The operation, known as prefrontal lobotomy, seemed to work. Aggressive behavior was reduced. Moniz received the 1949 Nobel Prize in Medicine for his work—but, in one of those strange twists of fate, he was later shot and killed by one of his lobotomized patients!
Encouraged by Moniz’s work, psychiatrists all over the world rushed to treat mental disorders through various forms of psychosurgery brain operations designed to change abnormal behavior. Tens of thousands of patients were given prefrontal lobotomies and related operations.
Unfortunately, it soon became apparent that the results were not always positive. While some forms of objectionable or dangerous behavior did decrease, serious side effects sometimes occurred. Some patients became highly excitable and impulsive; others slipped into profound apathy and a total absence of emotion.
In view of these outcomes, most physicians stopped performing prefrontal lobotomies, and few are done today. However, other, more limited operations on the brain continue. For instance, in one modern procedure, cingulotomy, connections between a very small area of the brain and the limbic system are severed.
Results indicate that this limited kind of psychosurgery may be effective with individuals suffering from depression, anxiety disorders, and especially obsessive compulsive disorder who have not responded to any other type of J treatment. Still newer procedures involve inserting tiny video cameras into the brain or using computer-guided imagery (e.g., MRI scans) to help surgeons make very precise lesions in the brain. It is too early to tell whether such psychosurgery will yield long-term gains.
One final point: Even if such operations are successful, they raise important ethical questions. Is it right to destroy healthy tissue in a person’s brain in the hopes that this will relieve symptoms of mental disorders? And given that the benefits are still uncertain, should such irreversible procedures be permitted? These and related issues have led most psychologists to conclude that psychosurgery should be viewed as a very drastic form of treatment, an approach to be tried only when everything else has failed.
C. Indigenous Therapies:
In ancient Indian literature, vast varieties of practices have been mentioned for cure of psychological disorders. Atharva-Veda, Charak Samhita, Susrut Sahmita, Ashtang Sangrah, Yoga Sutra, Buddhist and Jain literatures contain a number of psychotherapeutic practices.
Some are purely psychogenic, some are psychosomatic, and others are physiological in nature. In recent times, many of these perspectives have been popularized in the media, but none more than Yoga. Yoga, as a science of mind, provides effective techniques for promoting mental peace and tranquility.
Yoga:
Patanjali, composed the Yoga Sutras between 200 bc and 200 ad. The objective of yoga is chittavrittinirodh or restraining of the mental modifications and realization of true self. Patanjali presented the eightfold path of yoga or the Ashtanga Yoga for the overall development of the human personality. These are: (1) Yama, (2) Niyama, (3) Asana, (4) Pranayama, (5) Pratyahara, (6) Dharana, (7) Dhyana, and (8) Samadhi.
A brief description of these steps is as follows:
1) Yama:
Yama is social behavior, how you treat others and the world around you. These are moral principles. Sometimes they are called the don’ts or the thou shalt nots.
There are five yamas:
a) Ahimsa (Nonviolence):
Do no harm to any creature in thought or deed. In his book Autobiography of a Yogi, Paramahansa Yogananda asks Mahatma Gandhi the definition of ahimsa. Gandhi said, “The avoidance of harm to any living creature in thought or deed.” Yogananda asked if one could kill a cobra to protect a child. Gandhi maintained he would still hold to his vow of ahimsa, but added, “I must confess that I could not serenely carry on this conversation were I faced by a cobra.”
b) Satya (truthfulness):
Tell no lies.
c) Asteya (Non-Stealing):
Do not steal material objects or misappropriating things belonging to others.
d) Brahmacharya (Celibacy):
Purity of sexual life.
e) Aparigraha (Non-Possessiveness):
Free yourself from greed, hoarding, and collecting. Make your life as simple as possible.
2) Niyama:
Niyama is inner discipline and responsibility, how we treat ourselves. These are sometimes called observances, the do’s or the thou shalts.
There are five niyamas:
a) Saucha:
Saucha (purity) is achieved through the practice of the five yamas, which help clear away the negative physical and mental states of being. Keep yourself, your clothing, and your surroundings clean. Eat fresh and healthy food.
b) Santosha (Contentment):
Cultivate contentment and tranquility by finding happiness with what you have and who you are. Seek happiness in the moment, take responsibility for where you are, and choose to grow from there.
c) Tapas (Austerity):
Show discipline in body, speech, and mind. The purpose of developing self- discipline is not to become ascetic, but to control and direct the mind and body for higher spiritual aims or purposes.
d) Svadhyaya (Study of the Sacred Text):
Education changes a person’s outlook on life. As Iyengar says, a person starts “to realize that all creation is meant for bhakti (adoration) rather than for bhoga (enjoyment), that all creation is divine, that there is divinity within himself and that the energy which moves him is the same that moves the entire universe.”
e) Ishvara Pranidhana (Living with an Awareness of the Divine):
Be devoted to God, Buddha, or whatever you consider divine.
3) Asanas:
These are special patterns of postures that stabilize the mind and the body. By practicing various bodily postures, some of the dormant psychophysical systems of the body are activated. Every asana should be performed effortlessly and maintained for a comfortable time. Asanas may be classified as (i) meditative, (ii) stretching, and (iii) relaxative.
4) Pranayama:
It refers to regulation of breath. The basic movements of pranayama are inhalation, retention of breath, and exhalation. Practice of pranayama purifies and removes distractions from the mind making it easier to concentrate and meditate.
5) Pratyahara:
It involves withdrawal of the senses that occurs during meditation, breathing exercises, or the practice of yoga postures any time when you are directing your attention inward. Concentration, in the yoga room or the boardroom, is a battle with distracting senses.
6) Dharana or Concentration:
It involves teaching the mind to focus on one point or image. “Concentration is binding thought in one place,” says Patanjali. The goal is to still the mind gently pushing away superfluous thoughts—by fixing your mind on some object such as a candle flame, a flower, or a mantra. In dharana, concentration is effortless. You know the mind is concentrating when there is no sense of time passing.
7) Dhyana:
It involves uninterrupted meditation. The goal of meditation is heightened awareness and oneness with the universe. How do you tell the difference between concentration and meditation? If there is awareness of distraction, you are only concentrating and not meditating. The calm achieved in meditation spills over into all aspects of your life; during a hectic day at work, shopping for groceries, coordinating the Halloween party at your child’s school.
8) Samadhi:
It is the ultimate goal of the eightfold path to yoga. This is pure contemplation, super consciousness, in which knower and known become one. Those who have achieved samadhi are enlightened. Paramahansa Yoganananda called it the state of God-Union.
The Eight Limbs Work together:
The first five steps yama, niyama, asana, pranayama, and pratyahara are the preliminaries of yoga and build the foundation for spiritual life. They are concerned with the body and the brain. The last three, which would not be possible without the previous steps, are concerned with reconditioning the mind. They help the learner (Sadhaka) to attain enlightenment or the full realization of oneness with Spirit.
There is growing empirical support that yogasanas are effective in the treatment of anxiety, depression, alcohol dependence, attention deficit hyperactivity disorder and somatoform disorders. Yogic practices lay stress on synchronizing breathing with movement and paying attention to both the sensation generated by the movement and stillness. This augments body awareness and makes the person sensitive to the inner processes.
The yogic asanas help dealing with emotional blocks and muscle tensions and coping with occupational stress. In addition, long-term practitioners of yoga develop voluntary control over their autonomic processes, which results in effective coping with stress. Janakiramaiah et al. (1998, 2000) have demonstrated the efficacy of Sudarshan Kriya Yoga in dysthymic disorder.
Nature of Meditation:
As a composite of body, mind and consciousness, a person’s behaviour bears the influence of body and mind in unfolding consciousness. Here lies the neuro-behaviourial connection studied in psychology. Such a connection explains behaviour only partially and possibly at lower levels of functioning. In order to explore the influence of mind with its subjective characteristics manifest in the person the usual neurophysiological methods are essentially inadequate.
Other methods are needed to explore this dimension of human nature. In the Indian tradition, where psychology existed more in the form of practices rather than as theory, we find various specialized techniques and strategies for self-realization in the form of different kinds of yoga. The same techniques could be used to explore and study the nuances of subjective experience. Meditation is one of them.
Meditation as a practice takes place at two different levels, which are variously emphasized by different systems of meditation like Vipasana and Patanjali yoga. Meditation is essentially a method of controlling a variety of influences that affect the mind, corrupt and cloud one’s consciousness.
In practices of the concentration type of meditation attention is focused and restricted to exclude extraneous intrusions into one’s perceptual experience. In the passive forms of meditation, the restriction is not of external intrusions but elimination of internal biases by focusing on non-interpretative reception of incoming information.
It is somewhat similar to Husserl’s “bracketing natural attitude”, which is believed to give “apodictic evidence” of absolute indubitability in a “universe of absolute freedom from prejudice. In the final analysis, successful meditation should involve both kinds of restrictions, the externally inflicted and the internally generated.
Once the intrusions are eliminated in a state of meditation such as samadhi, subjective experience loses its capricious variability and becomes in a significant sense objective, enjoying inter-subjective validity. Thus meditation opens up the possibility of studying subjective experience objectively. Indeed it could be an important gateway that would open up enormous possibilities for studying neuro-phenomenology of consciousness.
The use of various forms of yoga such as Karma Yoga, Yoga Nidra, Raja Yoga, and various forms of meditation such as Vipasana have been recommended for monitoring and regulating the mind and enhancing well-being. Neki (1973) proposed Guru-Chela therapy as an indigenous paradigm of therapy in which the dependence relationship between Guru and disciple is used to help the patient and move toward health and wellbeing.
Vasudevan, Kumaraiah, Mishra and Balodhi (1994) showed that yogic meditation led to significant reduction in pain perception in tension headache. Positive effects of meditation have also been reported in drug-resistant epilepsy. The practice of Vipassana led to reduction in anxiety and codependence.
Reduced negative affect and increase in positive affect and life satisfaction has also been found in the practitioners of meditation. Jhansi and Krishna Rao (1996) found that transcendental meditation (TM) improves the attention regulation. The practices are found to yield maximum benefit if they become a part of the individual’s lifestyle and are sustained over long periods.
The use of mythological resources in therapeutic practices has also been recommended they can help to (a) stimulate association and insight, (b) explain about etiology and develop alternate modes of coping in a patient or a key family member, and (c) stimulate the therapist to experiment with a new therapeutic strategy.
The indigenous healing practices prevalent in the different parts of India are quite varied and have been following in the masses. Saeeduzzafar and Aijaz (2008) have proposed an Islamic approach to stress management in which overcoming greed for power, realizing the temporary nature of the physical world, practicing justice and honesty, refraining from suspicion and spitefulness, and self-restraint are key components.
The Indian perspective locates health and well-being in the process of balancing and emphasize on the life style. The maintenance and restoration of health and cure of disorders, therefore, relate importantly to the thoughts, diet, and conduct. This necessitates multipronged interventions and organizing life in tune with the environment.