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Psychological

factors

personality

cognitive style

social skills

symptoms of

psychopathology

(diagnosis)

iological

factors

brain structure

neurochemistry

hormones

autonomic nervous

system functions

Social factors

marital adjustment

family functioning

peer relationships

work & school

satisfaction

The clinicians conceptual approach to a persons problem will

determine the selection of assessment instruments. This figure

lists examples of variables that might be considered within each

broad conceptual level.

The

BIOPSYCHOSOCI L

Model


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Psychological

factors

personality

cognitive style

social skills

symptoms of

psychopathology

(diagnosis)

iological

factors

brain structure

neurochemistry

hormones

autonomic nervous

system functions

Social factors

marital adjustment

family functioning

peer relationships

work & school

satisfaction

The clinicians conceptual approach to a persons problem will

determine the selection of assessment instruments. This figure

lists examples of variables that might be considered within each

broad conceptual level.

Levels of Analysis in

ASSESSMENT


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Modes of ssessment

Clinical psychologists typically employ three primary mode

of assessment

INTERVIEWS:gather informationfrom the persons point of view.

TESTS:can be objective orprojective.

DIRECT OBSERVATION:may beused as signs or samples of

behavior.

The model or perspective subscribed

to by the assessor inf luences the

assessment:

e.g., the interview conducted by apsychoanalytically oriented clinicianis very different from a behavior

therapists interview.


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CASE FORMULATION: he therapists

hypothesis about the nature of the psychological

mechanisms underlying the clients difficulties

DOES THE CASE FORMULATION

IMPROVE TREATMENT OUTCOME?

DIFFERS FROM BEHAVIOURAL

ANALYSIS IN PLACING MUCH MORE

EMPHASIS ON UNDERLYING

COGNITIONS

VIEWS CLIENTS PROBLEMS AS

EXISTING AT TWO LEVELS:

OVERT DIFFICULTIES=the actual problems in living

that clients seek help for (e.g., depression, relationship

difficulties)

UNDERLYING MECHANISMS=the underlying (central

psychological mechanisms that produce and maintain the

overt difficulties (e.g., dysfunctional attitudes or beliefs

about the self, others, and the world; schemas or networkof related dysfunctional attitudes)


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CRITICAL

THINKING DO YOU THINK THAT

THERE ARE

ADVANTAGES ( ANDDISADVANTAGES) INGETTING HELP FORPSYCHOLOGICALPROBLEMS FROM A

FRIEND RATHER THANFROM A PROFESSIONALTHERAPIST? WHAT ARETHE ADVANTAGES (ANDDISADVANTAGES) OFGETTING HELP FROMTHE PROFESSIONALTHERAPIST RATHERTHAN FROM YOURFRIEND?


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Advantages ofgetting help

from a friendrather than a

therapist

COST

LESS STIGM

CONVENIENCE

INTIM TEKNOWLEDGE

Advantages ofgetting help from

a therapist ratherthan from a

friend

EXPERT OPINION

KNOWLEDGE OF

RESOURCES

UNDERST NDING OF

SERIOUS PROBLEMS

CONFIDENTI LITY

OBJECTIVITY

SEP R TION FROMPERSON L LIFE


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TARASOFF AND THE

DUTY TO WARN AND

PROTECT POTENTIAL

VICTIMS

PROSENJIT PODDAR KILLEDTATIANA TARASOFF ONOCTOBER 27, 1969.

THE CALIFORNIA SUPREMECOURT RULED THAT PODDARSTHERAPIST (A CLINICAL

PSYCHOLOGIST AT THE

UNIVERSITY OF CALIFORNIA ATBERKELEY) SHOULD HAVE

WARNED TARASOFF THAT HER

LIFE MIGHT BE IN DANGER.


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Ego nalysis

PSYCHODYNAMICTREATMENTS DEVELOPEDBY SULLIVAN, HORNEY,ERIKSON, AND OTHERFOLLOWERS OF FREUD;INSIGHT IS GOAL BUT THEPRESENT, THE CONSCIOUSMIND, AND SOCIALRELATIONSHIPS (THEEGO) CONSIDERED BYMORE ACTIVE, WARMTHERAPIST.LONG-TERM BUT SHORTERTHAN PSYCHOANALYSIS

Psychodynamic

Psychotherapy

MANY VARIATIONS OF THIS

SHORT-TERM INSIGHT-ORIENTED TREATMENT;THERAPIST IS MOREDIRECTIVE ORCONFRONTATIONAL ININTERPRETING DEFENSES;TREATMENT FOCUSES ONSINGLE ISSUE OR THEME

Psychoanalysis

FREUDS CLASSIC

TREATMENT FOCUSES ONCHILDHOOD MEMORIES ANDUNCONSCIOUS CONFLICTS;TECHNIQUES INCLUDE FREE

ASSOCIATION, DREAMANALYSIS, TRANSFERENCE,AND INTERPRETATION;

SEVERAL MEETINGS A WEEKFOR SEVERAL YEARS;THERAPIST ALOOF.


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A discrete per iod of intense fear or discomfort in which

four (or more) of the following symptoms developed

abruptly and reached a peak within 10 minutes.

palpitations, pounding heart, accelerated heart rate

sweating

trembling or shaking

sensations of shortness of breath/ smothering feeling of choking

chest pain or discomfort

nausea or abdominal distress

feeling dizzy, unsteady, faint or lightheaded

derealization or depersonalization

fear of losing control or going crazy

fear of dying

paresthesias (numbness or tingling sensations)

chills or hot flushes

Criteria fora Panic Attack

TYPES

1) Cued or Situationally Bound

2) Situationally Predisposed

3) Unexpected (Uncued)


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Typical Situations Avoided

by a Person with

Agoraphobia

Shopping

malls Cars

Trains

Buses Subways

Wide streets

Tunnels

Restaurants

Theatres

Supermarkets

Stores Crowds

Planes

Elevators Escalators

Waiting inline

Being farfrom home


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Anxiety and Panic:An Integrated Causal Model

Biological Factors

sychological FactorsSocial/Environmenta

Factors

genetics

neurobiology

(BIS, FFS)

sense of controllability

conditioning

cognitions/expectancies of

danger

anxiety sensitivity

stressful life

events

social

pressures to

succeed


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Differential Diagnosis

Anxiety

Disorder

GAD

Panic

Disorder

Specific

Phobia

Social

Phobia

PTSD

OCD

Focus of the Anxiety

minor everyday events

the next panic attack

specific situations/objects

embarrassment/evaluation insocial situations

avoidance of thoughts/images ofpast trauma

avoidance of intrusive thoughts

or neutralization through rituals


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Panic Disorderwith andwithout Agoraphobia

Panic Disorder (PD)

recurrent unexpected panic attacks

one month of anticipatory anxiety OR asignificant change in behaviour related to

the attacks

Panic Disorder with Agoraphobia (PDA)

anxiety about being in places or

situations from which escape might be

difficult or embarrassing in the event of a

panic attack

situations are avoided or are endured

with marked distress or anxiety about

having a panic attack OR require the

presence of a companion


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1. Psychoeducation

2. Rationale/Goals for Treatment

three components of fear/anxiety3. Exposure(+Response prevention ?)

to feared objects, situations

imaginal vs. in vivo

hierarchy

4. Modeling

5. Interoceptive Exposure

6. Breathing Retraining7. Deep Muscle Relaxation

8. Cognitive Therapy (Restructuring)

probability overestimation, catastrophic

cognitions, self-talk

Overview: Cognitive-Behavioral

Treatment Strategies


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9. Social Skills/Assertiveness Training

0. Coping Skills

1. Problem Solving

2. Homework

handouts, tapes, self monitoring

3. Pharmacotherapy

SSRIs, high potency benzodiazepines,

TCAs

**Variation: individual vs. group

Overview: Cognitive-BehavioralTreatment Strategies -- continued


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Treatment for

Panic Disorder

1. Exposure to Agoraphobic

Situations

2. Interoceptive Exposure

3. Cognitive Therapy

4. Breathing Retraining

5. Relaxation Therapy

6. Medication (imipramine,

alprazolam)


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Duration of Exposure

Massed vs. Spaced Exposure Graduated Exposure vs. Flooding

Structuring Exposure Sessions in Advance

Predictability

Perceived Control Distraction, Safety Signals, & Overprotective

Behaviors

Imaginal vs. in-vivoExposure

Fighting the Fear Focus of Attention (e.g., on finding an escape)

Measuring Success

Integrating Exposure and other Strategies

Overlearning

Principles of Effective

Exposure


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Exposure Hierarchies:Example of Height Phobia

1. Standing on a chair

2. Standing on a table

3. Standing ten steps up on a ladder4. Looking out of a 12th floor closed window

5. Looking over a second floor open balcony

6. Looking over a fifth floor open balcony

7. Looking over a tenth floor open balcony with

water below

8. Looking over a tenth floor open balcony with

concrete below

9. Going up the CN Tower & looking out the

window

10. Going up the CN Tower and stepping out onto

he observation deck


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Typical Situations Avoided

by a Person with

Agoraphobia

Shopping

malls Cars

Trains

Buses Subways

Wide streets

Tunnels

Restaurants

Theatres

Supermarkets

Stores Crowds

Planes

Elevators Escalators

Waiting inline

Being farfrom home


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Becks Cognitive- Behavioral Therapy:Three-Column Technique

EVENT AUTOMATIC

NEGATIVE

THOUGHTS

My boyfriend Hes losing interest

didnt call on in me.

Friday. Hell leave me.

I feel rejected.

It means Im

undesirable. No

one will ever love

me. Ill always be

alone.

RATIONAL REPLIES

Whats the error? I cant read his

mind or foretell the future.

Whats the evidence?He doesnt call

as much as he used to.

However,hes been very busyatwork.

Could I collect more information? I

could ask him how he thinks our

relationship is going.

Is there another way to look at it?

Hes probably just busy and

couldnt call. Even if he is losing

interest, however, that doesntmean hell leave me. Maybe we

can improve things.

So what? Even if the worst is true and

he did leave me, I could survive.

Ive been on my own before, and

even if it was hard at the time, it

wasnt impossible.

(Ask the same kinds of

questions as those listed

above, and try to come up

with more realistic

thoughts.)


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MEICHENBAUMS

CONSTRUCTIVIST COGNITIVE-

BEHAVIORAL TREATMENT

MODEL Donald Meichenbaum has developed several manualized and empirically-supported

treatments using cognitive-behavioral approaches. His approach is partly based on the

literature on common factors in psychotherapy and his interests in the psychotherapy

integration movement. The following tasks of psychotherapy form the core of his

constructivist cognitive-behavioral treatment approach; he also views these as the

common elements in all successful therapy.DEVELOP A THERAPEUTIC ALLIANCE AND HELP CLIENTS TELL THEIR

STORIES.

EDUCATE CLIENTS ABOUT THE CLINICAL PROBLEM.

HELP CLIENTS RECONCEPTUALIZE THEIR PROBLEMS IN A MORE

HOPEFUL FASHION.

ENSURE THAT CLIENTS HAVE COPING SKILLS.

ENCOURAGE CLIENTS TO PERFORM PERSONAL EXPERIMENTS.ENSURE THAT CLIENTS TAKE CREDIT FOR CHANGES THEY HAVE

BROUGHT ABOUT.

CONDUCT RELAPSE PREVENTION.

The constructivist narrative perspective which Meichenbaum adds to traditional

cognitive therapy is based in a view of people as meaning-making agents who

construct their own stories to explain their lives and experiences. In contrast to

traditional Cognitive Therapy, Meichenbaums approach is less structured, more

exploratory, and more discovery-oriented. Clients are assisted in telling their stories and

in creating new stories through therapy.

TASK: Using this framework evaluate the therapies studied in this course to determine

which have these elements in common.


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Prevalenceof Schizophrenia Varies depending on whether a broad (Bleuler)

or narrow (Kraepelin, Schneider) definition of

the disorder is used. (DSM-IV is considered a

middle-of-the-road compromise).

Schizophrenia occurs:

worldwide at a lifetime prevalence rate

of about 1% (morbidity risk) range: 0.2 to 2.0%

equally in males and females

earlier (at least 5 years) for males than

females men hospitalized more often and prognosis is poorer

usually in the late teens or early 20s, butas late as the 50s

Schizophrenia and related psychoses were not included in

the Ontario Health Survey (1990) Mental Health

Supplementbecause the sample did not identify enough

people to permit meaningful study.


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TYPES OF DELUSIONS

F ixed beliefs with no basis in real i ty

There are several types of delusions that areoften woven together in a complex and

frightening system of beliefs

PERSECUTORY delusionsdelusions of BEING

CONTROLLED

THOUGHT BROADCASTINGTHOUGHT INSERTION

THOUGHT WITHDRAWL

delusions of GUILT or SINSOMATIC delusions

GRANDIOSE delusions


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SchizophreniaDIATHESES Genetic factors

Physical traumaprenatally orduring birth

Structuralabnormalities ofthe brain

Abnormalities inneurotransmittersystems

Psychosis-pronepersonality

STRESSORS

Physical trauma,

prenatally or during

birth

Chronic

psychological and

social stressors and

environmental

hazards associated

with urban living and

poverty

Family environment

with high Expressed

Emotion


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Genetic Factors

and Schizophrenia The closer a persons biological relationship to someon

diagnosed with schizophrenia, the greater that person

risk of developing schizophrenia or one of the

schizophrenia spectrum disorders.

The evidence is clear on several other points:Schizophrenia runs or aggregates in families.

This aggregation is found regardless of the type ofresearch methodology (family, adoption or twin

studies) used or the country in which the study is

performed.In many cases a vulnerability that predisposes a

person to schizophrenia (scientists dont know exactly

what) is genetically transmitted.

Genes alone are not sufficient to account for thedevelopment of schizophrenia.

Today most investigators believe that the genetic contribution to the majority

of cases of schizophrenia is polygenic meaning that a mosaic of differentgenes act in concert to influence the development probability and severity of

schizophrenia.


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PSYCHOSOCIAL FACTORS AND

SCHIZOPHRENIAThe two psychosocial factors receiving the most attention in

the study of schizophrenia are: socioeconomic class and

associated stressors; and family environment and familycommunication patterns.

Explanations for the disproportionate rate

of schizophrenia among urban and

lower SES groups include:

the social drif t hypothesis, whichsuggests that, as people develop

schizophrenic symptoms, they gradually

slide down the socioeconomic ladder;

andthe breeder or social causationhypothesis, which suggests that social

strains and environmental hazards

breed schizophrenic episodes in

vulnerable individuals.

Many schizophrenic people come from familiesthat are socially and economically advantaged.

Despite suffering psychotic symptoms for yearson end, many schizophrenics do not drift into lives

of poverty or marginality.


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The Role of EXPRESSED

EMOTION and SchizophreniaHow do you think you would act if you lived with a person who had schizophrenia? Would

you feel afraid? Would you be a nag? Would you challenge the person to become more

socially involved or would you feel sorry for the person?

There is a strong relation between a familys emotional

overinvolvement and the rate at which patients suffer

relapses of schizophrenia.

EXPRESSED EMOTIONusually involves high levels of criticism(

You dont do anything but sit in front of the TV

hostility(Im sick and tired of your craziness) and

overinvolvementIll go downtown with you so we can have time

together. or Dont you realize how hard I try to help you out?).

How might EE lead to relapse? Perhaps schizophrenics are

sensitive to environmental stimulation, particularly social criticism,

which may drive up their levels of psychophysiological arousal. Under

this heightened arousal, they might lose some of their already-impaired

ability to process information accurately. Result? They feel bombarded

with negative stimuli, their symptoms increase, and soon their condition

deteriorates into a full-blown episode of psychosis. Family stressors

involving EE could also combine with other life events to heighten the

risk of relapse.


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ONTARIOS FIRST MENTAL HOSPITAL WAS

ESTABL ISHED IN THE OLD YORK (TORONTO)

JAI L , IN JANUARY, 1841.

IT WAS ULTIMATELY ESTABLISHED AS THEOTORIOUS 999 ON QUEEN STREET IN 1850.

OFFICIAL TITLE:LUNATIC ASYLUM

LONDON PSYCHIATRIC HOSPITAL WAS CALLED THE:

IDIOT BRANCH

ORILLIA PSYCHIATRIC HOSPITAL WAS CALLED THE:

HOSPITAL FOR IDIOTS AND IMBECILES


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Chronic

Social Breakdown

Syndrome

APATHY

DEPENDENCY

SOCIALWITHDRAWL


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Antipsychotic (Neuroleptic)

Treatment of Schizophrenia The phenothiazines, the primary treatment for

schizophrenia,

relieve positive symptoms for 60 to 70% ofpatients (however, fewer than 30% respond wel

enough to live in communities entirely on their

own); and

cause several kinds of serious side effects (e.g.,extra-pyramidal symptoms such as

Parkinsonism, tardive dyskinesia, and

neuroleptic malignant syndrome)

Newer, atypical antipsychotic drugs (e.g.,clozapine):

relieve negative symptoms as well as positivesymptoms; and

help some patients who are resistant to thephenothiazines.

It is a mistake in my view to think about the treatment of schizophrenia in

purely biological terms. Drugs are usually necessary for

controlling symptoms, but they cannot make a new

life for patients or teach them to cope with the

negative consequences of the disorder.


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Psychosocial Treatment

The most effective psychosocial treatments forschizophrenia focus on:

training in self-help and social skills family therapy in which families are taught how to

deal with patients when they return home

psychosocial rehabilitation that helps patients live incommunities by strengthening their independent livinskills and creating more supportive environments

vocational rehabilitation

The very best programs also include: individual case managers who serve as advocates and

help patients obtain necessary services

social support that wraps around patients and holdthem in the community

peer support groups

safe houses

individualized plans to help clients avoid or managecrises

patients help write proactive crisis plan specific vocational rehabilitation plan identifying

occupational goals and needed skills

job clubs or transitional employment

interpersonal work skills


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Prevention?Stopping Relapse in Young

Schizophrenic Patients

Although scientists have discovered no effective

ways to prevent schizophrenia, psychosocial

rehabilitation coupled with regular medication

comes the closest to constituting a form of

secondary prevention.

Many programs pay special attention to serving

relatively young schizophrenic patients who are

not yet chronically disabled from the disorder.

The search for more effective

treatment must include the pursuit of

new medications and the discovery ofhow psychosocial and cultural

stressors and buffers can be changed

to lessen the incidence of

schizophrenia.


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rue reform is up to all of us

By Scott Simmie,

The Toronto Star, October 10, 1998

MONEY

HOUSING

COMMUNITY

MENTAL HEALTHCENTRES

PROVINCIALPSYCHIATRICHOSPITALS

RISK ASSESSMENT

DIVERSIONPROGRAMS

COMMUNITYTREATMENT ORDERS

BEST DRUGS FIRST

KIDS--A CLEARPRIORITY

CRISIS CENTRES--AC O GO

ALTERNATIVEBUSINESSES

INCOME SUPPORTS

DRUG COVERAGEEXTENSION

THE DOCTORS

ANTI-STIGMACAMPAIGN

THE AGENCIES

EMPLOYERS

CONSUMERS

THE POLICE

THE MEDIA

BUILDING A SYSTEM

THE PUBLIC

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