Psychological Disorders & Treatment

This is Unit Twelve of Psychology, Part Three: treatment. Parts One and Two described what disorders are and how they get identified. This part is about what is done — and the useful thing to notice early is that the behavioral therapies are Unit Five, applied. Extinction, exposure without avoidance, and conditioning are all here doing clinical work. Then the cognitive therapies, one of which is stated outright as having the broadest evidence base among psychotherapies. That is a ranking, and the course makes it rather than leaving all approaches level. Then medication in four classes — and one entry saying that for several disorders the combination outperforms either treatment alone. The last third is the part with lasting use in it. A method for matching a treatment to a disorder that ends by naming what the choice trades away. And then four points for evaluating any therapy claim you will ever encounter — because outperforming a waitlist means something much narrower than it sounds like. By the end you will be able to do five things. One: say what the behavioral therapies do. Two: say what the cognitive therapies add. Three: name the four medication classes. Four: match a treatment, and name what it trades away. Five: evaluate a therapy claim on four points.

Two entries setting the scene. A twentieth-century movement that changed where treatment happens, and a definition of the thing itself — which is structured interaction with a trained therapist rather than conversation.

The movement.

Psych 1393 Deinstitutionalization

The mid-twentieth-century movement of psychiatric patients out of large hospitals into community settings. It changed where treatment happens, and whether the community provision arrived is a separate question.

The treatment.

Psych 1395 Psychotherapy

Treatment of psychological disorders through structured interaction with a trained therapist. Structured and trained — both words are doing work in that definition.

Three entries, and every one of them is a mechanism from Unit Five put to clinical use. The second is the clearest — avoidance is what has been preventing extinction, so the treatment is confronting the feared thing without it.

The first.

Psych 1397 Systematic Desensitization

Treating phobia by pairing relaxation with a graduated hierarchy of feared stimuli. Classical conditioning, run deliberately in the opposite direction.

The second.

Psych 1399 Exposure Therapy

Treating anxiety disorders by confronting feared stimuli without the avoidance that has prevented extinction. The avoidance was the reason the fear survived, which is why removing it is the treatment.

The third.

Psych 1401 Aversive Conditioning

Pairing an unwanted behavior with an unpleasant stimulus to reduce its frequency. The most direct application of conditioning here, and the narrowest in use.

Three entries. Treating the thought patterns that maintain a disorder rather than the behavior — and then a combination which the course states plainly has the broadest evidence base of any psychotherapy.

The approach.

Psych 1403 Cognitive Therapy

Identifying and testing the distorted thought patterns that maintain a disorder. Testing rather than disputing — the patterns are treated as hypotheses that can be checked.

The combination.

Psych 1405 Cognitive Behavioral Therapy

Combining cognitive restructuring with behavioral techniques, and having the broadest evidence base among psychotherapies. A stated ranking rather than a description.

Another.

Psych 1407 Dialectical Behavior Therapy

Combining acceptance and change strategies to build emotion regulation and distress tolerance skills. Two strategies that sound opposed, deliberately held together.

Three entries. Therapies drawn from the humanistic and psychodynamic traditions of Unit Ten — each one being that tradition's account of personality, turned into a treatment — and then what changes when more than one person is in the room.

The humanistic one.

Psych 1409 Humanistic Therapy

Providing unconditional positive regard, empathy and genuineness so the client can direct their own change. The therapist supplies conditions rather than direction — which follows exactly from the tradition's account of personality.

The psychodynamic one.

Psych 1411 Psychoanalytic Therapy

Bringing unconscious conflict into awareness through free association, dream analysis, and examination of the therapy relationship. The tradition's central claim, turned into a method.

Two formats.

Psych 1413 Group and Family Therapy

Group therapy treats several clients together; family therapy treats the family system rather than one member. The second is a different target, not a different setting.

Five entries. Four classes, each named by what it acts on — and Unit Two's transmitters appear in every one of them. Then an entry saying that for several disorders the combination of medication and therapy beats either by itself.

The first class.

Psych 1415 Antidepressant Medications

Raising the availability of serotonin or norepinephrine, and requiring several weeks to reach full effect. The delay is clinically important — the medication is working before it feels like it is.

The second.

Psych 1417 Antianxiety Medications

Increasing GABA activity and reducing arousal quickly. The brain's main inhibitory transmitter from Unit Two, amplified.

The third.

Psych 1419 Antipsychotic Medications

Reducing psychotic symptoms primarily by blocking dopamine receptors. Which is the dopamine hypothesis from Part Two, acted on.

The fourth.

Psych 1421 Mood Stabilizers

Reducing the frequency and severity of manic and depressive episodes. Both directions of the cycle, from one class.

And combining.

Psych 1423 Combining Medication and Psychotherapy

For several disorders, combined medication and psychotherapy outperforms either treatment alone. Which makes the choice between them a false one in those cases.

Three entries. One factor predicts outcome across every therapy type — which is a striking finding given how different the therapies are. And then what stops people getting any of it.

The predictor.

Psych 1425 The Therapeutic Alliance

The collaborative bond between client and therapist, which predicts outcome across therapy types. Across types — it predicts better than the choice of therapy does in many comparisons.

The barriers.

Psych 1427 Barriers to Treatment

Cost, availability, stigma, transportation, and mistrust arising from past mistreatment. The last one is a historical fact about how people were treated rather than a misapprehension.

One of them, named.

Psych 1429 Stigma

The negative attitude and discrimination directed at people with psychological disorders. Unit Eleven's distinction, applied — an attitude and a behavior, both present.

Five entries, and the method has a step most treatment discussions leave out. Select the approach with the strongest evidence for that specific disorder and severity — and then name what the choice trades away, because every choice trades something.

The method.

Psych 1431 Matching Treatment to Disorder

Selecting the approach with the strongest evidence for that specific disorder and severity, then naming what the choice trades away. Specific disorder and severity — a treatment that is best in general may not be best here.

The first case.

Psych 1432 Matching Treatment: Specific Phobia

Specific phobia is matched to graduated exposure, which has the strongest evidence and works in relatively few sessions. Short course, strong evidence — an unusually clean case.

The second.

Psych 1434 Matching Treatment: Obsessive-Compulsive Disorder

Obsessive-compulsive disorder is matched to exposure with response prevention — meeting the feared situation and not performing the compulsion. Which follows directly from why the cycle holds.

The third.

Psych 1436 Matching Treatment: Moderate Depression

Moderate to severe depression is matched to combined medication and psychotherapy, which outperforms either alone. The combination entry, applied to a specific case.

And the fourth.

Psych 1438 Matching Treatment: A First Psychotic Episode

A first psychotic episode is matched to antipsychotic medication alongside coordinated specialty care, and earlier treatment predicts better outcome. Earlier — which makes the prodromal window from Part Two consequential.

Five entries closing the unit, and the first four are the most portable thing in it. Four points every therapy claim gets checked on — and then three claims checked against them, showing what each kind of study actually supports.

The four points.

Psych 1440 Evaluating a Therapy Claim

The control condition, the outcome measure, the follow-up period, and whether the comparison was active. Four questions, and a claim can pass three and still be weak.

The first claim.

Psych 1441 Evaluating a Waitlist-Controlled Claim

A therapy outperforming a waitlist has been shown to beat no treatment — which does not establish that it beats an alternative. A real result, and a much narrower one than it sounds.

The second.

Psych 1443 Evaluating a Claim Without Follow-Up

A therapy measured only at the end of treatment supports a claim about immediate change and none about durability. The missing measurement decides what can be claimed.

And the third.

Psych 1445 Evaluating an Actively-Compared Claim

A therapy compared against an active alternative with long follow-up supports the strongest claim available in the psychotherapy literature. Strongest available — which is a bounded statement, not an unbounded one.

The capstone. One case, three levels.

Psych 1447 One Case, Three Levels

Explaining one presentation biologically, psychologically and socioculturally, then building a treatment plan that addresses all three. All three parts of this unit, on one person.

Five things you can now do, and Unit Twelve is complete. You can say what the behavioral therapies do and which mechanism each uses — relaxation against a hierarchy, confronting a fear without the avoidance that prevented extinction, and pairing a behavior with an unpleasant stimulus. You can say what the cognitive therapies add — testing the distorted thought patterns that maintain a disorder — and that the combined cognitive-behavioral form has the broadest evidence base. You can name the four medication classes and what each acts on: serotonin or norepinephrine availability, GABA activity, dopamine receptors, and episode frequency and severity. You can match a treatment to a disorder and severity — and name what the choice trades away, which is the step most discussions leave out. And you can evaluate any therapy claim on four points: the control condition, the outcome measure, the follow-up period, and whether the comparison was active.