1、Chapter 15 Treatment of Psychological Disorders (心理错乱/障碍的治疗)psychotherapy or Treatment 心理治疗?在这个过程中，一个人希望消除症状，或解决生活中出现的问题，或寻求个人发展而进入的一种含蓄的或明确的契约关系，以一种规定的方式与心理治疗家相互作用；?以消除、缓解、纠正现有症状，调节异常行为、促进积极人格发展为目的；?治疗师与患者建立良好的人际关系；?治疗师应接受专业的训练，得到社会认可，拥有相应的理论指导，可以解释心理障碍的原因并为解决障碍提供有效措施；心理咨询counseling?咨询内容包括：职业指导、教育辅
2、导、心理健康咨询、婚姻家庭咨询等；?在咨询师与来访者来访者之间建立良好的人际关系，帮助来访者学会更有效地认识自己、对待自己、对待他人以及生活中的难题；?例如：心理援助、心理干预；?咨询的最核心条件：共情、理解和尊重；?咨询能力：咨询者专业技能，对待来访者的态度或关心人的能力；?通过一种由专业人员引导的人际关系而实现的帮助过程、教育过程、增长过程。关于心理治疗的主要问题?治疗师在心理治疗过程中要做些什么?他们是如何进行治疗的?不同理论?不同技术-?针对不同的问题-?寻求治疗的是一些什么样的人?或什么人需要心理治疗？?如何评估治疗效果?十十八八世世纪纪时时心心理理治治疗疗所所使使用用的的“镇镇静静
3、椅椅”?Original point:psychoanalysis by Sigmund Freud(1856-1939)?Psychoanalysis(精神分析);?“Talk therapy”（谈话疗法）;?To solve unconscious conflicts;?Psychotherapists:who provide psychotherapy(心理治疗师)?Client(来访者);who seeks therapy;The Elements of the Treatment Process?Treatments:How many types are there?Discussi
4、on(讨论)?Psychological testing(心理测验)?Advice（建议）?Emotional support(情绪支持)?Persuasion(劝告)?Conditioning procedures(条件反射训练)?Relaxation training(松弛训练)?Role playing(角色扮演)?Drug therapy(药物治疗)?Biofeedback(生物反馈)?Group therapy(群体治疗)The Elements of the Treatment Process?Types?Insight therapies(省悟疗法)：通过复杂的言语交流来洞悉当事
5、人内心的困苦并找出解决之道（“Talk therapy”-谈话疗法）?Individual therapy(个别治疗）?Family therapy(家庭治疗)?Marital therapy(婚姻治疗)?Group therapy(群体治疗）?Behavior therapies(行为疗法)?the principles of learning(学习原则)：改变外显行为?改变反应和不良习惯而不是分析内心世界?Biomedical therapies(生物医学疗法)?干预当事人的生物机能?Drug therapy(药物治疗)?Electroconvulsive therapy(电休克疗法)?T
6、he right to prescribe medication(处方权)The Elements of the Treatment Process?Clients:Who seeks therapy?15%of U.S population in a given year?Most common presenting problems Most common presenting problems?Anxiety and Depression?Unsatisfactory interpersonal relations?Troublesome habits(强迫动作思维)?Poor self
7、 control?Low self-esteem（自尊低落）?Marital conflicts（婚姻冲突）?Self doubt（自我怀疑）?Sense of emptiness（空虚感）?Feelings of personal stagnation(个人发展停滞）The Elements of the Treatment Process Figure 15.2 Therapy utilization rates Figure 15.3 Psychological disorders and professional treatment?Therapists:who provides pr
8、ofessional treatment?Psychologists(PhD,PsyD,EdD)?Clinical psychologist(临床心理学家)?full-fledged disorders?Counseling psychologist(咨询心理学家)?Everyday adjustment problem?Behavioral techniques other than psychoanalysis?Psychiatrists(精神病学家)with an MD?More severe disorders?Drug therapy?More likely to use psych
9、oanalysis and less likely to use behavioral&group therapy?Others?Clinical social worker(临床社工)?Psychiatric nurse(精神科护士)?Counselor(咨询师)Figure 15.3 Who people see for therapy.Based on a national survey by Olfson and Pincus(1994),this pie chart shows how therapy visits were distributed among psychologis
10、ts,psychiatrists,other mental health professionals(social workers,counselors,and such)and general medical professionals(typically physicians specializing in family practice and internal medicine).As you can see,psychologists and psychiatrists account for about 62%of outpatient门诊病人 treatment.?Insight
11、 therapy?通过言语交流来增进自我了解并进而促成人格以及行为上积极改变。?Psychoanalysis,?Related psychodynamic approaches,?Client-centered therapy?Cognitive therapy Insight Therapies?Treatment of anxiety-dominated disorders?Neurosis(神经症):?Phobic 恐惧症,?Panic恐慌症,?obsessive-compulsive强迫症,?conversion disorders?Goal:to discover unresolve
12、d unconscious conflicts,motive and defense Insight Therapies:Psychoanalysis心理分析心理分析 Insight Therapies:Psychoanalysis?Sigmund Freud and followers?Goal:discover unresolved unconscious conflicts?Free association?Dream analysis?Interpretation?Resistance and transference 为什么源自弗洛伊德研究的精神分析疗法通常被称为“谈话疗法”?Fig
13、ure 15.4 Freuds view of the roots of disorders?procedures?Probing the unconscious?Free association?Dream analysis?Interpretation(解释)?Inch by inch?Oedipal complex(伊底普斯情结)恋母情结?Resistance(抵抗)?Late?Pretend to engage in the therapy?Hostile?Transference(移情)Insight Therapies:Psychoanalysis?Other psychodyna
14、mic therapies(心理动力学疗法)?Carl Jung?集体无意识与外界（社会、文化、人际等）压力的冲突是心理异常的主要原因。?Alfred Adler?自卑“情结”?精神分析学派治疗思想共同点?无意识?早期经验?差异：?Jung：集体无意识/顺应天性;?Freud：性与攻击/征服无意识;?Adler:自卑/克服自卑;?精神分析法就是通过谈话，帮助病人了解自己，尤其是无意识里的问题，然后解决问题。?主治：各类神经症（焦虑症）Insight Therapies:Psychoanalysis?Carl Rogers（1902-1987）?Humanistic perspective(人本
15、主义观点)：human potential movement(发掘人类潜能运动)?Maslow的治疗观点：实现自我潜能；?当事人在决定治疗的进度和方向上起到主要作用。?原因:Incongruence不一致 or inconsistency between self-concept and reality?Over-dependence on others for approval and acceptance?Anxious-defense mechanism distorted reality or stifled 窒息personal development Insight Therapi
16、es:Client Centered Therapy(当事人中心疗法当事人中心疗法)?Goal:restructure self-concept to better correspond to reality?Therapeutic Climate治疗氛围?Genuineness真诚?Unconditional positive regard无条件地尊重?Empathy同感/神入/同情?Respect ones own feelings and values?Therapeutic process 治疗进程?Provide feedback:clarification澄清?Little gui
17、dance and advice;?Human mirror;Insight Therapies:Client Centered Therapy(当事人中心疗法当事人中心疗法)准确的感知觉 歪曲事实 否认事实 歪曲 否认 适应程度低的个体 适应程度高的个体 Figure 15.5 Rogerss view of the roots of disorders EMPATHY（共情）?来访者：那次考试之后我感觉非常差，我没有想到我考得那么差；?治疗者（1）：你对这次考试感到很失望。?治疗者（2）：你对这次考试的情况感到惊讶和失望，因为你曾经希望自己做得更好一些。谈话技巧：鼓励、重复、及对情感的反映
18、 来访者：我父母从不认真听我说什么，好象我就不可能有对的时候。治疗者：你觉得你父母不重视你，你感觉很委屈，你觉得自己已经长大了。来访者：他们不相信我，他们觉得哪件重要的事也处理不好，治疗者：你觉得自己的自尊心受到了伤害，实际上你非常希望父母相信你，你觉得自己有能力处理好某些重要的事情。非指导式治疗?以某种方式确认来访者表达自己时所反映出来的情感与态度；共情、澄清。?确认或说明来访者的行为举止所反映的情感和态度；?指出对话的主题，让来访者自由发挥；?确认来访者主题；?讨论、说明或提供与问题或治疗相关的信息；?根据来访者的情况确定会谈的内容。指导式治疗?指出非常特定的问题；?讨论说明或提供与问题或
19、治疗有关的信息；?指出对话的主题，但让来访者自行发挥；?向来访者提出活动建议；?确认来访者谈话的主题；?列出证据，说服来访者采纳行动建议；列出证据，说服来访者采纳行动建议；?指出需要纠正的问题或条件；指出需要纠正的问题或条件；人本主义治疗的一般过程?来访者前来求助；?治疗者向来访者说明咨询或治疗的情况；?鼓励来访者情感的自由表达；?治疗者能够接受、认识、澄清对方的消极情感；来访者成长的萌动；?治疗者对来访者的积极情感要加以接受和认识；?来访者开始接受真正的自我；?帮助来访者澄清可能的决定及应采取的行动；?疗效的产生；?进一步扩大疗效；?来访者的全面成长；?治疗结束。.认知治疗认知治疗 改变改变
20、 错误的信念错误的信念 认知行为矫正认知行为矫正 认知治疗?认知重建法:消极陈述 积极的想法和陈述?理性情绪疗法:改变非理性的信念 认知行为矫正认知行为矫正 改变错误的信念改变错误的信念 如果你正在学习编织,而且你想学得越来越好,那么你应给你自己什么样的内部信息应给你自己什么样的内部信息?Aaron Beck(1976,1987)?Cognitive therapy（认知疗法）?Recognizing and changing negative thoughts and maladaptive不适应的 behavior?Depression:?过分自责?只看消极事件?对未来悲观-消极认知与抑郁
21、：谁因？谁果？?积极的认知建构；Insight Therapies:Cognitive Therapy Figure 15.6 Becks view of the roots of disorders.Becks theory initially focused on the causes of depression,although it was gradually broadened to explain other disorders.According to Beck,depression is caused by the types of negative thinking show
22、n here.?Albert Ellis(1973,1989)?Rational-emotive therapy（理性情绪疗法）?Alter 转变 clients patterns of irrational thinking to reduce maladaptive emotion and behavior;Insight Therapies:Cognitive Therapy?Goal:to change the way clients think?Detect and recognize negative thoughts?Reality testing(use more reason
23、able standards,looking for the unrealistic assumption 假定)?Process?Therapist actively主动 involves in determining the pace and direction of treatment?Relatively short-term(4-20 sessions)Insight Therapies:Cognitive Therapy ABCDE理论?A:activating events?B:beliefs?C:consequences?D：disputing irrational belie
24、fs?E:New emotive and behavioral effects;-情绪不是由事件本身引起的，而是有个体对事件的评价和解释引起的；ABC-治疗关键：确定和纠正不合理和观念。ABCDE 治疗技巧?与不合理信念辩论?质疑式：“你有什么证据能证明你自己的这一观点？”“是否别人都可以有失败的时候，而你就不能？”“是否别人都要按你的意思去做？”“请证实你的观点”?目的：认识到不合理/不符合逻辑的观念，形成/采纳理性的信念；ABCDE治疗法?夸张式：治疗者故意夸大来访者的不合理观念，帮助认识其不合理和不合逻辑的观念；?例：?来访者（社交恐惧症）：别人都在看着我。?治疗者：是否别人都不做自己的
25、事情，都在看着你？?来访者：没有；?治疗者：要不要在身上帖上”不要看我“的字样？?来访者：那别人都要来看我了；?治疗者：。是否别人都在看你？?来访者：我自己想象的。认知的家庭作业?合理情绪治疗自助量表；?在表中确定AC及B（不合理的信念）；?与不合理信念辩论?讨论自己的观念是否合理；?合理的自我分析；?采取合理的观念，到达治疗效果；-认知/理性改变之后，情绪依然如故，怎么办？认知领悟疗法?钟友彬(1988)中国心理分析:认知领悟心理疗法?病源：儿童时期的精神创伤在脑内留下了痕迹；?适应症：强迫症、恐惧症、性变态等神经症；?改变认知/悟性；?具体方法：谈话、家庭作业（写治疗感受）；.小组治疗小组
26、治疗 社会性支持小组小组 婚姻及家庭 治疗治疗 小组治疗?Participants role?4-15 people(8 is ideal)?Exclude persons who seem likely to be disruptive 错乱?Participants essentially function as therapists for each other.Insight Therapies:Group Therapy 小组治疗?优势：?威胁性较小威胁性较小?影响个体的适应不良行为良行为?为参与者提供观察为参与者提供观察和实践机会?矫正个体的情绪体矫正个体的情绪体验验?Therap
27、ists responsibility?Selecting participants?Setting goals?Initiating and maintaining the therapeutic process?Protecting clients受辅者 from harm?Advantages of the group experience?Save time and money?More people as me,with problems Insight Therapies:Group Therapy?Hans Eysenck(1952)?Treated:2/3 recovery r
28、ate,?untreated:2/3 recovery rate in neurotic problems.?Insight therapies helpless?Superior to no treatment or to placebo 安慰剂）treatment?Spontaneous remission（自愈率）:30%-40%.(Bergin,1971)；Evaluating Insight Therapies Possible facilitate Factors in insight therapies?The development of therapeutic allianc
29、e with a professional helper;发展专业的治疗关系?The provision of emotional support and empathic understanding by the therapists;获得支持与理解?The cultivation of hope and positive expectations in the clients;希望和正性期望?The provision of a rationale for for the problem and methods to improve;获得理性和改善的方法?The possible to e
30、xpress emotions,face problem and gain new insights and learn new patterns of behaviors;表达情感,面对问题,习得新的知识和行为;?History?B.F.Skinner(1953 in US)?Hans Eysenck(1959 in UK)?Joseph Wolpe(1958 in SA)?Main assumption?Behavior is a product of learning?What has been learned can be unlearned?Classical conditionin
31、g;?Operant conditioning;?Observational learning 观察学习 Behavior Therapies(行为疗法行为疗法)?Goal:unlearning忘却 maladaptive behavior and learning adaptive ones?Systematic Desensitization(系统脱敏)Joseph Wolpe?Three steps?Anxiety Hierarchy(焦虑层级):anxiety stimuli list?Deep muscle relaxation(深度肌肉放松)?Learning to remain
32、relaxed while imagining each stimulus?Facing real stimuli?Phobic disorder of Snake,test,height Behavior Therapies(行为疗法行为疗法)Figure 15.7 The logic underlying systematic desensitization.Behaviorists argue that many phobic responses are acquired through classical conditioning,as in the example diagramme
33、d here.Systematic desensitization targets the conditioned associations between phobic stimuli and fear responses.?Aversion therapy(厌恶疗法)?Alcoholism,sexual deviance,smoking,etc.?Paired with unpleasant stimuli,shock,drug-induced nausea.?Social skills training（社会技能训练）?Modeling（模仿）?Behavioral rehearsal（
34、行为重复）?Shaping(定形)Behavior Therapies(行为疗法行为疗法)Figure 15.9 Aversion therapy.Aversion therapy uses classical conditioning to create an aversion to a stimulus that has elicited problematic behavior.For example,in the treatment of drinking problems,alcohol may be paired with a nausea-inducing drug to cre
35、ate an aversion to drinking.生物医学治疗 药物治疗 精神外科手术 和电休克疗法 生物医学治疗?精神外科手术:不可逆的损伤,结果的永久性?电休克疗法(ECT):副作用，病人常常出现遗忘症 精神外科手术和电休克疗法?抗精神病药物?抗抑郁药物?抗焦虑药物 药物治疗药物治疗 抗抑郁药物 百优解 Anxiety reducing drugsAnxiety reducing drugs?Anti-anxiety drugs（抗焦虑药物）decrease fear and anxiety by facilitating inhibition at GABA synapses；?杏
36、仁核中的兴奋/抑制性神经递质?GABA:inhibitory neurotransmitter?CCK（缩胆囊素）:excitatory neurotransmitter?兴奋CCK，兴奋杏仁核：引起惊跳反射；?阻断GABA，兴奋杏仁核：引起极度惊慌；?Antipsychotic（抗精神症状药物）-Thorazine(chlorpromazine 氯丙嗪),Mellaril（thioridazine 硫醚嗪）,Haldol(haloperidol 氟哌丁苯)?Schizophrenia and severe mood disorder?Reduce the activity of dopami
37、ne 多巴胺synapse?Clozapine?Side effect?Drowsiness,睡意 constipation,便秘 cotton mouth?Resembling Parkinsons disease?Tardive dyskinesia(慢性运动障碍)?Involuntary writhing and ticlike movement of the mouth,tongue,face,hands,or feet?Atypical antipsychotic drugs?Clozapine(氯氮平),olanzapine,quetiapine Biomedical Therap
38、ies（生物医学疗法）（生物医学疗法）Launch Video?Antidepressant（抗抑郁药物）?Tricyclics(三环类药物)Elavil,Tofranil?Mao inhibitors(MAOIs)-Nardil?Selective serotonin reuptake inhibitors(SSRIs 选择性5-羟色胺再摄抑制剂)Prozac（百优解）,Paxil（赛乐特）,Zoloft?Lithium(锂)?Bipolar mood disorders双极 Biomedical Therapies（生物医学疗法）（生物医学疗法）Launch Video Figure 15
39、.11 Antidepressant drugs mechanisms of action.The three types of antidepressant drugs all increase activity at serotonin synapses,which is probably the principal basis for their therapeutic effects.However,they increase serotonin activity in different ways,with different spillover effects(Marangell
40、et al.1999).Tricyclics and MAO inhibitors have effects at a much greater variety of synapses,which presumably explains why they have more side effects.The more recently developed SSRIs are much more specific in targeting serotonin synapses.Figure 15.10 The time course of antipsychotic drug effects.Antipsychotic drugs reduce psychotic symptoms gradually,over a span of weeks,as graphed here.In contrast,patients given placebo pills show little improvement.(Data from Cole,Goldberg,&Davis,1966;Davis,1985)
