If you saw our last lesson on psychotherapy you might be wondering: What happened to Bernice?
Has she found a way to manage her depression? Is she still wracked with anxiety?
Well it's really nice of you to ask. And I'll tell her you said, "hi." But for our purposes
as students of psychology, the bigger question arising from Bernice's case is "has psychotherapy
helped?" and just as important, "how can we tell?"
Well believe it or not, one of the main ways experts use is to simply ask the client, and
see how they say they're doing.
Is Bernice out of bed, and living her life? Did she make it through mid-terms without
spiraling into a crisis? And did she take that plane trip to Baja to party with her girls?
As a clinician, that would all be useful to know, right? But the key is that we want to
ask these questions in a scientifically rigorous manner, so that we really know a treatment
works, rather than just extrapolating from individual cases.
And there's also a whole other category of treatment that's pretty different from the
talking and listening that goes on in psychotherapy.
These are as much medical intervention as they are psychological science; the biomedical
treatments. These can be as common-place as medications like Zoloft or Lithium, or a bit
more unusual and invasive like magnetic stimulation, neural implants, or even electroshock therapy.
And YES, it's still a thing.
Healing a troublesome mind isn't like healing a broken arm. So one of the challenges that
psychologists face is simply knowing whether they're doing their job, and doing it well.
The methods psychologists use to assess how effective treatments are mostly involve client
and clinician perceptions along with outcome research. Client perceptions are just what
they sound like, you see a therapist, and someone asks you how you feel after your treatment.
It varies by treatment, but client perception tends to be pretty rosy. One study found that
89% of folks said that they were at least "fairly well satisfied" with their treatment.
But of course, perceptions are inherently subjective, and some believe that the therapeutic
relationship lends itself to a positive bias in client reviews. Basically, if you're sticking
to your treatment, you probably like your therapist.
Clinician perspectives can be similarly skewed, not only in terms of a self-serving bias,
but also because they may not be around to see a client's future relapses or setbacks
in mental health. A patient could see ten therapists over time, feel better at the end
of each treatment, but keep struggling over the long term, even though each
therapist thought the treatment was a success.
So, can we objectively measure how well psychotherapy works? Well, we have treatment
outcome research, a way of systematically measuring which therapies work best for which problems.
And the gold standard of treatment outcome research is the randomized clinical trial, or RCT.
If you will remember your research methods, you'll know that RCTs generally require randomly
selected and assigned participants, a control group, and at least one experimental group
that receives the treatment. This design accounts for individual differences between people
and other extraneous factors, so that we know that if people in the experimental group get
better and people in the control group don't,
it was truly the therapeutic intervention that made the difference.
And once enough researchers have run their own RCTs, you can gather data via meta analysis,
measuring results across multiple trials to see basically whether a treatment works, and
how well it does, across a variety of settings.
Two important terms you should know here are effectiveness and efficacy. Effectiveness
is whether or not a given therapy works in a "real-world setting," whereas efficacy is
whether a therapy works better than some other, comparable intervention, or a control. Both
terms matter, and you'll wanna get them straight, if you're tryin' to parse the research literature.
Dozens of studies have confirmed that psychotherapy is both effective and efficacious. While controls,
usually people who don't get any therapy, often do get better on their own, those in
psychotherapy usually improve faster, and with a significantly lower risk of relapse.
However, and try not to look too shocked when I tell you this, there is a lot of argument
about which therapies work best.
In some cases, like phobias, there are clear winners, behavior therapy for instance. In
others, like major depressive disorder, there are cognitive, behavioral and psychodynamic
interventions that have all been successful in RCTs. And while a lot of psychologists
seem to get a kick out of arguing about which therapies are better than others, there do
seem to be some common factors that unite the more effective ones.
A big one is simply instilling hope, helping demoralized clients regain hope that things
can, and will get better. There is also the value of getting a new perspective, learning
that there is a plausible explanation for your troubles, and finding a new way of looking
at yourself, the world around you, and what your future might look like. And across the
board, any good therapist provides genuine empathy within a trusting, caring relationship.
They seek to listen, and understand and not judge, and offer clear and positive communication.
But psychotherapy, or talking it out, is just one way to treat psychological disorders.
Quite often, biomedical therapies are an option, sometimes for the more severe disorders, but
in many cases, in combination with psychotherapy. Biomedical therapies aim to physiologically
change the brain's electrochemical state with psychotropic drugs, magnetic impulses, or
even electrical currents and surgery. As you might expect, pharmacotherapy is by far the
most widely used, that's the one where you just take drugs. Psychotropic drugs are just
any pharmaceutical that affects your mental state, the most commonly used ones fall into
four major categories; antipsychotics, anxiolytics, antidepressants, and mood stabilizers,
each aimed at a specific family of problems.
Antipsychotics are used to treat schizophrenia and other types of severe thought disorders.
Most of these medications alter the effects of the neurotransmitter dopamine in the brain
by blocking its receptor sites, and blocking its uptake. This is based on the assumption
that an overactive dopamine system contributes to schizophrenia, but, like many psychotropic
drugs, antipsychotics come with nasty side effects.
Anxiolytics, or anti-anxiety meds, usually work by depressing activity in the central
nervous system, much like a stiff drink might. For this reason, and others, it can be super
dangerous to mix certain anxiety meds with booze. Also, letting your nerves mellow out
can feel so good that patients may risk becoming addicted to some anxiolytics.
Antidepressants are used to treat depression, as you might expect, but also a number of
anxiety disorders. Each type is thought to work a bit differently, mainly by altering
the availability of various neurotransmitters, like serotonin and norepinephrine in the brain,
which in turn appears to help with mood and anxiety problems. Some of the most common
are selective serotonin re-uptake inhibitors, or SSRIs, like Zoloft, Paxil, and Prozac,
which partially block the normal re-uptake of serotonin. This makes it more available
to the synapses, which, hypothetically at least, allows its mood-enhancing effects to
kick in. Current research suggests that the use of antidepressant medication is most effective
when combined with psychotherapy, which makes a lot of sense, and the same goes for a number
of other psychological disorders.
It's worth pointing out here that some meta-analyses suggest that antidepressants aren't any more
effective than psychotherapy when symptoms are mild to moderate. One meta analysis that
riled people up in recent years even suggested that antidepressants are no better than a
placebo in those cases. So psychotropic drugs can help, but sometimes you also need to start
exploring the root causes of your issues and reevaluate how you deal with them, which is
what psychotherapy is perfect for.
Bernice, for example, probably would have benefited from both talk therapy and a dose
of anxiolytic or antidepressant meds.
The last big psychotropic drug group is the mood-stabilizers. They can be extremely effective
in smoothing out the highs and lows of bipolar disorder. Simple salts of Lithium were the
first of these drugs used, and they remain in widespread use today. Dr. Kay Redfield
Jamison, who we talked about a few weeks ago has said that Lithium "prevents my disastrous
highs, diminishes my depressions, gentles me out, keeps me from ruining my career and
relationships, keeps me out of a hospital, and alive."
And while drugs are the most popular biomedical treatment, they aren't the only kind. For
one, there's electro-shock therapy. Now, hear me out, this does carry a long history of
negative connotations, like of people being strapped down and shocked into mental oblivion,
but the technology has made a comeback, and can actually be quite effective in treating
severe, treatment-resistant depression. It's properly called electroconvulsive therapy,
or ECT, and it involves sending a brief electrical current through the brain of an anesthetized
patient. This excites the neurons, causing them to fire rapidly, until the patient goes
through a small, controlled seizure that lasts about two minutes. And we're not exactly sure
why this helps to relieve negative symptoms, but there are several theories that are being pursued.
One suggests that the resulting seizure beneficially alters neurotransmitter activity in areas
of the brain associated with moods and emotions, effectively jumpstarting a severely depressed
brain. Another theory suggests that these electrical impulses modify stress hormone
activity in the brain, which we know could play a role in sleep, energy, appetite, and
mood. ECT may also re-activate previously dormant or suppressed neurons, or possibly
stimulate the growth of new ones in key brain regions, helping the brain regain some level of lost functioning.
There are a couple of other brain-stimulation treatments, too, that are more gentle. One
is repetitive transcranial magnetic stimulation, rTMS, which involves the painless application
of repeated electromagnetic pulses. Another, deep-brain stimulation, DBS, is more invasive,
and calls for surgically implanting a kind of "brain pacemaker" that sends out electrical
impulses to specific parts of the brain. Despite all the new research and often positive results
around rTMS and DBS, we're still sorting out how these treatments work to heal the brain
and mind, but they're hypothesized to jump-start the neural circuitry in a depressed brain, similarly to ECT.
So you'll notice that all these options come with certain risks, and really no treatment
is entirely risk free, perhaps not even psychotherapy. But we should also note that some of the less
severe manifestations of psychological disorders may be improved with pretty simple lifestyle
changes. Thirty to sixty minutes of daily aerobic exercise has been shown to be as effective
as antidepressant medications in research on mild depression. Just remember those words;
"daily" and "aerobic." Adequate sleep, social interaction, and good nutrition also all play
a part in managing moods. In other words, general healthy living helps. There's an Old
English proverb that says "different sores have different salves" and the same is true
here. What works for one person may not work for another, and sometimes a few different
kinds of intervention might be needed all at once.
Today you learned how client and clinician perceptions, outcome research, and meta-analytic
reviews work together to determine the efficacy and effectiveness of psychological treatments.
You also learned how biomedical therapies work, including the four major families of
drug therapies, along with electro-convulsive therapy, repetitive transcranial magnetic
stimulation, and deep brain stimulation. And also how lifestyle changes and general healthy
living can improve mental health.
Thanks for watching, especially to all our Subbable subscribers who make Crash Course
available to not just themselves but also to all of all people. To find out how you
can become a supporter just go to subbable.com.
This episode was written by Kathleen Yale, edited by Blake de Pastino, and our consultant
is Dr. Ranjit Bhagwat. Our director and editor is Nicholas Jenkins, the script supervisor
and sound designer is Michael Aranda, and the graphics team is Thought Cafe.