—
—
Transcript Provided by YouTube:
00:00
If you saw our last lesson on psychotherapy you might be wondering: What happened to Bernice?
00:05
Has she found a way to manage her depression? Is she still wracked with anxiety?
00:08
Well it’s really nice of you to ask. And I’ll tell her you said, “hi.” But for our purposes
00:12
as students of psychology, the bigger question arising from Bernice’s case is “has psychotherapy
00:17
helped?” and just as important, “how can we tell?”
00:19
Well believe it or not, one of the main ways experts use is to simply ask the client, and
00:24
see how they say they’re doing.
00:26
Is Bernice out of bed, and living her life? Did she make it through mid-terms without
00:30
spiraling into a crisis? And did she take that plane trip to Baja to party with her girls?
00:34
As a clinician, that would all be useful to know, right? But the key is that we want to
00:38
ask these questions in a scientifically rigorous manner, so that we really know a treatment
00:43
works, rather than just extrapolating from individual cases.
00:46
And there’s also a whole other category of treatment that’s pretty different from the
00:49
talking and listening that goes on in psychotherapy.
00:51
These are as much medical intervention as they are psychological science; the biomedical
00:56
treatments. These can be as common-place as medications like Zoloft or Lithium, or a bit
01:00
more unusual and invasive like magnetic stimulation, neural implants, or even electroshock therapy.
01:06
And YES, it’s still a thing.
01:19
Healing a troublesome mind isn’t like healing a broken arm. So one of the challenges that
01:23
psychologists face is simply knowing whether they’re doing their job, and doing it well.
01:27
The methods psychologists use to assess how effective treatments are mostly involve client
01:32
and clinician perceptions along with outcome research. Client perceptions are just what
01:36
they sound like, you see a therapist, and someone asks you how you feel after your treatment.
01:40
It varies by treatment, but client perception tends to be pretty rosy. One study found that
01:45
89% of folks said that they were at least “fairly well satisfied” with their treatment.
01:49
But of course, perceptions are inherently subjective, and some believe that the therapeutic
01:53
relationship lends itself to a positive bias in client reviews. Basically, if you’re sticking
01:58
to your treatment, you probably like your therapist.
02:00
Clinician perspectives can be similarly skewed, not only in terms of a self-serving bias,
02:05
but also because they may not be around to see a client’s future relapses or setbacks
02:09
in mental health. A patient could see ten therapists over time, feel better at the end
02:13
of each treatment, but keep struggling over the long term, even though each
02:17
therapist thought the treatment was a success.
02:19
So, can we objectively measure how well psychotherapy works? Well, we have treatment
02:24
outcome research, a way of systematically measuring which therapies work best for which problems.
02:29
And the gold standard of treatment outcome research is the randomized clinical trial, or RCT.
02:34
If you will remember your research methods, you’ll know that RCTs generally require randomly
02:39
selected and assigned participants, a control group, and at least one experimental group
02:43
that receives the treatment. This design accounts for individual differences between people
02:47
and other extraneous factors, so that we know that if people in the experimental group get
02:52
better and people in the control group don’t,
02:54
it was truly the therapeutic intervention that made the difference.
02:57
And once enough researchers have run their own RCTs, you can gather data via meta analysis,
03:02
measuring results across multiple trials to see basically whether a treatment works, and
03:07
how well it does, across a variety of settings.
03:10
Two important terms you should know here are effectiveness and efficacy. Effectiveness
03:15
is whether or not a given therapy works in a “real-world setting,” whereas efficacy is
03:19
whether a therapy works better than some other, comparable intervention, or a control. Both
03:25
terms matter, and you’ll wanna get them straight, if you’re tryin’ to parse the research literature.
03:29
Dozens of studies have confirmed that psychotherapy is both effective and efficacious. While controls,
03:36
usually people who don’t get any therapy, often do get better on their own, those in
03:40
psychotherapy usually improve faster, and with a significantly lower risk of relapse.
03:45
However, and try not to look too shocked when I tell you this, there is a lot of argument
03:49
about which therapies work best.
03:51
In some cases, like phobias, there are clear winners, behavior therapy for instance. In
03:56
others, like major depressive disorder, there are cognitive, behavioral and psychodynamic
04:00
interventions that have all been successful in RCTs. And while a lot of psychologists
04:05
seem to get a kick out of arguing about which therapies are better than others, there do
04:09
seem to be some common factors that unite the more effective ones.
04:12
A big one is simply instilling hope, helping demoralized clients regain hope that things
04:18
can, and will get better. There is also the value of getting a new perspective, learning
04:23
that there is a plausible explanation for your troubles, and finding a new way of looking
04:27
at yourself, the world around you, and what your future might look like. And across the
04:31
board, any good therapist provides genuine empathy within a trusting, caring relationship.
04:37
They seek to listen, and understand and not judge, and offer clear and positive communication.
04:42
But psychotherapy, or talking it out, is just one way to treat psychological disorders.
04:47
Quite often, biomedical therapies are an option, sometimes for the more severe disorders, but
04:51
in many cases, in combination with psychotherapy. Biomedical therapies aim to physiologically
04:56
change the brain’s electrochemical state with psychotropic drugs, magnetic impulses, or
05:01
even electrical currents and surgery. As you might expect, pharmacotherapy is by far the
05:06
most widely used, that’s the one where you just take drugs. Psychotropic drugs are just
05:10
any pharmaceutical that affects your mental state, the most commonly used ones fall into
05:13
four major categories; antipsychotics, anxiolytics, antidepressants, and mood stabilizers,
05:19
each aimed at a specific family of problems.
05:21
Antipsychotics are used to treat schizophrenia and other types of severe thought disorders.
05:26
Most of these medications alter the effects of the neurotransmitter dopamine in the brain
05:30
by blocking its receptor sites, and blocking its uptake. This is based on the assumption
05:34
that an overactive dopamine system contributes to schizophrenia, but, like many psychotropic
05:39
drugs, antipsychotics come with nasty side effects.
05:42
Anxiolytics, or anti-anxiety meds, usually work by depressing activity in the central
05:46
nervous system, much like a stiff drink might. For this reason, and others, it can be super
05:51
dangerous to mix certain anxiety meds with booze. Also, letting your nerves mellow out
05:56
can feel so good that patients may risk becoming addicted to some anxiolytics.
06:00
Antidepressants are used to treat depression, as you might expect, but also a number of
06:04
anxiety disorders. Each type is thought to work a bit differently, mainly by altering
06:09
the availability of various neurotransmitters, like serotonin and norepinephrine in the brain,
06:13
which in turn appears to help with mood and anxiety problems. Some of the most common
06:17
are selective serotonin re-uptake inhibitors, or SSRIs, like Zoloft, Paxil, and Prozac,
06:24
which partially block the normal re-uptake of serotonin. This makes it more available
06:28
to the synapses, which, hypothetically at least, allows its mood-enhancing effects to
06:32
kick in. Current research suggests that the use of antidepressant medication is most effective
06:36
when combined with psychotherapy, which makes a lot of sense, and the same goes for a number
06:41
of other psychological disorders.
06:43
It’s worth pointing out here that some meta-analyses suggest that antidepressants aren’t any more
06:47
effective than psychotherapy when symptoms are mild to moderate. One meta analysis that
06:51
riled people up in recent years even suggested that antidepressants are no better than a
06:56
placebo in those cases. So psychotropic drugs can help, but sometimes you also need to start
07:01
exploring the root causes of your issues and reevaluate how you deal with them, which is
07:05
what psychotherapy is perfect for.
07:07
Bernice, for example, probably would have benefited from both talk therapy and a dose
07:11
of anxiolytic or antidepressant meds.
07:13
The last big psychotropic drug group is the mood-stabilizers. They can be extremely effective
07:17
in smoothing out the highs and lows of bipolar disorder. Simple salts of Lithium were the
07:22
first of these drugs used, and they remain in widespread use today. Dr. Kay Redfield
07:26
Jamison, who we talked about a few weeks ago has said that Lithium “prevents my disastrous
07:30
highs, diminishes my depressions, gentles me out, keeps me from ruining my career and
07:35
relationships, keeps me out of a hospital, and alive.”
07:38
And while drugs are the most popular biomedical treatment, they aren’t the only kind. For
07:42
one, there’s electro-shock therapy. Now, hear me out, this does carry a long history of
07:47
negative connotations, like of people being strapped down and shocked into mental oblivion,
07:52
but the technology has made a comeback, and can actually be quite effective in treating
07:56
severe, treatment-resistant depression. It’s properly called electroconvulsive therapy,
08:00
or ECT, and it involves sending a brief electrical current through the brain of an anesthetized
08:05
patient. This excites the neurons, causing them to fire rapidly, until the patient goes
08:10
through a small, controlled seizure that lasts about two minutes. And we’re not exactly sure
08:15
why this helps to relieve negative symptoms, but there are several theories that are being pursued.
08:19
One suggests that the resulting seizure beneficially alters neurotransmitter activity in areas
08:24
of the brain associated with moods and emotions, effectively jumpstarting a severely depressed
08:29
brain. Another theory suggests that these electrical impulses modify stress hormone
08:33
activity in the brain, which we know could play a role in sleep, energy, appetite, and
08:38
mood. ECT may also re-activate previously dormant or suppressed neurons, or possibly
08:43
stimulate the growth of new ones in key brain regions, helping the brain regain some level of lost functioning.
08:49
There are a couple of other brain-stimulation treatments, too, that are more gentle. One
08:53
is repetitive transcranial magnetic stimulation, rTMS, which involves the painless application
08:59
of repeated electromagnetic pulses. Another, deep-brain stimulation, DBS, is more invasive,
09:05
and calls for surgically implanting a kind of “brain pacemaker” that sends out electrical
09:09
impulses to specific parts of the brain. Despite all the new research and often positive results
09:14
around rTMS and DBS, we’re still sorting out how these treatments work to heal the brain
09:20
and mind, but they’re hypothesized to jump-start the neural circuitry in a depressed brain, similarly to ECT.
09:26
So you’ll notice that all these options come with certain risks, and really no treatment
09:30
is entirely risk free, perhaps not even psychotherapy. But we should also note that some of the less
09:35
severe manifestations of psychological disorders may be improved with pretty simple lifestyle
09:40
changes. Thirty to sixty minutes of daily aerobic exercise has been shown to be as effective
09:44
as antidepressant medications in research on mild depression. Just remember those words;
09:49
“daily” and “aerobic.” Adequate sleep, social interaction, and good nutrition also all play
09:54
a part in managing moods. In other words, general healthy living helps. There’s an Old
09:58
English proverb that says “different sores have different salves” and the same is true
10:03
here. What works for one person may not work for another, and sometimes a few different
10:06
kinds of intervention might be needed all at once.
10:09
Today you learned how client and clinician perceptions, outcome research, and meta-analytic
10:13
reviews work together to determine the efficacy and effectiveness of psychological treatments.
10:18
You also learned how biomedical therapies work, including the four major families of
10:22
drug therapies, along with electro-convulsive therapy, repetitive transcranial magnetic
10:27
stimulation, and deep brain stimulation. And also how lifestyle changes and general healthy
10:32
living can improve mental health.
10:34
Thanks for watching, especially to all our Subbable subscribers who make Crash Course
10:38
available to not just themselves but also to all of all people. To find out how you
10:43
can become a supporter just go to subbable.com.
10:46
This episode was written by Kathleen Yale, edited by Blake de Pastino, and our consultant
10:50
is Dr. Ranjit Bhagwat. Our director and editor is Nicholas Jenkins, the script supervisor
10:54
and sound designer is Michael Aranda, and the graphics team is Thought Cafe.
—
This post was previously published on YouTube.
—
Photo credit: Screenshot from video.