Chapter 16: Therapy and Treatment

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Imagine for a second that you are dealing with some really severe anxiety or maybe a heavy bout of depression and you finally decide to seek help, but the cure that is offered to you involves drilling a literal hole into your skull to let the bad demons out.

Oh man.

Yeah, thankfully we have moved way past that.

We really have.

Welcome to this deep dive, by the way.

Today we are tracking the incredible, sometimes dark and ultimately hopeful evolution of how we treat the human mind.

Absolutely.

We're basically your personal tutors today guiding you through chapter 16 of your psychology text therapy and treatment.

We're going to cover everything exactly as it lays out in the book from ancient exorcisms all the way to modern virtual reality therapy.

It really is a staggering evolution.

When we look at the historical timeline, the clinical context of mental health care is deeply intertwined with our basic understanding of human nature.

Today we are unpacking the major therapeutic orientations, how those treatments are actually in a room, the specific biological challenges of addiction,

and the very real cultural barriers that still keep people from getting help.

Okay, so let's unpack this past to present timeline first because for most of human history, mental illness was entirely misunderstood.

Completely.

And as a result, it was treated with extreme cruelty.

I mentioned try finding earlier that skull drilling technique, but even moving into medieval times, the prevailing theory was that abnormal behavior equaled demonic possession.

Right.

So the logical treatment in their minds, at least, was exorcism.

Exactly.

And by the 18th century, society kind of shifted toward institutionalization.

But we use the term asylum very loosely here.

Very loosely.

Yeah.

If you look at historical artifacts like Francisco Goya's famous painting, The Madhouse, you do not see a hospital.

You see a dark dungeon where people are kept in chains, just essentially thrown away by society.

The underlying logic back then was purely about isolation.

It was not about rehabilitation at all.

But a crucial shift did begin in the late 1700s.

Right, with Filipino.

Yes.

A French physician who started arguing that these were medical conditions, they required humane treatment.

In 1795, he literally unchained patients at a Paris asylum.

Wow.

And we saw a similar crusade in the 19th century United States with Dorothea Dix.

She investigated the system and found a completely unregulated, underfunded nightmare where the mentally ill were routinely abused.

She was relentless, too.

She was.

She lobbied Congress to create the first true mental asylums in the U .S., which was a massive step forward in recognizing mental health as a public responsibility.

But even with those reforms, the dark realities of those institutions persisted for a shockingly long time.

It really did.

Records from places like the Willard Psychiatric Center in New York are just chilling.

Patients were subjected to treatments like long, freezing, cold baths, or they were placed in rooms where the water turned to ice overnight.

It's awful.

And they used electroshock therapy without any anesthesia.

The convulsions were so violent that patients frequently suffered broken backs.

And the most mind -blowing part to me is that facility didn't close its doors until 1995.

1995.

It's really hard to believe.

Yeah.

But the real turning point away from those massive institutions actually started in the 1950s, and it was driven by biology.

So what happened in the 50s?

We saw the introduction of antipsychotic medications.

For the first time, we had a chemical way to actually control the severe symptoms of thought disorders like psychosis or schizophrenia.

Oh, I see.

Because patients were no longer actively hallucinating or severely agitated, long -term confinement just seemed unnecessary.

This paved the way for the 1963 Mental Retardation Facilities and Community Mental Health Centers Construction Act, which was signed by John F.

Kennedy.

That's a mouthful.

It is.

But that legislation triggered what we call deinstitutionalization.

That is the process of closing those massive state asylums and moving patients back into local community -based care.

Okay, wait.

I have to jump in here.

Because deinstitutionalization was meant to be this massive human rights victory, the goal was to integrate people back into society.

That was the vision, yes.

But without proper funding for those local community centers, did we just shift the population from asylums to prisons and the streets?

That is exactly the tragic paradox of the 1963 act.

The staff of these new local centers simply weren't trained to handle severe chronic illnesses like schizophrenia.

So they were overwhelmed.

Completely.

Yeah.

And without a robust support system for housing or job training, many of these individuals ended up homeless.

Today,

statistics show that roughly 26 % of homeless adults living in shelters experience severe mental illness.

26%.

That is heartbreaking.

And the correctional system has essentially become the new asylum.

It is burdened with hundreds of thousands of mentally ill inmates who aren't getting proper psychiatric care.

And for those who do manage to get hospital care today, the stays are incredibly short, like often just a few days.

That comes down to pure economics.

It costs between $800 and $1 ,000 a night to keep someone in a psychiatric ward.

It is incredibly expensive.

So insurance companies dictate that hospitalization is usually reserved strictly for people who are an imminent threat to themselves or others.

But let's look at the broader picture of who is actually getting help today.

Sure.

According to the text, if you look at figure 16 .2, data shows that roughly 13 .4 % of U .S.

adults receive some form of mental health treatment annually.

And the numbers get even more nuanced when we look at adolescents, specifically ages 8 to 15.

That is mapped out in figure 16 .3.

Okay.

What does that show?

About half of kids with diagnosed mental disorders receive treatment, but the likelihood varies wildly by the condition.

Oh, so?

Well, children externalizing their struggles, like those with ADHD or conduct disorders, they are the most frequently treated, mainly because their behavior disrupts the classroom or the home.

Ah, right.

The adults notice it more.

Exactly.

Meanwhile, children internalizing their pain, like those with anxiety disorders,

they are the least likely to receive care in that age group.

Which brings up a quick but vital distinction for you as you study this chapter.

Treatment can be voluntary, meaning you actively choose to seek help or involuntary.

Involuntary treatment might look like a court -mandated anger management class or maybe therapy as a condition of parole.

But regardless of how someone ends up in therapy, since we no longer just lock people away, we need to understand the actual mechanics of modern treatment.

What are the tools?

Broadly speaking, we divide modern treatments into two camps.

There's psychotherapy, which is psychological treatment, often called talk therapy.

And then there's biomedical therapy, which involves medication or medical procedures.

Let's start with the foundation of psychotherapy, which is psychoanalysis, developed by Sigmund Freud.

This is the classic pop culture image of therapy, the patient lying on the couch staring at the ceiling.

Freud's core theory was that our current psychological problems stem from repressed childhood trauma and unconscious impulses.

And because these issues are buried deep in the unconscious, he had to invent ways to dig them out.

He used free association for that.

Yeah, where you just say whatever comes to mind without filtering it at all, hoping a buried truth slips out.

He also relied heavily on dream analysis.

And then there's this concept of transference, which always fascinated me.

Transference is a huge part of it.

The text gives a great clinical example of a client named Crystal.

Over years of psychoanalysis, she starts to project all the unresolved anger and longing she has for her absent father directly onto her therapist.

Let's look at why that happens.

In psychoanalysis, transference isn't an accident.

It is practically the goal.

Oh, really?

Yes.

By becoming a blank slate, the therapist allows the client to recreate their most problematic relationships right there in the room.

The therapist doesn't take Crystal's anger personally.

They use it.

Like a tool.

Exactly.

It becomes a safe laboratory for Crystal to finally process those emotions.

Now, if we apply psychoanalytic concepts to children, it obviously has to adapt.

A seven -year -old is not going to lie on a couch and free associate about their subconscious.

Right.

So that morphs into play therapy.

The book has this great image, figure 16 .10, showing a room with a sandbox and shelves full of tiny figurines, animals, and people.

The sand tray.

Yeah, the sand tray.

Since children lack the vocabulary to articulate complex emotional trauma, they play it out.

A therapist might use a non -directive approach, just sitting back and observing how the child interacts with the toys to understand their internal world.

Or they might be directive,

specifically asking the child to set up a scene in the sand tray to guide the processing of a specific event.

Okay, so while psychoanalysis digs into the past, behavior therapy completely flips the script.

It really does.

Behaviorists do not care about your unconscious mind or your childhood dreams.

They care about what you are doing right now.

They use established learning principles to extinguish undesirable behaviors and teach new ones.

A prime example from the chapter is using classical conditioning to treat something like bedwetting.

Let's walk through how that actually works in practice.

Yeah, please do.

Take an eight -year -old girl, let's call her Emmy, who struggles with bedwetting.

A behaviorist would use a liquid -sensitive pad hooked to an alarm.

Okay.

When Emmy sleeps and a single drop of moisture hits the pad, the alarm blares and wakes her up.

That sounds intense.

It is, but the biological mechanism here is association.

Over time, her brain associates the physical sensation of urinary relaxation with the jarring alarm.

Within a few weeks, the brain learns to wake her up before the relaxation happens.

That makes perfect sense.

It's just rewiring a physical response.

Exactly.

And there's another classical conditioning technique called counter conditioning, where a client learns a completely new response to a stimulus that is causing them trouble.

One form is aversive conditioning, which essentially pairs an unpleasant outcome with a bad habit.

For alcohol addiction, doctors sometimes prescribe a drug called anti -abuse.

If a person drinks alcohol while taking anti -abuse, it triggers violent nausea and heart palpitations.

The mechanism there is crucial.

Addiction relies on a dopamine reward loop.

Drinking feels good.

Aversive conditioning hijacks that loop.

By replacing the pleasure of alcohol with the immediate terrible consequence of nausea, the brain's association with the substance fundamentally changes.

And the opposite approach to aversive conditioning is exposure therapy, right?

Yes.

Instead of running from a fear, you are systematically exposed to it until the fear response burns out.

This goes all the way back to 1924 with Mary Cover Jones.

She is often considered the mother of behavior therapy.

She did groundbreaking work.

She had a patient, a little boy named Peter, who was terrified of rabbits.

To cure him, she didn't talk to him about his fear.

She put a rabbit in the room while Peter ate his favorite snack.

And day by day, she moved the rabbit an inch closer.

Yeah.

The physiological relaxation of eating a snack eventually overpowered and replaced the anxiety of the rabbit.

Decades later, Joseph Wolpe refined this into systematic desensitization.

That is where a therapist helps you achieve a deep state of calm and then slowly introduces anxiety -inducing stimuli, step by step.

The modern application of this is incredible.

We now use virtual reality exposure therapy.

It's amazing technology.

For combat veterans suffering from PTSD, there is a simulation called Virtual A Rock.

It creates a highly realistic immersive environment that mimics Middle Eastern cities and combat scenarios.

It allows soldiers to neurologically process their trauma while their brain knows they are in a physically safe environment.

It has shown remarkable success in reducing PTSD symptoms.

That is just so cool.

But behavior therapy isn't just about classical conditioning.

It also heavily utilizes operant conditioning, which is all about rewards and punishments.

Right, like Applied Behavior Analysis or ABA, which is widely used for children with autism.

If a child makes eye contact or uses a new word, they are immediately rewarded with a sticker or extra playtime.

That reinforces the desired behavior.

You also see this with token economies in psychiatric hospitals.

Patients earn physical tokens for healthy behaviors, like brushing their teeth or socializing, which they can later exchange for privileges like TV time.

It bridges the gap between the behavior and the ultimate reward.

It does.

But eventually, psychology realized we can't just look at behavior.

We have to look at the thoughts driving it.

Which brings us to cognitive therapy, developed by Aaron Beck.

Okay, Beck's approach is fascinating.

He realized that it's not the events in our lives that cause distress.

It's our interpretation of those events.

Think about figure 16 .13 in the text where someone fails a test.

If your internal monologue immediately says, I am worthless and stupid,

the biological and emotional result is depression.

But if your internal belief is, you know, I'm smart, I just used the wrong study method this time, you might feel disappointed, but you won't fall into depression.

The cognitive therapist's job is to identify and correct those cognitive distortions.

Here's where it gets really interesting to me, because this evolves perfectly into cognitive behavioral therapy or CBT.

Yes, CBT is huge today.

If psychoanalysis is like digging deep into the hardware's manufacturing history to find a flaw, CBT seems like just updating the software of your brain when there's a glitch in your daily processing.

That software analogy is spot on.

CBT relies heavily on Albert Ellis's ABC model, the action, the belief about that action and the consequence.

CBT actively targets cognitive distortions.

Those bugs in the software, like all or nothing thinking, overgeneralization, and jumping to conclusions.

We've all done this right.

Let's say you text a friend, Savannah invites Hilaire out for coffee, and Hilaire never responds.

We've all been there.

Yeah.

If Savannah jumps to the conclusion that Hilaire secretly hates her and is ignoring her on purpose, that's a cognitive distortion causing massive unnecessary anxiety.

So CBT steps in to say, hey, maybe she just lost her phone or is stuck in a meeting.

Right.

It helps replace those irrational thoughts while simultaneously practicing healthier behavioral responses.

Now taking a slightly different angle, we have humanistic therapy pioneered by Carl Rogers with his client -centered approach.

How does that differ?

Unlike psychoanalysis, which views the patient as broken and in need of fixing by the expert doctor, Rogers believed people have an innate capacity for self -healing.

Oh, I like that.

The therapist's role is simply to provide the right environment.

They use active listening and, most importantly, unconditional positive regard.

Just total acceptance.

Exactly.

By accepting the client completely without any judgment, it allows the client to stop defending themselves and actually look at their own life honestly.

Focus is strictly on the present and future, not the past.

So those are the primary talk therapies.

But we also have biomedical therapies, which physically alter the brain's chemistry.

This is covered well in Table 16 .2.

Yeah.

For schizophrenia, antipsychotics work by literally blocking dopamine receptors, which dials down hallucinations.

For depression, we have anti -depressants like SSRIs.

How do those actually work?

Normally,

after the neurotransmitter serotonin is released in the brain, it gets reabsorbed.

SSRIs block that reabsorption.

Oh, so it keeps the mood -boosting chemical active in the synapse longer?

Precisely.

We also use anti -anxiety medications, which act by depressing central nervous system activity, essentially slowing down the physical panic response.

And for bipolar disorder, mood stabilizers are prescribed to chemically level out the extreme highs of mania and the crushing lows of depression.

Interestingly, for ADHD, we use stimulants.

Which sounds completely backwards.

It sounds counterintuitive, I know.

But stimulants actually increase neurotransmitter activity in the areas of the brain responsible for impulse control and focus.

Wow.

And when medication and talk therapy fail, especially in cases of severe treatment -resistant depression, there are brain stimulation therapies.

Yes.

Electroconvulsive therapy or ECT.

It induces a mild, highly controlled seizure that can rapidly reboot brain chemistry.

And there's also transcranial magnetic stimulation, TMS.

That uses localized magnetic fields to stimulate specific nerve cells in the brain without inducing a seizure at all.

Okay, so now that we understand the specific tools, the what of therapy, we need to look at how these tools are actually deployed in a room.

Right, the modalities.

Regardless of the tool, every therapeutic relationship begins with an intake session.

This is the critical first meeting where the therapist assesses the client's immediate needs, establishes a baseline, and sets collaborative goals.

And crucially, this is when the rules of confidentiality are established.

Very important.

The client needs to know that the therapist cannot legally share what is discussed unless mandated by law, such as a severe threat to life.

From there, the format is chosen.

The most traditional is individual therapy, which is your standard one -on -one session.

But group therapy is an incredibly powerful modality as well.

Oh, for sure.

Let's say there's a teenager who has suffered from a specific type of abuse.

If they are placed in a group with five other kids who survived the exact same thing, the immediate benefit is a massive reduction in shame.

They realize they aren't alone.

Yeah, and they can see others who are further along in their healing process.

It's also highly economical, which is why schools frequently run psychoeducational groups for widespread issues like test anxiety or bullying.

But there are limitations to groups.

Like what?

Some people are terrified to speak in front of strangers, and the biggest risk is that another group member might breach confidentiality.

The therapist can't guarantee what other clients will do.

That makes sense.

Then we have couples therapy, which heavily relies on the CBT principles we discussed earlier.

There's a brilliant quote from the Couples Institute in the text.

It compares cumulus counseling to piloting a helicopter in a hurricane.

I love that quote so much.

The emotional turbulence is just intense.

The therapist's goal isn't to pick sides, but to improve how the couple communicates and resolves conflict.

It is also vital to note that success in couples therapy doesn't always mean staying together.

Right.

Sometimes the healthiest possible outcome is helping the couple separate amicably and safely.

And finally, we have family therapy.

This relies on what is called the systems approach.

So what does this all mean for family therapy?

It sounds like the patient isn't actually a single person sitting on the couch, but the invisible web connecting everyone.

The family dynamic itself is the patient.

That is a brilliant paradigm shift.

You cannot treat a child's behavioral issue without looking at the ecosystem they live in.

Right.

If we look at structural family therapy, the therapist examines the actual boundaries and hierarchy of the home.

Who makes the rules?

How are decisions made?

Are the parents acting like parents?

Or is a kid basically running the house?

Exactly.

Alternatively, strategic family therapy is much more targeted.

The therapist works with the family to solve one very specific problem in a short amount of time using detailed, actionable plans.

Now, while these modalities apply to a broad range of psychological issues, there is one specific class of disorder that requires a uniquely specialized long -term approach,

mainly because it physically alters the brain's architecture.

You're talking about substance -related and addictive disorders.

Yes, section 16 .4.

The medical community firmly views addiction as a chronic disease, not a moral failing or a lack of willpower.

That is such an important point.

While the initial choice to use a substance might be voluntary,

chronic use permanently alters the neural structure, specifically in the prefrontal cortex.

And that is the brain's decision -making and judgment center.

Yes.

When the very part of your brain responsible for saying no is chemically damaged, it explains why the relapse rates for addiction are so staggeringly high.

Usually between 40 and 60 percent.

The demographic data in figure 16 .1e is wild, too.

Drug use prevalence peaks sharply in the 18 to 25 age group.

Because addiction essentially rewires the brain's survival hierarchy, treatment has to be incredibly robust.

Research shows that for addiction treatment to achieve a positive outcome, it generally needs to last at least three months.

Wow.

Three months.

Minimum.

And it has to be holistic.

You can't just detox the body.

You have to treat the vocational stress, the legal troubles, and the family dysfunction that trigger the use in the first place.

That's why group therapy is so widespread in addiction treatment.

The affiliation and peer support are vital, but so is peer confrontation.

Peer confrontation is huge.

When someone in recovery tries to minimize their behavior, a group of peers who have been through the exact same denial can confront them much more effectively than a clinician can.

But the treatment puzzle gets vastly more complicated when an individual has comorbid disorders.

Meaning two or more overlapping diagnoses.

Right, this is the makepic category.

Mentally ill and chemically addicted.

Yes.

A person might be dealing with severe bipolar disorder and a heroin addiction.

Or clinical depression and a meth addiction.

The standard protocol is that you have to treat both simultaneously.

You can't tell someone to get sober before you'll treat their depression, because the depression is driving the substance use.

For instance, a doctor might prescribe Welbutrin, an antidepressant that uniquely helps treat the underlying depressive symptoms while simultaneously reducing the chemical cravings for methamphetamine.

The simultaneous approach is non -negotiable for lasting recovery.

You know, if addiction literally rewires the brain's decision -making center, does that mean we need to completely reframe how society views relapse?

I think we absolutely do.

It's not a failure of character, but an expected symptom of a chronic disease.

It's much like a diabetic experiencing a blood sugar spike.

It absolutely is.

Relapse is simply a clinical indicator that the treatment protocol needs to be reinstated or adjusted.

Not that the individual is a failure, but this brings up a larger issue.

Just as we have to look at the biological context of addiction,

we must look at the broader cultural context of any person seeking treatment.

A scientifically proven therapy is only effective if a patient actually feels comfortable seeking it and stays in the room.

This introduces the sociocultural model.

This is all about cultural competence.

A therapist cannot just apply a Eurocentric therapy model, which usually focuses heavily on individualism and personal independence, to absolutely everyone.

No, they can't.

The text gives a great example.

Imagine an 18 -year -old Hispanic male named Jose.

He's gay.

And he comes from a highly traditional, deeply religious family that views homosexuality as a sin.

A culturally competent therapist has to deeply understand that specific cultural friction.

They can't just tell Jose to be himself and ignore his family.

Right, because in his culture, family cohesion might be central to his identity.

Beyond the simple logistics of finding the time and money for therapy, stigma is a massive, often insurmountable barrier.

For example, research shows that eating disorders like bulimia are highly prevalent in Hispanic and African American women, yet they seek treatment at far lower rates than Caucasian women.

The reasons for that are really multifaceted.

It's a lack of bilingual care facilities,

a deep -seated community stigma around mental health, and strong cultural values regarding keeping family problems private.

When traditional clinical services feel alienating or unavailable, people naturally look for cultural alternatives.

Historically, the Black Church has served as a highly trusted alternative to the clinical mental health system, providing counseling, prevention, and treatment -type programs for its members in an environment they already know and trust.

Language barriers drastically compound the effects of stigma, too.

A compelling study focused on older Korean -Americans living in Florida.

Oh, the statistics from that study were staggering.

The findings were stark.

71 % of the respondents believed that depression was simply a sign of personal weakness.

71%.

And 14 % felt that admitting to mental illness would bring profound shame to their entire family.

To make matters worse, at the time of the study, there were zero Korean -speaking mental health professionals available in their area.

None.

This raises an incredibly important question for us to consider.

We can invent all the sophisticated, evidence -based CBT techniques and advanced biomedical therapies in the world.

Right.

But if a person feels too ashamed to walk through the clinic door, or if their therapist doesn't speak their language or understand their cultural worldview,

what good is all that science?

It remains completely theoretical.

The public perception of mental health still needs a massive overhaul.

Consider the tragedy of the Sandy Hook shooting, which the book touches on.

Yeah, Suzy DeYoung, co -founder of Sandy Hook Promise, pointed out how quickly society vilified the shooter's mother as a monster.

Instead, society should have recognized a family in profound psychiatric crisis.

Another mother who lost her child in that tragedy publicly stated that the shooter's mother was a victim herself, and that America desperately needs to start looking at mental illness with compassion, offering help before a crisis explodes.

When society stigmatizes mental illness, rather than offering that compassionate help, the results aren't just sad, they can be devastating.

Psychology has learned that it must treat the whole person within their whole world.

It truly has to be an integrated approach.

We have to address the biology of the brain,

the cognitive software of the mind, the immediate dynamics of the family, and the overarching cultural values of the community.

Which leaves you with a final thought to mull over.

As our world becomes more interconnected on a global scale, yet increasingly isolated on a digital personal level,

how might the next evolution of therapy shift?

That is a great question.

Perhaps the future isn't just about repairing individual minds in a vacuum, but about healing our broader social communities.

If the environment we all live in is sick,

how can the individual possibly stay well?

Something to really think about.

On behalf of the Last Minute Lecture team, thank you for studying with us today, and we'll see you for your next deep dive.

Oh, and remember, if you're having a rough day, at least nobody is trying to drill a hole in your skull.