I. Structure of the Mental Health System
   Many people major in psychology because they are interested mental illnesses and harbor the notion that they might like to be a mental health professional at some point.  However, they often do so without a clear idea of the structure of the mental health system and those that work in it.  But one thing everyone that has such aspirations needs to be perfectly aware of.  A bachelor's degree alone is utterly insufficient top work as a mental health practitioner.  Some degree of additional post-graduate work will be necessary.

 

A. Places of Treatment
   The landscape of where people go to be treated has changed in the last 30 years, particularly for the care and treatment of chronic mental health conditions.  Starting in the 1960's state-run psychiatric mental hospitals started to lose favor. Until then, due in part to the lack of drug treatments suitable for some conditions, patients unable to care for themselves (schizophrenics, the severely mentally disabled) were institutionalized in mental hospitals. But such care was sometimes deemed inhumane and was expensive as well.  In the 1980's massive budget cuts to social welfare programs led to the closing of many mental hospitals with patients released to outpatient care programs.  While some mental hospitals still exist, they usually only provide care for short periods of time (2-4 week), particularly for acute episodes where patients (often indigents) are so debilitated that they can't care for themselves. Today, most inpatient mental health-related hospital inpatient stays occur in general hospitals, within specialized psychiatric wards. As psychiatric patients age, some of them are placed in nursing homes for care. However, most nursing homes have few, if any, specialized treatment personnel so the quality of care and conditions for aged psychiatric patients varies greatly. Today, many patients are served by halfway houses which provide assisted living for an extended period of time. They often provide help acquiring living skills and help finding outside employment and living arrangements for their patients in an effort to guide as many patients as are able to become a part of mainstream society.  Community mental health centers often provide free or low-cost mental health services in an effort to prevent serious psychological problems from developing. Some provide a wide variety of services such as inpatient, outpatient, day hospital, night hospital, emergency, aftercare, rehabilitation, public education, consultation, and evaluation services. Lastly, clinicians' private practice offices are often preferred by those that can afford them.

 

B. Providers of Treatment
   There are a variety of mental health professionals that can treat patients though there is a hierarchy of treatment capacities and responsibilities. While a bachelor's degree is insufficient to treat or diagnose individuals, not all positions as a clinical mental health provider require doctoral level training.

   At the top of the clinical hierarchy is the psychiatrist, who is a medical doctor (an M.D.) with specialized psychiatric training during residency.  They are qualified to work in any treatment setting, but most prefer to work in hospital or private practice settings. They are the ONLY mental health professional that can prescribe drugs.  Because of their medical training, they typically prefer to treat disorders by medication.  However, they sometimes incorporate various non-medical forms of therapy which may take into account biological, psychological, and social/cultural perspectives. 

   Clinical psychologists are limited to various forms of psychotherapy and cannot prescribe drugs.  They have non-medical doctorate degrees; either PhD or the PsyD and may also work in any setting from hospitals, to private practice, but many may focus on research as well as have a private practice.  Many are employed in universities as faculty.  The main difference between the PhD and the PsyD degrees is the relative emphasis of research and clinical treatment in the course of study. The PhD has a much higher research requirement for the awarding of the degree. The PsyD degree emphasizes the clinical practice requirements and minimizes the research component.  Students who want to eventually teach or do research typically opt for PhD programs while those who are definitely interested only in clinical practice with no interest in teaching or research may be well-served by a PsyD program.

   A counseling psychologist is similar to a clinical psychologist, also possessing a non-medical doctoral degree (PhD or PsyD).  However, they typically do not see patients with a severe psychopathological disorder and they are less likely to take a biologically based approach and more likely to adopt more traditional talking therapies, especially the client-centered Humanistic/Phenomenological approach of Carl Rogers and Abraham Maslow.  They also often counsel clients on their experiences from normal developmental processes of growing up to aging and common life experiences.  Counseling psychologists typically do not work in hospital settings.

   Counselors have a master's degree in counseling and also go through a state certification. Under some circumstances they may be required to have a teaching certificate. They are often employed in schools and institutions, but also may work in halfway houses, community mental health centers and in private practice.  They may help people with school- or job-related problems as well as substance abuse, behavioral, mental health or family and relationship problems.

   Psychiatric social workers have a master's degree in social work with additional professional or academic training in psychology and/or psychotherapy. Many work for governmental agencies, or hospital in the management of outpatient cases (problems ranging from substance abuse to strokes to mood disorders and others) but some do go into private practice.  In some jobs they may visit clients or patients in their home settings to assess their conditions.

   The psychiatric nurse has a minimum bachelor's or master's degree in nursing with additional psychological/psychiatric training but may also seek doctoral level training. They usually work in hospitals or community care centers. They can conduct psychotherapy sessions with the appropriate training and may dispense medication (but not prescribe) under the supervision of an MD.

 

II. Assessment
   So, an obvious question would be how does a person with a mental disorder get treated? Who decides what treatment and in what environment?  Well, first, the person's behavior and mental condition must be assessed.

   Let's take a hypothetical case.  Suppose a man is walking on the sidewalk in front of a busy office building.  He is unkempt, seems agitated and is speaking gibberish. Occasionally he yells and runs into traffic and then back onto the sidewalk.  The police try to place him into custody but he is unresponsive to their requests for information just replying in confusing nonsensical meandering sentences before he faints. The police then take him to the hospital for an evaluation.

   In the hospital the first question is to determine whether the man's disoriented behavior has an organic basis or a psychiatric basis.  Basically, is it due to a medical or neurological condition (a hypoglycemic drop in blood sugar due to diabetes, an adverse reaction to medication, a stroke in the frontal lobes or language processing areas) or a psychological disorder (schizophrenia or a dissociative disorder)?  The first step is the initial interview where the patient is asked questions or if they are unresponsive, a search is done of their personal effects to find a medical alert bracelet or personal I.D documents to search for any medical records.  If a clear answer isn't forthcoming, then one next step would be the use of some non-invasive imaging technology to look at the brain for evidence of damage or malfunction. Usually, the first choice is to look for structural damage. For this the computerized axial tomography (CAT or CT) scan is often used.  The CAT scan is a 3-D X-ray machine with multiple X-ray sources and detectors in a circular arrangement around the patient.  The information is then processed by computer software to generate a three dimensional reconstruction of the body.  The strengths of the CAT scan are that it is relatively inexpensive compared to the other major imaging option, magnetic resonance imaging (MRI), and can detect most forms of brain damage due to blows, old clot-based strokes, tumors and hemorrhagic strokes. The weaknesses are that it does not have as fine a resolution as an MRI (The MRI can see smaller features) so it may miss some tumors, especially small ones, and it cannot detect a clot-based stoke in its early stages. The MRI does not expose the body to ionizing radiation but it does place the body in a very strong magnetic field that is repeatedly turned on and off. When the magnetic field is turned on, the field forces the water molecules in the tissues to align themselves with the lines of magnetic force. When the field is turned off the water molecules rebound and in doing so emit radiofrequency energy which is detected by a circular array of detectors surrounding the patient.  Similar to the CAT scan, computer software compiles a 3-D image of the body. Because of varying water content across tissues (blood, bone, myelinated axonal pathways, neuronal cell bodies), the image generated provides a very accurate high resolution image of the brain's structure. The strengths of the MRI are that it is better able to tell the difference between similar tissues (for example, tumor vs. brain tissue) and has typically better fine resolution that the CAT scan. Its weaknesses are its relatively higher cost and the noise and enclosed nature of the machine that may make it disturbing and difficult to endure for some patients. However, both CAT scans and MRIs are good choices for structural analysis of the brain.

   However, in some instances the structure of the brain may be reasonably intact and it may be necessary to try and assess the function of the brain.  One of the most commonly used is methods is positron emission tomography (PET) scans which allow for the examination of brain metabolic activity through the use of weakly radioactive markers which emit positrons during their decay.  The consequences of positron emission are then detected by a circular array of sensitive radiation detectors around the body.  The radioactive markers are often compounds such as glucose or water that have been tagged with a radioactive isotope. They accumulate wherever cerebral blood flow is greatest (presumably due to higher brain activity levels requiring more blood flow).  The information from the detectors is then computer analyzed to generate a 3-D image of brain activity. The strengths of the PET scan are that it is relatively inexpensive (compared to an MRI) and long-used imaging technology and it can detect metabolic activity throughout the entire brain. The weaknesses are that the metabolic activity data is relative (all the tissues are alive and requiring some blood flow) and that requires some time for subtle differences to arise.  It can take a session of several minutes to a half hour or more to be able to determine which areas may be more or less metabolically active. Also, the spatial resolution is not very good. Often the PET scan is combined with a CAT scan or MRI to get a clear idea of where the differences in metabolism are located. Another older, but still useful, technology is electroencephalography (EEG). In EEG, multiple electrodes are placed on the surface of the skull to detect the electrical activity of the underlying brainÕs cortex.  The strength of this technique is that it can detect the electrical activity of the brain in real-time down to the millisecond level and its low cost. The weakness are that it can only resolve activity within a few centimeters and it can only detect electrical activity on the surface of the brain, deeper structures are not detectable. There is one last imaging technology, functional magnetic resonance imaging (fMRI). It is basically and MRI with a much, much, much stronger magnetic field that is currently only used for research due to its cost.  A typical MRI uses a magnetic field of 0.3 to 1.5 Tesla (A Tesla is a unit of magnetic field strength). An fMRI uses a minimum of a 3 Tesla field with some experimental units using up to 9 Tesla fields.  The reason for such strong fields is that the fMRI is used to generate and detect differences in the radio frequency signatures of the hemoglobin in blood that is carrying oxygen vs. the hemoglobin that is carrying carbon dioxide.  Because of that this technique can examine the structural and functional state of the brain.

   If the patient is responsive there are a variety of psychological assessment techniques that be used. One of the first is the mini-mental state examination (MMSE), a series of 30 questions used to assess mental functioning. The questions are simple but tap basic functions like the transfer of memory from short term to long term, cognitive skills like simple arithmetic, basic orientation and semantic knowledge and memory.  It is not a comprehensive test but it is a quick and dirty assessment of the intactness of a person's cognitive state and capacities. Another test sometimes used to screen for dissociative disorders and the faking of symptoms is the amytal interview.  In this test, a dose of the barbiturate, sodium amytal, is administered and the person is then interviewed by a clinician. Sodium amytal is not a truth serum (there are no truth serums) but the rationale is that the drug will lower inhibitions and make deception more difficult. In the absence of drugs, the most common interview techniques are the structured and unstructured clinical interviews.  The structured interview is a scripted list of interview questions to assist in making diagnoses of disorders. The strength of the structured interview is that due to its standardization it can be administered repeatedly at different times and places by different clinicians and the results compared. Its weakness is that because of its standardization an experienced clinician is not free to explore responses that may provide additional insight into the condition of the patient. The responses by the patient are often limited to yes/no or definitely/somewhat/not at all. The unstructured interview is an interview conducted by an experienced clinician where he or she conducts the interview according to their own skill, experience and the response of the patient. The questions allow for more open-ended responses by the patient.  While the flexibility is its strength, because of the unique nature of the interview its weakness is that the results of different unstructured interviews by different administrators at different times can't be compared.  Other forms of assessment include pen-and-paper formal diagnostic tests which are questionnaires and assessments taken by the patient/client such as I.Q. tests (for example the Wechsler Adult Intelligence Scale; WAIS) and personality tests (for example, the Minnesota Multiphasic Personality Inventory, MMPI).  Lastly, there are projective tests such as the Rorschach Inkblot Test and the Thematic Apperception Test (TAT).  In projective tests, the client is asked to respond to a series of vague ambiguous visual images (blots or pictures).  The rationale behind these tests is that the subject will respond to these ambiguous images in a manner that will allow hidden or suppressed feelings, thoughts and attitudes to be reflected in the responses.

 

III. Techniques
   There are three basic categories of approaches to psychological therapy: Psychoanalytic, Cognitive and Behavioral.  The techniques in each category reflect the basic points of view inherent within the basis of each category. For instance, psychoanalytic therapy techniques operate from the basic assumption that the source of a psychological problem or disorder is going to reside in the unconscious mind, inaccessible to the conscious mind. Two chief psychoanalytic techniques are free association and dream analysis. Both techniques are attempts to get around the individual's conscious mind's tendency to edit and censor one's own thoughts, a phenomenon called resistance. In free association, the client is encouraged to talk freely and openly about any and everything, no matter how trivial or even uncomfortable or embarrassing. Over time, in the "safe" therapeutic environment it is expected that the memories involved in the unconscious conflicts will come to the surface. In dream analysis, the client and therapist go over the content of the client's dreams. Dreams are considered important because during dreaming psychoanalytic theory holds that the conscious mind's resistance is lessened.  The content of the dream is divided into two types, the manifest content (which is the literal obvious conscious content) and the latent content (the hidden or unconscious content).  Through the application of free association to the manifest content the hope is to uncover the latent content of the dream and through that the nature of the psychological conflict or problem.

   Cognitive therapies are based on the point of view that our thoughts, ideas, attitudes, and mindsets which are often formed in childhood cause us to feel and act the way we do.  The goal is to replace or modify dysfunctional thoughts with more beneficial ones. Cognitive therapists hold that a person's core beliefs contribute to 'automatic thoughts' that reflexively emerge in our daily lives. The thrust of all cognitive therapies is to identify the problematic psychological condition, then to identify the negative or irrational beliefs or thoughts which generate or maintain the problem and challenge them and eventually replace them.

   Behaviorally-based therapies rely on the processes of classical and operant conditioning and observational learning. Of the classical conditioning based approaches the two most often used and successful are based on counter-conditioning.  In counter conditioning, a given conditioned stimulus (CS) is trained to a new and different unconditioned stimulus (UCS).  In aversion therapy, the CS has been originally trained to predict a UCS that is inappropriately attractive. An example would be someone that has come to have a problem with drinking alcohol. The cues (sight, smell, taste) associated with the drinking experience predict the following feelings of lowered anxiety, lowered behavioral inhibitions and euphoria.  An aversion therapy approach might include the administration of the drug Antabuse (chemical name, disulfiram) which causes rapid intense flushing of the skin, accelerated heart rate, shortness of breath, nausea, and vomiting when even small amounts of alcohol is ingested; essentially, an instant massive hangover results without the enjoyable feelings of alcohol consumption. So, the stimuli (CSs; sight, smell, taste) which used to predict pleasant feelings now predict extremely unpleasant ones. In the other major counter-conditioning therapy, systematic desensitization, CSs which predicted an unpleasant UCS are now trained to a pleasant outcome. As a practical matter it is used to treat phobias and anxiety disorders. In systematic desensitization, the individual is gradually exposed to the object or situation which elicits fear until it can be tolerated.  The presentation usually follows a pattern similar to the following: First, the patient may be taught relaxation and mediation techniques in response to the mere thought of an encounter with the feared stimulus. Then, when that has been mastered, thee patient then may progress to using the same relaxation and meditation techniques to photographs of the feared stimulus, then to the stimulus itself at a great distance.  Over time, systematically, the feared stimulus is brought closer and closer while the individual learns to relax. Eventually, the patient is able to be brought into close contact with the stimulus and not be afraid. The next two classical conditioning based therapies are based on extinction and are also used to treat phobias or anxiety disorders. However they are less thorough and effective than systematic desensitization but they do not take as long to undergo. The first of these therapies is called flooding. In flooding the patient is exposed to the object of their fear directly and they are made to confront it. In doing so, by experiencing an encounter with the object or situation that they fear greatly but coming to no actual harm, they may extinguish their learned (acquired) fear response. By contrast, in implosion therapy the patient is never brought in direct contact with the object or situation they fear but they are asked to imagine or visualize coming in contact with it again and again until the fear is reduced.

   A token economy is the chief operant learning-based behavioral therapy technique. In a token economy the goal is to increase desirable behavior and/or decrease undesirable behavior in return for some sort of credits (tokens) which can be redeemed for a meaningful object or privilege.  For instance, your parents may calculate credits of varying value for each time you do something the like (such as clean your room) or don't do something that they donÕt like (such as not fighting with your brother or sister). As you accumulate points/credits you can redeem them to do something that you like which costs you points which you may not normally get to do (like staying up late on a school night or sleeping until noon on a Saturday).

   The observational learning-based therapies include modeling and behavioral rehearsal/role-playing. In modeling, one person (the model) demonstrates a behavior for the patient/client (the observer) who watches what the model does. The models can be actually present, or symbolic if they are observed indirectly (in movies or television). Observing the model provides the observer with information on what the model does, as well as on consequences of the model's actions. It is expected that the observer will acquire the model's behaviors, and/or accept of the model's behaviors as guidance for their own actions. In behavioral rehearsal (also known as role-playing), the client/patient participates in acting out a scenario or script in order to practice skills and behaviors that they want to master and exhibit. The goal is to get the patient/client to practice desired behaviors in a safe structured situation with corrective and positive feedback before performing the behaviors in a real target situation with a greater risk of failure.

 

IV. Effectiveness
   Is psychotherapy effective? The answer is yes, but it is difficult to quantify the degree of effectiveness. For wide ranging psychological problems both subjective client reports and objective observations indicate that counseling and psychotherapy are effective.  This includes both the short term and longer time periods. For some problems with biological components, such as endogenous depression, evidence also suggests that psychotherapy can enhance the effects of medication. What is unclear is the relative effectiveness of different styles of therapy.  There seems to be no clear one-size-fits-all champion. This may be partly because most therapists are eclectic in their therapeutic approach, using a variety of styles and techniques as they deem useful and appropriate based on their experience and their assessment of the client.  Even when therapists do preferentially specialize in one approach all therapists have some qualities in common: They try to create an atmosphere of warmth and trust, they provide reassurance and support, the act of simply dealing with the problem openly with another person provides some amount of desensitization for the client, therapists will reinforce any adaptive responses they see, and they try to promote understanding and insight in the client. Taken together these factors probably explain why there is no single clear cut universally applied from of psychotherapy

 

V. Biological Therapies
   There are three categories of disorders that are commonly treated with psychoactive drugs. Anxiety disorders, schizophrenia and depression.  The most common anti-anxiety drugs (anxiolytics) are the family of compounds called benzodiazepines (BZDs). These include compounds with brand names such as Librium, Valium, and Xanax.  BZDs are fast-acting and cross the blood-brain barrier readily to relieve the symptoms of anxiety within 20-30 minutes of administration. They enhance the activity of the inhibitory transmitter GABA by binding to some, but not all, GABAA receptors.  The limbic system (important in emotion and motivation) has high numbers of BZD sensitive GABA receptors, especially the amygdala which is involved in memory and emotion.  BZDs have a potential for abuse and dependence. They can enhance the action of other chemicals like alcohol which also enhance GABA activity.  This is potentially dangerous and can lead to an unintentional overdose. But another source of problems is that long-term use of BZDs will down-regulate baseline GABA activity.  If a patient then tries to suddenly stop using the BZDs, they often experience a sudden rebound anxiety worse than the anxiety that initially led them to seek treatment.  For this reason their administration must be gradually tapered off.

   Antipsychotic medications typically block excessive dopamine transmission directly at the receptor; they are direct antagonists.  The first antipsychotic drug was a member of a chemical family called phenothiazines, chlorpromazine (brand name, Thorazine) that was being tried on chronic schizophrenics in the 1950Õs as a sedative. The compound is a good blocker of dopamine D2 receptors which are plentiful in the basal ganglia which is involved in voluntary movements.  However, after being medicated for some time, the schizophrenic patients reported the loss of their positive symptoms (hallucinations and delusions).  This lead to the adoption of chlorpromazine and other phenothiazines as antipsychotic medications with some success. However, one curiosity is that the drugs chemically begin to do their direct antagonist job at the receptor level almost immediately but a minimum to 10 days to 2 weeks are required for symptomatic relief and maximal relief may not be reached for weeks to months. One possible unpleasant side effect is tardive dyskinesia, a disorder with spontaneous uncontrollable writhing movements.  This is presumed to occur because the motor systemÕs D2 receptors become overly sensitive to dopamine due to their constant blockade. Newer antipsychotic medications called novel antipsychotic avoid this side-effect. They seem do this by blocking D4 receptors (a part of the D2–like receptor family) which are found in the cortex but not in the motor system. However, they also block serotonin 5HT3 receptors. Since many hallucinogens are serotonin agonists, it is unclear how much, if any influence blocking 5HT3 receptors may have on the reduction of hallucinations and delusions.

   Antidepressant medications share the same curiosity as antipsychotics in that they are biochemically active almost immediately but may take 10 days to 2 weeks for symptomatic relief and may not be maximally effective for weeks to months. The first antidepressants were monoamine oxidase inhibitors (MAOIs), monoamine oxidase being the enzyme responsible for breaking down dopamine, norepinephrine and serotonin in the terminal buttons of their terminal buttons after reuptake. These drugs were used on depressed patients in the 1950Õs after the observation that some depressed people had low levels of monoamine metabolites in cerebrospinal fluid samples taken from them.  Not long after MAOIs (still in the 1950's), the next generation antidepressants, tricyclic antidepressants (TCAs) were developed.  TCAs had less toxicity than MAOIs and acted primarily by preventing the reuptake of norepinephrine, thereby increasing levels in the synapse. While research continued on new antidepressants, it wasn't until the 1980's that selective serotonin reuptake inhibitors (SSRIs) were developed. These include drugs with brand names like Prozac, Paxil and Zoloft.  These drugs have low toxicity but have been reported to facilitate aggression and suicide in some rare cases.  Still despite the range of drugs that can be used to treat depression some cases are resistant. As a last resort electroconvulsive therapy (ECT) is used in those cases. ECT has been commonly referred to as "shock therapy" since it involves passing an electric current through the brain to induce a seizure. It is controversial but often effective in many drug-resistant cases of depression, at least in the short-term.  The mechanism by which it works is not clear. Unlike what you may have seen in the movies, ECT is administered while the patient is anesthetized and unconscious a shock lasting a few seconds. Shocks are administered until a seizure lasts at least 15 seconds. Treatments are usually given 2-3 times per week for a total of 6-12 treatments. Side effects can include memory loss and confusion.