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Abnormal Psychology Unit 10: Treatment Approaches, Law and Ethics

This unit ties the course together by comparing treatments, showing how researchers judge whether they work and explaining the ethical and legal rules that govern mental health care. These topics appear on almost every final exam.

Covers: Major forms of psychotherapy and third-wave approaches, Biological treatments: medication and brain stimulation, Evaluating treatment: evidence-based practice and effect sizes, Common factors and the therapeutic alliance, Professional ethics: consent, confidentiality and duty to protect, Civil commitment and patients' rights, The insanity defense and competence to stand trial, Prevention and culturally responsive care

Study guide

Psychotherapies differ in what they target. Psychodynamic therapy uses free association, interpretation of resistance and transference, and insight into unconscious patterns; modern short-term versions focus on relationship themes. Cognitive-behavioral therapy (CBT) changes maladaptive thoughts and behaviors through techniques such as cognitive restructuring, exposure and skills training, and it has the broadest research base. Humanistic therapy, especially Rogers' client-centered approach, provides empathy, genuineness and unconditional positive regard. Family and couples therapy treat relationship systems, and group therapy adds peer support and feedback. Third-wave behavioral therapies add acceptance and mindfulness: acceptance and commitment therapy (ACT) teaches people to accept thoughts without fighting them and act on their values, mindfulness-based cognitive therapy reduces depressive relapse, and DBT balances acceptance with change.

Biological treatments include several medication classes: antidepressants (SSRIs, SNRIs, tricyclics, MAO inhibitors), anxiolytics (benzodiazepines and buspirone), mood stabilizers (lithium and certain anticonvulsants), antipsychotics (first and second generation) and stimulants. Brain stimulation treatments include electroconvulsive therapy for severe depression, transcranial magnetic stimulation, which uses magnetic pulses over the scalp, and deep brain stimulation, which uses implanted electrodes and is used for some treatment-resistant cases. Psychosurgery has a troubled history: Egas Moniz won a 1949 Nobel Prize for the prefrontal lobotomy, which was widely overused and caused severe harm before antipsychotics replaced it. Modern neurosurgical procedures are rare, highly targeted and reserved for severe, treatment-resistant conditions. Medication and psychotherapy are often combined.

How do we know whether therapy works? In 1952 Hans Eysenck claimed that therapy was no better than no treatment, which spurred outcome research. In 1977 Mary Lee Smith and Gene Glass used meta-analysis, a method that combines results across studies using effect sizes, and found an average effect size of about 0.68, meaning the average treated client was better off than about 75% of untreated clients. Effect size d expresses a difference in standard deviation units, and the normal curve converts d into a percentile. Another useful statistic is the number needed to treat, 1 ÷ (treatment response rate − control response rate). Evidence-based practice integrates the best research with clinical expertise and patient characteristics, culture and preferences. Efficacy refers to results in controlled trials, while effectiveness refers to results in real-world settings.

Many therapies produce similar overall effects, a finding called the dodo bird verdict. One explanation is common factors shared by all good therapies: the therapeutic alliance (the collaborative bond between client and therapist), empathy, hope and a credible rationale for change. The alliance consistently predicts outcome. Still, specific treatments matter for specific disorders, such as exposure for anxiety disorders and ERP for OCD. Ethical rules protect clients. The American Psychological Association's Ethics Code requires competence, informed consent, avoidance of exploitative multiple relationships and protection of confidentiality, which has limits such as suspected child abuse and imminent danger. After Tarasoff v. Regents of the University of California (1976), many states require or allow therapists to take reasonable steps to protect an identifiable person whom a client seriously threatens, summarized as 'the protective privilege ends where the public peril begins.'

Civil commitment allows involuntary hospitalization when a person with a mental disorder is a danger to self or others or, in many states, is gravely disabled. Addington v. Texas (1979) requires clear and convincing evidence, and O'Connor v. Donaldson (1975) held that a state cannot confine a nondangerous person who can live safely in freedom. Patients have rights to treatment, to refuse some treatments and to the least restrictive setting. In criminal law, the insanity defense concerns mental state at the time of the crime. The M'Naghten rule (1843) asks whether the person knew the nature of the act or that it was wrong, and the American Law Institute test added an inability to conform behavior to the law. After John Hinckley's 1982 acquittal, the federal Insanity Defense Reform Act of 1984 returned to a M'Naghten-like standard. Competence to stand trial, set in Dusky v. United States (1960), concerns present ability to understand proceedings and assist counsel.

Key ideas

• CBT, psychodynamic, humanistic, family and third-wave therapies target different mechanisms, and CBT has the broadest research support.
• Meta-analyses show psychotherapy is effective, with average effects near d = 0.68 in Smith and Glass's classic review.
• Common factors such as the therapeutic alliance predict outcome, but some disorders need specific treatments.
• Evidence-based practice combines research, clinical expertise and client characteristics and preferences.
• Confidentiality has limits, including the duty to protect identifiable victims after Tarasoff.
• Civil commitment requires mental illness plus danger or grave disability, proven by clear and convincing evidence.
• Insanity concerns mental state at the time of the crime; competence concerns current ability to take part in trial.

Formulas and rules

Common mistakes

• Confusing competence to stand trial (present ability) with insanity (state of mind at the time of the crime).
• Thinking confidentiality is absolute; it has legal and ethical limits.
• Overestimating the insanity defense; it is raised in roughly 1% of felony cases and rarely succeeds.
• Treating efficacy in controlled trials as proof of effectiveness in everyday clinics.
• Assuming the dodo bird verdict means technique never matters; specific treatments matter for some disorders.

Before the test, make sure you can

• Compare psychodynamic, cognitive-behavioral, humanistic, family and third-wave therapies by goals and techniques.
• Describe medication classes and brain stimulation treatments and their uses.
• Interpret effect sizes and calculate the number needed to treat.
• Explain common factors, the therapeutic alliance and the dodo bird verdict.
• Apply ethical rules on informed consent, confidentiality, multiple relationships and the duty to protect.
• State the criteria and key court cases for civil commitment and patients' rights.
• Distinguish the M'Naghten and ALI insanity tests and contrast insanity with competence to stand trial.

Words to know

Cognitive restructuring

A CBT technique for identifying, challenging and replacing distorted thoughts.

Transference

In psychodynamic therapy, a client's redirection of feelings about important people onto the therapist.

Acceptance and commitment therapy

A third-wave therapy that teaches acceptance of thoughts and feelings and commitment to value-based action.

Mindfulness-based cognitive therapy

A program combining mindfulness meditation and cognitive therapy that reduces relapse in recurrent depression.

Transcranial magnetic stimulation

A noninvasive treatment that uses magnetic pulses over the scalp to stimulate brain regions, used for depression.

Deep brain stimulation

A treatment in which implanted electrodes deliver electrical stimulation to specific brain areas.

Meta-analysis

A statistical method that combines effect sizes across many studies to estimate an overall effect.

Effect size

A standardized measure of the size of a difference between groups, such as Cohen's d.

Number needed to treat

The number of people who must receive a treatment for one additional person to benefit compared with control.

Therapeutic alliance

The collaborative bond between client and therapist, including agreement on goals and tasks.

Dodo bird verdict

The finding that many bona fide psychotherapies produce broadly similar overall outcomes.

Informed consent

A client's voluntary agreement to treatment after learning its nature, risks, benefits and alternatives.

Duty to protect

The obligation, following Tarasoff, to take reasonable steps to protect an identifiable person a client seriously threatens.

Civil commitment

Involuntary hospitalization of a person with a mental disorder who is dangerous or gravely disabled.

Least restrictive environment

The principle that patients should be treated in the least confining setting that meets their needs.

M'Naghten rule

An insanity test asking whether a defendant knew the nature of the act or that it was wrong.

Competence to stand trial

A defendant's present ability to understand legal proceedings and assist in their own defense.

Tertiary prevention

Efforts to reduce disability and relapse in people who already have a disorder.

Sample practice questions

30 more questions like these, from level 1 to 5, are in the practice set.