1
Q
What is efficacy in psychotherapy
A
extent to which psychotherapy works in controlled
research:
Maximizes internal validity
Features well-defined groups
Minimizes variability among
therapists
2
Q
What is Effectiveness: in psychotherapy
A
extent to which psychotherapy works in the real
world
* Includes a wider range of clients
* Allows for greater variability
* Lacks internal validity
* Has greater external validity
3
Q
Results of Efficacy Studies
A
- Benefits endure over long periods
- Psychotherapy not a panacea
- Transdiagnostic approach
- Emotional disorder
- Unified protocol- Barlow and associates
4
Q
Bridging the Gap Between Research and Practice
A
- Efficacy study results not always heeded by practitioners in the
real world - Understanding reluctance of practitioners
- Higher value placed on own intuition and judgments
- Research seen as irrelevant to day-to-day practice
- Dissemination of treatments affected by this gap
- Practice-oriented research
- Practice-research networks
5
Q
Results of Effectiveness Studies
A
- Not as frequent as efficacy studies
- Consumer Reports study of 1995
- Very positive, lasting effects of psychotherapy for majority of
respondents - Treatment by mental health professional usually worked
- Findings converge with meta-analyses of efficacy
- Study constrained by methodological questions
6
Q
Which Type of
Psychotherapy
Is Best?
A
The “Dodo Bird Verdict” and Common Factors
* Dodo bird verdict
* Empirical outcomes of therapies shows that
competing therapies work about equally well
* Common factors across all forms of
psychotherapy
7
Q
Therapeutic Relationship/Alliance .1
A
Strong relationship between therapist and client
contributes to psychotherapy outcome
* Relationship has multiple names
* Therapeutic relationship,
* Therapeutic alliance, or
* Working alliance
8
Q
Therapeutic Relationship/Alliance .2
A
- Most crucial single aspect of therapy
- Best predictor of therapy outcome
- Accounts for more variability
- Facilitates positive change
- Quality of therapeutic relationship vital to therapy
- Reciprocal relationship between client and therapist
- Demonstrably effective relationship components
9
Q
Other Common Factors of psychotherapy (which one is better)
A
- Hope or positive expectations
- Attention or Hawthorne effect
- Goal Consensus
- Empathy
- Positive regard and affirmation
- Therapist genuineness
- Three-stage sequential model of common factors
- Support factors
- Learning factors
- Action factors
10
Q
Eclectic therapy
A
Therapy involves selecting the best treatment
for a given client based on empirical data from studies
of the treatment of similar clients
11
Q
Integrative therapy
A
Therapy involves blending approaches in
order to create a new hybrid
12
Q
Psychodynamic Psychotherapy
A
- It came first historically
- Many other therapies were reactions against it
- Despite a recent decline, it still influences many clinical
psychologists
13
Q
Goal of Psychodynamic Psychotherapy
A
The primary goal of psychodynamic psychotherapy is to make the
unconscious conscious
* “Insight” into thoughts, feelings, and other mental activity previously
outside of awareness
* Awareness of unconscious processes to control them deliberately,
rather than being controlled by them
* The very presence of the unconscious was a fundamental idea of
Sigmund Freud
* Unconscious exerts powerful influence on day-to-day and minute-tominute lives; underlies all forms of psychopathology
14
Q
Freudian “slips”
A
Verbal or behavioral “mistakes” reveals unconscious wishes
15
Q
2 Freudian slips
A
dreams, resistance
16
Q
Dreams
A
Manifest content represents latent content, which contains
unconscious wishes
* “Royal Road” to unconscious
17
Q
Resistance
A
- Anxiety of unconscious thoughts/feelings being laid bare too
quickly - Creation of distractions/obstacles that impede exploration of
thoughts and feelings
18
Q
Ways of accessing the unconscious
A
by Defence Mechanisms
19
Q
Defence Mechanisms that protect the unconscious
A
Unconscious techniques created by ego, as an attempt
to handle conflict between id and superego
* Repression—keep impulse in unconscious
* Projection—attribute impulse to others
* Reaction formation—do opposite of impulse
* Displacement—redirect impulse
* Sublimation—redirect impulse in a way that benefits
others
20
Q
Defence Mechanisms that protect the unconscious-Transference
A
-Transference
* Clients’ tendency to form relationships with therapists in which they
unconsciously and unrealistically expect the therapist to behave like
important people from the clients’ pasts
* Clients bring transference issues to the client-therapist relationship,
just as they do to many of the other relationships in their lives
* Help clients become aware transference tendencies and the ways these unrealistic perceptions affect relationships and lives
* Interpretation, followed by working through phase
* “Blank screen” role of therapist facilitates transference
-Counter transference
21
Q
Psychodynamic
psychotherapy reinvented
in countless forms
A
Most revisions
deemphasize biological
and sexual elements of
theory
22
Q
Ego psychology (Erik Erikson)
A
Emphasizes social relationships over
psychosexual stages
23
Q
Object relations (Melanie Klein)
A
Emphasizes relationships between
internalized “objects”
24
Q
Self-psychology (Han Kohut)
A
Emphasizes parental
roles in the development of the self,
with special attention to
narcissism
25
Most recent forms of psycho dynamic therapy emphasize efficiency or brevity
Brief Psychodynamic Psychotherapies
* Fewer than 24 sessions
* Successful when
Problems are mild and narrowly defined
Therapist is active / quick alliance
Focus is on the present rather than solely on the past
26
Interpersonal Therapy (IPT)- psychodynamic
* Designed to treat depression in 14–18
sessions
* Improving interpersonal relationships will
alleviate depression
* Emphasis on role expectations
* Assumption that depression happens in the
context of interpersonal relationships
* Improving relationships facilitates
improvement in depressive symptoms
* Three stages of IPT
27
Interpersonal and Social Rhythm Therapy
(IPSRT)
* Variation of IPT for clients with bipolar disorder
* Control and stabilize daily rhythms, sleep cycles,
social interactions
28
Time-Limited Dynamic Psychotherapy
(TLDP)
* Focus on transference and a therapy relationship
that doesn’t follow the same unhealthy,
unconscious “script” as previous relationships
* Modern application of “corrective emotional
experience”
29
How Well Does Psychodynamic Psychotherapy
Work?
Very difficult to empirically measure the outcome of psychodynamic
psychotherapy
* Improvement can’t be objectively measured
* Also difficult to manualize, which inhibits empirical study
* Regardless, large-scale reviews support its benefits with some disorders,
but remains unproven with others
Allegiance effects may influence outcome studies, particularly for
psychodynamic therapy
* Few empirical outcome researchers are psychodynamic
* Researchers’ own orientations may bias the results of their studies
30
Humanistic
Psychotherapy
Carl Rogers was a leading figure
Humanism was a reaction against Freud’s approach
Assumed that human nature wasn’t so bad (e.g., iddriven)
Overlapping terms for humanism include
“nondirective,” “client-centered,” and “personcentered”
31
Humanistic
Concepts: Clinical
Implications
Self-actualization u People have an inborn
tendency toward self
- actualization
Occurs when an
inborn tendency
develops if
environment fosters it Positive regard u Warmth, love, and
acceptance of those
around us
Prizing
32
Basic Concepts of Humanistic therapy
Psychological problems byproducts of
blocked self-actualization.
To foster self-actualization
Work to remove conditions that interfere
with growth
33
Goal of Humanistic Therapy
In humanistic therapy, there are no
conditions of worth on the client
Clients’ real selves can match their
ideal selves
This match is known as congruence, and
is the root of psychological wellness
Mismatch between real and ideal selves
is known as incongruence, and is the
root of psychopathology
34
Elements of Humanistic
Psychotherapy
Empathy, Unconditional Positive Regard, Genuineness
35
Empathy
Involves a deep, nonjudgmental understanding of
client’s experiences
Ability to sense client’s emotions.
Empathy enables clients to clarify their own feelings.
36
Unconditional Positive Regard
Full acceptance of another person “no matter what”
Climate in which clients are free to be wholly
themselves.
Facilitates higher levels of congruence and selfactualization
UPR builds unconditional positive self-regard.
37
Genuineness
Also called therapist congruence
Helps therapists establish relationships that feel “real”
Humanists encourage a relatively high degree of
transparency by the therapist
Congruence between therapist’s real and ideal selves.
38
Therapist Attitudes, Not Behaviors-Humanistic therapy
Humanists view empathy, UPR and
genuiness as attitudes, not behaviors
They emphasize on how therapists
should be with clients
Therapy should not be mechanical or
formulaic
Attitudes, not specific techniques or
skills, should be emphasized
39
An Important Therapist Response in humanistic view....
Reflection:
Reflection—when a therapist responds to a client by
rephrasing or restating the client’s statements in a way
that highlights the client’s feelings or emotions
Reflection should also be an attitude rather than a
technical skill (with humility- not mechanical)
shows the therapist’s appreciation of the client’s emotional
experience
Therapists should not become overconfident in their ability to
read clients’ emotions and should always defer to the clients’
expertise on their own feelings
40
Alternatives to Humanism
Existential psychotherapy, Gestalt therapy, Motivational Interviewing,Positive Interventions and
Strength-Based Counseling, Emotionally
Focused Therapy,
41
Existential psychotherapy
Each person is essentially alone and realization of this fact
can overwhelm us with anxiety
Therapists place great emphasis on clients’ abilities to
overcome meaninglessness by creating their own meaning
through the decisions they make
Therapists encourage clients to make choices that are true
to themselves in the present and future
Works well for some clients, especially those who are
physically ill or concerned with the meaning of life
42
Gestalt therapy
Includes both mental and physical
perceptions, and Gestalt therapists
attend to both these aspects of client
communication
Deemphasize clients’ past experiences
and instead focus almost exclusively on
the present moment
43
Motivational Interviewing
A revised application of basic humanistic principles
Help clients see the discrepancy between their behavior
and values
Elicit motivation to change from client; don’t impose it
on client
Much empirical data supporting its efficacy with many
problems
Consistent with positive psychology movement
Expressing empathy
Developing the discrepancy
Avoiding argumentation
Rolling with resistance
Identifying “sustain talk” and “change talk”
Supporting self-efficacy
44
Positive Interventions and
Strength-Based Counseling
Emphasizes human strengths rather than pathology, and
cultivation of happiness in addition to reduction of
symptoms in psychotherapy
Often labeled positive interventions or strength-based
counseling
Emerged in 1990s
Martin Seligman
Bolster strengths to prevent and treat psychological
problems
45
Seven basic categories of positive psychology techniques
Savoring - Empathy
Gratitude - Optimism
Kindness - Strength-based activities
Meaning
46
Behavior therapy
Represents a reaction against the lack of empiricism
inherent in psychodynamic and humanistic approaches
* A reaction against mental processes that can’t be
precisely defined, directly observed, or scientifically
tested
47
Origins of Behavior Therapy
* The clinical application of behavioral principles
* Roots of behaviorism include
* Ivan Pavlov’s classical conditioning studies with dogs in
Russia
* John Watson’s efforts to bring classical conditioning to US
* B. F. Skinner’s and E. L. Thorndike’s law of effect & studies
of operant conditioning
48
The primary goal of behavior therapy is....
observable behavior change
49
Facts of Behavior Therapy
* No emphasis on internal, mental processes
* Emphasis on empiricism
* Study of human behavior should be
scientific
* Clinical methods should be scientifically
evaluated via testable hypotheses and
empirical data based on observable
variables
* For example, baseline measures of
problem behavior at treatment outset;
subsequent measures after some
therapy
50
Goal of behavior therapy
Defining problems behaviorally
* Client behaviors are not symptoms of some
underlying problem—those behaviors are
the problem
* Behavioral definitions make it easy to
identify target behaviors and measure
changes in therapy
* Clients’ own definitions can be very hard
to assess or measure
* Baselines
Measuring change observably
* Other kinds of therapists may measure
change in clients in more inferential ways,
but behavioral therapists use more
unambiguous indications of progress
* Introspection is not an acceptable way to
measure progress—not directly observable
* Emphasizes external, environmental
51
Two types of conditioning
* Classical conditioning
Generalization or discrimination to similar stimuli may
take place
* Operant conditioning
Contingencies, or internal “if…then…” statements, are
the product of operant conditioning
52
Techniques Based on Classical Conditioning
Exposure therapy, Anxiety hierarchy, Systematic desensitization, Assertiveness training, Contingency management
* Extinction
* Token economies
* Shaping
* Behavioral activation
* Observational learning (or modeling)
53
Cognitive therapy focuses on
important mental processes,
and tends to be brief.
Important historical events.
* Internal mental
processes can exert a
strong influence.
* Ellis and Beck
disillusioned with
psychoanalytic therapy
in which they were
trained
54
Goal of Cognitive Therapy
Increase in logical thinking
* The way we think about events determines the way we respond
emotionally
* Psychological problems arise from illogical cognitions
55
3-step model. Cognitive therapy
* Things happen.
* Interpretation.
* Interpretation influences feelings.
56
Revising Cognitions
Goal: ensure thoughts correspond to event itself – identify more
logical cognition
* Generally follows a 3-stage sequence:
* Identify illogical cognition
* Challenge illogical cognition
* Replace with more logical cognition
* Automatic thoughts
* Cultural sensitivity
57
Unhelpful thinking styles
1- all or nothing, over generalazing, mental filter, disqualifying the positive, jumping the conclusions, magnification, emotional reasoning, should/must, labelling, personalization "my fault"
58
Teaching as a Therapy Tool- cognitive
* Cognitive therapists function as teachers on the cognitive approach.
* Ultimate goal: clients are no longer dependent on the teacher.
Homework
* Client’s assignment to complete between sessions.
* Much of the work happens between sessions.
* 3 categories of factors influence homework completion:
* Client factors
* Therapists factors
* Therapeutic alliance
A Brief, Structured, Focused Approach
* Factors contributing to brevity of cognitive therapy: focus on current
problems, focus on clear symptoms, and structured therapy.
59
Two Approaches to Cognitive Therapy
Rational Emotive Behavior Therapy (REBT)
Aaron Beck cbt
60
Rational Emotive Behavior Therapy (REBT)- albert ellis
ABCDE model- Activating (event/adversity), Beliefs (about event/adversity), Consequences (emotional), Disputations to challenge self defeating belief, Effect (or consequence of challenging self deafiting belief.
61
Aaron Beck CT
Beck’s goal – increase logical thinking
* Cognitive triad – thoughts about the self, the world, and the future
contribute to mental health
* Common thought distortions.
* Beliefs are hypotheses.
62
Variations of Cognitive Therapy
Mindfulness- and Acceptance-Based Therapies
Dialectical behavior therapy
Metacognitive therapy
Schema Therapy
63
Externalising disorders
Child acts out, and becomes disruptive, ADHD, conduct disorder, ODD,
64
Internalising disorders
Maladaptive thoughts and feelings=depression, anxiety.
65
PSYCHOLOGICAL ISSUES OF
CHILDHOOD
Resilience and vulnerability
– Some children develop psychological problems while
others don’t, even from similar settings
– Factors may include
* Environmental factors (e.g., poverty, family)
* Parental factors (e.g., parent health, IQ)
* Child factors (e.g., temperament, health, IQ)
– Parents’ mental health and relationship with siblings also
contribute
– Adverse Childhood Experiences (ACES)
66
Grotbert’s (2003) resiliency categories
External supports – “I have”
Inner strengths – “I am”
Interpersonal and problem-solving skills – “I can”
67
Child’s “implicit theory” about their own
characteristics
Fixed vs. malleable
68
Developmental Perspective- ASSESSMENT OF
CHILDREN AND ADOLESCENTS
-Essential to understand the child’s
behavior within the context of the
child’s developmental stage
– Developmental expectations vary across
cultures
69
Assessment of a child must consider:
* Presenting problem
* Development
* Parents/family
* Environment
70
Pluralistic approach
* Multisource, multimethod, multisetting approach
71
ASSESSMENT METHODS OF CHILDREN AND
ADOLESCENTS
– Interviews
* Both child and adults in child’s life
* Rapport is essential—communicate respect and concern
– Behavioral Observations
* In the office (analogue) or where the problem occurs (naturalistic)
* Formal, systematic coding is preferred
* Consider reactivity, as observation can itself change behavior
– Behavior Rating Scales
* Standardized pencil-and-paper forms that parents, teachers, or other adults
complete regarding a child’s presenting problems
* Convenient and objective, but restricted responses
– Self-Report Scales
* Questionnaires completed by children about their own behaviors
* Requires appropriate reading, language, and attention abilities
- Projective/Expressive Techniques
* Some shared with adults—Rorschach, TAT, sentence
completion techniques
* Some specific to children—CAT, TEMAS, drawing
techniques
– Intellectual Tests
* Intelligence and achievement tests
* Often used in specific learning disorder evaluations, and for
other purposes as well
72
Play therapy
Allows communication through actions
with objects / play
– Three basic functions (Brems, 2008):
* Formation of important relationships
* Disclosure of feelings and thoughts
* Healing
73
Play Therapy—Psychodynamic
* Children symbolically communicate their mental processes through play
* Through interpretation, make child more aware of unconscious processes
74
Play Therapy—Humanistic
* Similar to psychodynamic in terms of activities, but emphasis is on reflection and unconditional positive regard rather than interpretation of unconscious
75
HOW WELL DOES PSYCHOTHERAPY WORK FOR
CHILDREN AND ADOLESCENTS WORK?
Most meta-analyses find various approaches to be equally effective
– Some find cognitive-behavioral approaches to be slightly more efficacious
– Some specific therapies (mostly cognitive-behavioral) have been found
efficacious with specific disorders (externalising disorders, anxiety disorders, depression)
76
Behavioral Medicine
* Integration of
knowledge from
social sciences with
knowledge from
medical disciplines
77
Health psychology
Deals with how
psychological
processes interact
with health and
illness
78
Health Psychologists
responsible for
* Development
* Assessment
* Application of
programs to promote
wellness
* Promote healthy
behaviours for preventing
illness
79
Stress and psychology
* Psychological/physiological
response to difficult or demanding
internal or external circumstances
* Stress can negatively impact the
body
* On experiencing stress, we respond
by
* Fight-or-flight
* Tend-and-befriend
* Chronic stress
* Consistently high stress levels due
to a hectic, fast-paced lifestyle
* Seyle’s GAS
* Due to chronic stress our bodies
eventually wear out and break
down
80
Stress and Physical Illness
* Chronic stress can lead to
* Increased levels of thyroid hormones, resulting in insomnia and
weight loss
* Depleted endorphins, resulting in bodily pain
* Reduced sex hormones, leading to amenorrhea or infertility
* The shutting down of the digestive system, resulting in nausea,
bloating, and dry mouth
* Excess of cholesterol release can contribute to blocked arteries,
blood pressure increases of up to 400%, stroke, or aneurism
* Weakens our immune system
* Evidence suggests stress plays a role in cancer and HIV
81
* Factors determining how well one copes with stress:
Genetics or biological vulnerability
* Disease-prone personality: a theorized genotypic inclination that
predisposes people to stress-related illnesses
* Appraisal: the way the person evaluates and perceives the stressors in
their life, which may or may not be realistic
* Primary appraisal—determining how stressful an event in your life is
* Secondary appraisal—determining how capable you are to cope with it
82
Problem-focused coping:
emphasizes changing the stressor itself that works well
when a stressor is more controllable
83
Emotion-focused coping:
emphasizes changing your emotional reaction to the
stressor that works well when a stressor is less controllable
84
* Hypotheses for why social support protects health
* Positive feelings associated with having social support allow
us to perceive our stressors in a more manageable light
* Those who have strong social networks are more likely to
confide in others, which bolsters health (James Pennebaker)
* Regular, loving touch can promote better health outcomes
and lower stress (Harry Harlow
85
Clinical psychologists fulfill many demands
of legal system like
* Evaluate criminal defendants’ sanity
* Assess legal competency to stand trial
* Assess families in child custody disputes
* Predict dangerousness
* Serve as expert witnesses
Clinical Psych
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