1
Q
what were the original psychotherapy locations
A
Starts from a long tradition of people looking to help others. Retreat centers, tribal ceremonies, religious healing.
2
Q
where did modern medicine start
A
Modern medicine started with the hellenists claiming that the brain is the seed of knowledge - that is where mental illness lies
3
Q
Hippocrates
A
father of modern medicine we need to address illness by natural
4
Q
Leibniz
A
starts modern study of psychotherapy, started the ball rolling with looking into the unconscious. Drivers outside of our conscious awareness that greatly impact us. Leibniz: proto ai, gave foundations of the major focus in the history of psychotherapy. He is very interested in perception.
He is particularly interested in the subliminal: without our conscious awareness we can take in information that can impact us.
Dynamic: he coins the term to talk about these unconscious forces. Leads into psychodynamic theory which leads into psychoanalytics today.
5
Q
Mesmer
A
Patient therapist rapport,
Therapist characteristics: range, and finding the match between p and c.
Patient confidence in treatment: placebo effect - our brain responds based on expectations rather than reality. The belief the patient has in the treatment will influence their response in the treatment and vice versa. Need patient buy in
Spontaneous remission (aka regression to the mean): we often see in psychopathology, symptoms, distress levels, wax and wane over time, variability in display. Some just get better. Ie depressive episodes wax and wane to create mdi.
When we see someone getting better in therapy it is not necessarily because of therapy.
6
Q
19th century psychology
A
Natural science empiricists,
psychologist philosophers,
modern clinician researchers
7
Q
Natural science empiricists
A
lab based scientific study - Basic science
Empiricism: knowledge can be based on experiences. We can observe and manipulate natural phenomena and observe the outcome of those manipulations and turn that into empirical data.
Fechner: psychophysics: invented the othomniscope. Interested in perception. How does light hit the back of the eye.
Hemholtz
Kraeplin: founder of experimental psychopharmacology. Classified mental disorders founded the dsm. Looked at perception and caffeine and alcohol. Pushed the importance of translation: the idea of basic science work must translate outside of the lab. Establishes a framework that it is not about a single symptom but a constellation of symptoms. That we can have multiple symptoms in one disorder. Looks at clusters of symptoms to establish a course of a disorder and a prognosis.
8
Q
Psychologist philosophers
A
closer to philosophy than psychology but thought about psychology and influenced the formation of psychology
Schopenhauer: the world as will and representation - we know things we don’t even know. Subliminal perception impacts us and we don’t even know we know them. We are driven by blind irrational forces.
Carus: there are levels in the unconscious -the unconscious of two people can speak to each other. Simultaneous communication between two consciouses and unconsciouses.
Lays the foundation for transference and countertransference
Nietzsche: We lie to ourselves more than we lie to others. We tell ourselves things that may not accurately represent the world around us.
9
Q
Clinical researchers:
A
emergence of analytic psychotherapy. Clinical observations can lead to scientific discovery.
10
Q
Three modern perspectives as to what it means to be a psychologist who conducts therapy today
A
Practitioner scholar, scientist practitioner, clinical scientist. Spanning the spectrum from treatment to research.
11
Q
practitioner scholar
A
on the treatment side of things, these folks are primarily trained for clinical practice. Psyd. trained in stand alone schools. Trained in clinical practice, trained to use the science generated by others.
12
Q
Scientist practitioner
A
boulder model) we wear two hats. You are trained to live in both worlds of science and practice. You are trained in both and ideally you are bringing your science into the practice and you are taking your observation from the clinical and bringing it into your research
13
Q
clinical scientist
A
scientists who are clinically oriented
14
Q
impacts of biological al sciences
A
questions of nature and nurture. epigenetics, neural placsticity
15
Q
Epigenetics
A
environmental influences impact the development and use of genes. Some disorders happen when needed genes are not being used properly. Some genes turn on and off due to circadian rhythm. When sleep misaligned with rhythm impacts the on and off a gene.
16
Q
Impact of psychiatric diagnoses
A
Homosexualuty was a disorder
Disorders impact how we feel about ourselves.
Bias samples or questions can create an oppressive system
17
Q
Stages of intervention development (nih)
A
- basic science
- creation and preliminary testing
- pure efficacy
- real world efficacy
- effectiveness
- implementation and dissemination
18
Q
step 1 in stages of intervention development nit: basic science
A
basic science to start
19
Q
step two in Stages of intervention development (nih)
creation and preliminary testing
A
includes preliminary and pilot with the goal of establishing feasibility and accessibility (generally takes 2 years)
Creating the intervention material
Get stakeholder input
This process sharpens the intervention material and proves that the research side works
20
Q
step three in stages of intervention and development pure efficacy
A
Scales trial to prove statistical significance of effects/ power
Answers: does it work under perfectly controlled research conditions
Looks for internal validity: high confidence that we have controlled everything so well that what controlled the difference is our experimental manipulation
21
Q
stage four in Stages of intervention development (nih) Real world efficacy
A
Non researchers but interventionists highly trained and works closely with research team
22
Q
step five Stages of intervention development (nih) effectiveness
A
Effectiveness regards external validity as opposed to internal validity.
Answers: does what we measure in the lab an approximation of what we think it is measuring?
Asks what is normal practice, can we do the training quickly, attempts to train practitioners rapidly and in mass to see if intervention works in the real world with real world circumstances and people, does it come to life?
Also changes who we let into the trial: often very homogeneous - more open to letting people in regarding who is at the clinic
Often single site, sometimes multi site
23
Q
Implementation and dissemination
A
How do we scale? Can it be automated? Ect. how can we get this into the hands of people so the people needing it get access
24
Q
Prospective treatment assignment
A
researchers assigned the treatment and what is measured comes next - research had control at the start of the research
25
observational study
no control or manipulation of variables
either descriptive study of analytical study
26
descriptive study
a type of observational study (no control or manipulation of variables) but also no comparison group
27
analytical study
a type of observational study so no control or manipulation of variables but thetre is a comparison group. split into cohort studies, case control studies, and cross sectional studies
28
cohort studies
a type of observational study, an analytical study so there is a comparison group. identifies two groups. one received a treatment and one did not receive a treatment. follows the groups forward in time to determine if they experience different outcomes.
strengths: treatment comes before outcome - temporal precedence - although must be cautious due to recall bias. provides estimates of incidence of outcomes over time
limitations: cost, rare outcomes are hard to observe, studies may need to be very long to observe outcomes
29
case-control studies
a type of observational study, an analytical study so there is a comparison group,
identifies two groups one with an identified outcome, one without an identified outcome. assesses wether there were differences in treatment exposure retrospectively, chart reviews, self report, interviews, ect.
strengths: useful for rare outcomes, can save time and money
limitations: Difficult to select an appropriate comparison group, recall bias, cannot tell you how prevalent the outcome of the treatment is, only odds of experiencing both
30
cross sectional studies
Observational study, analytical so there is a comparison group,
one time point where we assess both outcome and treatment exposure. ie has a doctor ever told you to quit smoking, will track how often a doctor asks, are you obese and do you eat McDonalds - ask at the same time.
can provide estimates of frequency or prevalence of outcome or treatment, but cannot tell you which came first - only odds of experiencing both
30
rate (she will ask on this)
frequency of an event in the population over a period of time. number of people who got x with y/ number of people with just y
31
ratio
important when discussing risk, number of people in one condition relative to the number in another. number of people who did x/ number of people who did no x
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absolute risk
probability of an outcome
33
relative risk
probability of an outcome in one group relative to another group. does not tell you the actual size of the risk. does not tell you the actual size of the risk for each group, just the amount of risk relative to one another
34
odds ratio
likelihood of membership in one group given membership in another. also relative. given membership in the treatment group vs non treatment group.
35
methedological considerations for rcts
inclusion criteria: can bias
diagnosis - will we require that people meet a certain diagnosis.
clinical staging: not the same thing as the stages of intervention development. here, what stage are you at in terms of the progression of your mental health condition. stage 0 - no symptoms yet, stage 1, some symptoms present but are not specific they can show up across many disorders. stage 2 emergence of enough symptoms where someone meets diagnostic criteria, stage 3 multiple relapses, stage 4 persistent unremitting symptoms
prior treatment
iatrogenic comorbidity: differences sin the symptom or disorder based on treatment they have received. get more on this.
recruitment: how are participant identified, is the sample representative
inclusion criteria: diagnosis, clinical staging, prior treatment and iatrogenic comorbidity
control groups (know the different levels)
36
control groups
Increasing rigor as progresses below
no treatment vs waitlist: most often no treatment is given. potentially put people on a waitlist and offer them treatment after a trial
minimal attention: doing something but not much
treatment as usual: let doctors treat them as they usually would. this can be a wide range of treatments
attention placebo control: develop a treatment that is matched in time and attention received, what is asked of them ad their attention, bit with no evidence that the treatment will work
other active treatment: another treatment that we want to compare it to
additional controls needed when pharmacotherapy is added: there are states that allow phd level psychologists to prescribe psychiatric medications. this expanse trial significantly for it is another variable. thus, often psychological treatment trials only focus on the treatment especially in early trials, then sometimes ad if we think is relevant later on in trials but can make research challenging
37
designs:
parallel treatment, adaptive treatment, dismantling
38
parallel treatment
participants are randomized to an active or control group and followed simultaneously
39
adaptive treatment design
assignment is done in stages. escalating level of care as time goes on. not everyone needs an intensive intervention. can we start out with a basic video, ask if that works better than usual care? and then if not we continue to gather more information. continue to randomize groups with the non healing group escalating intensity of intervention
40
dismantling
goal is to determine the active ingredient. can get super complicated with many arms
41
assessments/ assessing effects of our trials
treatment allocation should be concealed from those administering assessment
pre and post treatment, we must consider length of treatment and follow up
we must be sensitive to change: understanding stages of change and maybe they are not binary, not heal or no heal, but healing over time and choosing measures that are sensitive to the change in a person over the course of treatment
incremental validity: multiple ways of measuring the same general concept. how do I choose which to include and if I am going to include multiple it must be because they are adding something else
patient reported vs observer rated are important to consider
assess for adverse effects, not just desired effects
42
outcomes
define successful outcome a priori
what level of improvement will mean treatment was successful? remission, reductions of symptoms, longevity of change?
43
translating research into practice
clinicians face challenges staying up to date, they often lag behind research. scientific litteracy necessary to utilize research in practice
44
efficacy vs effectiveness gap
the last piece of the stage model - how is this effective and how do we disseminate this matters. brings research to life.
efficacy is a product of very well controlled trials,
Effectiveness is when that can generalize to a diverse unbiased real life population
45
Empirically-supported treatments
treatments that have been determined to be well established or efficacious about rigor of study. extreme rigor for design. must have the most rigorous control group, must have a large sample, more than one research group has to have done their own clinical trial. typically they are annualized which means they are following a strict method of moving through treatment. prioritizes internal validity.
46
evidence based practice
combination of the clinical expertise of the therapist, the patients values and preferences, and the best available research evidence. therapy is messy and human and although we have rigorous scientific research there is a challenge in what that science means for the real world. we must balance these challenges and be really aware of the challenges we face alongside the importance of what it means to have scientific knowledge
47
Breuer
anna o is a famous case study on hysteria - occurred when people had unexplained physical ailments that look sudden and dramatic, could be paralysis of a limb or inability to speak - physical manifestation with no physical cause. Trauma that people were jot consciously aware of made these manifest in their bodies.
Breuer coins talking cure, aims for an experimental approach,
48
Hysteria
becomes a functional neurological disorder. we now know that there seems to be some issues with the connectivity of the parts of the brain that are involved in emotion processing, fight or flight, and motor control.
there is a link between stress and heightened emotions and the symptoms they experience. this is not faking, that why it is called functional
treatment is talk therapy
49
frued and hysteria
enters the scene and deepens that the hysteria comes from trauma specifically. Breuer was more open open to stress happening in the moment but fried claimed it was unconscious trauma, that people are attempting to avoid feeling painful emotions by repressing the trauma, it has so come out somehow so it must be physical.
he argues for catharsis/ argues for scientific rigor and that we should be in search of the truth and not suggestion. frued wants to pursue the truth in the patients mind, to do so he moves from hypnosis to free association - the therapists job is to interpret what the patient brings forth
50
according to frued, on what levels does the psychoanalyst interpret
manifest content: surface level content
latent content: deeper level, the why behind
he argues that every experience you have shapes you and the way you see the world and that comes out in latent content
51
drive theory
early frued: the libido produces states of tension
libido is will
in frueds terms it as psychic energy, which motivates us to do what we do.
the libido produces a state of tension because often what we are motivated to do is in conflict with what is okay to do.
we are constantly in search of ways to release the libidinal tension for we experience it as pleasurable.
introduces the pleasure principle which drives us to repeat the experiences that release tension. this becomes the backbone of psychoanalytic theory.
52
freuds stages of psychosexual development
this fits into drive theory for drives have some sexual nature to them, freud sees the ability to release that tension with sexual gratification
oral phase, anal phase, phallic phase, latency period, genital phase
53
oral phase
in childhood, the gratification comes from feeding
54
anal phase
comes from learning to control and pass feces. cautions us around toilet training and avoiding shame. anal retentive.
55
phallic phase
gratification is shifting the genital. freud talks about the oedipus complex and the idea that there are innate sexual drives that people have like exhibitionism and voyeurism in kids and frued points to that as an example of libidinal drives showing up in a person who has not yet internalized what is and is not expected yet
56
latency period
where learning shows and kids are taught what is and is not acceptable
57
genital phase
puberty through adulthood where gratification shifts to sexual activity in adulthood
58
ego psychology
later, after going through drive theory and its connection to the stages of psychosexual development he lands at ego psychology.
claims there is a very real structure to our personality and minds. it is heriarchical.
majority of personality structure is unconscious
id, ego, and superego
59
id
drive and desires, present from birth, often instinctual, often toward repressed sexual expression.
instincts toward aggression.
frued thinks its sexual, aggressive, and immature
these are the wishes, desires, and fantasies that would happen if there were no consequences ever
60
ego
emerges gradually as we develop through childhood. represents reality, the ability to delay gratification. tries to find a way for the desires of the id to emerge in ways that are suitable.
partly unconscious
61
superego
oversees the voice from the ego that understands right and wrong.
develops when we internalize the norms of society.
often becomes overly harsh and demanding. dichotomizes right and wrong good and bad.
this is protective but can lead to shame
a weak ego also leads to an overly harsh superego. for many a harsh absolute moral voice that is telling them they are bad
62
the two ways of thinking about personality
primary process: beings at birth, operates unconsciously, often raw and primitive battle of id and ego
secondary though processes: happen in consciousness in logical and sequential orderly
63
frued on the primary process
it is unconscious so we need to find a way in to understand what it is trying to communicate. we dint they are expressed in metaphor or analyzing dreams, themes reappearing in free association, themes in everyday lie.
64
jung
intitally studied under freud and broke in 1912 to create his own school, analytical or jungian psychology. he coined the term complexes - repressed ideas that have been repressed because they are emotionally threatening. thought we could study these experimentally through delayed reaction time.
65
key differences between freud and Jung
Jung believed in the collective unconscious - that there is a shared unconscious knowledge base that all people are born with. part of being a person is having these shared unconscious traits and experiences. we are all born with the same unconscious and and our individual life experiences shape our own conscious. argues that people have shared experiences repeatedly like dreams of falling.
jung believes that the unconscious is not always bad but can be creative and growth oriented
he argues we can understand unconsciousness through complexes
puts less emphasis on sexual motivation
66
psychoanalytic pluralism
British system, freud, klien and middle group
United States: contemporary psychoanlalysis and ego psychology. argues therapist is a blank slate to pick up what the client is pulling out and find the themes
67
common principles of psychoanalytic perspectives
humans are motivated by wishes and fantasies that are unconscious. imagination playing out.
humans are ambivalent about changing. part of people want to change because of aversive conditions, but also comfort within the status quo.
therapy should help people understand how they are perpetuating patterns, and the role that their construction plays in said patterns
68
conflict theory:
someone experiences distress when they have a conflict between their unconscious wishes and their defenses. anything out mind uses to prevent us from experiencing negative emotions
childhood neurosis is common and expressed through anxiety
in adulthood, neurosis occurs due to conflict between unconscious wishes and defenses - intrapsychic conflict
69
object relations theory
we form internal working models. internal representations that guide perception and actions.
this leads into attachment theory
70
attachment theory
humans build internal working models of caregivers that allow them to maintain proximity. we learn from our caregivers a model of how people will treat us. this internal working model of how people will treat us. this internal representation of our caregiver guides our perception and actions. we hold belief systems that we filter our perceptions through.
71
several ways healthy attachment styles can go awry
developmental arrest: something did not go right in this process. healthy development from this perspective would occur when an infant learns optimal disillusionment - this is a balance between feeling protected and safe and that may needs will be met, but also recognize that I may to be the priority all of the time. the ability to recognize that other people will let us down.
optimal disillusionment comes from good enough parenting. children learn to except the limitations of others and develop a healthy sense of them and other and still develop a cohesive sense of self
child can develop a sense of omnipotence if they don't realize they are not always the priority
false self: when an infant is neglected, tendency for the child to overajust to the needs of others. infant learns "I don't matter"
72
defense mechanisms
a concept introduced by frued and developed by Anna freud. they exist to avoid experiencing negative emotions.
defense styles:
impact our physical and mental health,
have implications for treatment
used as a way to avoid experiencing emotional pain.
work in the short term but in the long term cause us to engage in patterns that bring distress
there are normal and healthy levels of all the defense mechanisms, but repeating them into a pattern is where they turn sour
73
sublimation
rerouting an unacceptable thought through a productive outlet
this does not address the root cause
people have a tendency to obsess on their productive outlet
74
repression
forgetting the thing that is negative or unwanted. walling it off in the unconscious so you don't encounter it consciously
75
displacement
rerouting negative emotions. not sublimation because not expressing it in a completely acceptable way
76
regression
reverting to childlike behaviors. this is the ego throwing its hands up. pure id
77
denial
refusing to accept the truth of reality. repression is placing the knowledge out of consciousness - denial remains conscious but denies the truth of the information
78
splitting
we find a way to mentally separate food and bad and only look at one of the sides. this is often found in the context of other people.
79
projection
attributing your feelings of negativity or threats onto another person. why are you making me feel insecure, why are you judging me?
80
reaction formation
denying the threatening feeling by proclaiming the opposite.
81
intellectualization
a key component in psychoanalytic theory is avoiding emotion. intellectualization is the ability to talk about the emotion and the logic of it but not the feeling of it
82
rationalization
excuses by creating a reason for why something happened rather than taking responsibility for the occurrence. externalizing the reason for the bad feeling
83
theory of personality for psychodynamic therapy
Theory of personality: from birth we develop beliefs or schemas, internal representations of working models of what the world looks like. A lot of that is informed by early caregiving experience. Who we are and how we fit into the world. We try to avoid experiencing negative emotions. This often leads us to maladaptive patterns with ourselves or interpersonal relationships (starts with infant caregiver), we have our own conflicts between our id, or superego, and our ego - intrapsychic conflict. We engage in defense mechanisms to not feel negative emotions coming from us which can cause us more distress and interpersonal problems
We are constantly filtering the information around us through our schemas.
Early on in theory there was a strong belief that the therapist was an objective observer who let their personhood at the door. One-person psychology - the idea that there was only one person in the room, the patient
As theory evolved people realized that was an unattainable goal. Two-person psychology , recognizes that the therapist is bringing their person into the room and uses this as a tool. This is a super dramatic departure.
Both therapist and patient are interacting with each other consciously and unconsciously. Therapy becomes a negotiation of reality
84
enactment
the interactions that take place between a patient and therapist inside the therapy room will mirror the interactions a patient has with other people in their daily lives. it is the job of both the therapist and client to recognize their schemas and biases
85
transference
patient transfers feelings where the therapist steps in as an authority figure which shapes the patient's perception of the therapeutic relationship. this can be used as an insight
86
countertransference
initially had a narrow definition. just the therapists reaction to the patients transference itself - in one person psychology
in two person modern theory where both the client and the therapist are seen as active agents in therapy and countertransference is seen as the therapists reaction to the client based on the therapists on reality. every therapeutic reaction becomes a complex transference - countertransference matrix. it is the therapists job to make this clear in the relationship
87
common factors
components of psychotherapy that are not specific to one type of therapy. account for a larger percentage of success.
therapeutic alliance is one of the most important factors
a shared goal
level of trust
level of genuine human caring felt by patient
alliance is key in psychoanalytic theory
88
resistance
psychoanalytic theory believes patient come to therapy ambivalent about change. common form is lateness and no-showing. this is important. not a sign that there is something wrong but an expected part of therapy to work through and presents an authentic opportunity to identify maladaptive to deal with
89
methods of psychoanalytic therapy
empathy: the attempt to emotionally immerse yourself into someone else's experience
empathetic conjectures: I would imagine if I were in you shoes I would feel ... this is important for if the therapist resonates then they have identified an emotion to work with that may have been avoided, helps someone recognize what they are feeling to begin with. can also be helpful if the conjecture is not correct for it brings up the opportunity for clarification which can be healthy for the therapeutic relationship but also clarity what someone is feeling
90
clarification
working together with patient to better understand what the feeling is
91
interpretation
the therapists job is interpret the content (manifest and latent) of what is going on with the patient. it is the therapist job to make interpretations as to what is happening in the patients unconscious. all interpretations are made based on the theory, taking content and putting into fixed theory, very if then...
case formulation/ case conceptualization - in any type of psychotherapy a therapist takes the theory and all the information from the patient and with the two forms a hypothesis. interpretation arises from layering the theory and information from the patient. the significance of the skills of interpreting is in weighing how accurate the therapist feels that are and how useful they think the interpretations are
also considers how deep the interpretation goes. deep has multiple meanings depending on the school of though, here is means how far back in time does this go? schema, defense mechanism, ect.
92
opening phase of therapy
patient reveals information, therapist can help move it along but the patient does so at their own pace. gathering patterns and themes. starts to develop conceptualization of what is going on for this person.
93
development of transference
as the opening phase of therapy develops the patient develops transference. the therapist is looking out for schemas the patient is bringing into the room and uncovers potential transferences and the schema beneath it. attempts to help the patient understand how the past informs these patterns and tap into unconscious
94
working through
as transference and schemas of the past are uncovered the therapy takes a the time to work with these understandings and unfolds them.
this is psychoanalytic therapy - noticing themes of transference, offering interpretation and insights
95
termination
awkward in psychotherapy for there is no timeset. This can bring a conversation about when termination is appropriate. Maybe they put up resistance, the therapist must be aware of countertransference, are they saying they are resistant because they don’t want them to leave. Becomes super complex. Both need to explore motivations for leaving, therapists can’t try too hard to hold on. Therapists will try to help patients consolidate gains and come to the understanding of the role the patient came to in therapy. Will help recognize the good and the bad parts of therapy and ambiguity, therapist can’t be complicit of avoiding negative emotions.
96
mechanisms of change in psychoanalytic therapy
emotional insight - combining the logic of what is going on with the emotion and the experience
making the unconscious conscious
historical reconstruction: recognizing how the past makes the present and help the patient make a narrative out of it to make meaning and help patients understand their own agency. this balances taking responsibility for past actions while not being overly punitive or overexcusing past behavior
containment: the therapists ability to process and manage their own difficult feelings
rupture and repair: a model for optimal disillusionment - the therapist won't be perfect, the therapeutic alliance won't be 100%, there will be times when there will be rupture. this will happen when the therapist makes mistakes. rupture is considered inevitable, the key is what occurs in the repair. this is an opportunity to teach people that through the therapeutic relationship one can express needs which may not be met, this gives a healthy model for disagreement
97
appropriate candidates for psychoanalytic therapy
Motivated
Problems of living rather than specific disorders
Openly disclosing
Willing to self scrutinize
Not needed in immediate crisis intervention
Used in personality disorders. People are unstable in self or unstable in relationship with others
98
evidence base for psychoanalytic therapy
short term dynamic psychotherapy ( less than 40 sessions)
studies are often uncontrolled or lack rigorous active control groups, may be limited by small sample sizes
meta analysis of 23 rcts provides some evidence for improvement. found more improvement increased over the long term
long term studies are usually naturalistic. they find that more experienced therapists make a major impact
99
Cultural considerations:
Developed for educated middle class western europeans
Therapists must be aware of their own bias, society attitudes, moral judgements
Many theories here are moral judgments as superego
Ready to utilize a range of techniques specifically where there might be differences between t and p, think how can I empathic conjecture when I have different moral or societal background
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Psychotherapy
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