Transcript Psychotherapy & Intervention

Psychotherapy & Intervention
Review of the Homework
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Trull: Chapter 11 (Interventions)
Yalom: Three Unopened Letters
(chapter)
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Questions?
Comments?
How does this fit in?
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Interventions Overview
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Defining Intervention
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Psychological intervention (from text):
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A method of inducing changes in a person’s
behavior, thoughts, or feelings.
Alleviation of human suffering
Removal of psychopathology
Reduction in disordered behavior,
cognitions, feelings
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Interventions Overview
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Psychotherapy is one specific way to
alleviate suffering
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Many things can be therapeutic (playing
music, reading, etc.)
Not all things are psychotherapy
Therapy is a specified intervention
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New suggestion to differentiate therapy from
treatment (Barlow, 2004)
Consistent with medical profession
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Interventions Overview
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Psychotherapy as an intervention
should…
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be
be
be
be
specifiable
plausible
replicable
trainable
Example: EMDR (or power therapies)
for PTSD
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The Different Foci of
Interventions
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Solve a specific problem
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Improve the individual’s capacity to deal
with existing behaviors, feelings, or
thoughts
Prevention of problems
Increasing person’s ability to take
pleasure in life or achieve potential
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Interventions Overview
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Overall Effectiveness of Psychotherapy
as an Intervention
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Overall, evidence shows that
psychotherapy works
The average person receiving therapy is
functioning better than 80% of those not
receiving treatment
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Meta-analysis
Smith, Glass, & Miller (1980)
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Interventions Overview
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Consumer Reports Survey
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(Nov, 1995)
4,000 readers responded
Therapy resulted in some improvement for the
majority (relative)
MD, PhD, and MSW all about the same
Therapy alone was as good as therapy + meds
More treatment was related to more improvement
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Interventions Overview
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Consumer Reports Survey
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Serious Limitations/Criticisms:
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Probably unrepresentative sample
Retrospective—halo effect
Cognitive dissonance effect may be occurring
May only say that folks like getting therapy
Not external validity, not internal validity, more
customer satisfaction
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which matters!, just differently
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Interventions Overview
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Commonalities of treatments (According
to Lambert & Bergin, 1994)
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Therapist as some kind of expert
Release of emotions/catharsis
Therapeutic alliance/relationship
Anxiety reduction/release of tension
Interpretation/Insight
Building competency/mastery
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Interventions Overview
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Nonspecific factors
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Goal of clinical science is to specify
The therapeutic relationship
“Magical powers”
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Interventions Overview
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What therapy is not for
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Working on therapists issues
Seeking intimate relationships with others
Getting therapist needs met (attention,
affection)
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Interventions Overview
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Variables thought to be related to
psychotherapeutic outcome
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Client
YAVIS client
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Not research related
Some research on these variables, though
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Young
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Age:  age =  outcome
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Weak evidence
Why any evidence?
Is this also “Attractive” variable???
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Verbal
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Openness:  openness =  outcome
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Why?
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Intelligent
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Intelligence:
 intelligence =  outcome
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not w/behavior change
Why?
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Other variables of interest
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Degree of client distress: distress =
outcome
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Motivation
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Mixed results
Does not matter
Evidence is inferential
Gender
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Doesn’t matter overall
Need to be sensitive to power issues
May matter in certain situations
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Interventions Overview
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What about therapist variables?
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Empathy, warmth, and genuineness?
Age?
Personality?
Freedom from personal problems?
Experience and professional identification?
What about own values about ethnicities,
genders, orientations, etc.?
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Interventions Overview
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Therapist Variables
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Empathy, warmth, and genuineness
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Age
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Not related to outcome
Personality
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 these =  outcome
Too difficult to specify
Freedom from personal problems
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Too hard to specify
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Critical Thinking Moment
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Freedom from personal problems
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Should psychologists not have a history of
psychological problems?
Is this feasible?
What if they have a history of problems?
How could we specify this issue where it might
matter?
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Past or present?
Degree?
Type?
Level?
Does this affect thoughts on requiring therapy?
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Interventions Overview
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Therapist Variables
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Experience
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Professional identification
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Does matter
More experience, better outcomes
This is equivocal
Does not matter
What about own values about ethnicities,
genders, orientations, etc.?
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Typical Elements of Therapy
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Initial contact
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Lay down the basics
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Policy of not acknowledging client outside of
therapy first
Informing of 24-hour vs. not 24-hour care
Providing opportunity for informed consent
for services
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Typical Elements of Therapy
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Assessment
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Typically called “intake”
Assessment measures (gathering objective
data)
What are they coming in for?
What attempts have they made in the past
to deal with problems?
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Typical Elements of Therapy
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Assessment
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What are their strengths/weaknesses?
Harm to self or others?
Alcohol, drug, medication, medical
conditions, health, nutrition, etc
Social support available
History/family history
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Typical Elements of Therapy
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Implementation of treatment
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Working towards targeted goals
May be following manualized treatment,
may not
On-going assessment of progress
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Typical Elements of Therapy
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Termination
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Final assessment of progress
Summarize treatment gains
Process termination
Anticipate pitfalls
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Typical Elements of Therapy
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Termination
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Can get feedback about therapist skills
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Not looking to process therapist’s own issues
Schedule “Booster sessions”
May schedule follow-up session 3, 6, or 12
months later
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Theoretical Perspectives and
Assumptions of Psychopathology
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Different paradigms have different
assumptions about what creates human
suffering, and what alleviates it
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Each paradigm is complete
Each has pros and cons
Each will dramatically affect choices of
assessment and intervention
Some are more scientific
Some are more applicable to psychology
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Main paradigms
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Psychoanalytic/psychodynamic
Humanistic/Existential
Behavioral/Learning
Cognitive
Biological
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Main paradigms
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Note: these are culturally rooted and
take an individual (not pluralist or
cultural) approach to pathology
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Community psychology
Feminist psychology
Each will understand psychopathology
differently
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Review of the Homework
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Trull: Chapter 12 (Dynamic therapies)
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Questions?
Comments?
How does this fit in?
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Psychoanalytic/Psychodynamic/
Freudian theories
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Assumptions of psychopathology
Role of the unconscious
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Limited access to what occurs for us
psychologically
Unconscious conflict leads to tension 
anxiety
Conflicts are NOT expressed directly
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Psychoanalytic…
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These all take psychic energy
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Fixed amount of psychic energy = Hydraulic Model
If one uses too many defense mechanisms one
will run out of psychic energy --- or if you use too
much energy in one
Result in less well-functioning organism
In pathology, look for symptoms of distress,
cannot see the actual pathology directly
(disease model)
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Psychoanalytic
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Assumptions of curative factors in
psychoanalytic theory
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Curative process is the resolution of the
unconscious tension
Need to free up the psychic energy being spent on
defenses
Challenges
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We cannot directly access unconscious conflict
Uses hypothetical constructs for problems
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Review of the Homework
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Trull: Chapter 13 (Humanistic)
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Questions?
Comments?
How does this fit in?
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Humanistic/Existential Theories
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Assumptions of psychopathology
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Blocked in ability to grow, or
How we understand ourselves becomes
incongruent with what we actually see
Anxiety
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Feel anxious when contact with information that is
not consistent with how we view ourselves (our
self-concept)
Incongruence between the self-concept and
society
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Humanistic Theories
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Assumptions of curative factors
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Want to create a fully functioning person
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Need to remove conditions of worth
Need to allow client to find meaning and
do own growth
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Continue to pursue our greatness, our own full
potential
Client holds the key to psychological health
happiness
This is called non-directive therapy
Also called person-centered or clientcentered therapy
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Humanistic Theories
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Therapist provides
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Genuineness
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Unconditional positive regard
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Therapist is not “phony,” expresses feelings
openly and honestly
Therapist does not place conditions of worth on
client
Accepts and respects client no matter how
client behaves, no matter what client says
Empathy
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Therapist tries to see things from the client’s
perspective
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Review of the Homework
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Trull: Chapter 14 (Behavioral & CBT)
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Questions?
Comments?
How does this fit in?
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Behavioral or Learning Models
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Assumptions of psychopathology
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People learn their problems
Problems occur naturally through a learning
process
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Classical conditioning
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Operant conditioning
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e.g., Substance abuse, Personality disorders, depression
This learning is NOT direct instruction
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e.g., phobias
Typically natural and can even be passive
Problems are sustained largely through escape
and avoidance of aversive events
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Behavioral or Learning Models
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Thoughts require a slightly modified analysis
but are still understood as both important and
as behaviors
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The avoidance of thoughts can lead to more
problems in living
It is the avoidance that produces the problems, not
the thoughts
Interpersonal problems can be fundamental
in bringing about and sustaining ineffective
behaviors (psychopathology)
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Behavioral or Learning Models
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Assumptions of curative factors
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If problems are learned, new and more
effective behaviors can be learned as well
Real key is exposure and extinction
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Keep in mind both classical and operant
conditioning
Techniques
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Graduated exposure treatments
Flooding
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Graduated Exposure
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Person gradually taken into the feared
situation or exposed to the feared stimulus or
traumatic memory until the anxiety subsides
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Systematic desensitization
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Use counterconditioning
extinction to reduce fear
Work through an “anxiety hierarchy” of situations that
lead to fearful reactions
Imagine fearful situations while remaining relaxed
Also used in
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Cognitive processing therapies (CPT) for sexual assault
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Systematic Desensitization
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Systematic Desensitization
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Flooding
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Person is taken directly into the feared
situation until the anxiety subsides
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Escape response is prevented completely
Pros and cons to this
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When would you NOT use this?
Just as effective as systematic
desensitization for phobias
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Behavioral or Learning Models
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Challenge
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Hard to conceptualize problems contextually that
include rich factors
Challenge
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Difficult to identify all key variables in behavioral
analysis
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Behavioral or Learning Models
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Contemporary Behavior Therapies
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All have very active behavioral component
Acceptance Commitment Therapy
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Functional Analytic Psychotherapy
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Focus on intrapersonal acceptance
Having emotional unwanted experiences
Focus on interpersonal processes
Creating better relationships
Dialectical Behavior Therapy
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Focus on emotional regulation and suicidal behaviors
Used with Borderline Personality Disorder
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Cognitive Approaches
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Assumptions of psychopathology
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Thoughts are the cause of our problems
Way we think about the world dictates how
we feel about ourselves, others, and the
future
This is a cognitive triad
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Depressed people have a negative cognitive
triad
Combined with logical errors  get depressed
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Cognitive Approaches
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Assumptions of curative factors
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Need to identify dysfunctional core schema and
replace with more accurate and effective schema
Need to challenge the cognitive distortions or false
beliefs with evidence and look for more accurate
thoughts
Techniques
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Identify irrational beliefs, maladaptive interpretations of
events
Challenge beliefs directly
Encourage more rational beliefs and interpretations
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Cognitive Approaches
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Challenge
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Schema are metaphorical
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What is it that you are changing?
How do you measure this?
Challenge
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Evidence that thoughts do not lead
behavior, they follow behavior
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Biological Approaches
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Assumptions of psychopathology
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Psychological problems are caused by events at
the biological (cellular) level
Disruptions in neurotransmitters cause the
expression of emotional or psychological
disturbances
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Behavior at the level of physiology has direct expression
at the level of psychology
Look for symptoms of distress, cannot see
the actual disease entity for most
psychopathology (c.f. Alzheimer’s)
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Disease model of psychopathology
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Biological Approaches
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Assumptions of curative factors
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Repairing disrupted neurotransmitter levels
will produce a corresponding change in
behavior
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Repair should function similarly for all people
(given variations in body chemistry)
Drug therapies
Electroconvulsive Therapy (ECT)
Psychosurgery
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Biological Approaches
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Challenge
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Origins of psychopathology do not have
known physiology
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So what are we doing?
Challenge
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Not all drugs work for all people
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Critical Thinking Moment
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Reviewing eclecticism
Why not combine all of the theories?
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Remember theoretical vs. technical eclecticism
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OK to take technology
Need to explain in broader theory
Remember that these theories have
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Competing assumptions of origins of pathology AND
Corresponding curative factors
How do you know which to believe at which time?
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