Exam 1 Practice Terms

Lambert’s Pie

Describes the percentage of improvement in therapy clients as a function of therapeutic factors.

• 40% = client variables and extra-therapeutic events

• 30% = the therapeutic relationship

• 15% = technique and model factors

• 15% = expectancy and placebo effects

Dodo Bird Verdict

Most treatments are effective at least some of the time

• Differences between therapists > differences between therapies

• Some caveats:

  • Establishing “empirical support” is a lengthy process

    • Can take decades to say one type of therapy works for one disorder

  • Some treatments are clearly better/best for certain conditions (eg., ERP for OCD, DBT for BPD)

  • Some “treatments” do harm (eg., conversion therapy, critical incident stress debriefing, etc)

  • Clearly defined problems are easier to treat (eg., phobia versus GAD (generalized anxiety disorder) or MDD (major depressive disorder)); less chronic problems are easier to treat

  • Many researchers emphasize this as being due to “common factors”

critical incident stress debriefing

Makes individuals talk about the trauma in great detail immediately.

Key Common Factors for Keeping Clients in Therapy and Fostering Change

• Up to 89 common factors identified

  • Strong therapeutic relationship, new understanding/perspective, corrective experiences and new behaviors, expectation for improvement, confronting/facing the problem (exposure), establishing mastery and control, attributing success to internal causes, “ritual” of attending therapy

Wisdom for a New Therapist

• The client is the expert on their own experience

• Avoid advice or problem-solving, especially at first

  • Client states that they’re fighting with their parents over their choice of major → the therapist CANNOT assume that they need to work on self-advocacy skills, as they don’t know until you spend time together (it could be that they’re seeing issues where there aren’t any (parents are curious, not aggressive))

• Avoid self-disclosure

  • Don’t want client to perceive counselor as in a fragile state (if the counselor discloses their partner died, client is now worried about the counselor)

  • Client can become worried about the counselor not being able to relate to them (if they self-disclosed once but not on another issue, the client will feel they can’t relate to that issue)

• It’s okay to not have the same experiences as your client

• No two people will experience the same event the same way

• When in doubt, stop talking and listen

  • Means that if you’re caught on/worried about what you should say, it means that you’re no longer active listening, then take a purposeful pause

• Deep listening leads to empathy

  • If you are actually actively listening, it is very common that you feel empathy for your clients

  • Stillness is vital in therapy (pauses allow realizations)

• Never work harder than your client

  • Unless it’s mandated and you have to try harder the first few sessions, don’t work harder, as it can lead to burnout

    • Want to teach the client how to fish (give them the tools/fishing rod, not just catch a fish for them)

• The goal of treatment is to leave treatment

  • Ask from the start how they want to end

• Demonstrate boundaries and self-care

  • Don’t always follow up with clients outside of sessions → take care of yourself and your needs

• Invite feedback and reflection; it’s okay not to “click”

  • Ask them how they feel therapy is going

• Therapy for yourself is almost never a bad idea

  • Need to work through your own problems, so that you don’t look at a client’s issues through your own lens/issues

• You will mess up; it’s (probably) okay

Intake Assessment

• Goal is to formulate a treatment plan (& often assign a diagnosis)

• Ask about

  • Demographics

  • Presenting problem(s)

  • Current living situation, employment/educational circumstances

  • Social support & relationships

  • Psychological analysis & assessment (mental status exam, personality, intelligence, GAF, symptoms, etc.)

  • Psychosocial developmental history

  • Health & medical history (including prior psychological treatment)

  • History of high-risk behavior (substance use, eating disorders, self-injury, suicidality or violence)

  • Goals

Why Do We Need Ethical Principles in Psychotherapy?

• Therapeutic relationships are inherently unbalanced

  • Therapist inevitably has more power

• Therapeutic relationships are complicated (“client/provider”? “doctor/patient”? “teacher/student”?)

  • And clients’ issues are complicated

• Principles provide guidance & accountability for inevitable complications

  • …But even still, the answers are rarely crystal clear!

Ethical Codes

• Guidelines for what psychologists can & cannot do

• Developed by each discipline’s organizational body

• Include principle ethics (obligations) & virtue ethics (aspirations, idealistic)

• Ambiguous by design (written broadly in order to apply to psychologists in varied roles)

  • First step: Consult!!!

• Beneficence and nonmaleficence, fidelity and responsibility, integrity, justice, respect for people’s rights and dignity

Principle Ethics

An ethical framework based on objective, universal moral principles and codified standards that guide a clinician's duty and decision-making when resolving ethical dilemmas

• ex. Don’t abandon the client (instead of just emailing the client that the therapy sessions are over, from the start and slowly introduce the concept of ending therapy)

Virtue Ethics

A moral philosophy that focuses on building a good character and practicing good habits rather than just following strict rules or looking only at the results of an action

• ex. Trying to make every therapy session free as a therapist

Key Ethical Issues Affecting Clinical Practice

Competence, client welfare, informed consent, confidentiality, dual relationship, sexual relationship

Competence

Therapists must only provide services for which they are qualified

• To provide this, therapists need to:

  • Only provide services for which they are qualified

  • Accurately represent their credentials and qualifications

  • Keep up on current information in the field, especially in speciality areas

  • Seek counseling when they have personal issues

  • Malpractice can occur if a therapist fails to provide reasonable care that is generally provided by other professionals and it results in injury to the client

Malpractice

Can occur if a therapist fails to provide reasonable care that is generally provided by other professionals and it results in injury to the client

Termination

• Must terminate if treatment is no longer effective or no longer needed

  • If someone came with a fear of heights and they did exposure therapy and now can live on a day-to-day basis, exposure therapy is no longer needed

• Must plan & process

• Must assess whether the client can maintain gains

• Must discuss follow-up if needed

Informed Consent

• All of the following must be covered for client to make informed choice

  • Cost of treatment

  • Special arrangements (e.g., telehealth? cancellations procedures? after-hours/vacation coverage?)

  • Therapist competencies

  • Nature of treatment

  • Confidentiality & its limits

Privileged Communication (Confidentiality)

• Legal protection of the client that prevents therapist from disclosing what was said in session(s)

• 1996: Supreme Court establishes psychotherapist-client privilege (Jaffee v. Redmond)

• Law specifics vary state to state

Jaffee v. Redmond

A police officer pursued a foot chase with a person who had stabbed someone and was continuing to threaten other people’s lives. Redmond ended up shooting and killing the person they were pursuing. The family of the victim sued Redmond, and their lawyer found the officer’s therapy records and used the records against Redmond in court to say the officer was mentally unstable. The officer then initially lost the case, got fired, taken off the force

• SCOTUS then held in the next trial that confidential communications between a patient and licensed psychotherapist are protected by federal evidentiary privilege.

Exceptions to Privileged Communication (Confidentiality)

• Suicidal (risk assessment required)

• Hospitalization required

• Court-ordered evaluations

• Client sues therapist

• Client pursuing NGRI or similar legal defense

• Minor or elder abuse

• “Duty to warn” someone in danger

  • Tarasoff v. Regents of the University of California (1976)

Tarasoff v. Regents of the University of California (1976)

A patient told his therapist that he intended to kill Tatiana Tarasoff. The therapist warned the police and the school but did not warn Tarasoff directly. The patient later killed her. The California Supreme Court held that a therapist has a duty to take reasonable steps to protect an identifiable victim when the therapist determines, or should determine, that a patient poses a serious danger of violence to that person.

Dual Relationships

When a therapist has two or more roles with the same client (e.g., therapist + friend, business partner, teacher, or romantic partner), creating a risk of conflict of interest, exploitation, or impaired professional judgment.

• Guiding Questions:

  • Is it necessary?

  • Is it exploitation?

  • Who does the dual relationship benefit?

  • Is there a risk the dual relationship could damage the client or disrupt the therapeutic relationship?

• Recommendations:

  • Consult!

  • Document!

  • Obtain informed consent!

Sexual Relationships with Clients

• Current clients

  • Never acceptable

  • Power imbalance means consent is not possible

  • Breaks trust, safety, objectivity

  • 90% are harmed (clients)

  • 4% of therapists acknowledge that they DID have intercourse or touch a client

• Former Clients

  • Only after 2 years minimum

  • Burden is on therapist

  • Consider time elapsed, nature of treatment, circumstances of termination, client’s personal history, current mental status, likelihood of adverse impact, any leading suggestions during treatment

• Most therapists are highly ethical!

Pros in Telehealth

• Increased access to care

• Cost, geography, expertise

• Enhanced communication

• Ability to practice skills in vivo (instead of talking in retrospect about practicing skills, you call them in the moment and do it together)

  • ex. If a client is scared of social settings, such as going to a grocery store, then a client can call the therapist and have the therapist there online to talk them through breathing techniques and such as they go through the store

• Convenience

• Anonymity

Cons in Telehealth

• Privacy, confidentiality, & security

• Therapist competence & need for special training

• Wide range of diversity issues

  • Language barriers, significant cultural differences, and others

• Communication issues specific to tech

  • Glitches, losing info on nonverbals, etc.

• Research gaps

• Emergency issues

  • ex. if someone is a suicide risk but lives far away from therapist, the therapist might not know where to send them

Psychoanalytic and Psychodynamic Historical Context

• Sigmund Freud, the father of psychoanalysis, offers the first organized way to explain human behavior (1880s – 1930s)

• ”If Freud’s discovery had to be summed up in a single word, that word would without a doubt have to be unconscious.”

• Psychoanalytic = Freud

• Psychodynamic = Broader set of constructs that has analysis as foundation

Psychodynamic View

• Forms of treatment that are based on psychoanalytic theory but lack some of the defining characteristics of psychoanalysis

  • emerged as a way of shortening and simplifying the lengthy process of classical psychoanalysis

  • attention to unconscious processes, especially as they are manifested and potentially influenced in the relationship with the therapist

• Client developmental history is critical for full client understanding

• Most important in developmental history are key people (object relations)

• We are unconscious of the impact of biology, development, and culture in determining behavior

• We constantly act out developmental history & biological drives in daily lives

• The task of therapy is to help the client discover the unconscious roots of present behavior

  • fostering the client’s capacities to cope with and solve their own problems

Freud: Feminist, LGBTQ+, Class-Related, & Multicultural Critiques

• Many of Freud’s original ideas are now recognized as blatantly sexist &/or heterosexist

  • ex. “penis envy” → women are missing something from birth → must marry a man and birth a son to be “healed”

• Traditional Freudian psychoanalysis is often viewed as elitist

  • Clients must be highly educated and vocal (the therapist doesn’t lead the conversation, and the cost is not usually covered by insurance)

• Personal understanding, insight, self-disclosure & interpersonal openness are not universally viewed as positives

  • In some cultures insight isn’t seen as appropriate (don’t have time, and should be thinking of the collective whole/your family → example, in Chinese culture, they view thinking too much about an issue will cause problems)

Id

a reservoir of unconscious psychic energy that, according to Freud, strives to satisfy basic sexual and aggressive drives. It operates on the pleasure principle, demanding immediate gratification (the drives, desires, and the “I Wants” → is the devil on your shoulder)

• Is present at birth 

• functions entirely in the unconscious 

• ex. Have a chocolate cake → wants you to eat all you can/as much as you want

Ego

the partly conscious, “executive” part of personality that, according to Freud, mediates among the demands of the other two and reality (can’t give in to one and will never be as good as the other wants). It operates on the reality principle, satisfying the id’s desires in ways that will realistically bring pleasure rather than pain.

• represents the self, or the part of one’s personality that is visible to others

• ex. Have chocolate cake → don’t eat all the cake (will make you sick) 

Superego

The partly conscious part of personality that develops as a child interacts with others, and, according to Freud, represents internalized ideals and provides standards for judgment (the conscience) and for future aspirations. Strives for perfection and judges our behavior, leading to feelings of pride or—when we fall short of the ideal—feelings of guilt (this is what I should be, what I should aspire to, and is the best version of myself → angel on your shoulder)

• the point of taking in these imagined expectations is to protect ourselves from our own impulses → may be more punitive and demanding than the person’s parents really were

• tells you what you should and shouldn’t do (judicial branch of personality)

  • moral code, the main concern being whether an action is good or bad, right or wrong

    • represents the ideal rather than the real and strives for perfection

• Functions to inhibit the id impulses, persuades the ego to substitute moralistic goals for realistic ones, and strives for perfection

• Related to psychological rewards and punishments → rewards are feelings of pride and self-love; punishments, feelings of guilt and inferiority

• get this from your parents

• ex. Have a chocolate cake → share the cake with others

Central Constructs of Psychodynamic Theory (Ego Defense Mechanisms)

Help the individual cope with anxiety and prevent the ego from being overwhelmed

• rather than being pathological, ego defenses are normal behaviors that can have adaptive value provided that they don’t become a style of life that enables the individual to avoid facing reality

  • defenses employed depend on the individual’s level of development and degree of anxiety

    • have two characteristics in common: they deny or distort reality, and they operate on an unconscious level

• These are: denial, displacement, projection, rationalization, reaction formation, regression, repression, and sublimatio

Denial

Refusing to accept real events because they’re unpleasant (your ego denies)

• ex. Kaila refuses to admit she has an alcohol problem, although she is unable to go to a single day without drinking excessively 

Displacement

Transferring inappropriate urges or behaviors from an unacceptable target onto a more acceptable or less threatening target 

• ex. During lunch at a restaurant, Mark is angry at his older brother, but does not express it and instead is verbally abusive to the server 

• ex. Hate your mom, but it’s unacceptable to hit her, but “okay” to hit the dog

Projection

Take the negative feeling you have, and rather than own it, you attribute the unacceptable desires to others

• ex. Kim often cheats on her boyfriend because she suspects he is already cheating on her 

Rationalization

Justifying behaviors by substituting acceptable reasons for less acceptable real reasons 

• ex. Chris failed his history course because he did not study or attend class, but he told his roommates that he failed because the professor didn’t like him

Reaction Formation

Reducing anxiety by adopting beliefs contrary to your own beliefs/switching the unacceptable desire into something opposite

• ex. Nadia is angry with her coworker Beth for always arriving late to work after a night of partying, but she is nice and agreeable to Beth and affirms that partying is “cool.”

• ex. Nick has a unconscious deep-seated hatred of his younger sibling because of an event → becomes an obsessive love that he showers onto the sibling (does it because he can’t cope with the fact that he hates them)

Regression

Returning to coping strategies for less mature stages of development 

• ex. After failing to pass his doctoral examinations, Giorgio spends days in bed cuddling his favorite childhood toy

Repression

Suppressing painful memories and thoughts.

• ex. LaShea cannot remember her grandfather’s fatal heart attack, although she was present

Sublimation

Redirecting unacceptable desires through socially acceptable channels.

• ex. Jerome’s desire for revenge on the drunk driver who killed his son is channeled into a community support group for people who’ve lost loved ones to drunk driving. 

• ex. Kyle gets frustrated while playing golf → throws raw eggs at a tree in the yard to channel his frustration

Key Techniques in Psychodynamic Therapy

• Free association

• Interpretation and analysis

  • Of “Freudian slips”

  • Of transference and countertransference

  • Of dreams

  • Of resistance

Six Basic Techniques of Psychoanalysis: Free association

The basic technique and strategy of the psychodynamic approach

• with or without a prompt, client gives voice to the thoughts that enter their mind, without exception

Freudian slip

When you sometimes say things that you don’t intend to say by unintentionally substituting another word for the one you meant

• Happens in free association (“I have to call my murder later,” “I’ll pick you up at sex”)

  • Freud suggests that slips of the tongue are actually sexual or aggressive urges accidentally slipping out of our unconscious 

    • Linguists today have found that slips of tongue occur when we are tired, nervous, or not at our optimal level of cognitive functioning 

Six Basic Techniques of Psychoanalysis: Interpretation and Analysis

• Sophisticated and complex skill

• Intellectual knowledge of psychodynamic theory is integrated with clinical data about the client

• Renaming of client experience from an alternative frame of reference or worldview

  • ex. client as a child was abandoned and abused by their mother → now has trouble with partners, as they feel no one is living up to expectations → could be that they now feel power rejecting others (taking back power from being abandoned by now abandoning others)

• Offer interpretation and then check with the client

  • “How do you react to that?” “Does that ring a bell?” “Does that make sense?” Does that resonate?”

Six Basic Techniques of Psychoanalysis: Transference

Client unconsciously transfers wishes or feelings about someone from the past onto the therapist

• If therapy is to produce change, the transference relationship must be worked through

  • working-through = a process that consists of repetitive and elaborate explorations of unconscious material and defenses, most of which originated in early childhood

    • Clients learn to accept their defensive structures and recognize how they may have served a purpose in the past

      • resolution of old patterns and ability to make new choices

• Positive = If a client expresses idea that the therapist is all-knowing, it isn’t about the therapist but the client going through life unmoored

• Negative = If client interprets therapy homework as nagging → feel as if they can’t do anything and that it exceeds their capabilities

• Sexualized = projecting sexual feelings onto therapist (rarely comes off as just a come-on)

  • ex. “The Sopranos” → feels that he loves the therapist → she has been a blank slate who is gentle and sympathetic; everything he feels is looking in his mother and wife

Counter-transference

Therapist transfers their own unresolved conflicts, emotions, or wishes onto the client

• Can also play out in multiple ways (can feel very maternal/paternal or sexual)

• Critical to attend to and process in supervision

Dreams

A sequence of images, emotions, and thoughts passing through a sleeping person’s mind.

• Assumption = unconscious material is processed during sleep and expressed in ____

  • Disguised fulfillment of a repressed wish

  • Super-ego is weakened during sleep

  • Manifest vs latent content

• To understand the significance, the therapist must explore latent content via free association

  • Although some modern therapists focus on manifest content

Manifest Content

Surface level (what’s happening in the dream)

• ex. tidal wave comes and sweeps an entire city away

• ex. 9th grader dreams of being on a train with the math teacher and talking/having fun before the train goes through a dark tunnel

Latent Content

Hidden meaning behind the dream

• ex. 9th grader dreams of being on a train with the math teacher and talking/having fun before the train goes through a dark tunnel

  • The dream is about sex, with the train being the penis and the tunnel being the vagina

• ex. tidal wave comes and sweeps an entire city away

  • depends on the characteristics of a person

    • talk about the dream through free association → ask what the most salient feeling was when the tidal wave swept it all away (was it peace, fear, etc.) → go from there

Six Basic Techniques of Psychoanalysis: Resistance

Anything that works against the process of therapy and prevents the client from producing previously unconscious material.

• client’s reluctance to bring to the surface of awareness unconscious material that’s been repressed

• client’s tendency to cling to familiar patterns no matter how painful they may be → therapist's need to create a safe climate so client’s reorganize resistance and explore it in therapy

• Not just something to overcome → representative of usual defensive approaches in daily life → need to be recognized as devices that defend against anxiety but that interfere with ability to accept change

• These words and actions must be identified and analyzed (perhaps via free association) in order to understand their significance, or rapport and progress are lost

• Properly managed, it can be an opportunity (THE opportunity!), rather than a problem

Psychodynamic Approach: Empirical Support

• Comparably effective to other approaches; may excel at long-term follow-up

  • In all therapies, the patient is better at the end, but these patients excel in 1-5+ years after the end of therapy

• Anorexia nervosa, several personality disorders, depressive disorders, generalized anxiety disorder, panic disorder, social anxiety disorder, somatic symptom disorder

• Worldview and Constructs

  • Unconscious emotional responses exist

  • We can map defense mechanisms (ex., suppression) with fMRI

  • Implicit memories, split-brain patients, conversion disorder, and more

    • At its root, unconscious processes are guiding our behaviors

Interpersonal Psychotherapy History

• Late 1960s: Weissman, Markowitz, and Klerman develop IPT

  • Time-limited (12-16 weeks) treatment for depression

  • Targets the interpersonal context

• All client problems occur against a social backdrop

  • Social support is protective

  • Mental health problems are often linked to disruptions in social relationships & roles

  • Mental health problems increase during times of interpersonal stress

• Past social relationships are critical and directly impact current interpersonal context

  • Object relations theory

Object relations theory

encompasses the work of a number of rather different psychoanalytic theorists who are especially concerned with investigating attachment and separation

• emphasize how our relationships with other people are affected by the way we have internalized our experiences of others and set up representations of others within ourselves

• object = refer to that which satisfies a need, or to the significant person or thing that is the object, or target, of one’s feelings or drives

  • Means you carry items of key people/representation of them → have internalized objects in you

Interpersonal Psychotherapy (IPT) Controversy

Psychodynamic Influences

• Object relations theory

• Past relationships are critical

• Focus on feelings (not thoughts)

• Shares a lot in common with theory

Cognitive-Behavioral Influences

• Time-limited

• Structured interviews

• Specific assessment tools

• Shares a lot in common with techniques

Potential Interpersonal Problem Areas

• Grief and loss

• Role transition

  • Having a baby; their role is now as a parent

• Role dispute

  • Some sort of conflict in relationships

    • ex, In therapy, a client learns about boundaries → tries to assert them with their partner → partner isn’t used to this and is now angry with the client

• Interpersonal conflict

  • Problems that don’t fit into other categories (ex. lack of social support)

  • Skills deficit (ex., have problems with scheduling/hanging out with friends → the friends think that they hate them → now have a lack of friends)

Selected Techniques to Help Interpersonal Understanding

Closeness Circle, Interpersonal Relationship Worksheet, and Mood Thermometer

Selected Techniques to Help Interpersonal Understanding: Closeness Circle

A therapeutic technique used to help clients visualize and understand their relationships. The client places people in their life on a series of circles based on how emotionally close or distant they feel from each person. It can help identify patterns, supportive relationships, loneliness, and relationship concerns.

Selected Techniques to Help Interpersonal Understanding: Interpersonal Relationship Worksheet

A therapeutic tool that helps clients identify and examine important relationships by considering factors such as the nature of the relationship, communication patterns, strengths, problems, and feelings. It helps clients gain insight into how their relationships affect their thoughts, emotions, and behavior.

Selected Techniques to Help Interpersonal Understanding: Mood Thermometer

A therapeutic tool that helps clients rate and track the intensity of their emotions or mood (often on a numerical scale). It helps identify emotional patterns, triggers, and changes in mood over time, increasing awareness of how situations affect feelings.

Interpersonal Psychotherapy (IPT) Empirical Support

• Major depression, generalized anxiety disorder, eating disorders, social phobia

• Incorporated into IPSRT for bipolar disorder

• Teens, adults, elderly, perinatal populations

  • Role transitions

• Common group therapy approach; group = interpersonal context!

  • Initially validated for use with binge eating disorder → now common group for a lot of diagnoses

Essential Elements of IPSRT for bipolar disorder

Psychoeducation

• Focus on medication adherence

• Education about types of BD & meds (side effects, function/duration, common challenges)

Social Rhythm Therapy

• Link between regular routines and mood

• Regulate daily routines

  • Helps maintain regular mundane routines

    • Particularly sleep (crucial to get the same amount of sleep at the same times for BPD)

Interpersonal Psychotherapy

• Link between life elements

• Focus on one of the 4 interpersonal problem areas

Gestalt therapy: History

• Developed in the 1930s in reaction to perceived theoretical “holes” in psychoanalysis → problems with psychoanalysis is that there is no evidence/backing with concepts such as penis envy, focus too much in the past, allows you to get way with your problems since it’s subconscious

  • Fritz and Laura Perls were trained in psychoanalysis

  • Believed more in freedom and responsibility, immediacy of experience, striving to create meaning in life

• The first humanistic, client-centered approach?

  • Here-and-now focus

  • Striving towards wholeness

  • Potential for self-healing and growth

• The whole person is greater than the sum of their parts

  • Failure to integrate parts of personality causes conflict and distress

Gestalt Therapy

• Resolve internal conflicts & ambiguities resulting from failure to integrate features of personality

  • ex. Two-chair technique

• Teach people to become aware of significant sensations within themselves and the environment so they can respond fully and reasonably to life’s challenges

  • Exaggeration and contrast technique

• Focus on here and now

  • But once a client is aware of the present, they can confront past conflicts & “unfinished business” (“incomplete Gestalts”)

    • Empty chair technique

• Clarify intrapsychic and interpersonal conflicts via active exercises

  • Act out repressed parts of personality, role-play, or re-enact a conflict, adopt role of another person, act out dreams

• Assumes inclination to health, wholeness, realizing full potential

• Tell clients to change their language to focus on the here and now, increase awareness and responsibility

  • “Do you think I’ll ever feel better?” → “I’m worried that I won’t get better”

• Stay with the feeling

• Dialogue = I/Thou moments → create inclusion, which occurs when the client understands at a very genuine level that the therapist “gets it”

• Experiment = moving from “talking about” a topic to trying out an activity

Two-chair technique

A Gestalt therapy technique in which the client alternates between two chairs, speaking from different parts of themselves or different sides of an internal conflict. This helps the client express and explore opposing feelings, needs, or perspectives and work toward greater awareness and integration.

• allows introjects to surface, and the client can experience the feeling more fully

  • conflict can be resolved by the client’s acceptance and integration of both sides

    • helps clients get in touch with a feeling/side they may be denying

      • interpretation discourages clients from disassociating the feeling

Exaggeration (and Contrast) Technique

A Gestalt technique in which the therapist asks the client to exaggerate a gesture, movement, word, or behavior to bring greater awareness to the feelings or meaning behind it. Contrast involves highlighting opposing behaviors or emotions to help the client recognize conflicts and patterns.

Empty Chair Technique

A Gestalt technique in which the client imagines another person in an empty chair and speaks to them as if they were present. This helps the client express unresolved feelings, explore different perspectives, and achieve greater awareness or closure.

Gestalt Therapy: Empirical Support

• Equivalent effects to other major treatment modalities

• Depression, chronic illness, addictions, certain specific psychological dilemmas

  • Increasing present-moment awareness is the main mechanism of action

    • x → y → z

      • Increases present-moment awareness → then helps the individual better (helps with the addiction, chronic illness, addition, etc)

      • for psychodynamic it’s making the subconscious aware for their main mechanism of action

Client-Centered Therapy: History

• Also called person-centered therapy or Rogerian therapy

• One of the most influential types of therapy

• A humanistic-existential approach

• Carl Rogers (main work 1930-1960s)

  • Initially training to be a minister

  • Began to question religion → spiritualist and agnostic

  • Switched from seminary to MA and PhD in psychology

Client-Centered Therapy

• Underlies most therapies (is the core of therapy)

• Therapist enters the worldview of the client, facilitates them finding their own new direction & frame of thinking

  • Provides an atmosphere in which the client, through exploration of the situation, comes to see more clearly and accept their personality

Necessary and Sufficient Conditions for Therapeutic Change to Occur in Client-Centered Therapy

• Two persons in psychological contact

• Client is in a state of incongruence

• Therapist is genuine in the relationship

• Therapist experiences unconditional positive regard for the client

• Therapist experiences empathic understanding of the client & communicates this to them

• This communication of empathy & unconditional positive regard is at least minimally achieved

Humanistic Psychology

Takes the less anxiety-evoking and more optimistic view that each of us has a natural potential that we can actualize and through which we can find meaning

• potential for self-healing, goals

  • vision of this psychology is captured in the metaphor of an acorn → provided with appropriate conditions, it will “automatically” grow in positive ways, pushed naturally toward its actualization as an oak

• Influenced by Maslow’s basic philosophy

  • Maslow criticizes Freudian psychology for what he saw as its preoccupation with the sick and dark side of human nature

    • Argued that there was too much research on anxiety, hostility, neurosis, and too little on joy, creativity, and self-fulfillment

    • Influential in furthering the understanding of self-actualizing individuals

Existential

Take the position that we’re faced with the anxiety of choosing to create an identity in a world that lacks intrinsic meaning (grappling with hard things)

• acknowledges the stark realities of human experience, and their writings focus on death, anxiety, meaninglessness, and isolation

  • Life has meaning, but only because we’re all going to die and are scared of doing so

Client-Centered Therapy: “Being-in-the-world”

• We are in the world & acting on it while it simultaneously acts on us

• Any attempt to separate ourselves from the world causes alienation (à anxiety & aloneness)

• Racism, sexism, homophobia, etc. → separation → alienation → anxiety & aloneness

• Failure to make decisions & act in the world → separation → alienation → anxiety & aloneness

• Clients must assume responsibility for choice & act intentionally in the world

Client-Centered Therapy: Prime Ideas

• You have free will

• You can use it to choose the life you want to live

• The choice is yours

Client-Centered View: Hierarchy of needs

Maslow's level of human needs, beginning at the base with physiological needs. Often visualized as a pyramid, with needs near the base taking priority until they are satisfied.

Physiological needs (1st level for Maslow)

need to satisfy hunger and thirst

Security needs (2nd level for Maslow)

need to feel that the world is organized and predictable; need to feel safe, secure, and stable

Belongingness and love needs (3rd level for Maslow)

need to love and be loved, to belong and be accepted; need to avoid loneliness and separation

Esteem needs (4th level for Maslow)

Need for self-esteem, achievement, competence, and independence; need for recognition and respect from others

Cognitive needs (5th level for Maslow)

The need for knowledge, understanding, learning, and exploring. People seek to gain information, make sense of the world, and satisfy curiosity.

Aesthetic needs (6th level for Maslow)

The need for beauty, balance, harmony, and order. People seek to experience and create beauty in their surroundings and lives.

Self-actualization (7th for Maslow)

According to Maslow, one of the ultimate psychological needs that arises after basic physical and psychological needs are met and self-esteem is achieved; the motivation to fulfill one's potential.

Self-transcendence (8th for Maslow)

The need to go beyond oneself by seeking meaning, purpose, or connection to something greater than the individual, such as helping others, serving a cause, or pursuing spiritual fulfillment.

Critiques of the Existential-Humanistic Perspective and the Client-Centered Approach to Treatment

• Intense preoccupation with the individual & free choice

  • doesn’t work with collective cultures

• Not all groups have the necessary conditions for growth, self-actualization

• Blind (?) faith that people are positive, forward-moving, basically good, & ultimately self-actualizing

• Very verbal treatment, no clear endpoint; appeals mostly to middle- & high-socioeconomic status clients

Client-Centered Approach: Empirical Support

• Rogerian techniques essentially form the basis for all therapeutic orientations (Fiedler, 1950a, b, 1951)

• Therapeutic relationship quality is critical & highly predictive of success, regardless of specific orientation or techniques (Lambert & Barley, 2001; Orlinsky & Howard, 1986; Strupp, 1989; Wallerstein, 1989)

• Person-centered/experiential therapies yield large pre-post client change, effects are clinically & statistically equal to other therapies, gains are maintained over time (Elliott & Friere, 2008)

• Effective for depression, interpersonal difficulties, coping with psychosis, self-damaging behaviors, chronic medical conditions (Angus et al., 2015); some support for use with bipolar disorder, generalized anxiety disorder, PTSD

Motivational Interviewing: History

• First developed in early 1980s as a treatment for “problem drinkers” - Miller & Rollnick

• Grew out of a person-centered approach…

  • Core belief that client has capacity for self-direction & change

• …But much more directive

  • Explicit goals: draw out & explore ambivalence, enhance motivation for change

“Problem drinkers”

Defined as individuals with alcoholism or those who don’t fully meet the criteria, but the drinking is still causing them issues

Motivational Interviewing: Current Support

• Alcohol and other addictions

• Health-related behaviors

• OCD, anxiety, depression

• Other behavior change

Motivational Interviewing: Stages of Change

1. Pre-Contemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance

6. Relapse

Upward Spiral - learn from each relapse

Motivational Interviewing: Pre-Contemplation

No intention of changing their behavior

• I don’t have a problem with drinking

Motivational Interviewing: Contemplation

Aware that a problem exists but with no commitment to action

• I have a problem with drinking

Motivational Interviewing: Preparation

Intent on taking action to address the problem

• Where can I find a therapist to help with my drinking addiction?

• Looking at sources online to help

Motivational Interviewing: Action

Active modification of behavior

• Going to see a therapist about alcoholism

Motivational Interviewing: Maintenance

Sustained change: new behavior replaces old

• No longer drinks as much alcohol, or any alcohol at all

Motivational Interviewing: Relapse

Fall back into old patterns of behavior

• Starts drinking alcohol again

Motivational Interviewing: Spirit of the Approach

• Motivation to change is elicited from the client (not imposed from therapist)

• It is the client’s task (not the therapist’s) to articulate & resolve ambivalence

• Direct persuasion is not effective for resolving ambivalence

• Counseling style is quiet & eliciting, collaborative & friendly

• Therapist is directive in helping clients examine & resolve ambivalence

• Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction

• Therapeutic relationship is more like a partnership than expert/recipient roles

• Is more of an interpersonal style than a set of techniques

• Express empathy. Support self-efficacy. Roll with resistance. Develop discrepancy

Motivational Interviewing: Some Specific Techniques

• Open-ended questions

• Providing feedback (e.g., the average American has 1 drink per week)

• Evoking personal meaning (“How does this statistic make you feel?”)

• Pros & cons (ask the client to talk about the pros and cons of drinking → usually realize the cons outweigh the pros)

• Enhancing motivation (how does their current behavior fit with their long-term goals?)

• Summarizing

• Reflection

• Readiness assessment

• Negotiating commitment

• Affirmations

Some Motivational Interviewing “Traps” to Avoid

• Question/answer trap

  • Have you thought about trying to lose weight so your blood pressure comes down? Pt.: Well yes, but it's not so easy, and I must say, I really enjoy eating. It’s pleasurable to me. Dr.: But it's not a matter of depriving yourself of food. You just need to eat different, healthier foods. Do you know what I mean?. Pt.: Yes, I know, I did try to eat less meat and more fruit and that sort of thing, but I never keep going for too long. I always have these binges when I break all my rules, and I just gain weight. Dr.: What about....? Pt.: Yes, but....

• Confrontation/denial trap

  • Client voices really risky behavior, therapist wants to confront but client responds with reasonable explanation (want to lose weight but it’s hard, eating is pleasurable, etc)

• Expert trap

  • Dr.: Well, I can tell you that drinking that much alcohol is associated with a bunch of negative health outcomes like weight gain, cognitive decline, increased blood pressure and cholesterol, and more. Also, it can wreak havoc on your marriage and other relationships. We need to decrease your alcohol intake right away. Let’s make a weekly plan for strategies you can use to distract yourself and avoid drinking when you feel a craving.

    • Client feels like you’re blaming them → dig their heels in

• Labeling trap

  • Dr.: Based on what you’ve told me, you meet criteria for 7 of the 11 possible diagnostic criteria for alcohol use disorder.

• Premature focus trap

  • Dr. (5 minutes into the first conversation): Ah! I see what the problem is. Let’s get to work.

• Blaming trap

  • Client blaming others

    • Pt.: It’s not really possible to change how much I drink, though. My parents were both alcoholics and it’s so much a part of my social scene at this age.

  • Therapist blaming Client

    • Dr.: I’m hearing you talk about all these problems in your life with your job, your friends, financial challenges, your health. You see how all of this is because of your drinking, though, right?

Approach to Counseling: Make Personal Contact

The relationship between counselor and client is vital

• making ____ ____ is difficult

  • Be open to your client’s lead

    • Encourages the development of trust

Approach to Counseling: Develop a Working Alliance

The task of a counselor is to engage the client in counseling

• Such alliances do not occur, for example, when the counselor attempts to force the client to change or when the client is unmotivated

  • Counselors invite their clients into this working alliance by extending understanding, respect, and warmth

    • Counselors must be skilled interpersonally and as listeners

  • Without this alliance, many clients are unable to change (need to learn about clients through attentive listening and acceptance)

Approach to Counseling: Explaining Counseling to the Client

Clients frequently approach counseling with misconceptions about the process

• Beginning counselors should avoid giving explanations until they feel comfortable and knowledgeable enough to do so → Practice first role-plays

• Clients may find it helpful to know:

  • they will do most of the talking

  • they may experience painful feelings before they begin to feel better

  • exceptions exist regarding confidentiality of counseling

  • persons in counseling are not inherently weak

  • Most individuals in counseling are quite sane

  • Tell them it may take some time to find a proper resolution

  • Give client informed consent forms

Approach to Counseling: Pace and Lead the Client

Refers to how much direction the counselor exerts with the client

• When pacing, a counselor follows along on terms of the client

• Reflection of feeling = refers to the counselor’s recognition of the client’s feeling and subsequent mirroring of that feeling

• Restatement of content = the counselor notices the client’s thoughts and restates that content

  • Discussing timing (counselors should develop a sense for when they direct or lead)

    • When counselors lead too much, they lose their clients