Clinical Psychology - Exam 3

NYU Clinical Psychology Exam 3 Lectures on General Issues in Psychotherapy, Psychodynamic Psychotherapy, Humanistic Psychotherapy, Behavior Therapy, Cognitive Psychotherapy and Mindfulness-Based Therapies

Evidence supporting psychotherapy in the mid-1900’s

Evidence supporting psychotherapy in the mid-1900’s

In the form of anecdotes, testimonials, and case studies

Hans Eysenck (1952)

• Study concluded that clients got better without therapy and psychotherapy was of little benefit

• Methods have since been criticized and overturned

Meta-analysis

• Statistically combines the results of many separate studies – in some cases, hundreds – to create numerical representations of the effects of psychotherapy as tested across massive numbers of settings, therapists, and clients

• Have yielded consistently supportive results about how well psychotherapy works

Hans Strupp

• Identified three parties that should be considered when asking if psychotherapy works

• Invented the Tripartite Model

Tripartite Model

Acknowledges the viewpoints of:

• The client 

• The therapist 

• Third parties (e.g., society, family, or managed-care companies)

The client (the first party)

• Opinions are valuable, but could also be biased

  • Those who are overly eager to see positive results may overestimate the benefits of therapy

  • Those who are negatively influenced by factors that brought them into therapy may underestimate the benefits of therapy

The therapist (the second party)

• Typically have more experience

• Views can be biased

Society (the third party)

An outsider to the therapy process who has an interest in how therapy progresses

When should researchers ask if psychotherapy is helpful? 

• How long should the benefits last?

• What about benefits before therapy ends? 

Self-report 

• Researchers can solicit the opinions of an interested party using a questionnaire or interview 

  • The content and structure of these will have an impact on the data they yield 

Behavioral measures 

Researchers could directly observe someone at school or at home to determine whether their behavior has changed

Efficacy and Effectiveness

Two categories for empirical studies of psychotherapy

Efficacy

The success of a particular therapy in a controlled study conducted with clients who were chose according to particular study criteria

• Maximize internal validity by controlling as many aspects as possible

  • Well-defined groups of patients 

  • Manualized treatment guidelines

  • Random assignment

Effectiveness

The success of a therapy in actual clinical settings in which client problems span a wider range and are not chosen as a result of meeting certain diagnostic criteria

• Measure the extent that therapy works in “the real world”

• Maximize external validity 

  • Wider range of clients 

  • Greater variability between therapists’ methods 

  • May or may not include a control group 

Smith, Glass, & Miller, 1980

“The average person who receives therapy is better off at the end of it than 80 percent of the persons who do not”

The benefits of psychotherapy appear to…

• Endure over long periods of time 

• Exceed placebo effects 

• Represent clinically (not just statistically) significant change in clients’ well-being

Psychotherapy is not a panacea 

Some clients experience negative effects. These negative effects clearly appear to be the exception rather than the rule 

What factors influence therapists’ clinical decisions?

• Research such as efficacy studies had little influence over their choices 

• Their own clinical experience had a lot

(Place a higher value on their own intuition and judgements than on any data collected more methodically and scientifically)

Efficacy studies 

Indicate that psychotherapy works when tested in controlled settings

Effectiveness studies

Indicate that psychotherapy works as it is commonly applied in realistic settings

The “Dodo bird verdict”

A nickname for the common research finding that different forms of psychotherapy are roughly equally effective

Common factors

The notion that different therapies benefit from the same underlying mechanisms

• Each type of therapy shares some fundamental components

• Function as “active ingredients” in all forms of psychotherapy

Therapeutic relationship/alliance

A coalition or partnership between two allies (client and therapist) working in a trusting relationship towards a mutual goal

• The most important common factor

• The therapeutic relationship is the most crucial single aspect of therapy

  • Best predictor of therapy outcome

    • Higher correlation for the cognitive-behavior group

  • Accounts for more variability in therapy outcome

• Clients prefer a warm therapist with whom they can related to over a treatment with empirical support

• Vital to therapy no matter how much emphasis the therapist places on it

How does the therapeutic relationship contribute to successful therapy? 

Three possibilites:

1. A good alliance facilitates client improvement 

2. As clients improve, they experience an enhanced relationship with their therapists 

   • Just imagine how you would rate your alliance with a physician if he or she cured your serious disease

3. A reciprocal relationship could also exist

Correlation does not equal causation

Hope

Optimism that things will begin to improve

• The improvement can begin before mechanisms are implemented

Attention

Acknowledging the problem and focusing on it may result in improvement

Types of Psychotherapy

• Eclectic/integrative therapy

  • Most commonly endorsed until 2010

• Cognitive therapy

  • Currently most popular

• Psychodynamic/psychoanalytic therapy

  • Declined significantly since 1960

Psychodynamic Therapy

• Came first historically

  • Many later therapies were reactions against this approach

• Despite its decline, remains relevant and widely used 

  • Influences clinical psychology through adaptations of its traditional methods into novel approaches that better suit contemporary culture 

Psychodynamic psychotherapy

An approach to psychotherapy deriving from the theories of Sigmund Freud

• Sigmund Freud - The pioneer of the psychodynamic approach to clinical psychology 

Known in its classic form as psychoanalysis (replaced by other terms at various points)

Goal of Psychodynamic Psychotherapy

To make the unconscious conscious

• Once we become aware of unconscious processes (through insight) we can make efforts to control them deliberately rather than them controlling us 

Insight

Looking inside oneself and noticing something that had previously gone unseen

Unconscious

Mental activity occurring outside our awareness

• One of Freud’s most important and enduring contributions to clinical psychology 

According to Freudians:

• It exists and exerts a powerful influence on our day-to-day and minute-to-minute lives

• Its processes underlie all forms of psychopathology

Accessing the Unconscious 

• Not done in an empirical and/or factual way 

• Done through inference, deduction, and conjecture 

Free Association

A technique in which the psychodynamic psychotherapists ask clients to say whatever comes to mind without censoring themselves at all

• The client’s task is to verbalize any thought that occurs 

• The idea is that the words of people in such states of mind can be revealing of their innermost thoughts and feelings 

Freudian “slips”

Verbal or behavioral mistakes determined, according to the psychodynamic psychotherapists, by unconscious motivations

• All our behavior is determined 

• There is no such thing as a mistake, accident, or slip 

Dreams

Communicate unconscious material

• Our minds convert latent content (the raw thoughts and feelings of the unconscious) to manifest content (the actual plot of the dream as we remember it) 

Dream work

The process of converting the latent content of a dream to its manifest content

• Dream interpretations (and other attempts to understand the unconscious) are inferential rather than factual

Resistance

Client behavior that impedes discussion or conscious awareness of selected topics or emotions

• Clients feel anxious when thoughts and feelings are being laid bare too extensively or too quickly

Freud’s Structural Model of the Mind 

Three forces (the id, ego, and superego), the interaction of which occurs largely outside our awareness

• Our unconscious mental processes involve a constant battle between an id demanding instant gratification and a superego demanding constant restraint

The id

The part of the mind that generates all the pleasure-seeking, selfish, indulgent, animalistic impulses 

• Seeks immediate satisfaction of its wishes

The superego

The part of the mind that establishes rules, restrictions, and prohibitions 

• Tells us what we “should” do

• An internalization of the rules and demands that came from authority figures

The ego

A mediator and compromise maker between the id and superego 

• Faces two challenges: 

  • Partially satisfying both of these opposing forces 

  • Meeting the demands of reality

• The person negotiating between the demands for instant pleasure and the demands to follow rules

Defense mechanisms

Techniques used by the ego to manage conflict between the id and superego

Repression

When the id has an impulse and the superego rejects it the ego can repress conscious awareness of the impulse and the id/superego conflict around it 

• “sweep them under the rug”

Projection

When the id has an impulse and the superego rejects it, the ego can project the id impulse onto other people around us

• We convince ourselves that the unacceptable impulse belongs to someone else, not to ourselves

Reaction formation

When the id has an impulse and the superego rejects it, the ego can form a reaction against the id impulse 

• Essentially, do the exact opposite

Displacement

When the id has an impulse and the superego rejects it, the ego can displace the id impulse toward a safer target 

• Redirect the impulse towards another person or object to minimize repercussions

Sublimation

When the id has an impulse and the superego rejects it, the ego can sublimate it 

• Redirect it in such a way that the resulting behavior actually benefits others

Some defense mechanisms are more mature/healthier than others

• Denial and repression are considered immature 

• Sublimation is considered mature

Transference

Clients’ tendency to form relationships with therapists in which they unconsciously and unrealistically expect the therapist to behave like important people from the clients’ past

• Transference may be the most essential means for the psychodynamic therapist to access a client’s unconscious material 

Countertransference

Transference by therapists onto clients 

• Generally strive to minimize it

Psychosexual Stages

Oral, anal, phallic, latency, and genital

Fixation

Unsuccessful resolution of the psychological tasks of a particular developmental stage

• Most often occurs when parents do “too much” or “too little” in response to the child’s needs at a certain developmental point

Oral stage

The first of the psychosexual stages and the stage from which issues of dependency may emerge

• Occurs during the first year and a half

• Children whose parents mismanage this stage may display blatantly “oral” behaviors later in life 

• The primary issue at this stage is dependency 

  • If parents overindulge children, children may become overly trusting, naïve, and unrealistically optimistic personalities as adults

  • If parents are not responsive to children, children may develop overly mistrusting, suspicious, and unrealistically pessimistic personalities

Anal stage

The second of the psychosexual developmental stages, and the stage from which issues of control may emerge

• Occurs when the child is about 1.5 to 3 years old 

• The primary issue at this stage is control 

  • If parents are too demanding of children, children can become overly concerned about getting everything just right 

  • If parents are too lenient of children at this stage, children can become lax about organization

Phallic stage

The third of the psychosexual stages, and the stage from which issues of self-worth may emerge 

• Occurs from about age 3 to about age 6

• The view of the self – self-worth – is the key consequence

  • When parents respond too positively, they overinflate the child’s sense of self

  • When parents reject their child’s wishes for a special, close relationship, self-worth can be wounded

Humanistic Psychotherapy 

People arrive with an inborn tendency to grow

• Stood in opposition to the psychodynamic approach

• Several terms for the concept: nondirective, client-centered, and person-centered

Carl Rogers

The single most prominent figure in terms of influence on how therapists practice psychotherapy

Self actualization

The inborn tendency to grow in a healthy way

Positive regard

Warmth, love, and acceptance from those around us

• When this is conditional we will:

  • Emphasize certain aspects “branches” of ourselves 

  • Suppress other aspects “branches” of ourselves 

• This need can override the natural tendency to self-actualize 

  • Choice between 

    • Receiving this need from the important people in our lives 

    • Following our natural inclinations

Goals of Humanistic Psychotherapy 

To foster self actualization 

• Psychological problems and pathology are the byproduct of a stifled growth process

• To create a climate in which clients can resume their natural growth towards psychological wellness 

Conditional positive regard

Communicates that we are prized “only if” we meet certain conditions 

Conditions of worth

The stipulations that individuals may place on their positive regard of others

• To meet these conditions, children often go astray of their own self-actualization tendencies

• Conditional positive regard from others brings forth conditional positive self-regard 

• Unconditional positive regard from others brings forth unconditional positive self-regard

Real self 

The self that an individual actually experiences

Ideal self

The self than an individual could experience if he or she fulfilled his or her own potential

Incongruency

The discrepancy between the real self and the ideal self

• Humanist view this as the root of psychopathology 

Congruence

A match between the real self and the ideal self 

• Achieved when self-actualization is allowed to guide a person’s life without interference by any conditions of worth 

• Happens when persons experience unconditional positive regard from others

Elements of Humanistic Psychotherapy 

Three essential therapeutic conditions 

• Empathy 

• Unconditional positive regard 

• Genuineness

Claimed they are both necessary and sufficient

• Appear to be common factors

Attitudes, not behaviors

• Humanists tend to emphasize how therapists should be with clients 

Empathy

The therapist’s ability to sense the client’s emotions just as the client would, to perceive and understand the events of the client’s life in a compassionate way 

• Involves a deep, nonjudgmental understanding of the client’s experiences 

  • The therapist’s own values and point of view are temporarily suspended 

• The therapist sees life through the client’s eyes and adopts the client’s frame of reference 

  • Hence the term client-centered therapy 

• Can have a profound and positive impact

Unconditional positive regard

The full acceptance of another person without any conditions or stipulations “no matter what”

• Allows clients to grow in a purely self-directed way 

• Contributes to a climate in which clients realize they are free to be wholly true to themselves 

• Facilitates higher levels of congruence and self-actualization

• Conditional situations impede growth and cause us to drift away from our true selves 

• Top priority to accept clients entirely and unconditionally 

  • Allow them to grow naturally into their own potential rather than being pressured by others to grow in various directions

Genuineness

The quality in the therapist of truthfulness, realness, or congruence. Is in contrast to playing the therapist role falsely

• Also called therapist congruence

  • Match between the therapists real and ideal selves

• The therapist is truly empathic towards clients and truly does unconditionally prize them

• The therapist's personality plays a more prominent role 

• Encourage a relatively high degree of transparency by the therapist

Reflection

A therapist’s response to a client involving a rephrase or restatement of the client’s statement in a way that highlights the client’s feelings or emotions

• Serves as a mechanism by which 

  • Empathy, unconditional positive regard, and genuineness can be communicated 

  • The therapist can express the attitudes that humanists emphasize

Existential Psychotherapy 

Each person is essentially alone in the world

• This anxiety is the root of all psychopathology

• Contributes to a powerful sense of meaningless

• Overcome meaninglessness by creating their own meaning and make choices that are true to themselves in the present and future

Gestalt Therapy 

Emphasizes a holistic approach to enhancing the client’s experience and deemphasize clients’ past experiences

• Founded by Fritz Perls 

Positive psychology

A broad based approach that emphasizes 

• Human strengths rather than pathology

  • Develop and maintain positive attributes

  • Suggests that this thought process prevents problems such as depression and anxiety and improves the lives of those who already experience such problems 

• The cultivation of happiness in addition to the reduction of symptoms in psychotherapy 

  • “embraces both healing what is weak and nurturing what is strong”

• Founded by Martin Seligman

Emotionally Focused Therapy (EFT)

A short-term humanistic therapy

• Emphasizes the expression, acknowledgement, and healing power of emotions in the present moment 

  • Emotions that may have been “bottled up” for a long time

• Show clients unconditional acceptance

• “Empty chair” technique

Why use behavioral therapy?

• The psychodynamic and humanistic approaches are not entirely empirical 

• They are characterized by speculations of mental processes that can’t be defined, directly observed, or scientifically tested

Behavior therapy

An approach to psychotherapy emphasizing empiricism, observable and quantifiable problems and progress, and a lack of speculation about internal mental processes 

• The clinical application of behavioral principles

Ivan Pavlov

Discovered “classical conditioning” 

• Through experience—dogs learned that food was often preceded by a particular stimulus

John Watson

Claimed that “psychology should not study the inner workings of the mind that may occur in between”

Edward Lee Thorndike

Coined the Law of Effect 

The Law of Effect 

All organisms pay attention to the consequences (or effects) of their actions

• Actions followed by pleasurable consequences are more likely to occur 

• Actions followed by unpleasant consequences are less likely to occur

B. F. Skinner

Argued that operant conditioning was as great an influence on human behavior as classical conditioning

Goal of behavior therapy

Observable behavior change

Behavior therapy emphasizes empiricism

The study of human behavior should be scientific

• Methods that can be scientifically evaluated (i.e. testable hypotheses)

• Collect empirical data (allows the therapist to evaluate change)

Defining problems behaviorally

Behaviors are not symptoms of some underlying problem – those behaviors are the problem

Classical Conditioning

Conditioning in which an unconditioned stimulus that produces an unconditioned response is paired with a conditioned stimulus such that the conditioned stimulus elicits a similar response

• It’s passive

Operant Conditioning

Conditioning in which the organism “operates” on the environment, notices the consequences of the behavior, and incorporates those consequences into decisions regarding future behavior

• Behavior is a function of its consequences

• It’s active

• Proponents of this methodology believe consequences shape all behavior

Unconditioned stimulus

The stimulus that elicits the unconditioned response before any conditioning has taken place

Unconditioned response

The response elicited by the unconditioned stimulus before any conditioning has taken place (inborn association)

Conditioned stimulus

The stimulus paired with the unconditioned stimulus that ultimately elicits the conditioned response

Conditioned response

The response elicited by the conditioned stimulus after the conditioned stimulus has been paired with the unconditioned stimulus

Generalization

A process by which the conditioned response is evoked by stimuli that are similar to, but not an exact match for, the conditioned stimulus

Discrimination

A process by which the conditioned response is not evoked by stimuli that are similar to, but not an exact match for, the conditioned stimulus

Contingencies

The “if…, then…” statements connecting actions to outcomes that organisms learn through operant conditioning 

• These include those labeled as abnormal 

• Behavior therapists induce behavior change by revising these

Exposure therapy

A form of behavior therapy based on classical conditioning in which clients gradually face a feared object or situation

Phobias

According to the behavior therapist, these are the result of classical conditioning 

Imaginal exposure

Exposure to anxiety-provoking objects via imagination 

In vivo exposure

Exposure to anxiety-provoking objects in real life 

Graded exposure

A gradual approach to exposing clients to feared objects or situations 

• The client and therapist collaboratively create an anxiety hierarchy