CCE: Clinical Psych

Freud's personality theory (id, ego, superego, & defense mechanisms)

id: our primal part; life/death instincts, source of all psychic energy; operates on pleasure principle, seeking immediate gratification and instinctual drives

ego: the mediator (btw id & superego); shows up @ ~6 months old & defers gratification;

superego: internalized societal messages/standards: arrives @ 4-5 yrs old

defense mechanisms: the reinforcements called on when ego can't solve things on it's own; these distort reality to make it digestible

aspects of freudian analysis

confrontation, clarification, interpretation, working through

psychoanalysis: working through

final & longest stage; ct gradually assimilates new insights to personality

characteristics of brife psychodynamic therapies

e.g., Prochaska & Norcross

- time-limited

- target specific IP problem

- use interpretation early

- emphasize strong working alliance & positive countertransference (vs negative)

Harry Stack Sullivan

Sullivan believed that human behavior is motivated by two needs - the need for satisfaction and the need for security. The need for satisfaction is fulfilled by things that meet the individual's biological needs (food, water, shelter, etc.), while the need for security is fulfilled by gratifying experiences with others. Sullivan emphasized the role of anxiety in personality development and psychopathology. As described by Sullivan, excessive anxiety is the result of interpersonal insecurity that can be traced to problems in interpersonal relationships (especially during infancy and childhood) and is the basis for most psychiatric problems.

transtheoretical model: view of maladaptive behavior

doesn't comment on this, just focuses on change processes supported by their meta-analysis

strategic family therapy

- by Jay Haley

- influenced by communication/interaction & structural schools of family therapy

Milan systemic family therapy: view of maladaptive behavior

happens when circular patterns become too fixed/stuck, so family members aren't able to act creatively or make new choices about their lives

behavioral family therapy: therapy goal

alter environmental factors (antecedents, consequences) that are maintaining the problematic bx

Racial/Cultural Identity Development Model: Stage 3

Stage 3: Resistance and Immersion

- actively reject dominant society; show appreciation for self & members of same cultural minority group

- prefers therapist of same racial/cultural group

- perceives their problems as the result of oppression

most basic defense mechanism

repression; underlies all other defense mechanisms; occurs when id's drives/needs are excluded from conscious awareness by living on in the unconscious

reaction formation

avoiding an anxiety-inducing impulse by expressing its opposite

projection

threatening impulse is attributed to another person/external source

psychoanalysis: therapy goals & techniques

goal = unconscious material ➡️ conscious

techniques = analysis (main targets being ct's free associations, dreams, resistances, & transferences); psychic determinism underlies this (all bx's meaningful/functional; e.g., parapraxes (aka Freudian slips))

psychoanalysis: clarification

clarifying ct's feelings & restating their remarks in clearer terms

current status of psychoanalytic therapy abt transference/countertransference

not distortions, but...

transferece: Pt's response to T's actual bx as an attempt to imbue w/meaning

coutnertransference: potential source of info & contributor to the process

Jung's unconscious (personal & collective unconscious)

personal = experiences unconsciously perceived

collective = memory traces passed generationally

Mahler's separation anxiety

conflict btw independence & dependence

gestalt therapy principles rooted in gestalt psychology

(1) ppl seek closure

(2) a person's "gestalts" (perceptions of parts as wholes) reflects their current needs

(3) current behavior represents whole that's greater than the sum of its parts

(4) behavior can only be fully understood when it's in context

(5) we experience in terms of figure/ground principle

motivational interviewing: goals & techniques

goal: enhance ct's intrinsic motivation to alter behavior, by helping resolve ambivalence abt change

techniques: 4 general principles:

(1) express empathy

(2) develop discrepancies btw current bx & personal goals/values

(3) roll w/the resistance! (rather than opposing it)

(4) support self-efficacy

structural family therapy: therapy goals & techniques

goal: restructuring the family is primary goal; can still address short-term goals though

techniques:

- joining = Tp's 1st task; to insert themselves into the system as someone of leadership, involves being chameleon to fit into fam system to "speak their language"

- evaluating family structure = can happen once therapist joined; invovles mapping transactional patterns, etc. to get an idea of the system

- restructuring the family = usually, involves creating an imbalance/disruption of status quo in the family to catalyze growth; can involve enactment and reframing

strategic family therapy: therapy goals & techniques

goals: help current symptosm by changing fam's transactions/organization, esp its hierarchies & generational boundaries; changes in perceptions & emotions facilitate growth

techniques:

- 1st session important

- (very structured) 4 stages:

(1) social stage = Tp watches fam's interactions, tries to get everyone involved

(2) problem stage = information-gathering on reason for therapy

(3) interaction stage = fam discusses identified problems, Tp observes these interactions to learn more

(4) goal-setting = Tp & fam members agree on contract the defines the goals of treatment

overall, therapist is in active, take-charge role

group therapy: premature termination

10-35% of group members drop out w/in 12-20 sessions

pre-screening can help prevent premature termination

psychotherapy outcome studies: Smith, Glass, & Miller (meta-analysis/effect size)

Smith et al. were the first to do a meta-analysis w/psychotherapy outcome research

- meta-analysis = used to combine results of multiple studies by calculating an effect size

- their work contradicted Eysenck's finding -- combined results of 475 outcome studies & found effect size of .85

--> avg therapy client better off than 80% of those untreated that need therapy

acculturation: marginalization

don't identify w/own culture or dominant culture

Ridley's cultural vs. functional paranoia

cultural paranoia = healthy reaction to racism where an African American individual doesn't disclose to White therapist out of fear of being hurt, misunderstood, etc.

--> aka: paranoia that discriminates

functional paranoia = like actual, clinical-level paranoia; unwilling to disclose to ANY therapist, regardless of race/ethnicity; general mistrust suspicion

--> aka: indiscriminate paranoia

telepsychology

any tele- based medium where mental health treatment/assessment is occurring

potential benefits:

- less expensive/more affordable, accessible

challenges:

- confidentiality, privacy

- crossing state lines

- scope of practice

- encryption

- knowledge of local emergency services

triangular model of supervision

- common modern form of supervision

- organizational policies & professional knowledge serve as the foundation

- supervisor relationship is the core - emphais is on providing service to the clients

core features of psychodynamic therapies

- human behavior motivated by unconscious processes

- early development has big impact on adulthood

- universal principles explain personality/behavior

- insight into unconscious processes is key aspect of therapy

Freudian view of maladaptive behavior

psychopathology stems from unconscious, unresolved conflict occurring during childhood

psychoanalysis: confrontation

statements to help client see bx in new way (i.e., the OG guided discovery)

psychoanalysis: interpretation

a step further than clarification; explicitly connecting current bx to unconscious processes

more effective when lifting @ "lower weight" (as in, commenting on material closer to the surface of consciousness) vs. material deeper and more inaccessible

Adler's individual psychology

- more social (than sexual)

- teleological approach = says bx motivated by one's future goals, rather than determined by past behavior

Adler's personality theory

- inferiority feelings develop during childhood as a result of bio, psych, or social weaknesses

- we inherently strive for superiority (or "perfect completion")

- our specific style of compensating for inferiority to achieve superiority

what are Adler's healthy vs. mistaken style of life

healthy style of life = goals reflecting optimism, confidence, & concern about welfare of others

mistaken style of life = goals reflecting self-centeredness, competitiveness, & striving for personal power

how is style of life developed? important factors?

devloped by 4-5 yrs;

affected by early experiences, esp w/family:

- neglected: dominated by need for revenge

- pampered: do not develop social feelings

Adler's view of maladaptive behavior

disorders represent mistaken style of life - maladaptive compensation attempts, preoccupation w/power, and lack of social interest

Adlerian therapy goals & techniques

use "lifestyle investigation" to get info abt family constellation, fictional (hidden) goals, & "basic mistakes"

this helps w/broader process of (a) evaluating lifestyle and (b) reorienting to more adaptive lifestyle

Adlerian techniques applied

- Systematic Training for Effective Teaching (STET) = all bx goal-directed & purposeful; misbehavior of kids has 1/4 goals (attention, power, revenge, or displaying deficiency) and each goal reflecting desire to belong

Jung's analytical psychotherapy

says personality/behavior consequence of both conscious & unconscious factors

Jung's conscious

oriented toward external world, governed by the ego, represents thoughts, ideas, feelings, sensory pereptions, & memories

Jung's archetypes

"primordial images" that cause ppl to experience/understand phenomena in universal way

(i.e., Jung's explanation for universality of certain personality types/patterns)

archetypes of particular importance to personality development

important the self (strives for unity of parts); the persona (public mask); the shadow ("dark side"); anima (feminine) and animus (masculine aspects)

Jung's personality theory: 2 basic attitudes & 4 basic psychological functions

1) extraversion & introveresion

2) thinking, feeling, sensing, & intuiting - all present in everyone; 1 active @ any given moment

Jung's theory on development

continues through the lifespan; Jung most interested in growth in mid-30s

Jung's individuation

key concept in his personality theory; integration of conscious & unconscious, leads to unique identity; accomplishes wisdom

Jung's view of maladaptive behavior

says symptoms are our unconscious saying "hey, something's wrong!"

Jung's therapy goals & techniques

goals: reconnect conscious & unconscious (personal & collective)

strategies: interpretation of dreams & transferences (projections of personal & collective unconscious) to become aware of inner world

why was Jung so interested in dreams?

bc, he says, material in the collective unconscious often expressed symbolically

Object Relations theorists

consider object-seeking (relationships w/others) basic, inherent drive in us; our early relationships w/objects (caregivers) emphasized, especially our internalized representations ("introjects") of these. These become part of the self & influence our interactions w/others later

object-relations theorists

Melanie Klein, Ronald Fairbairn, Margaret Mahler, Otto Kernberg

Mahler's object relations theory

focuses on how we assume our physical & psychological identity;

Phases:

1) normal infantile autism (≤1 month) = infant focused on the self, oblivious to everything else like external world

2) normal symbiotic = we become aware of mom, but can't yet separate "me" vs. "not me"

3) separation-individuation (4-5 mo.) = where object relations developed; includes differentiation, practicing, reapproachement, & object constancy

4) object constancy (by 3 yrs) = we've developed a permanent sense of self & object ("object constancy")

object relations theorists view of maladaptive behaviors (Mahler & others)

result of abnormalities in early obejct relations;

- Mahler: "if they're messed up, it's cause something went wrong with separation-individuation"

- most object relations theorists: "inadequate resolution of "good" vs. "bad" splitting"

- Kernberg: "BPD bc of failed integration w/good vs. bad, thus the oscillation"

object relations theory therapy goals & techniques

goals:

- unconscious relationship dynamics ➡️ consciousness - replace messed up introjects w/better ones

techniques:

- focus on splitting, projective identification, defense mechanisms that maintain messed up Or

shared characteristics of the humanistic therapies

- phenomenological approach (i.e., to understand someone, you gotta know in-depth their subjective experience)

- belief in individual's inherent potential for self-determination & self-actualization

- therapy = authentic, collaborative, egalitarian relationship

- reject traditional assmt & diagnostic labels

humanistic therapies

person-centered, Gestalt, existential, & reality therapy

what are constructivist psychotherapies?

emphasizes client's perceived reality, which is to some extent individually/socially constructed...

- meaning creation > accuracy/rationality of meanings

EX: (paradigm) Kelly's personal construct therapy

Carl Roger's person-centered therapy (aka client-centered therapy)

based on the belief all ppl have innate "self-actualizing tendency", the main process guiding healthy growth

person-centered therapy's personality theory

#1) notion of the self - conceptual gestalt made up of perceptions, characteristics, etc.

#2) ability to self-actualize - Roger's said everyone's got it; we can all reach full potential if self remains unified, organized, & whole

Roger's view of maladaptive behavior

bc of incongruence (discrepancy btw sense of self & external world); can happen via conditional worth (vs. unconditional love).

incongruence --> anxiety signalizing unified self threatened --> attempts to fix this via defenses (which can be counter to self-actualization)

person-centered therapy: goals & techniques

goal:

#1) achieve congruence - so can become functioning, self-actualized person

techniques:

- genuine positive regard (respect): no +/- judgments, just acceptance

- genuineness (congruence): be authentic & honest

- accurate empathetic understanding: see world as client does & convey this

** non-directive & 🚫 diagnosis or transference interpretation! **

gestalt therapy

- Fritz Perls

- says everyone's capable of taking personal responsibility for own thoughts, feelings, & actions and living as an integrated whole"

gestalt therapy's personality theory

we consist of our self & our self-image

self: creative aspect of the personslity that promotes our tendency for self-actualization & our ability to live as a fully integrated person

self-image: "darker side"; hinders growth & self-actualization by imposing external standards

- interactions w/our early environment determine which part prevails

gestalt therapy: view of maladaptive behavior

- neurotic (maladaptive) behavior = "growth disorder"

- caused by abandonment of the self for the self-image, creating lack of integration

- boundary disturbances contribute to this

gestalt therapy types of boundary disturbances: introjection, projection, retroflection, confluence

1) introjection = when you psychologically swallow whole concepts (w/out tasting or parsing through)

--> interjectors = overly compliant

2) projection = disowning aspects of the self by assigning to other ppl

--> can create paranoia in extreme cases

3) retroflection = doing to oneself what you want to do to others

--> e.g., turning anger inward vs. outward

4) confluence = no boundary btw self & environment

--> causes intolerance of difference btw self & others, often underlies feelings of guilt & resentment

gestalt therapy: goals & techniques

goals: integrate aspects of the self to create unified whole

techniques: a lot of role play (e.g., empty chair technique, talking to parts of self); awareness is primary curative factor; client's transference seen as counterproductive, respond to it by emphasizing diff btw "transference fantasy" vs reality; here-and-now/present-focused

existential therapy

logotherapy (Frankl) & other existential therapies:

- emphasize personal choice & responsibility for developing a meaningful life

- assume ppl aren't static, but constantly changing & evolving

existential therapy: view of maladaptive behavior

result of inability to cope authentically with/ultimate concerns of existence (death, freedom, existential isolation, meaninglessness)

--> e.g., existential anxiety vs neurotic anxiety

existential therapy: goals & techniques

goals:

- help Ct live in more committed, self-aware, authentic, & meaningful ways

- recognize freedom to choose own destiny & accept responsibility for changing own life

techniques:

- therapist-client relationship most important tool

- sometimes specific interventions can be used (e.g., paradoxical intention)

reality therapy

- William Glasser

- based on choice theory (previous control theory), which assumes ppl responsible for the choices they make

- focuses on how ppl make choices that affect the course of their lives

reality therapy: personality theory

Glasser: "we have 5 basic innate needs that motivate us.."

1) love and belonging = most important, bc relationships w/others needed to fulfill all other needs

- survival

- power

- freedom

- fun

--> when we fulfill our needs in a responsible way, we've adopted a success identity

--> if not (not fulfilled or done so in irresponsible way), then 've adopted a failure identity

reality therapy: view of maladaptive behavior

- mental illness is result of your choices

--> "you're not depressed bc your father beat you or you have a chemical imbalance, you're depressed because you're choosing to be depressed"

reality therapy: goals & techniques

goals: identify responsible, effective ways to satisfy needs (to develop success identity)

techniques: attention paid to ct's "total behavior"; primary emphasis on actions & thoughts bc these easily controllable

personal construct therapy

- by George Kelly

- focusees on how we experience the world

- assumes we choose how we deal w/the world & there's always alternative options

personal construct therapy: personality theory

our psych processes determined by how we "construe" (perceive, interpret, predict) events, which involves the use of "personal constructs" ( = bipolar dimensions of meaning) (e.g., happy/sad, competent, incompetent, friendly/unfriendly)

- individualized (no two ppl's constructs the same)

- we are like scientists, testing assumptions & reevaluating

personal construct therapy: view of maladaptive behavior

- rejects medical model, says instead it's inadequate personal constructs (e.g., what we're confronting is outside what our construct system equipped to handle)

- hostility --> overreliance/rigidity with constructs, forcing things to fit into them

personal construct therapy: goals & techniques

goals: therapist & ct "co-experimenters" that come up w/tasks to revise ct's personal constructs, in order to better "make sense" of experiences

techniques: some structured tools, e.g., repertory grid (assmt that has ct identify ppl w/various roles in their life); self-characterization sketch (describe self from perspective of close friend); fixed-role therapy (try on acting like someone different/fictional character)

characteristics of brief therapies

- ...well, brief! (i.e., time-limited, ~6-30 sessions)

- present-focused

- therapist has active role

- includes solution-focused, interpersonal, transtheoretical, & motivational interviewing

interpersonal therapy (IPT)

- by Klerman & Weissman, originally for depression, but later for other stuff

- combines CBT & psychodynamic psychotherapy

interpersonal therapy: view of maladaptive behavior

maladaptive bx related to problems in social roles/interpersonal relationships caused by lack of strong attachments in early life

interpersonal therapy: goals & techniques

goals: symptom reduction & interpersonal functioning

techniques: for symptom reduction - psychoeducation, instillation of hope, maybe pharmacotherapy; for interpersonal func. - targeting 1 of 4 problem areas (unresolved grief, interpersonal role disputes, role transitions, interpersonal deficits)

solution-focused therapy

- by de Shazar

- based on the assumption "you get more of what you talk about" (...so instead of talking about it, let's just DO something to fix it!)

solution-focused therapy: view of maladaptive behaivor

says "listen, we don't need to understand where it came from - solutions are ALL that matter!"

solution-focused therapy: goals & techniques

goals: client is the expert, therapist is just there to help ct realize this

techniques: questions like:

- miracle question: "suppose when you go to sleep tonight, a miracle happens & your problem is solved. When you wake up, how will you you know that a miracle has occurred? What will be different?"

- exception question: "can you think of a time in the past week when you did not have the problem (or problem was not as troublesome)?"

- scaling questions: "On a scale from 1 to 10, how did you feel last week?" "on a scale from 1 to 10, how motivated are you?"

transtheoretical model of behavior change

- Prochaska & DiClemente

- derived from recognition that change entails progress through series of predictable changes

- based on analysis fo 18 major approaches to therapy that led to the identification of 10 empirically supported change processes/interventions: consciousness raising, self liberation, social liberation, dramatic relief, self-reevaluation, counterconditioning, environmental reevaluation, reinforcement management, stimulus control, & helping/supportive relationships

- originally, developed for cigarette smoking/addiction

transtheoretical model: goals & techniques

6 change stages:

1) precontemplation: little insight/intent to change; maybe in denial;

2) contemplation: aware of need for change, intends to take action w/in 6 months, not committed to change yet though; might be ambivalent about change & stuck in this stage for a while

3) preparation: plans to take action in immediate future (usually w/in 1 month); has realistic plan of action for modifying behavior

4) action: taking concrete steps to change behavior; often begins with/making public committment to change

5) maintenance: has maintained change in behavior for at least 6 months, taking steps to prevent relapse

6) termination: feels can resist temptation & is confident there's no risk for relapse

**assumptions: change not linear, ppl can recycle through stages, interventions effective when match stage of change

transtheoretical model: mediative variables of decisional balance, self-efficacy, temptation

decisional balance: strength of perceived pros/cons of problem behavior; relevant in all stages, but especially in contemplation stage

self-efficacy: ct's belief they'll be able to cope w/high-risk situations w/out relapsing; important contributor to ct's ability to move form contemplation ➡️ preparation stage

temptation: intensity of urges to engage in problem behavior; inversely related to self-efficacy

motivational interviewing

a collaborative, person-centered form of guiding to elicit and strengthen motivation for change

motivational interviewing: view of maladaptive behavior

like transtheoretical model, doesn't concern itself with how/why developed, but just indiv's ability to change behavior

motivational interviewing: the OARS

Open-ended Q's

Affirmations

Reflective listening

Summaries (type of reflective listening)

influences on family therapy

all influenced to some extent by general systems theory & cybernetics

general systems theory

- first described by Ludwig von Bertalanffy

- says a system is something maintained by mutual interactions of its parts

- these interactions best understood in context

homeostasis (in context of family therapy)

tendency for family to act in ways that maintain family's equilibrium/status quo

- if probs of one fam member improve, disturbance likely to show up elsewhere in the fam

cybernetics

- first described by mathematician

- key feature is idea of feedback loop through which system receives info

cybernetics: negative feedback loop

reduces deviation, helps system maintain status quo

cybernetics: positive feedback loop

amplifies deviation/change, disrupts system

Nathan Ackerman

"grandfather of family therapy"

child psychiatrist that integrated psychoanalysis w/systems approach

Gregory Bateson

background in anthropology, ethnology; cited for work on double bind communication

- double-bind communication for 3+ generations involved in development of schizophrenia

double-bind communication

invovles conflicting negative injunctions

- EX: "do that and you'll be punished"

- EX: "don't do that and you'll be punished"

often one injunction expressed verbally, other expressed nonverbally; recipient of these is not allowed to seek help or comment

communication/interaction family therapy

- grew out of research @ Mental Research Institute (MRI) in Palo Alto from multiple people (Jackson, Satir, Riskin, Haley, etc.