Theories of Psychotherapy

Medical Model

• Focus: The medical model views health primarily as the absence of disease or physical abnormality. It emphasizes the biological and physiological aspects of illness, focusing on diagnosis, treatment, and the correction of specific problems.

• Approach: In this model, professionals (like doctors) are seen as the experts who diagnose and treat conditions through medical interventions such as surgery, medication, and other therapies.

• Key Characteristics:

  • Focuses on symptoms, diseases, and pathology.

  • Assumes that health issues are primarily caused by biological factors (e.g., infections, genetics, injuries).

  • Treatment is often standardized based on diagnosis, with less emphasis on the patient's broader context (social, psychological, environmental factors).

  • It objectively measures health (e.g., using lab tests, imaging).

• Example: If someone is diagnosed with depression, the medical model might focus on prescribing antidepressants or therapy to treat the symptoms, without necessarily addressing external factors like social or environmental stressors.

Contextual Model

• Three pathways to healing; pathways account for benefit of all therapies

• Step 1: client and therapist form initial bond; then first pathway can be traveled

  • Pathway 1: real relationship

    • Extent to which therapist and client are genuine with each other a perceive each other as real

    • Are you being genuine and honest?

  • Pathway 2: expectations

    • If you expect of hope a solution to work, it is more likely to work

    • Therapy provides seemingly appropriate tasks

    • Client believes that completing tasks will help

  • Pathway 3: specific ingredients

    • Refers to specific components of a treatment

    • All treatment will work because clients will complete tasks on basis of taking pathways 1&2

      • Cognitive restructuring

      • Mindfulness

      • Emotional awareness

      • Behavioral activation

      • Values

      • Opposite action

      • PMR

Client-centered/Rogerian approaches

• Developed by Carl Rogers

Core Concepts of the Client-Centered Approach:

• Unconditional Positive Regard

  • The therapist accepts the client without judgment, showing total support and acceptance regardless of what the client shares. This fosters a safe emotional climate.

• Empathy

  • The therapist deeply understands and reflects the client’s feelings and experiences without imposing their own judgments or interpretations.

• Congruence (Genuineness)

  • The therapist is authentic and transparent with the client rather than adopting a clinical or distant persona.

• Non-directiveness

  • The therapist avoids steering the conversation or offering advice. Instead, they facilitate the client’s own self-exploration and decision-making.

• Self-Actualization

  • The approach is built on the belief that all individuals have a natural tendency toward growth and fulfillment, and therapy should help remove obstacles to this process.

Goals of Client-Centered Therapy:

• Enhance self-esteem

• Improve openness to experience

• Align self-concept with actual experience

• Promote personal growth and autonomy

Strengths:

• Builds a strong therapeutic alliance

• Empowers the client

• Focuses on personal growth and self-awareness

Limitations:

• May be less structured than other therapies

• Might not address severe psychopathologies directly

• Some clients may require more guidance than this model offers

Stuck Points

• Stuck points are irrational or unhelpful beliefs formed in response to trauma or negative experiences.

• They often involve themes of safety, trust, control, self-worth, and intimacy.

• They keep people “stuck” in patterns of avoidance, guilt, shame, or fear.

Stuck Point Category	Example Thought

Self-blame

"The trauma was my fault."

Mistrust

"I can't trust anyone ever again."

Safety

"I'm never safe, even now."

Control

"I should have stopped it from happening."

Guilt/Shame

"I'm a terrible person for what I did/didn't do."

How CBT Helps Address Stuck Points:

1. Identify the stuck point

   • Through journaling, worksheets, or guided discussion.

2. Challenge the belief

   • Examine evidence for and against the thought.

3. Replace it with a more balanced belief

   • Develop healthier, more accurate thinking patterns.

4. Practice cognitive flexibility

   • Use techniques like thought records, Socratic questioning, and behavioral experiments.

Common CBT Tools Used:

• ABC Worksheets (Activating Event – Belief – Consequence)

• Cognitive Restructuring

• Thought logs

• CPT Stuck Point Logs (specific to trauma therapy)

Parent training for ADHD

Core Goals of Parent Training:

1. Improve child behavior

2. Reduce parent-child conflict

3. Support emotional regulation

4. Increase positive parent-child interactions

Key Components of ADHD Parent Training:

1. Education about ADHD

   • Helps parents understand the neurobiological basis of the condition

   • Reduces blame and frustration

2. Behavioral Strategies

   • Positive reinforcement (praise, rewards)

   • Consistent consequences for negative behavior

   • Token economies or point systems

   • Time-outs used appropriately

3. Clear Instructions and Routines

   • Breaking tasks into steps

   • Using visual schedules and checklists

   • Giving concise, one-step directions

4. Managing Attention and Impulsivity

   • Setting up structured environments

   • Limiting distractions

   • Using timers or cues for transitions

5. Stress and Emotion Management for Parents

   • Coping skills to handle frustration

   • Communication skills for co-parenting

Motivational interviewing

• “Collaborative conversation style for strengthening a person’s own motivation and commitment to chance” (Miller & Rollnick)

• Essentially: Communication strategies that encourage intrinsic motivation to change

  • The client HAS TO HAVE motivation, otherwise this won’t work

  • You don’t do MI to someone, you do it with someone

• Ambivalence: having or showing simultaneous conflicting reactions, beliefs, or feelings towards someone or something.

• Goal: work through ambivalence to facilitate change talk

  • Statements that indicate reasons for change, and what might constitute change

• 4 Critical Components

1. Partnership: the ability to work with someone, rather than direct them 

2. Acceptance: 

   1. Acceptance, absolute worth, have unconditional positive regard for every client

   2. Empathy, demonstrating interest in and showing effort to understand another’s subjective reality

   3. Autonomy Support, honoring clients capacity for self-determination

   4. Affirmation, asking about and discussing another's strengths and efforts

      1. Praise can come off patronizing 

3. Compassion: your commitment to do what is in the client’s best interests

4. Evocation: idea that as a therapist you draw out internal motivation for change

• Processes

1. Engage: process by which therapist and client establish a solid work relationship

2. Focusing: process of developing and maintaining a specific direction in conversation about change

3. Evoking: process of eliciting client’s own motivation for change

4. Planing: process of solidifying commitment to change and plan of action

• Techniques

• Open ended questions

  • Question that “invites a person to think before responding” and provides latitude for response

• Affirmation: comments that acknowledge a strength or something positive

  • NOT PRAISE

Relational cultural theory

Ecological systems theory

Multisystemic therapy

Multisystemic Therapy

• Main Goal: decrease adolescent externalizing behavior by working within and across systems in ecological system theory (microsystems, mesosystems, exosystems)

  • “Bad” behaviors- bullying, aggressive/violence

• Principles

1. Finding Fit: assess degree to which factors at various level contribute to problematic behavior

• Youth Factor: unique to the adolescent; impulsivity, emotional regulation

• Family Factor: parent communication style, parent mental health

• Socio-economic Factor: type of job a parent has, are basic necessities available

• Peer Factor: the type of people the client is around

2. Design specific goals and interventions; operationally defined for each client.

   1. Very direct, clear language

3. Interventions should target sequences (steps) within or between systems that maintain problems

   1. Focus on what is CHANGEABLE (malleable)

4. Interventions are designed to required daily or weekly effort by family members

   1. Because changing behavior requires constant practice and routine

   2. MST is a lot of work

Group therapy

Group Therapy

• Generally 5-10 clients meeting together with 1-2 therapist; weekly of 75-90 minutes

  • Clients generally are working towards the same goal

  • Or different goals, same theme

• Content groups

  • Goals are to increase knowledge and/or build skills

  • Usually structure, didactic

• Process-oriented groups

  • Goals is to openly discuss problem and corresponding thoughts/emotions

  • Unstructured, no didactic

• Group Development

  • Stage 1: Forming

    • Members orient themselves to the group; members attempt to establish levels of closeness that have been historically safe

  • Stage 2: Storming

    • Members determine how to maintain their identity while assuming new identity as a group member; essentially this is your reaction to belonging to the group

  • Stage 3: Norming

    • Members tolerate difficulties well as they work towards goals; group focus is flexible; members interact spontaneously

    • Ingerneral: intragroup processes are seen as primary source of learning, because they are linked to outside processes

    • Self concept can change on basis of what the group thinks

Absolute efficacy - Is psychotherapy efficacious [Does psychotherapy work?

• Conjectures - both medical and contextual

  • Psychotherapy is more effective than no therapy

  • with specific ingredients > without specific ingredients

  • without specific ingredients > no therapy

• Relative Efficacy - Are some treatments better than others?

• Medical model: Treatment A > Treatment B for a particular disorder

• Contextual model: all treatments intended to be therapeutic will be effective

Therapist effects - Is there variability among therapists with regard to outcomes?

• Medical model: no, if you are following the treatment instructions

• Contextual model: yes, therapist effects will be larger than effects of specific ingredients

Specific effects - To what degree are specific ingredients of a treatment responsible for its benefits?

• Medical model: removing a specific ingredient from a treatment will weaken it. Adherence to treatment instructions is critical.

• Contextual model: removing a specific ingredient from a treatment won’t matter. Adherence doesn’t matter.

Gestalt Therapy

• Goal: clients should become more aware of their experiences; through this awareness we change

• Paradoxical Theory of Change: we move between who we “should be” and who we “are”.

• Self-awareness, how would you define it?

• Field Theory: we exist in context of environment; problems occur at boundary between person and environment

  • Our problems are focused on: 

    • Figure – aspects of our experience that we focus on 

    • Ground – aspects of experience that we are not focusing on 

• Techniques:

  • Assume ownership of experiences

    • No one else is responsible for what you feel/think/do

    • No feelings are bad feelings

  • Focuses on language

    • “It” or “You” -> I

      • I statements

    • Qualifiers -> directness. No mabes or sort ofs

      • Be direct with your language

  • Focus on phenomenological inquiry

    • Meaning here and now - e.g., “What is happening now? How is it for you to be with me in the room right now?”

  • Unfinished Business/ Empty Chair

    • Occurs when figures emerge from background and emotions regarding them are unresolved

    • Empty Chair Technique:

      • Client explains thoughts/feelings in conflict to an empty chair; then client switches positions and explains response

Social-Ecological Theory (SET)

• Central Tenet: Behavior is influenced by multiple systems, and the interplay among those systems

  • systems=levels

• 4 Systems (lecture on 3)

1. Microsystem: relationship between a person and the environment in an immediate setting containing that person.

   1. Setting = place in which that person engages in activities in particular roles (e.g. daughter, student, etc.)

2. Mesosystem: refers to interrelations among major settings in a developing person’s life.

   1. More specifically: people within those settings

   2. Think connections

3. Exosystem: refers to settings that do not contain the developing person, but influence settings that do.

Group Therapy and Cohesion

Group cohesion refers to the sense of solidarity, trust, and belonging among members of a therapy group. It is one of the most critical factors for group therapy success.

Why Group Cohesion Matters:

1. Emotional Safety:
   Members feel safe enough to open up, share vulnerable experiences, and take emotional risks.

2. Increased Participation:
   Cohesion encourages consistent attendance and active involvement in the group process.

3. Support and Feedback:
   Group members are more likely to offer and receive constructive feedback in a cohesive group.

4. Modeling and Learning:
   Members learn from each other’s experiences, fostering insight and growth.

5. Improved Outcomes:
   High group cohesion is strongly associated with better therapeutic outcomes.

Factors That Promote Group Cohesion:

• Clear goals and group structure

• Trust and emotional safety

• Respectful and supportive communication

• Shared experiences or identities

• Skilled facilitation by the therapist

• Time and consistency—cohesion builds over time

Challenges to Cohesion:

• Interpersonal conflicts

• Lack of participation

• Judgmental attitudes

• Inconsistent attendance