PSYC 401 Final

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psychotherapy

used on person deemed abnormal and in need of help - any attempt to use known psychological principles to bring about improved emotional, cognitive, social adjustment

• involves person who recognized they are in need of help, expert who agrees to help, series of human interactions designed to change person’s behaviour

• don’t need to have a DSM disorder to be treated

levels of psychotherapy

what is most appropriate for each patient’s needs and their reduction of stress

• supportive approaches

• insight with re-educative goals exploratory

• insight with reconstructive goals

supportive approaches of psychotherapy

to resolve equilibrium and doesn’t change personality (guidance, environmental manipulation, reassurances, catharsis, medications, behavioural, psychoeducation, ECT)

used for

• symptom relief

• problems due to environmental stress

• those with limited coping mechanisms

• little capacity for change

• can’t handle anxiety

• those who are unmotivated

• those with lower intellectual functioning

insight with re-educative goals

• achieve insight into more conscious attitudes and conflicts

• insight not deep enough to make significant personality changes

• examines way person relates to self/others and sources of anxiety and tension

• includes client-centred therapy, individual psychotherapy (CBT), various group therapy

insight with reconstructive goals

• achieves extensive insight into personality and how they relate to their self and others

• emotional maturation from extensive understanding

• includes psychoanalysis (longer-term therapies)

is psychotherapy effective?

• 7/10 studies in meta analysis found psychotherapy worked

• effect size = .75 (CBT = .62 - 1.0, antidepressants = .17 - .31, psychodynamic therapy = .69 - 1.8)

• dodo bird effect = all therapies do the same thing

3 approaches to psychotherapy

1. psychodynamic

2. cognitive behavioural

3. emotion-focused

psychodynamic therapy with Nancy McWilliams

• importance of becoming conscious of internal conflict

• emphasis on unconscious factors is central

• emphasis on the past (childhood

• need trusting relationship between patient and therapist

• affect, attachment, personality, defence mechanisms

• let client do most of the talking

• paraphrase

why do people come to psychotherapy?

1. relief from distressing symptoms of psychological disorders (symptom relief)

2. help in dealing with problematic circumstances in their lives (problem resolution)

3. personal enrichment through enhanced capacities to work productively and relate to other people (increased sense of well-being)

patient characteristics in psychotherapy

• psychological good health predicts positive outcome in psychotherapy

• moderate levels of emotional distress to foster progress in psychotherapy (minimal limits person’s involvement in treatment, severe impairs individual’s ability to concentrate on therapy)

• eagerness to enter psychotherapy - high expectations

therapist characteristics

• empathy: listen carefully to patients and respond in ways that demonstrate accurate grasp of attitudes

• warmth: showing positive regard for patients that make them feel safe/secure/appreciated

• genuineness: relating to patients in an open, truthful, authentic fashion

relationship characteristics in psychotherapy

• explicit agreement between patient and therapist concerning goals of treatment + goal pursuit

• consensus on respective tasks to be used in pursuit of these goals

• strong patient-therapist bond to sustain collaboration

• stronger alliance = more effectively therapists repair ruptures = stay in psychotherapy

psychodynamic psychotherapy

• psychic determinism: every psychological event has a reason

• dynamic unconscious: behaviour influenced by thoughts not fully aware of

• substantial influence of early experience

• free association

• increase of self-understanding (insight)

• ~multiple sessions a week

• other: supportive-expressive therapy (combine expressive interventions to promote change with supportive interventions) and interpersonal therapy

cognitive-behavioural psychotherapy

• rational emotive behaviour therapy

• dialectical behaviour therapy

• cognitive therapy

rational emotive behaviour therapy

attributes psychological distress to unrealistic expectations, irrational beliefs, unwarranted feelings

• treatment focuses on what people say to themselves about traumatic events (logically challenged flawed convictions)

dialectical behaviour therapy

useful for working with suicidal patients, substance abuse, eating disorders, BPD, antisocial personality disorders

• warm acceptance of patients an their problems, change-oriented strategies

cognitive therapy

conceptualizes mental disorders as resulting from maladaptive or faulty ways of thinking and distorted attitudes

• concentrate efforts on cognitive restructuring (help people recognize their problems)

humanistic-experiential perspective on psychotherapy

emphasis of uniqueness of individuals, everyone is a product of their distinctive experiences

• people are capable of making constructive changes

• client-centred therapy, existential psychotherapy, Gestalt therapy, emotion-focused therapy

client-centred therapy

focuses on person, not person’s problems - facilitating personal growth through self-awareness, psychological resources, achievement of well-being, fulfillment

• expand self-awareness

• encouraging, supportive engaged

existential psychotherapy

emphasizes anxiety that often attends existence in a confusing world - help people find meaning in their lives

gestalt therapy

attributes psychological difficulties to insufficient contact with oneself and environment

• promote personal growth by sharpening how people experience themselves/free expression

emotion-focused therapy

person-centred, emotional change regarded as essential ingredient of improving one’s life/achieving greater sense of well-being

integrative perspective of psychotherapy

eclectic preference of drawing on many conceptualizations

• technical eclecticism: applies whatever intervention is helpful

• theoretical integration: blends theoretical frameworks to enhance conceptual understanding

• common factors: emphasis core ingredients that characterize all therapies and are effective (strong working alliance, expectation of change, therapist warmth, genuineness, empathetic understanding)

• assimilative integration: therapies favour a theoretical orientation, but draw from other perspectives when appropriate

outcome studies

determine whether psychotherapy works and whether some treatment methods work better

• control group: people on waitlist for therapy or people at the beginning of treatment vs. the end

• dose-effect ratio: how much treatment vs. benefits

• efficacy studies: control and study therapy administration in lab

• effectiveness studies: studying outcome of therapy as it is delivered - external validity

process studies

explore how psychotherapy works with attention to ingredients of treatment and interactions that promote positive change

• progress in psychotherapy ingredients: high expectations, receptivity, positivity, emotional release, attention, exposure

comparative outcome research

many treatment methods show little difference in overall effectiveness (Dodo Bird Effect)

how do treatment outcomes between psychodynamic and CBT compare?

found that psychodynamic therapists applied CBT strategies in addition to psychodynamic strategies

• CBT therapists applied CBT techniques but did not foster a psychodynamic process

• psychodynamic associated with positive outcome consistently

• CBT associated with more rigid techniques

methodology of psychotherapy research

• depends where one is in cycle of developing or refining a therapy

• therapeutic effect may be evaluated through single case studies → small single group designs → randomized control trial

• effectiveness established through field trials

psychotherapy study design concepts

• randomized controlled trial

• correlational process-outcome studies

• case study

• qualitative and quantitative research

• grounded theory: derive theoretical categories from commonalities from multiple observations

• scientific vs. hermeneutic (gaining deeper understanding of target material) research

psychotherapy research cautions

• reductionism

• non-representativeness

• context

• mistaking what is studied for what is important

• false positivism

• emphasis on mental disorders

• therapeutic change is not linear

• manualization

• randomization

• statistical problems

• group results do not predict individual reaction

history of psychotherapy

1. 1927-54: establishing role for scientific research

2. 1955-69: searching for scientific rigour

3. 1970-83: expansion, differentiation, organization

4. 1984-94+: consolidation, dissatisfaction, reformulation

person-centered theory in psychotherapy

starts with client as an agentic whole, strives to create conditions in which client can optimize psychological functioning

• focus on cultivation of warm, understanding, genuine interpersonal connection

• collaboration with therapists

person-centred therapy personality theory (Carl Rogers)

• phenomenological foundations: subjective human experience, perceptual field of individual as their reality, behaviour as perception of stimuli, part of our experiences never stand out as important

• developmental theory: organism has basic tendency to maintain/enhance itself - behaviour always purposeful

• non-directivity: encourage clients to find own path

therapeutic conditions for personality change

• 2 people in psychological contact (client and therapist)

• client in state of incongruence (vulnerable/anxious)

• therapist is congruent in relationship and experiences unconditional positive regard for client, empathy toward client’s internal experiences

• core conditions: congruence, unconditional positive regard, empathy

criticisms of person-centred therapy

• ethnocentrism and lack of appreciation of different cultures

• little evidence that core conditions are sufficient for personality change to occur across all clients

• non-directive stance - challenge with restricting psychotherapists in range of responses

branches of person-centred psychotherapy

• child-centred play therapy

• focusing-oriented psychotherapy

• emotion-focused therapy

• dialogical/relational approaches

• creative person-centred approaches

• pre-therapy

• integrative person-centred approaches

• person-centred experiential counselling for depression

when is humanistic therapy most effective?

for people with interpersonal difficulties, self-damaging activities, chronic health conditions, psychosis

• outcomes: appreciating self, self in relationships, and changed view of self/others

future directions of person-centred psychotherapy

• more process-guiding practices (incorporate experiential and emotion-focused methods)

• develop research into particular client groups that may be particularly suited to branches of this therapy

major features of psychoanalysis

• unconscious

• conflict

• past influences present

• transference

• defence

• psychological causation

features of psychoanalytic therapies

• focus on affect - emotional insight

• exploration of attempts to avoid

• identification of patterns in behaviour

• past experiences

• interpersonal relations

• exploration of fantasy life

goals of psychoanalytic therapy

• therapeutic

• change of personality and character structure

• aid in brining relevant unconscious material to consciousness

• supportive or explanatory

assumptions of cognitive therapies

• how person interprets events predicts how they will respond to them

• patients use maladaptive info processing strategies

• helps patients identify maladaptive beliefs and assess accuracy of beliefs

• use of experiments to test accuracy of maladaptive info processing

cognitive therapies

individual’s affect and behaviour determine by ways they structure the world - cognitions based on attitudes developed from previous experiences, changing maladaptive cognitions to reduce distress

• tend to be highly structured and very active and problem-focused

• provide patients with clear model of their difficulties/disorder

• encourage self-monitoring and assessment of progress

• short-term and time limited

Aaron Beck’s cognitive therapy postulates

• depressed people have negative views of themself, world, future

• distressed people have negative schemas/structures through which they perceive and interpret their experiences

Aaron Beck’s therapy style

• identifying thoughts that lead to stressful thinking

• asks about childhood to understand source of negative thoughts

• directly asks patient what he wants to talk about and solve

• prioritizes alliance always important

5 main themes of psychodynamic thinking

• existence of unconscious contents and processes, influencing defence mechanisms and behaviour always has meaning

• centrality of conflict in human life

• emphasis of early childhood experiences

• importance of representations of self, others, relationships

• emphasis on balancing needs and wishes for dependence and intimacy with independence and autonomy

Sigmund Freud

founder of psychodynamics - transference, levels of consciousness, unconscious thoughts influence, psychic determinism

Alfred Adler and psychodynamics

neurosis due to individual’s perceived sense of inferiority

Carl Jung and psychodynamics

emphasize self as psychological construct

ego psychology

goal: resolve internal conflicts, develop ego strength to mediate id and superego, develop better compromises between those agencies and replace primitive defences

• Erikson: extended psychosexual development through entire life

• defence mechanisms: regression, repression, denial, reaction formation, projection, displacement, sublimation

object relations

personality is shaped by relationship between infant and mother, determined by social context

• most central motivation is close relationships

• focuses on internal representation of self and others, relationships as repetitions of early object relations

attachment theory

individual’s personality shaped by early relationship with primary caretaker

• Ainsworth: 3 types - secure, insecure-avoidant, insecure-ambivalent

self psychology

importance of personal subjectivity, humans constantly work to maintain self-esteem

• self develops from early interactions with significant other who are self-objects (perceived as parts of self necessary for stable sense of self

• therapist fulfills self-object functions absent in childhood

interpersonal psychotherapies

emergence of self in context of relationships

• focus on problems in relationships

relational theory

human primary motivation is to be in a relationship - interactions between self, object, their interactions to create subjective experience

• importance of patient-therapist model

modern short-term dynamic psychopathology

take a more active stance in treatment - recommended for people with greater abilities to self-reflect, change, maintain healthy relationships

supportive-expressive therapy

focus on treatment, transference and core conflicts in relationships

multiculturalism and psychodynamic approaches

impact of ethnic/racial differences between therapist and client - explored cultural narratives, historical trauma, social oppression

depression clinically

• emphasis on loss of an object, internalized anger toward it, low self-esteem, disturbances of early attachments

• idealize others and perceive them as potential rescuers which causes inevitable disappointments and failures

• goal: promote change in patient’s relationships and self-esteem

obsessionality clincally

• OCD and obsessive-compulsive personality disorder

• result of inner conflict over feelings of aggression = use of defences

• Anal triad: orderliness, parsimony, obstinacy

• developmental failure to fuse love and hate, activity and passivity, libido and aggression - fear of negative feelings, causes anxiety

• goal: experience wider range of emotions, decrease sense of guilt, need for self-punishment and defences

• transference common so patients can control therapy sessions

fear of abandonment clinically

• BPD - severe impairment in attachment, tolerating loneliness, anger, sense of self, defences, impulsivity, etc.)

• fear of abandonment = aggression exacerbated by traumatic experiences during early relationships and failure to develop self-representations

• goal: integrate self and object representations, decrease emotional reactivity, increase ability to tolerate aloneness, sustain more stable and healthy relationships, mentalization

low self-esteem clinically

• narcissism: patterns of grandiosity, need for admiration, lack of empathy → unstable self-esteem, feelings of inferiority, constant need for approval, interpersonal exploitation, entitlement

• lack of nurturing and responsive environment = lack of adequate self-objects in early relationships

• goal: develop stronger self-esteem, more accurate self-concept, increased ability to tolerate frustrations

• transference depicts deficiencies in object relations

panic anxiety clinically

• defensive reaction to traumatic experiences, signal of repressed internal conflict

• prone to anger and fearful dependency

• importance of early relationships - traumatic parental experiences leading to conflict between fear of abandonment and control

• goal: developing strong alliance and creating narrative explaining panic attacks, new self-understanding, sense of hope, self-confidence

• transference = struggle over fear of separation and guilt over anxiety

trauma clinically

• uncontrollable/vivid memories - influence on interpersonal relationships and social functioning, emotional avoidance, numbness, detachment

• focus on intrapsychic meaning of trauma, internal conflicts, ambivalence

• goal: help restore sense of control/safety, therapeutic alliance, supportive relationships, going through how trauma shaped patient

• transference = perceiving therapist as abuse

8 mechanisms of making psychodynamic change

• insight

• defence mechanisms

• object relations

• relationship rigidity and transference

• relative function (mentalization)

• corrective emotional experience

• therapeutic relationship

phases of formulation

opening: psychodynamic formulation - assessment, conceptualization, of problems, emergence of symptoms, create treatment plan

middle: create comprehensive narrative of patient’s life course, increase self-awareness

ending: improved self-understanding, reflection, mature defences, confidence

efficacy of psychodynamic therapy on depression

more effective than no treatment, maintains in long and short term

efficacy of psychodynamic therapy on obsessionality

more effective than control for cluster C disorders, maintained in follow-up

efficacy of psychodynamic therapy on abandonment

manualized transference-focused therapy (object relations through transference) and mentalization-based therapy

efficacy of psychodynamic therapy on self-esteem

no research

efficacy of psychodynamic therapy on panic

psychodynamic more effective than control

efficacy of psychodynamic therapy on trauma

other therapies equally effective

Nancy Williams’s psychodynamic therapy

• focuses on each person’s unique view of the world and subjectivity

• understand person in context of relationship with therapist

• attends constantly to transference

• registers subtle data about emotional reactions and associations to understand communication through tone, facial affect, body language

• patients need new experiences, not just new knowledge

• not just one therapeutic mechanism

empty chair dialogue

Gestalt therapy exercise where you face an empty chair and imagine someone or yourself sitting there - speak openly about anything

systematic unfolding

therapy technique that helps person explore an experience in depth, step by step through gradually breaking down each part of the experience (context, attached emotions, meaning now vs. at the time, themes, patterns)

emotion-focused therapy

experience focused, emotional state dependent, integration of person-centred, gestalt and humanistic therapy

• how to work with emotion, working with emotion, transforming emotion

• find core painful emotion, core need - must make it to the painful emotion before you can change it

• collaborative relationship with therapist

ingredients for good emotion-focused therapy

• arousal of emotion

• reflection

• understanding emotion process

• able to access core emotions

early development of cognitive theory and therapies

• Piaget, Chomsky, Bandura

• critical role of language, organization of mental constructs that define meaning, importance of social learning

• importance of cognition when interpreting things

second wave of CBT development

• Ellis and Beck

• rational emotive therapy and cognitive therapy - focus on conscious cognitive constructs in forms of beliefs and thoughts as primary determinants of emotions

• 3 fundamental principles of CBT therapies

3 fundamental principles of CBT therapies

1. meditational hypothesis: cognitive processes mediate response to environment and cause behaviours

2. access hypothesis: cognitive processes not unconscious

3. change hypothesis: modification of cognitive processes yielding positive change

general cognitive therapy model

foundation in beliefs/schemas that individual has adopted are translated to beliefs/assumptions

• beliefs lie dormant until activated by relevant situation

• info processing biases reinforce beliefs, reduce likelihood on considering other evidence

• avoiding threats to beliefs prevents people from learning contrary info

unified protocol for CBT

emphasize commanlities across range of emotional problems - 5 treatment elements

• mindful awareness of emotional states

• cognitive flexibility

• identification of emotional avoidance patterns

• awareness and tolerance of physical sensations of emotional states

• exposure to interoceptive and situational distress

third wave of CBT

• constructivist psychotherapy: unique meaning attached to a thought that was critical for an experience, language is a fundamental way meaning is created

• acceptance and commitment therapy: active creating of meaning through language, uses relational frame theory

• dialectical behaviour theory: constructs, reframing thoughts, behaviour choice - used for severe psychopathology

  • focuses on rigidity, importance of meaning, focus on dialectical processes (stability vs. change, confrontation vs. support, reflection vs. action)

• mindfulness-based therapy: combat negative thoughts through transitional cognitive change methods

core change principles and role of cognitive theory in contemporary CBT

1. modified engagement in individual’s context (ex. exposure to challenging situations)

2. change in attentional processes (ex. attention towards thoughts)

3. cognitive change (ex. diffusion of thoughts)

• utilized in process-based CBT: general treatment processes instead of specific that can be applied more broadly

relationship factors in CBT

• importance of positive therapeutic relationship that is respectful

• collaborative empiricism

• standardized style of interventions may be a deficit to positive treatment

training of CBT therapists

• adherence: extent therapist works within model and does not incorporate ideas from other psychotherapy models

• competence: conceptualize given case and know when to apply a given method and when to not - relies on adherence

Judith Beck’s cognitive therapy

• cognitive therapy effective in variety of psychiatric disorders, medical disorders, with children, couples, families

• time-sensitive, structured, uses info-processing model to understand psychopathological conditions

• role of individual’s views of themself important

• people’s perceptions of situations influence emotional, behavioural reactions - identify automatic thoughts and modify distorted beliefs

• mood checks, bridges between sessions, prioritizing agendas, discussing specific problems, assignments, summaries, feedback

Greenburg’s Emotion-Focused Therapy

• clients learn that emotions tell what is important in a situation - learn to use primary to guide us to what is important

• discover value of greater awareness and more flexible management of emotions

• goal is help clients access to previously avoided feelings/thoughts

• therapist is expert in how/when to facilitate kinds of exploration of experience, but not on client’s experiences - therapy is discovery-oriented

theoretical background of EFT

• client viewed as expert for their own therapy

• process-direction - in collab with client, therapist just guides process in which topics are discused, focused on highlighting on emotion processing

• task analysis

• emotion propels us towards direction, fosters change and therapeutic interventions

task analysis (EFT)

research paradigm to study change processes and develop empirical foundation for EFT practices

emotion-focused therapy

• functioning depends on schemes

• all emotion states embedded within larger emotion scheme of related cognitions, motivation, behaviours

• emotion schemes

• dialectical constructivism

• theory of change

schemes (EFT)

multimodal networks of mentally represented info (affect, motivation, behaviour, physiological experiences, cognition)

emotion schemes

evolved emotion as means of orienting towards fulfillment of needs - many inherently adaptive even if they are distressing

• possible to develop maladaptive ones (don’t accomplish existential needs)

• primary and secondary and instrumental emotions

primary emotions

immediate reactions to stimuli - can motivate meeting unaddressed needs

secondary emotions

in response to other emotions often in attempt to protect from painful feelings

instrumental emotions

expressed to influence expression of others

dialectical constructivism (EFT)

meaning is actively and continually constructed, not just discovered

• top-down reflection to generate emotion and meaning

  • cyclical generation of emotion/meaning through bodily felt sensations, interpretation of sensations, which further impact felt sense

theory of change (EFT)

emotional schemes become dysfunctional when they no longer help seek out existential need - need to transform them or express more adaptive emotion

• activate emotion (amenable to memory reconsolidation)

• awareness of emotion (accept emotional experience)

• down-regulation of emotion (manage intensity)

• arousal and expression of emotion (full engage)

• changing emotion with emotion (undo other emotion states)

• reflection on emotion

EFT research

• found to be more effective than CBT when controlling for researcher allegiance

• individual therapy: reduces symptoms of depression, no sig differences from CBY, associated with greater reduction in interpersonal difficulties

• couples therapy: improved marital satisfaction

• group and family therapy: lower rates of violent recidivism, sig improvements with ED symptoms

EFT theoretical tenets

• therapeutic alliance (mechanism of change, prerequisite for working with vulnerable change)

• emotional arousal and productivity (moderate frequency of high arousal emotion associated with optimal treatment outcome)

• depth of experiencing (extent of emotional reflection)

• narrative processes (ways of emotion reflection)

• sequential order of emotions (global distress → primary maladaptive emotions → expression of unmet existential needs → expression of adaptive emotions that address unmet needs)