Psychotherapy Exam 3

Psychotherapy Orientations

Schools of thought that guide the theory & practice of psychological treatments

Psychotherapy Theory

The ideas, philosophies, &/or scientific principles that inform & underlie the psychotherapy

Therapeutic Techniques

Planned activity/skills used in therapy informed by psychological principles

• Ex. Leaves on a stream, cognitive restructuring

Case Conceptualization

The working model of our client & how they function

The processes we think contributes to the development & maintenance of their psychopathology

Unified and Eclectic Approaches Background

Commonalities among diff orientations

• Theoretical overlap

  • Psychological models & theories that inform the development of psychopathology & treatment

• Similar therapeutic techniques

  • The skills & approaches actually used in therapy

• Shared treatment mechanisms

  • The psychological processes treatment acts on to improve outcomes

• Integrative psychotherapy

  • Broad approach that recognizes commonalities between diff orientations

  • Incorporates ideas & concepts from diff orientations

• Rationale: Both clients & therapists may benefit from flexible use of therapeutic techniques compared to rigid systems

Orientation Overlap

Mind Body Awareness

• Mindfulness; Downward Arrow; 5 Senses

Behavior Modification

• TIPP

Cognitive Flexibility

• Defusion; Downward Arrow; Cognitive Restructuring

Exploration of Past

Integrative Psychotherapy

Broad approach of combining diff psychotherapy orientations

Eclectic:

• Selecting different psychotherapy techniques across 2 or more orientations based on what appears to be best for the current case/situation

  • Ex. Client learns to practice mindfulness in one session & to identify defense mechanisms in another session

Integration:

• Merging psychotherapy theory and techniques of two or more orientations into one cohesive psychotherapy approach

  • Ex. Combining psychodynamic and behavioral theory into a single treatment with a blended theory & approach where clients engage in free association & exposures

Types of Integrative Psychotherapy

Eclectic: picking out diff pieces of individual psychotherapy orientations

• Unsystematic eclecticism

  • Arbitrarily picking & choosing diff techniques w/little theoretical underpinning or integration

  • Poorly informed selection of therapy skills across orientations w/little consideration on how it addresses the client’s presenting problems

• Technical eclecticism

  1. Selecting skills that fit the need of the client

  2. Doesn’t subscribe to a specific theory, but should be based in evidence-based techniques

• Hard to determine what pieces of each orientation are helpful

Integration

• Theoretical integration

  • Blends together theory & techniques of individual psychotherapy orientations into 1 cohesive approach (UP)

  • Synthesizing models of psychopathology & treatment mechanisms from multiple orientations

  • Unclear how merged theories translate to clinical practice w/out a lot of research, hard to test these theories

Technical Eclecticism

Eclectic approach

• Most common psychotherapy orientation

Using multiple orientations to develop a case conceptualization to understand the client’s presenting problems & to select effective therapy skills to match those problems

Case conceptualization may not be grounded in a single orientation, but informed by multiple, well-established theories

As the clinical focus of therapy changes, new strategies or frameworks are introduced

• Case example:

  • Social anxiety disorder & Major depressive episode

  • Relationship anxiety stems from an insecure attachment style from an inconsistent mother

    • Start with managing transference within the therapeutic relationship

  • Current avoidance may be due to the core cognition “I am unlovable”

    • Move to cognitive restructuring

Requires slow, deliberate shifts

Pros and Cons of Eclecticism

Pros:

• Some research supports that matching client problems to specific techniques may be helpful

• Easier to be attentive to client preferences

• Simple to implement

Cons:

• Difficult to study

  • Unstandardized, no manuals

  • Practices vary

    • See unsystematic v. technical eclecticism

• Little research supports using eclecticism over single therapy approaches

Unified Protocol

Integrative approach (theoretical integration)

• Integrates both theory & techniques

• Primarily CBT-focused w/integration of ACT & DBT theory & techniques

Manualized approach blending the theory & therapy skills/techniques of multiple appraoches to address emotion regulation

Developed to treat a broad range of “emotional disorders,” E.g.,

• Anxiety disorders

• Mood disorders

• Mild borderline personality disorder

• Obsessive-compulsive disorders

Manualized

• Focused on improving emotion regulation

The Triple Vulnerability Model

Multiple factors contribute broadly to the development of all emotional disorders

• Biological vulnerabilities

  • Genetic factors that contribute to psychopathology

• Generalized psychological vulnerabilities

  • Learning from early life experiences that increase negative emotions in general

• Specific psychological vulnerabilities

  • Learning to associate specific thoughts, emotions, physical sensations w/danger

Unified protocal

Unified Protocol Therapeutic Techniques

Core modules:

1. Present-focused emotional awareness

2. Cognitive flexibility

3. Addressing emotion tolerance & emotion-driven behaviors (reducing emotional avoidance)

4. Exposures

Present-Focused Emotional Awareness

Identify emotions & reactions to emotions

Develop a more nonjudgemental, present-focused experience of emotions

Based in acceptance-based approaches → contact with the present moment

Mindfulness practices

Unified protocal

Addressing Emotion Tolerance

Identify emotions the client avoids & behaviors they engage in to avoid these emotions

• Emotionally driven behaviors

Develop greater acceptance, reduced avoidance of difficult emotions, reduce emotionally driven behaviors
Based in cognitive-behavioral and acceptance-based approaches

unified protocal

Cognitive Flexibility

Identify automatic thoughts & recurrent patterns of thinking

Develop more flexible thinking

Based in cognitive-behavioral approaches → Downward arrow, Thought records

Unified protocal

Exposures

Broad focus on situations that evoke specific, avoided emotions

Develop inhibitory learning, more flexible behaviors, & tolerance of negative emotions

Based in behavioral approaches

• Interoceptive exposures

• In-vivo exposures

• Imaginal exposures

• Behavioral activation

Pros and Cons of Integration

Pros:

• Easier to study

  • Can develop testable theories

  • Create manualized treatments

• More research supporting efficacy/effectiveness

Cons:

• Difficult to create treatments

  • Merging theory is complex

  • Unclear which techniques to choose

• Little evidence that blending treatments is more effective than focusing on a single treatment

Interpersonal Background

Interpersonal Psychotherapy (IPT)

• Focused on depressive symptoms

• Developed for randomized control trials (RCTs) for depression medications

Developed to be used in tandem with depression medication

• Found evidence that combining medication and therapy is better than either alone

Social-interpersonal focus

• Focuses on attachment and interpersonal domains

Medical Model of Depression

Depression is a treatable illness

• Not a personal failing

Diathesis-Stress Model

Diathesis-Stress Model

Diathesis = Biological predispositions that contributes to the development of symptoms

Stress = Life events that contributes to the development of symptoms

Focus on the Gene X Environment interaction

Interpersonal Sources of Psychopathology

Biological sources like genetics, neurotransmitter imbalance
Environmental sources, specifically social/interpersonal issues including:

• Grief

• Role dispute

• Role transition

• Social deficits from isolation

Interpersonal Focus of Therapy

Improving social functioning to reduce depressive symptoms

Manualized
Active therapist
Focused
Time-limited

• 12-16 weekly sessions

Interpersonal Why Keep It Time Limited?

Therapy, especially earlier interventions, included no time limits

• Catered towards wealthier clients, not those with the most need

Cost-benefit considerations

• Economic burden

  • People with psychopathology more likely to experience financial strain

  • Low socioeconomic status associated with psychopathology

Dose-response curve

• Identifying the “optimal” amount of treatment

• 13-18 sessions may be optimal for most people

• Not a one-size approach

Interpersonal Therapeutic Techniques

Reducing stigma and normalization of experiences

• The sick role

Linking mood and interpersonal contexts

Processing grief

The Sick Role

Applying a medical lens to the problem

• Labelling psychopathology as a treatable illness

• Temporary state

• Recovery focused

• Reduces self-stigma and blame

Linking Mood and Interpersonal Contexts

“How have things been since last session”

• When the client talks about mood, link it to an event

• When the client talks about an event, link it to a mood

“I spent the whole week in my room”

“I felt so lonely this week”

Processing Grief

“Grief” used broadly to apply to loss

• Loss of a loved one

• Loss of a role or identity

Encouragement of affect

• Practicing emotional expression, awareness, and regulation

• Understanding what emotions signal in interpersonal contexts

• Experiencing feelings related to grief

  • Expressing negative emotions

  • Allowing positive emotions without guilt

Identifying unproductive mourning and introducing productive mourning

• Cultivating new interests, relationships, roles

Interpersonal Treatment Mechanisms

Improved social functioning
Improved self-esteem
Decreased rumination

• Reduced repetitive, depressive thinking

Improved emotional processing

• Better able to identify and manage emotions

Systems-Oriented Therapies

Focused on “Systems” which are elements interacting within a group

Systems = elements interacting within a group

• AKA how individuals interact within a social group

  • Parents and children within a family

  • Spouses within a marriage

  • Family system = Individual family members (parents, children) + all interactions across all individuals

• Systems-oriented therapies typically focus on families or couples

  • Definitions of family and couples are expansive to account for different cultural/social norms

  • Therapy includes:

    • Understanding dynamics between individuals within the system

    • Improving individual and system functioning

      • i.e., improving healthy family functioning

Systems Approach to Child Psychotherapy

Children are typically not independent individuals

• Child behavior is, in part, dictated by the family

• Focusing psychotherapy exclusively on the individual (i.e., the child) does not address the effect of the system (i.e., the family) on behavior

A systems approach allows treatment to address both individual and system effects on behavior

• Can change behavior across multiple people in the system

  • I.e., treating both the child and the parent

Variation in how much the psychotherapy focuses on the individual v. the system

Childhood Psychopathology

Psychological issues differ across the lifespan

Developmental disorders

• Psychopathology emerging early in life, infancy or childhood

  • E.g., Attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD)

Non-developmental disorders also occur in childhood, but presentations differ compared to adults

• E.g., Anxiety symptoms in childhood

  • Somatic symptoms like stomach aches

  • Nightmares

  • Irritability, tantrums

  • Difficulties with school

Developmental and other types of psychopathology are highly comorbid

• About 1/3rd of children with ADHD also have an anxiety disorder!

Identifying and treating psychopathology in childhood is challenging

• What is developmentally appropriate?

• Difficulties verbalizing symptoms

  • Externalizing

    • Emotional and cognitive difficulties manifest externally

    • E.g., disruptive or destructive behavior

  • Internalizing

    • Emotional and cognitive difficulties manifest internally

    • E.g., depression or anxiety symptoms

Psychotherapy Approaches for Childhood Psychopathology

Child-focused

• Directly targeting difficulties experienced by the child

• Level of parental involvement depends on the problem, age of the child

• Example: CBT for anxiety in adolescents

Parent-focused (or care-givers)

• Focused on the parent-child relationship and how parents can address difficulties with the child

• Building skills with the parent to improve parenting behavior

  • Also reduces the child’s symptoms and problem behaviors

• Example: Parent Child Interaction Therapy (PCIT)

Family-focused

Child-focused Psychotherapy

Much of the session will only include the child

• Focus on difficulties with the child

• Caregivers will attend some sessions and/or join in for parts of the sessions

  • Parents take supportive, less active role in therapy

Adapted Interventions

Evidenced-based psychotherapies for adults → Tailored to be developmentally appropriate

• Less technical, more kid-friendly

Fewer, less verbal, simplified psychotherapy techniques

• Interactive activities

• Pictures/drawings

Less emphasis on complex topics

• Use of stories, metaphors, and acronyms to explain and remember harder concepts

Parent-reports if child-report not possible

CBT for Adolescent Anxiety

Traditional CBT adapted for children ages 12-17 years old
Simplified ABC model and functional analysis

• Concrete examples using stories

Less focus on core beliefs due to limited cognitive capacity

• More emphasis on behaviors

Focus on identifying emotions via physical feelings

Contingency management

• Target behaviors are encouraged through positive reinforcement

• Providing rewards

Modified therapy techniques example

• ABC Model: Functional analysis

Challenges with Child-Focused Psychotherapy

Addressing only the child’s problems may not improve outcomes

• Parents and family are key in treatment

• Home environment is highly influential on symptoms and behavior

Low psychotherapy engagement for unmotivated children

Parent-Focused Psychotherapy

Session includes both a caregiver and the “target” child

• Focus on difficulties between the parents and child

  • Parent active in therapy

Parent Child Interaction Therapy

Developed to address conduct problems or “antisocial” behaviors:

• Tantrums

• Physical violence

• Rule breaking

• Lying

• Stealing

Reduces the likelihood of parental abuse

Initially developed for children ages 2 to 7 years old

Based in attachment theory, modeling, and operant conditioning

Play therapy

• Using toys and games to practice therapy skills in real time

Overall therapy goals:

• Decrease problem behaviors

  • Negative punishment

• Increase prosocial behaviors

  • Positive reinforcement

Two stages of therapy:

• Child-directed interactions

  • Goal: Increase positive parent-child interactions

• Parent-directed interactions

  • Goal: Increase effective parent commands and child compliance

PCIT Therapeutic Techniques

Child-directed interactions

• Teaches parents to build a warm and responsive relationship during child-led play

• “Special time”

Foundational skills:

• Praise

• Verbal reflections

• Imitation

• Behavioral descriptions

• Enjoyment

• Ignoring inappropriate behavior

Parent-directed interactions

• Teach parents to monitor child behavior and apply consistent consequences

Foundational skills:

• Learning effective commands

  • Start with a brief “why” for the command

  • Direct

  • Calm

  • Specific

  • Positively stated

  • One at a time

• Providing consistent, predictable consequences

  • Time-outs

PRIDE Rule

Praise appropriate behavior

• “I like the way you’re being gentle with your toys”

Reflect appropriate talk

• Child: “I’m mad, it’s broke”

• Parent: “You’re mad because it isn’t working”

Imitate appropriate play

• “You’re drawing a cat. I’m going to draw one too!”

Describe appropriate behavior

• “You’re sharing your teddy with me.”

Enjoy

• Make eye contact, physical touch, show happiness.

Systems Theory

Families seek to balance organization with growth and change

• Family development: The family unit is constantly evolving including changes in relationships and roles

  • Balancing flexibility with stability and structure through specific behaviors

Family health

• Behaviors within a family systems may create healthy or unhealthy family dynamics

Family Health Factors

Key features that influence family health include:

• Attending to basic needs

  • Parent providing food and shelter for their children

• Boundaries

  • Allowing for family members to have some privacy

• Power dynamics

  • Parents serving as the authority figure

• Autonomy

  • Encouraging older children to be independent

• Interactions with outside community

  • Attending social events as a family

• Rules

  • Parents establishing clear, consistent restrictions for the well-being of a child

• Warmth and engagement

  • Spending enjoyable quality time as a family

• Communication norms

  • Establishing how to express needs

• Stress management

  • Strategies to handle family crises

Family Level Sources of Psychopathology

Psychopathology might be at the family and/or the individual level

Family-level

• Family dysfunction occurs when features of family health are absent or extreme

Key feature:

• Attending to basic needs

  • Childhood neglect

• Boundaries

  • “Parentification” of children, enmeshment of child and parental responsibilities

• Power dynamics

  • Parents asserting excessive control over children

• Autonomy

  • Refusing age-appropriate freedom for teenagers

• Interactions with outside community

  • Isolation of the family

• Rules

  • Inconsistent or covert family rules that were not negotiated between family members

• Warmth and engagement

  • Low emotional warmth, few family interactions

• Communication norms

  • Difficulties listening and responding to other family members

• Stress management

  • Maladaptive coping strategies like substance use, violence

Individual Level Sources of Psychopathology

Family therapies focus on the intersection of between:

1. An individual’s symptoms

2. The interpersonal context

   • Family context can increase the risk of psychopathology and worsen or prolong symptoms

Early family therapy focused on changing the family context for clients with schizophrenia

Toxic family stress

• Frequent, continuous emotional stress

Expressed emotion:

• Expression of emotions in unhelpful ways towards a family member with severe psychopathology

  • High levels of criticism

  • Hostility

  • Emotional overinvolvement

    • Overly protective or self-sacrificing

Historical Approaches

Rooted in psychodynamic therapy

Focus on the history of relationships within the family:

• Childhood experiences for each member

• Intergenerational transmission

• Unconscious manifestation of unresolved conflicts

Defense mechanism

Transference, counter-transference

Treatment seeks to manage transference, promote insight, and create positive alliances between family members

Type of family therapy

Present-Oriented Approaches

Focus on repetitive behavioral patterns within the family system:

• Overly broad application of behaviors

• Rigidly applied behaviors

Treatment seeks to enhance family:

• Collaboration

• Problem-solving

• Communication

Identify how unhelpful behaviors are maintained and modify behaviors

Type of family therapy

Functional Family Therapy

Present-oriented approach

Developed to address disruptive behavior problems in adolescents

• Conduct problems

• Substance use

Based in understanding family relationships and how behaviors function within the family

• Influenced by systems theories and CBT

• Understanding what is reinforced in the family that encourages specific behaviors

• 12-14 weekly sessions

• Includes all family members

  • Treatment focuses on applying therapy skills across every family member relationship

    • E.g., Parent-child, child-sibling, parent-parent

Family Therapies Therapeutic Techniques

Five phases:

1. Engagement-Maximizing engagement to attend therapy sessions

   • Establishing trust, listening/recognizing family struggles

2. Motivation-Increasing alliance between members

   • Reducing feelings of blame/hopelessness

3. Relational assessment-Identifying how family behaviors interact and function as well as the thoughts and feelings they cause

   • Reframing behavior

     • Not just labelling an individual’s behavior as good or bad, but understanding intention

     • Moving from external attributions (it’s your fault!) to internal attributions (I take responsibility for my feelings and needs)

4. Behavior change

   • Skills training including improving communication, anger management, managing expressed emotions, improving parental supervision and parenting skills

5. Generalization

   • Extending behavioral skills to other situations and fostering independence with these skills outside of session

Couples Therapies Background

A systems-orientated therapy

• Elements interacting within a group

  • Partners within a relationship

Focused on the health of the relationship system

• Understanding the dynamics between the partners

• Addressing the problems resulting from these interactions

Main goal is to reduce distress for the couple, but not necessarily maintain the relationship

• Maintaining and improving the relationship OR'

• Ending the relationship in a mutual and healthy way

When we use:

• Partners are experiencing distress and/or major relationship problems

• Secondary treatment for when a partner is experiencing psychopathology

  • Developing a support system

  • Repairing damage to the relationship from psychopathology

When we don’t use:

• Domestic violence

• Conflicting, irreconcilable goals

Couples Therapies Sources of Psychopathology

Neither partner is the problem, interactions between the partners are the problem

• Understanding reciprocal cycles within the relationship, how behaviors interact

• Example: Pursuer-distancer cycle

  • Imbalance of autonomy and closeness

  • Results in dissatisfaction with intimacy

4 horsemen of relationships

1. Criticism: Attacking the character of the other partner

2. Contempt: Holding moral superiority over the other partner

3. Defensiveness: Not taking responsibility, making excuses

4. Stonewalling: Withdrawing from or shutting down within interactions

Couples Focus of Therapy

Most sessions include both partners

Establish ground rules

• What if anything will be confidential between partners

• Taking turns talking

• Being respectful

Therapist can’t play sides

Address split alliance

• Building rapport and encourage participation with both partners

Couples Therapeutic Techniques

Behavior modification

Relational tools

Behavior Modification

Couples Therapeutic Technique

Developing a high ratio of positive to negative behaviors

• Positive/negative exchanges

  • Interpersonal events that are perceived as either positive or negative

• Simply creating structured positive exchange reduces the impact for the other partner

  • Sentiment override

    • The views or thoughts around a behavior are just as important as the behavior itself

  • Splitting: One’s partner is viewed as either all good or all bad

    • Positive or negative filters

      • Perception that reshapes a partner’s behavior as either positive or negative

Relational Tools

Couples Therapeutic Technique

Identify family of origin issues that contribute to relationship problems

Skills to improve relationship quality:

• Communication skills

  • E.g., Reflective listening

• Problem solving skills

  • E.g., Defining the problem and collaboratively developing a solution

• Sexual skills

  • E.g., Identifying desire mismatch

• Recognizing and working with behavioral patterns

  • E.g., Tracking patterns and enhancing positive reciprocally behaviors