Week 4

Different types of therapies: psychoanalytic/psychodynamic; CBT; cognitive, behavioral, and humanistic

Freud’s theory of personality and psychopathology

As you’re developing, PHYSICAL symptoms without a physical cause are the manifestation of mental issues. Behavior and behavioral problems are caused largely by unconscious conflicts among id, ego, and superego

Id

Source of wants, desires, impulses; like a baby. Particularly sexual and aggressive in nature

Ego

Mediator between id and superego. In contact w/ external world, functions in real life

Superego

Internalization of social rules; what you should or shouldn’t do. Delay of gratification

Defense mechanisms

Unconscious mental strategies or routines that the ego employs to ward off the anxiety produced by intrapsychic conflicts. Helps manage anxiety

Denial

Being unable to recognize or acknowledge threatening experiences

Repression

Anxiety-provoking thoughts and memories disappear into the unconscious

Regression

Retreating to coping strategies characteristic of earlier stages of development

* example: crying a lot because of stress, subconscious expectation that coping skills from childhood will magically resolve things now

Projection

Attributing one’s own negative motives and impulses to others

Reaction formation

Adopting thoughts and behaviors that are opposite of one’s own

Displacement

Directing pent up impulses toward a safe substitute rather than the target around those impulses

Rationalization

Providing socially appropriate, but untrue, explanations for one’s undesirable behavior

Intellectualization

Dealing with upsetting experiences in an overly logical manner

Compensation

Coping with feelings of inferiority in one area by working to become superior in another area

Sublimation

Channeling the expression of unacceptable impulses into a more socially acceptable activity

Psychoanalysis

How do we bring unconscious processes to the conscious level? Why are these unconscious processes occuring? How do we help the client’s ego manage the id and superego?

Psychoanalytic therapist roles

* Maintain a neutral (“analytic incognito”) stance in order to help clients explore their unconscious conflicts, impulses, and fantasies
* Analyze everyday behavior, dreams, transference, and resistance

Goals of psychoanalytic therapy

* Help clients gain conscious and emotional insight into the underlying causes of their problems
* Work through, or fully explore, the implications of those insights for everyday life
* Strengthen the ego’s control over the id and the superego and thereby bolster clients’ mastery over their sources of conflict

Psychoanalysis as a therapy and as a route toward understanding

* Resolve problems by bringing unconscious conflicts to the surface so the ego can deal with them
* Takes time and can be painful
* Patients must be comforted and guided through this process
* Therapeutic alliance, with power through transference and countertransference
* Seeming contradictions of thoughts and behavior can be resolved
* Leads to idea of the unconscious
* Use of free association; the talking cure
* Hypnosis
* Dream analysis

Transference

The process of unconscious redirection of feelings from one person to another, often based on past experiences or relationships.

countertransference

Unconscious emotions and attitudes that a therapist projects onto a client, based on their own past experiences. It can impact the therapeutic relationship and hinder objectivity.

Psychic determinism

Miracles, free will, and random accidents do not exist

* Freudian slips \[saying orgasm instead of organism\]

Unconscious

Areas and processes of the mind of which a person is not aware at all

Resistance

A process in which clients behave in ways that interfere with the psychoanalytic treatment process

* Disagreeing with therapist, not showing up, avoiding talking about difficult topics from previous sessions

Insight

A client’s conscious awareness of the underlying causes of psychological problems

Working through

Fully exploring the implications of insights gained in psychoanalysis

Critiques of Freud

Too much emphasis on sex and aggressive id impulses

Psychodynamic psychotherapy

Kept some of Freud’s ideas, but modified and built on them.

Differences of Psychodynamic therapy vs psychoanalysis

* Focuses on positive aspects of growth and personality and
* The nature, strength, and consequences of the attachment or bonding that occurs in early relationships with caregivers
* Sees the therapeutic relationship as healing in itself

Adler’s individual psychology

* Strives to overcome feelings of inferiority/helplessness (overprotection or underprotection in childhood) NOT aggressive or seuxal impulses
* Importance of social motives and social behavior
* Focused on interpretation of current behavior to promote insight

Jung’s analytical psychology

Humans are born not just with sexual and aggressive drives, but also drives for creativity, growth-oriented resolution of conflicts, and the productive blending of basic impulses with real-world demands

example: black sheep perception of self

Ego psychology

Focuses on current problems and bolstering adaptive ego functioning, and establishment of firm identity and intimacy

* Ego has its own goals
* Focus on more mature defense mechanisms

Object relations therapy

Modifying mental representations of interpersonal relationships that stem from early attachments and using the nurturing therapeutic relationship to support change

Relational psychodynamic psychotherapy

* Focuses on the interpersonal rather than intrapersonal contexts in which disorders appear
* Importance of relationships with caretakers and exploraition of the “intersubjective space” created jointly by client and therapist

Short-term psychodynamic psychotherapy

* Focuses on a current crisis or problem
* Quickly form a therapeutic alliance
* Encourage clients to adopt coping strategies to deal with specific problems within specific domains

Current status of psychodynamic psychotherapy

* Psychodyanmic psychotherapy is more popular than classical psychoanalysis
* Second most popular after cognitive/cognitive behavioral
* Psychodynamically-oriented research publications are on the rise
* Some forms of psychodynamic psychotherapy yield results that are comparable to those of therapies identifies as empirically supported
* Some clinicians are less ideological and combine psychodynamic techniques with cognitive behavioral features
* Acknowledgement of id, ego, and superego

Broad differences in psychoanalysis

* Individual psychology (Adler)
* Analytical psychology (Jung)
* Ego psychology
* Object relations therapy
* Relational psychodynamic and postmodern psychotherapy
* Short-term psychodynamic psychotherapy

Individual psychology (Adler)

Striving to overcome feelings of inferiority; importance of social motives

Analytical psychology (Jung)

Humans are born not just with sexual and aggressive drives but also drives for creativity, growth-oriented resolution of conflicts, and the productive bending of basic impulses with real-world demands

Ego psychology (Erickson)

Focus on current problems; bolster adaptive functioning and establishment of firm identity and intimacy

Object relations therapy

Modifying mental representations of interpersonal relationships that stem from early attachments’ using the nurturing therapeutic relationship to support change

Relational psychodynamic and postmodern therapy

The interpersonal rather than the intrapersonal context in which disorders appear. Importance of relationships with caregivers and exploration of the “intersubjective space” created jointly by client and therapist

Client and therapist have different perceptions

Short-term psychodynamic psychotherapy

Focus on current crisis of problems’ quickly form a therapeutic alliance and encourage clients to adapt to coping strategies and deal with specific problems

Interpersonal psychotherapy (ITP) basic assumptions

* IPT contains elements of Harry Stack Sullivan’s interpersonal theory and John Bowlby’s attachment theory
* Psychological problems are closely related to difficulties in relationships and interpersonal losses and transitions

Role of therapist in ITP

Supportive guide (coach)

Focuses the discussion on interpersonal issues and their links to psychological issues

ITP main treatment methods

Identify links between interpersonal problems and current symptoms:

* Loss of a loved one
* Ongoing conflict with family members, friends, or coworkers
* Major life changes that result in social role transition
* Not having enough significant interpersonal relationships

Analyze communication patterns that may contribute to interpersonal difficulties

Explore positive and negative aspects of key relationships and interpersonal role transitions

Practice relating to significant others in new ways, including through role-plays

Current status of ITP

Beneficial in treatment of acute depression, keeps less severe depressive symptoms from becoming acute, and preventing the reappearance of depression

Holds promise for treatment of eating disorder, anxiety disorders, and substance use disorders

Potential for use in community settings and low- and middle-income countries

Person-centered therapy (Rogers)

Create a therapy relationship featuring unconditional positive regard, empathy, and congruence

Use active listening and reflection to help clients become aware of their true thoughts and feelings, and thus restart blocked self-actualization

Themes across person-centered therapies

Assume clients’ lives can only be understood from the viewpoint of those clients, must take clients’ lens

View human beings as naturally good people (rather than instinct driven) who are able to make choices about their lives and determine their own destinies

Focus on amplifying clients’ strengths rather than just addressing the problems

See the therapeutic relationship as the primary vehicle by which treatment achieves its benefits

Importance of experiencing and exploring emotions that are confusing or painful and stress the importance of focusing on their immediate, here-and-now experiences

Goals of humanistic psychotherapy

Clients and experts viewed as equal

Help clients become clearly aware of their true thoughts and feelings and other experiences that conditions of worth may have suppressed

Provide an interpersonal relationship in which clients can feel accepted and free to be honest about how they really are and how they really think and feel

Unconditional positive regard

The therapist attitude that expresses caring for and acceptance of the client as a valued person

* Client doesn’t try to please therapist

Conditions of worth

The impression that a person’s ability to gain love and acceptance is dependent on their own thinking, feeling, and acting in ways that are approved

* Too many conditions of worth block self-actualization

Therapist empathy

Therapy must try to see the world as the client sees it in order to help the client understand their behavior

Incongruence

Ideal self and real self don’t match up; too many conditions of worth

Congruence

Ideal self and real self match up; you are the ideal person you’d like to be

Gestalt therapy (Fritz and Laura Perls)

Seeks to create conditions in which a client can become more unified, more self-aware, and

* Use **active methods**, such as a focus on the immediate present, role-playing, internal dialogues, attention to non-verbal messages, and the empty chair technique (imagine you’re talking to this person. now you are them)
* Help clients identify the interpersonal games they play, reject phony aspects of themselves, and get in touch with their true thoughts and feelings

Existential humanistic psychology

Use a combination of psychodynamic and person-centered methods to help clients in their potentially frightening search for the meaning of their lives.

Motivational interviewing

Uses reflection and other aspects of person-centered therapy that encourages clients to make decisions about how to solve their problems.

Emotion focused therapy

Use a supportive therapeutic relationship and a combination of directive and nondirective methods to help clients to become aware of and modify emotions associated with their problems

Current status of humanistic therapy

Relatively few therapists identify as humanistic.

Empirical evidence does not support it, but it is difficult to study because treatment goals and methods are not clearly articulated in advance

No approach to psychotherapy has done more than the humanistic approach to highlight the importance of the therapeutic relationship

The humanistic vision of the therapist and client as collaborators rather than as “doctor” and “patient” is attractive to many therapists, especially psychodynamic therapists

Theoretical foundations of behavior therapy

All behaviors seen in psychological problems develop through the same laws of learning that influence the development of other behaviors

Classical concditioning

When a neutral stimulus (musical tone) comes just before or otherwise signals the arrival of another stimulus (pin-prick) that automatically triggers a reflexive response, that neutral stimulus becomes a conditioned stimulus that will elicit a version of the reflexive response

Operant conditioning

When certain behaviors are strengthened or weakened by the rewards or punishments that follow those behaviors

Observational and vicarious learning

When behaviors are learned by watching how others behave and what happens to them as a result

Assessment in behavior therapy

Gather detailed info about a client’s problematic behaviors, the environmental circumstances under which these behaviors occur, and the reinforcers and other consequences that maintain the behaviors via:

Functional analysis and structured interviews

Functional analysis

Gathering info about environmental factors taht trigger and support behaviors. Examines the response trigger (stimulus), person responding (organism), response component (behavior), and consequence

Role of therapist in behavior therapy

Create empathic and supportive context in which specific techniques can operate to create change

Focus actively and directly on clients’ making changes in their environments, internal responses, and overt behaviors

Goals of behavior therapy

Help the client modify maladaptive overt behaviors and the cognitions, physical changes, and emotions that accompany those behaviors, and

The environmental contingencies that make it hard to sustain healthy, adaptive choices

Clinical applications of behavior therapy

Applied to wide variety of treatment packages

Each is tailored to address particular sets of problematic behaviors

Exposure therapy

Face and interact with frightening stimuli

* Systematic desensitization
* Progressive relaxation training (PRT)
* In vivo gradual exposure vs. flooding
* In vivo: Fear of planes: look at pictures of planes, going to the airport, then going on a plane
* Flooding: Go right to the plane and use relaxation techniques
* Exposure and response prevention
* Exposure techniques used for anxiety and OCD
* Seeking reassurance could be a compulsive response

Social skills training

Help clients develop skills necessary to establish and maintain satisfying interpersonal relationship and other social reinforcers

* How to shake hands, make eye contact, and conversation with roleplay
* Useful as component of treatment of adults with schizophrenia, depression, anxiety, and a variety of childhood disorders, including delinquency, adhd, asd
* Assertiveness training is especially valuable for use with adults whose inability to effectively express their needs and wishes to resentment, aggression, or depression

Behavioral activation and activity scheduling

Helps clients engage in behaviors that will provide more reinforcement from the environment and move clients closer to achieving their goals

* Useful for depression, social anxiety, and grief

Aversion therapy and punishment

Painful or unpleasant stimuli are used to decrease the probability of unwanted behaviors such as drug use, alcohol use disorders, smoking, and non-consensual sexual practices

* considerable debate about the ethics and effectiveness of aversion techniques, so hey are generally used as a last resort

Theoretical foundations of cognitive therapy

Identify, evaluate, adn change clients’ maladaptive cognitions

Principle is that a set of core beliefs of underlying automatic negative thoughts contribute to a variety of negative emotions and problematic behaviors

Beck and Ellis beliefs

In addition to events themselves, our interpretations of events have a big impact on how we feel

Our interpretations can vary in how accurate and helpful they are

We tend to develop patterns or cognitive styles

These negative cognitive styles can be activated so readily hat they are called automatic thoughts and they contribute to a variety of negative emotions and problematic behaviors

Cognitive mediation

The concept that normal and abnormal behavior is routinely triggered by our appraisals, attributions, or interpretation of events, not just the events themselves

Cognitive triangle

Thoughts, feelings, and behaviors are constantly interacting and influencing each other. Bidirectional relationship

Schemas

The organized knowledge structures or associations in memory that influence how we anticipate, perceive, interpret, and recall information. Our thoughts are guided by them

Automatic thoughts

Important mental events can take place without the client’s conscious awareness, such as cognitive distortions and cognitive biases

Cognitive distortions

* Dichotomous (all-or-nothing) thinking
* Overgeneralization
* Catastrophizing
* Personalization
* Selective abstraction
* Jumping to conclusions
* Fortune-telling error
* Mind reading
* Emotional reasoning
* Unrealistic expectations
* “Should” and “must” statements
* Labeling: “I’m unworthy”

dichotomous thinking

Tendency to view things as black or white, with no middle ground. Simplifies complex issues into two opposing categories. Limits understanding and hinders critical thinking.

Overgeneralization

Drawing broad conclusions based on limited evidence or experiences. Leads to making sweeping statements or assumptions without considering all relevant factors.

Personalization

Believing that others are putting the blame on you or that you are the one at fault for a situation that you are not at fault for.

Selective abstraction (magnification, minimization, disqualifying the positive)

The tendency to overshadow good information with the bad. Ex: “I got one “bad” and 10 “goods” in this evaluation-- i’m failing)

Emotional reasoning

Believing that emotions are always logical and can always dictate your behavior

Assessment in cognitive therapy

Involved developing a detailed understanding of the triggers, associated emotions and behaviors, and characteristic beliefs and assumptions that underlie the client’s automatic thoughts

Role of therapist in cognitive therapy

To build a storng therapist-client alliance and engage clients in active examination of the client’s beliefs and assumptions, especially the client’s negative emotional experiences and associated cognitive distortions

What is often seen in assessment during cognitive therapy?

Negative views about the world are global, stable, and internal

* Global- not just about one specific area of life
* Stable- consistent into the future
* Internal- negative views are about oneself

Goals of cognitive therapy

Educate clients about the role of maladaptive thinking in determining emotions, behaviors, and a range of relationship and other experience

Help clients learn to recognize when they engage in unhelpful thinking

Teach them skills to re-evaluate their maladaptive thoughts and generate more adaptive ones

Methods of cognitive therapy

Cognitive restructuring

Beck’s cognitive therapy

Ellis’ Rational-Emotive Behavior Therapy (REBT)

Psychoeducation

Re-Evaluating and replacing maladaptive thoughts

Socratic questioning and guided discovery

Thought records

Continuum technique

Beck’s cognitive therapy

Focuses on the assumption that depression determines the way that we think. Arises from biases and cognitive distortions. How can we change and challenge these automatic thoughts?

Rational Emotive Behavior Therapy (REBT)

Directly attacks irrational beliefs; more confrontational than traditional cognitive therapy. Instruct client on how to have more adaptive thinking patterns

Psychoeducation

Describe to a client what’s going on; how their thoughts may impact their behaviors

Socratic questioning

Asking simple questions to explore a situation. “I wonder if… What advice would you give to a friend in this situation…”

Continuum technique

Identifying when it is or isn’t appropriate to experiencing extreme emotions

Theoretical foundations of Cognitive-Behavior therapies

CBT combines the theories and techniques of behavior therapy with those of cognitive therapy. Systematic and structured

Has wide appeal and shown efficacy in relieving symptoms of many different disorders

Clinical applications of CBT and Acceptance-Based Therapies

Assess range of difficulties and try to see cognitive connections between them

Track progress in modifying core beliefs

In final phase, client encouraged to continue progress and become the therapist

Integrating CBT and Acceptance-Based approaches

Third wave methods emphasize attention to and acceptance of emotional experiences and clients’ personal values

* Mindfulness
* Acceptance and Commitment Therapy (ACT)
* The Unified Protocol
* Dialetical Behavior Therapy (DBT)

Mindfulness

Close observation and acceptance of one’s current experience without judging it

Intentionally living with awareness in the present moment, without attachment to and without judging the moment

Acceptance and Commitment Therapy (ACT)

Goal is to enhance psychological flexibility, the ability to engage fully in the present moment and respond to the situation at hand in a way that is consistent with one’s values

Work to identify primary values and assist in making changes to act and think in ways more consistent with the values

Decentering- strategies to help clients gain distance from their thoughts