Psychotherapy Exam 1 FInal

Witmer’s Clinic

The first psychological clinic emphasizing diagnostic assessment, interdisciplinary teams, prevention through early diagnosis, and psychological science as the foundation of treatment.

Psychometric tradition

A tradition focused on measuring stable individual differences (traits or characteristics) that vary across individuals and persist over time and situations.

Individual differences

Stable traits or characteristics that distinguish one organism from another and can be quantified and measured.

Nevil Maskelyne and reaction time

Maskelyne observed timing discrepancies in astronomical recordings, leading FW Bessel to identify individual differences in reaction time, influencing psychological research.

Franz Gall and phrenology

Gall correctly proposed functional specialization in the brain but incorrectly believed mental traits were localized in discrete skull regions reflected by bumps.

Key flaw of phrenology

Mental functions arise from distributed neural networks, and skull shape does not reflect psychological traits.

Darwin’s contribution to psychology

Darwin proposed natural variation within and between species, which inspired psychological research on individual differences.

Francis Galton

Galton applied Darwin’s ideas to mental ability, studying sensory discrimination and creating early testing frameworks.

James McKeen Cattell

Cattell developed standardized mental test batteries focusing on sensorimotor functioning and merged psychometric and empirical traditions.

Alfred Binet

Binet expanded testing to higher-order cognition, creating tests for children that assessed comprehension, attention, and suggestibility.

Stanford–Binet test

A widely adopted intelligence test derived from Binet’s original work, emphasizing higher-order cognitive processes.

Clinical tradition

A tradition focused on understanding and changing bizarre, irrational, or disordered behavior by targeting pathology.

Demonological explanations of psychopathology

Early belief that mental illness was caused by possession by evil spirits, leading to practices such as exorcism and trephining.

Trephining

A procedure involving drilling holes in the skull to release evil spirits believed to cause mental illness.

Hippocrates’ four humors

The first medical model of psychopathology, proposing imbalance among blood, phlegm, choler, and melancholy.

Renaissance treatment of mental illness

A shift back to medical explanations, emphasizing institutionalization, often under inhumane conditions.

What happened int he 18th and 19th century after the renaissance institutionalization?

The emergence of moral treatment, focusing on humane care and rehabilitation for the mentally ill.

Phillipe Pinel

Pioneered humane treatment of the mentally ill, demonstrating symptom improvement when patients were treated with dignity.

Benjamin Rush

Father of American psychiatry who advocated humane treatment but also endorsed harmful practices like bloodletting.

William Tuke

Father of British psychiatry who promoted moral treatment while still using problematic medical interventions.

Dorothea Dix

Advocated for state-supported institutions to improve conditions for the mentally ill in the U.S.

General paresis and psychiatry

The discovery that syphilis caused general paresis supported the biological basis of mental illness and revolutionized psychiatry.

“No twisted thought without a twisted molecule”

A phrase reflecting the growing biological emphasis in psychiatry during the 19th century.

Emil Kraepelin

Developed the first systematic classification of mental disorders based on observable symptoms, precursor to the DSM.

Jean-Martin Charcot

Used hypnosis to study hysteria, advancing psychological explanations for mental illness.

After the 19th century what did psychologists begin to do

practice psychotherapy

WWII impact on psychology

Increased demand for psychological services, leading psychologists to provide psychotherapy in hospitals and clinics.

Initiatives after WWII

1946 VA Initiative - increased mental health training, 1955 Mental Health Study Act - studied how both mental illness and care to evaluate the need in the USA, 1963 Community Mental Health Act - provided a grant to establish local mental health centers as an alternative to institutionalization

Did the APA initially resist clinical science?

Yes, the American Psychological Association initially resisted clinical science, focusing more on experimental psychology and research methodologies before gradually endorsing the clinical practice.

What established that PhD clinicans are qualified to practice in the USA?

The 1946 American Board of Examiners in Professional Psychology (ABPP) established to certify that PhD clinicians are qualified to practice

Boulder Conference (1949)

• Adopted Shakow’s recommendations 

• Established the scientist-practitioner model, emphasizing equal training in research and clinical practice.

• APA formed Commission on Accrediation

Scientist-practitioner model

A training model with roughly equal emphasis on psychological science and clinical application.

Shakow Report

• A clinical psychologist should be trained first and foremost as a psychologist scientist, not just as a clinician

• Clinical training should be as rigorous as the training for nonclinical areas of psychology

• Preparation of the clinical psychologist should be broad and directed towards assessment, research, and therapy

Criticisms of Shakow/Boulder model

Too much time spent on research training, to the detriment of clinical training. Not enough training in complex cases.

Not enough time spent on research training.

Many PhD clinical psychologists do not publish any research.

Vail Conference (1973)

Concluded that clinical psychology warranted practice-focused training and endorsed the practitioner-scholar model.

Practitioner-scholar model

Training model emphasizing applied clinical practice, common in PsyD programs.

PsyD degree

A professional doctorate focused on clinical training, typically producing consumers rather than producers of research.

Clinical scientist model

A model emphasizing scientific research as the core of clinical psychology, often accredited by PCSAS.

Criticisms of PsyD model

Concerns about the emphasis on clinical practice over research, potentially leading to a lack of research training and critical thinking skills among graduates.

Psychological Clinical Science Accreditation System

Developed to emphasize scientific rigor and evidence-based practice beyond APA standards.

Mental illness stats

1 in 5 US adults experience mental illnesses

1 in 20 US adults experience serious mental illness.

17% of youth experience a mental health disorder

Odds ratio

A statistic comparing the likelihood of an event occurring in one group versus another.

Who seeks psychotherapy more

More females than males

More gender and sexual minorities

Less racial minorities

Who completes psychotherapy more

Younger adults and lower levels of education usually do not show up for psychotherapy

Unemployed people drop out

Less financial strain

Therapist skills

Communication

Recognize differences and intensities in client’s emotions and be able to put those perceptions into words to convey back to the client

Help the client develop language around emotion and behavior to understand their problems

Relationship building

Balance warmth, empathy, sincerity with motivation, accountability

Self-monitoring

Ability to monitor own biases, emotions, reactions that might interfere with effectiveness

Client factors predicting better outcomes

Motivation, autonomy, openness, cooperation, hope, and low fear of change.

Therapist communication skill

Ability to accurately recognize, label, and reflect client emotions to promote understanding.

Therapeutic alliance

The emotional bond and shared understanding of goals and tasks between therapist and client, consistently linked to outcomes.

Therapist experience and outcomes

Therapists with more experience demonstrate better emotion recognition

Therapists with more experience have lower client dropout rates

Could be biased if a top clinician in their clinic orders their own clients that they want and can do their job well

Mixed evidence that experience matters for symptom reduction

A study on baseline anxiety severity showed that patients with severe anxiety improved with more qualified therapists. On the other hand, the moderate and mild clients benefited from a trainee therapist.

Severe clients may be more complex and nuanced and do not just follow textbook evidence. It is more nuanced than that.

Arguments for and against therapists having to complete psychotherapy before conducting it themselves

• Rationale for mandated personal psychotherapy 

  • Enhance trainee’s capacity for empathy towards client 

  • Gaining insight into therapeutic process

  • Reduce likelihood of harm to their clients 

  • Contribute to personal growth 

• Rationale for not mandating personal psychotherapy 

  • Unnecessary for psychologically healthy trainees 

  • Alternative paths for personal growth 

  • Logistical issues

  • Violation of informed consent 

  • No evidence for an impact on outcomes 

Alliance rupture

A mismatch between therapist and client goals that typically follows a high-low-high pattern and requires repair.

Assessment 

• Receive - from the provider 

• Plan data collection procedures

• Collect assessment data 

• Process data and form conclusions

• Share back

The referral question

• What is it that is unknown that needs to be known? 

• What do I want to know?

Planning data collection procedures 

• How do I find out? 

• Selection of interviews, measures to be administered 

• Weigh information that can be learned from a measure vs the logistics of administration 

  • Time, cost, incremental value

Collecting assessment data

• Interviews 

• Observations 

• Tests 

• Historical records

Processing data and forming conclusions

• What does the data mean?

• Convert the data into interpretatiions and conclusions that addres the referral question 

  • Sometimes might have competing information 

• How best to integrate data from diverse sources?

Communication results

• Write results in an assessment report

• Report should speak to the referral question

• Provides guide for subsequent treatment

Planning and evaluating treatment 

• Diagnosis can guide selection of therapy 

• Regular assessment can document progress and demonstrate treatment efficacy 

How does psychotherapy work?

• Step 1: informed consent. Step 2: planning assessment, etc.

• Step 3: Psychoeducation

  • Providing information about the client’s diagnosis, its treatment, and resources

  •  Can include the client’s family

  • Client has a basic level of understanding of their disorder and options for treatment 

Enhance expectations 

• Small but consistent effect of positive expectations on treatment outcome 

• What factors infleucne expectations 

  • Symptom severity (less severe = more hope)

  • Quality of life

  • Therapist warmth and competence 

    • High warmth high competence is most effective 

Why do expectations matter in psychotherapy?

• Facilitates the therapeutic alliance?

• More likely to complete homework assignments?

• More willing to engage in challenging aspects of therapy?

Placebo effect in psychotherapy

Symptom improvement driven by belief in treatment rather than active ingredients.

Why expectations matter

Positive expectations increase engagement, homework completion, and willingness to face therapeutic challenges.

How to enhance expectations

• Provide assurance that the therapist understands the client’s problem

• Provide assurance that desired changes are possible 

• Provide a theory-based rationale for why treatment will work

  • What is the mechanism and why? IF you cannot explain why is the client gonna do it?

• Facilitate early successes 

  • If you can give the client early on in therapy, that is going to set their expectations higher. 

• Highlights the role of the client’s actions in positive changes 

Insight in therapy

Client’s understanding of the causes and maintenance of their problems, varying by theoretical orientation.

Homework in therapy

Between-session activities that generalize learning and reinforce new behaviors.

Strong therapeutic alliance

• Combining technical skill with interpersonal warmth. Show you know what you are doing but also validating. 

• Communicating a genuine desire to understand the client 

• Supporting the client’s capacity to change

• Create a sense of safety

• Pay attention to body language 

• Provide helpful experiences during the FIRST session. 

Licensure vs certification

Licensure defines permitted services, while certification restricts professional titles.

different roles of state laws vs state boards in psychology

State laws establish the legal framework for practice, while state boards regulate and oversee licensure, ensuring compliance and standards.

Licensure

• Examination for Professional Practice in Psychology 

• Established in 1964 

• Used by all state boards as necessary but not sufficient qualification for licensure

Becoming a licensed clinical psychologist

• Complete a doctorate in clinical psychology 

• Complete a predoctoral internship 

• Complete postdoctoral supervised clinical hours

• Pass the EPPP

• Pass the state jurisprudence exam 

• Submit evidence of all this to state board

EPPP

A standardized exam required by all U.S. states as a necessary but insufficient condition for licensure.

Levels of care hierarchy

Outpatient, intensive outpatient, partial hospitalization, inpatient, and residential care.

Details of levels of care

• Outpatient 

  • Standard, low level of care

  • 1 time a week

  • The patient can come and go

• Intensive outpatient (IOP)

  • Generally, patients can still function

  • 3-4 hours of therapy, 3-4 days a week

• Partial hospitalization (PHP)

  • Therapy is essentially the client’s full-time job

  • Every day, usually 5 days a week, they are coming to the clinical setting and doing therapy roughly 8 hours a day

• Inpatient

  • Crisis management 

  • Someone who is a danger to themselves or others 

    • “I am going to hurt myself”, “I have a plan”

  • They are in the hospital 24/7 

• Residential 

  • A care setting that you could expect to find in a substance use treatment center

  • You live in the treatment center and do regular therapy 

  • Its not about crisis like inpatient, it's about long-term care

Treatment gap

The disparity between those needing mental health services and those receiving care.

Group therapy advantage

Instills hope, universality, altruism, and interpersonal learning through shared experience.

Group cohesion

The emotional bond among group members that buffers conflict and enhances treatment effectiveness.

Conisderations when forming a group

• What is the purpose of the group in helping clients?

  • A specific traumatic event, such as survivors of a disaster.

  • A specific diagnosis, such as obsessive-compulsive disorder.

  • A specific set of skills, such as social skills.

• How homogenous or heterogenous is the group?

  • Does the group consist of a gender or an age group?

  • The group should have sufficient similarity between members to allow for the formation of group cohesion.

  • Each member should be able to readily identify with at least one other member.

  • Sufficient heterogeneity helps the group function as a microcosm for the outside world.

• How long does the group run?

  • Groups can be close-ended, lasting a specific number of sessions.

  • Groups can be open-ended and last as long as the healthcare professional is able and willing to conduct sessions.

  • Sessions typically last 90 to 120 minutes in most treatment approaches.

• How many members does the group hav, and under what circumstances does the group accept new members 

  • Having too many members may exclude some clients from discussions and blur the group's focus.

  • Groups typically have 7 to 10 members in most treatment approaches.

Contraindications for group therapy

High acute distress, low motivation, and nonadherence.

Efficacy of group therapy

• Large improvements in symptoms and those effects stick over time.

• Comparing group therapy for depression vs 1 on 1 psychotherapy for depression

  • Small effect favoring individual 1 on 1 psychotherapy, at a 12-month follow-up, those differences disappeared

Telehealth psychotherapy

Psychotherapy delivered via telecommunications with provider involvement.

mHealth

Mental health interventions delivered via mobile devices, often without direct provider involvement.

• Advantages and disadvantages of digital psychotherapy 

• Advantages

  • Greater accessibility and convenience

  • Many clients feel more comfortable opening up in their own environment

• Disadvatanges

  • Therapists may miss important body language, subtle emotional signals, or changes in affect

  • Concerns about data security or confidentiality can disrupt sessions and affect client trust.

  • Impact on the therapeutic alliance, such as eye contact

  • Digital distractions 

  • Technology issues 

  • Privacy, safety

    • Privacy in the digital space, you do not want to use a not secure, non encrypted platform

    • Crisis management and risk, things get complicated with severe distress

eHealth

• : Uses telecommunication platforms to deliver psychotherapy. Includes telehealth

  • Includes some sort of interaction with a provider

Telehealth efficacy

Research shows telehealth produces symptom improvement comparable to in-person therapy.

• Lack of access to evidence based care (second part of treatment gap)

• Dissemination and implementation science

  • how to more effectively, sustainably, and widely distribute evidence-based treatments in forms that will be integrated and applied in diverse settings

  • Early efforts at D&I relied on emphasizing positive results of RCTs and effectiveness research

Two parts of the treatment gap

The treatment gap consists of lack of access to evidence-based care and underutilization of available services, leading to unmet mental health needs.

strategies for teletherapy difficulties

• Physical discomfort 

  • Stretch and take brief walks between sessions 

• Technology issues 

  • Minimum wifi demand on the network

• Emotional distancing 

  • Focusing on the client’s affect. 

• Remote risk of suicide, violence 

  • Careful monitoring 

Dissemination and implementation science

The study of how to effectively distribute and sustain evidence-based treatments in real-world settings.

• Treatments are promoted actively and disseminated by identifying and addressing organizational barriers

• Emphasizes interpersonal communication between researchers and adopting clinicians

Appropriability theory assumption

• 1. Clinicians will adopt new psychotherapies when emerging research shows they are effective

• 2. Adoption will naturally diffuse throughout clinics

• THIS IS NOT WHAT HAPPENS

Organizational barriers to EBPs

Billing pressure, rigid scheduling, lack of training resources, and leadership resistance.

Big question in psychotherapeutic research

• What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances, and how does it come about?

Alan Kazdin’s outcome goals

Efficacy, effectiveness, and identification of active treatment components.

Efficacy vs effectiveness

• Determine the efficacy of a treatment

  • Can we detect an effect in a laboratory setting under highly controlled conditions?

• Determine the effectiveness of a treatment 

  • The degree to which a treatment works in real-world applications 

Statistical vs clinical significance

Statistical significance reflects chance probability; clinical significance reflects meaningful life change.

• Statistical significance 

  • Likelihood results are found by chance

• Clinical significance 

  • Does the client feel and act more like somebody without the disorder

  • May or may not be statistical significant

Addtional goals for psychotherapy research

• Assess the durability of benefits

• Identity side effects 

• Identify treatment moderators 

  • Is the treatment more effective for specific people

• Identify cost-effectiveness

• Determine which delivery method works best 

• Understand mechanisms of treatment effects 

  • Why does it work?

Within-subject design 

A research design where participants are compared to themselves across different conditions or time points. This method allows for controlling individual variability.

• Between-subject design

A research design where different participants are assigned to different conditions or groups. This method helps to compare the effects of treatments among distinct groups.

Randomized controlled trial

A highly controlled between-subjects design emphasizing internal validity and treatment fidelity.

• Between-subjects designs 

• Super controlled, high internal validity 

  • Random assignment 

• Very restrictive inclusion criteria

  • The prototype of a given disorder 

  • Recruit people who are the most prototypical for depression

• People need to be a specific amount of disordered (specific amount depressed)

• Excluded for depression, or for a certain amount of time, number of episodes, etc. 

• High treatment fidelity 

  • A treatment manual

  • Trying to control inconsistencies 

    • We know this treatment was administered this way to everyone

  • Assess symptoms every session rigorously 

N=1 or case studies

• Little external validity 

• Good for rare disorders