Psychotherapy Notes

Introduction to Psychotherapy

• Common Misconception: Psychotherapy is only for "crazy people."

• Alternative View: Psychotherapy can be a valuable tool for many.

• Origin: Psychology evolved from explaining abnormal behavior (psychopathology).

• Psychotherapy isn't for everyone, but many find it beneficial.

• Chapter Overview:

  • Exploration of diverse approaches to treating mental disorders.

  • Discussion of treatment provision.

  • Examination of goals, techniques, and effectiveness of therapies.

  • Discussion of recent trends, including institutional treatment changes.

  • Personal application: Finding and choosing a therapist.

  • Critical thinking application: Determining therapy effectiveness.

Elements of the Treatment Process

• Sigmund Freud: Credited with launching modern psychotherapy (~1880).

• Talking things through: Freud and a colleague found that talking about emotionally charged experiences cleared up a patient's symptoms. Talking through issues releases bottled-up emotions.

• Psychoanalysis: Freud's new treatment procedure developed from the insight that talking things through can help.

• Psychoanalysis descendants: As Freud's followers developed their own systems of treatment. Approaches to psychotherapy have steadily grown more numerous, more diverse and more effective.

Treatments: How Many Types Are There?

• Many treatment methods: Mental health professionals use varied approaches.

• Expert estimate: Over 400 different treatment approaches.

• Three Major Categories:

  • Insight Therapies

    • Talk therapy, in the tradition of Freud's psychoanalysis.

    • Complex verbal interactions with a therapist.

    • Goal: Increased insight & sorting through possible solutions.

  • Behaviour Therapies

    • Based on learning principles.

    • Focus on changing problematic responses and maladaptive habits.

  • Biomedical Therapies

    • Involve interventions into a person's biological functioning.

    • Drug therapy and electroconvulsive (shock) therapy.

    • Dominant mode: Drug therapy.

    • Provided by doctors with a medical degree (usually psychiatrists).

Clients: Who Seeks Therapy?

• Full Range: People seeking treatment represent all human problems.

• Examples: Anxiety, depression, relationship issues, habits, self-esteem, etc.

Prevalence of Mental Disorders in South Africa

• First Nationally Representative Study: Conducted in 2014.

• Lifetime Prevalence: 30.3% for any disorder.

• Most Prevalent: Anxiety disorders.

• Gender Differences: Mood/anxiety more common in women, substance use in men (Herman et al., 2009).

• Statistics: More than 17 million South Africans deal with mental health issues.

• Proportion: About one-third of South Africans suffer some form of mental illness.

• Treatment Access: 75% will not have access to treatment.

• System Issues: Overburdened and understaffed; severe cases prioritized (Tromp et al., 2014).

• COVID-19 Impact: Mental health of nearly two-thirds of South Africans worsened during lockdown (Msomi, 2020).

• Overall: Lack of resources means many don't receive therapy (Tromp et al., 2014).

Reasons for Not Seeking Treatment

• Perception of Need: Influenced by knowledge, impairments, illness nature, & stigma.

• Stigma: Serious barrier; equates seeking therapy with weakness/cultural deficiency (Hugo et al., 2003).

• Inaccessibility: Reluctance to seek/continue services (Bruwer et al., 2011).

Utilisation of Mental Health Services in South Africa

• Service Delivery Levels:

  • Primary: Clinics, healthcare centres, district hospitals.

  • Secondary: Regional hospitals.

  • Tertiary: Provincial hospitals.

  • Quaternary: Specialised hospitals.

• Insufficiency: Psychological/psychiatric services insufficient at all levels.

Accountability in Public Health Care

• Monitoring: Achieved through patient feedback system.

• Research: Provides insight into the effectiveness and reasons for premature termination.

• Benefits: Understanding of therapeutic interventions and impacts on clients.

• Therapist-Client Alliance: Positive correlation with client retention.

Outcome and Session Rating Scale

• Description: A psychometric instrument or standardised scientific test, with international recognition.

• Research Support: supported by extensive research.

• Brief Process: Client feedback should be brief (Duncan et al., 2003; Miller et al., 2004).

Client-Centred Approach

• Therapeutic Alliance: Clinicians often overrate therapeutic alliance.

• Client Perspective: A more reliable predictor of therapeutic adherence (Miller, 2004).

• Outcome Evaluation: Client provides information based on their experience.

• Real-Time Feedback: Allows evaluation of approach and tracking progress.

• Controls: Service delivery, quality, and client retention.

Reality Check - Misconception on Seeking Psychotherapy

• Misconception: Seeking psychotherapy is a sign of weakness; people should be able to deal with their problems.

• Reality: This is a prejudicial belief that prevents many people from seeking the help they need. Psychological disorders can be severe, debilitating illnesses that require treatment. Recognising that one needs help is more a sign of courage than weakness.

Insight Therapies

• Commonality: Involve verbal interactions to enhance self-knowledge and promote changes.

Psychoanalysis

• Sigmund Freud: Developed innovative techniques for the treatment of psychological disorders and distress.

• Dominance: Dominated psychiatry for many decades.

• Influence: Psychoanalytic approaches to therapy remain influential today.

Logic of Psychoanalysis

• Emphasis: Recovery of unconscious conflicts, motives, and defences.

• Origins: Freud treated anxiety-dominated disturbances (neuroses: phobias, panic, OCD).

• Cause: Neurotic problems caused by unconscious conflicts from early childhood (see Chapter 11).

• Defence Mechanisms: People depend on them to avoid conflicts but are only partially successful.

• Figure 15.1: Illustrates Freud's view of the roots of disorders related to intrapsychic conflict, anxiety, and defence mechanisms.

Probing the Unconscious

• Goal: Discover unresolved conflicts causing neurotic behaviour.

• Techniques: Free association and dream analysis.

• Free Association: Expressing thoughts/feelings spontaneously with little censorship.

• Dream Analysis: Interpreting symbolic meaning of dreams.

• Case Example: Mr. N's treatment:

  • Problem: Unsatisfactory marriage, preferring prostitutes.

  • Background: Marital issues with his parents.

  • Dream: Waiting for a red traffic light when someone bumped into him from behind.

  • Associations: Love of cars, especially sports cars; racing past slow, old, expensive cars.

  • Father: Hinted at being a great athlete but never validated.

  • Therapist's Interpretation: Sexual overtones in the dream. Competition toward his father was based on associations.

  • Later Interpretation: Difficulties rooted in Oedipal complex (sexual feelings toward his mother and hostility toward his father).

Resistance and Transference

• Resistance: largely unconscious defensive tactics intended to hinder the progress of therapy (Samberg & Marcus, 2005).

• Reason: Avoid confronting painful conflicts.

• Dealing with Resistance: Handling of transference.

• Transference: Clients start relating to their therapists in ways that mimic critical relationships in their lives.

• Therapist's Role: Encouraging transference to bring conflicts to the surface.

• Undergoing psychoanalysis is a slow, painful process of self-examination that generally requires 3-5 years of hard work.

• Goal: Profound insights by effectively handling resistance and transference.

• According to Freud, once clients recognise the unconscious sources of conflicts, they can resolve these conflicts and abandon their neurotic defences.

Reality Check - Misconception About Psychoanalysis

• Misconception: Lying on a couch and talking about the past.

• Reality: As you will see throughout Chapter 15, there are many approaches to treating psychological disorders, and in the vast majority of them, clients do not lie on a couch and discuss their past.

Modern Psychodynamic Treatments

• Adaptations: Psychoanalysis adapted to different cultures and times (Karasu, 2017).

• Contemporary Approaches: Many modern psychodynamic approaches (Gold & Stricker, 2017).

• Core Features:

  1. Focus on emotional experience.

  2. Exploration of efforts to avoid distressing thoughts and feelings.

  3. Identification of recurring patterns.

  4. Discussion of past experience.

  5. Analysis of interpersonal relationships.

  6. Focus on the therapeutic relationship.

  7. Exploration of fantasy life .

Client-Centred Therapy

• Emergence: Human potential movement (Carl Rogers, 1951, 1986).

• Alternative Names: Person-centred therapy.

• Incongruence: Inconsistency between self-concept and reality (see Figure 15.3).

• Cause of Distress: Incongruence leads to defence mechanisms and restricted growth.

• Figure 15.3: Illustrates Rogers' view of the roots of disorders related to incongruent self-concept, anxiety, and defensive behaviour.

• Aim: Fostering self-acceptance and personal growth.

Therapeutic Climate

• Warm, supportive climate: Safe environment for confronting shortcomings.

• Three Conditions:

  1. Genuineness (honest communication).

  2. Unconditional positive regard (non-judgemental acceptance).

  3. Accurate empathy (understanding the client's point of view).

Therapeutic Process

• Client and therapist work as equals.

• Key task: Clarification.

• Therapist: Functions like a human mirror, reflecting statements with clarity.

• Aim: Reconstructing client's personality.

Group Therapy

• Definition: Simultaneous treatment of several clients in a group.

• Role of Therapist: Selecting participants, setting goals, maintaining the therapeutic process.

• Group therapies obviously save time and money, which can be a critical factor in understaffed mental hospitals and other institutional settings - a vital consideration in South Africa's mental healthcare landscape.

Couples and Family Therapy

• Marital/Couples therapy: Involves the treatment of both partners focusing on relationship issues.

• Family therapy: Involves the treatment of a family unit, focusing on family dynamics.

• Goal: Understanding fixed patterns that cause distress.

Insight Therapies

• Therapies inspired by positive psychology.

• Philosophical Approach: The field has historically focused far too heavily on pathology, weakness and suffering (and how to heal these conditions), rather than on health and resilience

Effectiveness of Insight Therapies

• Outcome Evaluations: Often subjective, with diverse problems at different levels of severity.

• Findings: Consistently indicate that insight therapy is superior to no treatment or to placebo treatment and that the effects of therapy are reasonably durable.

• Studies generally find the greatest improvement early in treatment (roughly the first 10 to 20 weekly sessions), with further gains gradually diminishing over time.

How Insight Therapies Work

• Common Factors: Therapeutic alliance, support, hope, rationale, and opportunity to express feelings.

• Importance: Development of a strong alliance between therapist and client; that is, a sense of their working together to achieve change (Fluckiger et al., 2018).

Behaviour Therapies

• Focus on changing clients' maladaptive behaviours.

• Not necessary to achieve grand insights about themselves.

• Two Main Assumptions:

  • Behaviour is a product of learning.

  • What has been learned can be unlearned.

Systematic Desensitisation

• Devised by Joseph Wolpe (1958).

• Definition: Behavior therapy to reduce phobic responses.

• Figure 15.5: Classical conditioning and systematic desensitisation.

• Three Steps:

  1. Building an anxiety hierarchy.

  2. Training in deep muscle relaxation.

  3. Working through the hierarchy while relaxing.

• Effectiveness: Proven successful in reducing phobic responses.

• Real-Life Exposure: Becoming treatment of choice for anxiety disorders (exposure therapies).

Social Skills Training

• Goal: To improve clients' social abilities.

• Methods: Modelling, behavioural rehearsal, and shaping.

• Benefits: Promising results in the treatment of depression, schizophrenia, attention-deficit/hyperactivity disorder and especially autism spectrum disorder.

Cognitive-Behavioural Treatments (CBT)

• Cognitive Factors: Play a key role in anxiety and mood disorders.

• Definition: Use combinations of verbal interventions and behaviour modification techniques to help clients change maladaptive patterns of thinking.

• Examples: Rational-emotive behaviour therapy (Albert Ellis) and cognitive therapy (Aaron Beck).

• Cognitive Therapy: Correcting habitual thinking errors.

• Goal: Change clients' negative thoughts and maladaptive beliefs (Wright et al., 2014).

Automated training programs.

• Cognitive training programmes can reduce individuals' attention, interpretation and prediction biases.

• New Interventions which have been applied to quite a range of disorders: These include but are not limited to; social anxiety disorder, panic disorder, depression , eating disorders, addictive disorders and obesity.

Effectiveness of Behaviour Therapies

• Wide application on treatment of phobias, obsessive-compulsive disorders, sexual dysfunction, schizophrenia, drug-related problems, eating disorders, psychosomatic disorders, hyperactivity, autism and intellectual disability.

Biomedical Therapies

• Definition: Physiological interventions to reduce symptoms.

Treatment with Medication

• Four Major Groups: Anti-anxiety drugs, antipsychotic drugs, antidepressant drugs, and mood stabilizers.

Anti-Anxiety Drugs

• Reduce tension, apprehension, and nervousness.

• Examples typically include Valium and Xanax.

Antipsychotic Drugs

• Used primarily in the treatment of schizophrenia and are used to gradually reduce psychotic symptoms.

Antidepressant Drugs

• Gradually elevate mood and help bring people out of depression; examples include SSRIs.

Mood Stabilizers

• Used to control mood swings in patients with bipolar mood disorders; examples include lithium and valproate.

Evaluating Drug Therapies

• Controversies: Critics argue about effectiveness, over prescription, side effects, and pharmaceutical influence in research.

• Critics maintain that the negative effects of psychiatric drugs are not fully appreciated because the pharmaceutical industry has managed to gain excessive influence over the research enterprise as it relates to drug testing.

Reality Check - Misconception about psychological disorders.

• Misconception: Psychological disorders are largely chronic and incurable.

• Reality: The vast majority of people who are diagnosed as mentally ill eventually improve and lead normal, productive lives. Even the most severe psychological disorders can be treated successfully.

Electroconvulsive Therapy (ECT)

• ECT still used in treatment today. Proponents include Charles Kellner.

• ECT Underutilisation: Advocates believe public believes misconceptions about its risks and side effects.

• Risks: Memory losses, impaired attention, and other cognitive deficits.

Institutional Treatment in Transition

• Traditional Approach: Treatment occurred in mental hospitals.

Deinstitutionalisation

• Definition: Transferring treatment to community-based facilities that emphasise outpatient care.

• Auxiliary institutions have risen because of the demand for more admission into mental treatment facilities.

• Deinstitutionalisation is a difficult process even under better circumstances.

Stigmatisation of Psychiatric Patients

• Stigmatisation: Stereotypes and predominantly negative judgements made about a group of people.

Current Trends in Treatment

• Increased Multicultural Sensitivity: Recognizing cultural impacts on abnormal behaviour and treatment.

Role of Traditional Healers

• Increasing interest in this in post-apartheid era. They provide an alternative understanding for abnormal behaviour.

Using Technology to Expand the Delivery of Clinical Services

• Delivery: The use of Technology has taken many different forms such as both individual and group therapy using phone.

• Benefits: Interventions delivered via the internet hold promise for reaching larger groups of people who might otherwise go untreated.

Blending Approaches to Treatment

• Eclecticism: Drawing ideas from two or more systems of therapy.

• Modern psychotherapy was created in a cultural environment that viewed the person as an independent, reflective, rational being, capable of self-improvement.