Clinical Psych Exam 3
Prior to 1950’s—subjective support
1950’s: start of controlled empirical studies
* Hans Eysenck: published a historical study concluding that most people improve on their own psychotherapy in general is of little benefit.
* Results hrb since been overturned
* Many empirical studies conducted in the 1960’s and 70’s
* Led to the meta-analysis
* Meta-analysis: combines the results of many separate studies to create numerical representations of the effects of psychotherapy cars massive numbers of settings, therapists, and studies.
* Have yielded consistently supportive results
Who Should Researchers Ask? Where are we getting our Data?
Hana Strupp: Identified 3 parties who have a stake in how well therapy works
* the client, therapist, society: can take the form of any outsider to the therapy process who has an interest in how therapy progresses (e.g., the legal system, client’s family and friends, managed care companies, client’s boss, etc)
* When should researchers ask?
* Immediately after therapy ends?
* How should researchers measure the outcome of psychotherapy?
* Can use questionnaires or interviews
* Many use more behavioral measures of therapy outcomes
Efficacy V.S. Effectiveness:
Efficacy: the extent to which psychotherapy works in controlled research study (in the lab)
* Efficacy studies maximize internal validity by controlling as many aspects of therapy as possible.
* 3 common features of efficacy studies:
1. Well-known group off clients
2. Manualized treatment guidelines
3. Random assignment of clients in a controlled groups and treatment groups
Effectiveness: the extent to which psychotherapy works in clinical settings (irl)
* Effectiveness lacks the internal validity of efficacy studies, but typically has greater external validity.
* 3 common features of effectiveness studies
1. Include a wider angle of client
2. Allow a greater variability between therapists methods
3. May or may not have a control group for comparison
Results of Efficacy:
There’s been thousands of efficacy studies that have been conducted
Reviews and meta-analysis have reached the same conclusion: Psychotherapy work!
Psychotherapy isn’t a panacea (answers to all the worlds problems)
* There continues to be a divide between those who conduct efficacy research on psychotherapy and those who practice therapy
* Clinicians and Academics
Bridging the Gap Between Research and Practice:
After asking 700 therapists, research found that efficacy studies had little influence over their choices. (Gyani, Shafran,Myles, and Rose, 2014)
* Why? —> numerous dissemination strategies have been employed to get therapists on board
* The strategy that has received the most attention?
* A: Practice-oriented research
* Increasing collaboration between researchers and practitioners
Results of Effectiveness Studies:
Effectiveness studies aren’t conducted frequently. but they yield positive results
* Surveyed its subscribers about their experiences w/ psychotherapy. Found that psychotherapy had positive, lasting effects for the vast majority of respondents.
* Methodological Criticisms: Potential sampling bias, How many would have improved from therapy, How reliable or valid is the client’s self-reports?
What types of Psychotherapy is best?
* Studies designed to compare different therapies against each other have all yelled similar results: TIE!
* Competing therapies are often found to work about equally well
The “dodo bird verdict”: “Everybody has won all must have prizes”
How could such different theories have similar results?
* All share some form of common factor to be successful.
Therapeutic Relationship/Alliance:
Alliance: a partnership between 2 allies working in a trusting relationship toward a mutual goal.
* Thought to be the most important role in therapy: strength of the bond is epically important from the clients pov
* A “good” therapist's relationship can be a result of many factors. But the overarching qualities is empathy and
Other Common Factors:
Hope or positive expectations
* Therapists generally provide an optimism that things will begin to improve
Attention: also known ad the Hawthorne Effect
* This stems forms the classic organizational psych studies in which factory workers performance improved as a result of being observed
* Clients may have previously tried to ignore problems that are later addressed in therapy.
Reconsidering the Dodo Bird Verdict:
The dodo bird theory has been challenged
* Some have argued that certain psychotherapies are superior
* Diann Chambless has argued against the idea that al psychotherapy approaches are equally efficacious
* Chambless proposes a prescriptive approach to therapy. Specific therapies are counseling of choice for specific symptoms/diagnosis
What Types of Psychotherapy Do Clinical Psychologists Practice?
* Division of clinical psych… (Division of 12 APA) members have been surveyed multiple times since 1960’s regarding the type of orientation of psychotherapy they practice.
* Eclectic/Integrative was most commonly used until 2010
* Endorsement of psychodynamic/psychoanalytic therapy has declined significantly since 1960
* Cognitive therapy has become very popular since the 80’s
* Endorsing a singular orientation often use other techniques as well
Stages of Change:
Stages of change model…
1. Precontemplation Stage: No intention to change
2. Contemplation Stage: Aware that a problem exists, considering doing something you address is but to ready to fully commit to any real effort
3. Preparation Stage: Intending to tackle action within a short time (weeks, a month)
4. Action Stage: Actively changing behavior and making notable efforts to overcome their problems
5. Maintenance Stage: Preventing relapse and retaining the gains made during the action stage
* Therapists must assess the stage their clients are in when they seek therapy
Future Predictions of Psych:
Increase of tele-psychology
* Therapy based on culture and diversity for clients
* Mindfulness based approaches to therapy
* Cognitive Behavioral therapy (CBT)
* Motivational interviewing (MI)
Eclectic V.S. Integrative Approaches:
Eclectic: involved selecting the best treatment for given client asked on empirical data from studies of the treatment of similar clients
Integrative: involves blending techniques in order to create an entirely new, hybrid form of therapy.
* Integrative approaches have increased in popularity since the 1980’s
Psychodynamic Psychotherapy:
* The term psychodynamic psychotherapy cover an extensive range of therapies
* Based on Freud’s organic work (but also the work for Carl Jung, Alfred Adler, Erik Erickson, Harry Stack Sullivan, etc.)
* Has been referred to by other names: psychoanalysis, psychoanalytic psychotherapy,neo-freudian theory.
Primary Goal: make the unconscious conscious
* Cinets should gain insight (looking inside oneself and noticing something that had previously gone unseen)
* The existence of the unconscious s the one of Freud’s most enduring contribution to clinical psychology
* Freud’s definition of the unconscious: “mental processes that are outside the awareness of the individual and have important, powerful influences on the conscious experiences.”
Accessing the Unconscious:
Psychodynamic psychotherapists attempt to understand their client’s unconscious
processes in a variety of ways:
1. Free Association
2. Freudian Slips
3. Dreams
4. Resistance
5. Defense Mechanisms
6. Transference
All of these methods are inferential
* Psychodynamic psychotherapist attempt to understand unconscious processes through influence and deduction
Free Association:
Demonstration Exercise…Take few mins and write down whatever comes to mind (w/o censoring yourself)
Free Association: technique which the therapist simply asks clients to say whatever comes to mind w/o censoring themselves
* May sound straightforward, free association distinct from word association (associated with Jung)
Freudian Slips:
* There is no such thing as a random mistake, accident or slip
* If behaviorism can;t be explained by motivation we’re consciously aware of, unconscious motivations must be the cause
* Psychodynamic therapists who witness Freudian’s slips may be able to glimpse client’ underlying intentions
* Most Freudian slips are verbal, but can be behavioral as well
Dreams:
Psychodynamic therapists believe that our dreams communicate unconscious material.
* Freud believed that when we sleep our minds convert latent content (raw thoughts and feelings of the unconscious) to manifest content (the actual plot of the dream as we remember it)
This process is called the dream work & it uses symbols to express wishes, which can result in unconscious wishes appearing in disguised or distorted forms
* Clients often assist in interpreting dreams
Resistance:
* When sensitive issues come up during a session, clients will respond with resistance
Ex: changing the subject, showing up late for appointments
* When clients feel that certain unconscious thoughts or feeling are being discussed too extensively or too quickly, they fell anxious
* Motivates them to create distractions or obstacles
* When therapists notice resistance, this indicates to them that they likely found an important topic to explore.
Defense Mechanisms:
* Bringing defense mechanisms to the client’s attention can improve clients’ lives
* What personality components produce defense mechanisms?
ID: part of the mind that generate all the pleasure seeking, selfish, indulgent animalistic impulses
Superego: the part of the mid that established rules, restrictions and prohibitions
Ego: the mediator, makes the compromises between the id and the superego
* One way the ego can handle id/superego conflict is through defense mechanisms
Projection:
Ego attributes its own unacceptable impulses, motives and desires.
Ex: the ego “projects” the id impulse onto other people around us
Example: an employee who represses their desire to be aggressive @ work may project their anger onto their boss and claim that it is actually the boss who is
hostile.
Transference:
Transference: referees to the clients tendency to form relationships w/ therapists in which they unconsciously and unrealistically expect the therapist to behave like an important person from their past.
* Client “transfers:” the feelings, expectations and assumptions forum early relationships
* The relationships we form in our early years shape our expectation for future relationships
* Therapists want to help clients be aware of their transference tendencies
Psychosexual Stages of Development: Clinical Implications
* Stages of Development: oral, anal, phallic, latency and genital
* At any stage these fixations can occur
Fixation: as children move through the developmental stages, they may become emotionally “suck” at any one of them to some extent and may continue to struggle w/ issues related to that stage for many years
* Most often occurs due to parental responses to a child’s needs
Psychosexual Stages: Oral Stage
* The oral stage takes place in the first year and a half of a child’s life
* Children experience all plausible sensation through their mouth (feeding)
* Associated w/ common “oral” behaviors later in life: smoking, overeating, drinking, nail biting, etc.
* Primary Issue: Dependency: parents overindulge children in the oral stage—children may learn depending on others always worked
* Ma result in overly trusting, naive, and unrealistically positive
* Conversely the child might become closed off and not trusting if they’re tended to enough during this stage
Psychosexual Stages: Phallic Stage
Stage Age: 3-6 years old
* Most controversial stage as it includes the Oedipus and Electra complexes—many of these ideas have fallen out of favor
* Children want to be close w/ their parents and have a special relationships remains key to the stage
* Primary issue: Is the child able to form a special relationship w/ their parents shapes the child’s view of self (their self-worth)
* Parents respond too positively… child may become narcissistic, grandiose view of themselves
* Parents don’t pay attention or have much positive things to say at all…child may develop anxiety and have low self worth
Contemporary Forms of Psychodynamic Psychotherapy:
Psychodynamic therapy has been reinvented many times.
* Has always been one of the longest and most expensive forms of psychotherapy
* led to the development of many forms of brief psychodynamic psychotherapy
* Definition of brief varies but typically fewer than 4 sessions
* Specific forms of brief varies, but typically fewer than 24 sessions
* Specific forms of brief psychodynamic psychotherapy: Interpersonal Therapy (IPT), Time limited Dynamic Psychotherapy
Transference Prt.2:
After identifying transference issues, therapist will likely offer an interpretation of the transference and bring it to client’s attention
* Clients may not fully understand or accept the interpretation.
* Interpretations are frequently re-vaulted houghton the course of therapy (working through the process)
* The “blank screen” role of the therapists is essential to psychodynamic therapy. Being objective as possible
* Therapists reveal little baotou themselves verbally and non verbally
* Just like clients can transfer over to their therapists, the therapists can do the same to their clients
It’s called countertransference!
Therapists strive to avoid this
* It involved reacting to the client in a way that is unconsciously distorted by the therapists own personal experiences
Interpersonal Therapy (IPT):
* Developed in the 1980’s to treat depression but has been used to treat other disorders
* Last 14 to 20 sessions
* Focuses on current interpersonal relationships and role expectation. Specifically these areas contribute to depression (or other psychopathology):
1 Role Transitions
2. Interpersonal Deficits
3.Grief
4. IPT proceeds in 3 stages:
1. Categorizing clients problems into one of the first 4 categories discussed (2 sessions)
2. Intermediate stage involves improving problems identified in the first stage (10-12 sessions)
3. Finally review the client’s accomplishments, efforts to prevent relapse (2-4 sessions)
One of the few forms of psychodynamic therapy w/ a large amount of empirical support
Evidence is primarily from the studies w/ depressed clients
Time-Limited Dynamic Psychotherapy (TLDP):
Provides the client with a ‘corrective emotional experience” 20-25 sessions
* Remember the brief the client's bring to therapy the same transference issues that they bring to other relationships.
* Therapists make the client aware of these patterns, and offer healthier alternatives . And more realistic ones
* Relationships between therapist and client is primary tool for change
Client’s Issues are organized into 4 categories:
1. Acts of self: how a person actually behaves in public Ex: their behavior on the first date
2. Expectations about the other’s reactions Ex: what the client thinks they were perceived on the date
3. Acts of others toward the self Ex: interpretations of their social interactions on the date
4. Acts of self toward the self. Ex: how do you treat yourself in response to the date?
* These help clients be aware of their behaviors (problematic and non problematic)
Empirical Support:
* Define and measure outcomes of psychodynamic theories is very hard
* Many try to measure the outcome
* Mixed evidence
* Empirically sound studies have even very few and far between
Word of Caution:
Allegiance Effects: the influence of a researcher’s own biases and preferences on the outcome of their empirical studies
* Surprisingly strong relationships between the away therapies were rated and the orientation of the researcher doing the rating (Luborsky et. al., 1999)
Original of Humanistic Psychotherapy:
* Founded by Carl Rogers and Abraham Maslow
* Roger’s was trained psychodynamically but disagreed w/ freud’s ideas
* Belief that people are basically good or neutral, but not bad
* Note: Humanistic therapy has also been referred to as: non directive, client-centered, and person-centered
Humanistic Concepts:
* People tend to build self actualization
Positive Regard: the warmth, love and acceptance of those around us
* Typically get positive regard from your parents
* It should be unconditional
Primary Goal is to foster self-actualization…
* Psychopathology is the result of a stifled growth process
* The therapist has to create a climate in which clients can resume their natural growth toward psychological wellness.
Condition of Worth:
* Condition positive regard has limited view of you being “prized if only” we meet certain conditions. I.E. conditions of worth
* VS unconditional self actualization = you’re always prized no matter what
* Children are typically aware of these conditions, try to meet them
* When compared to the “real self” and meeting those standards their potential “ideal self” they perceived as discrepancy or incongruence.
* Congruence: a match between the real self and ideal self
Essential Therapeutic Conditions:
* Therapists fosters the client’s self-healing tendencies toward growth
* Involves 3 necessary Conditions:
1. Empathy
2. Unconditional Positive Regard
3. Genuineness
Empathy:
Empathy: a deep, nonjudgmental understanding of the client’s experiences in which the therapist's own values and point of view are temporarily suspended
* Therapists who emphasizes this accurately and communicate this it the clients positively impact the client
Unconditional Positive Regard:
Unconditional Positive Regard: Full acceptance of another person
* The therapist accepts the client in totally rather than conditional way
* Allows the client to grow in a self directed wat w/ no concern about losing respect or acceptance from the therapists
Genuineness:
Empathy and unconditional positive regard aren’t helpful unless they are honest
* Therapists shouldn’t act empathetic…they truly need to show empathy and prize the client unconditionally
* Therapists Transparency is encouraged: this is very different from the psychodynamic idea of being a “blank screen”
Necessary and Sufficient?
Roger’s encourage empathy, genuineness and unconditional positive regard were both necessary and sufficient conditions for successful therapy
* Additional techniques or procedures are necessary
What does research suggest?
* This has been very controversial and has generated a lot of reset to test the assumptions
* General Conclusion” these conditions ARE necessary but not sufficient alone to cause change in all clients
Reflection:
* Humanistics don’t offer many specific suggestions on what therapists should do w/ clients (ie specific techniques) but focus on how therapists should be w/ clients (therapists attitudes)
* Humanists believe that reflection can contribute to success of therapy
* Roger’s did not want thi to be mechanical wooden response
Motivational Interviewing:
An offshoot of humanistics therapy
Originally developed to rest addictive behaviors (substance abuse)
* Centers on addressing client's ambivalence or uncertainty about making major changes to their way of life
* MI therapists do not pressure clients to make changes. The client must make the change on their own
* Often label clients to be ambivalent about change as resistance denial or lack of motivation
Central Principles of Motivational Interviewing MI:
* Expressing Empathy
* Developing the discrepancy
* Avoiding Argumentation
* Rolling w/ resistance
* Identifying “sustain talk” and “change talk”
Sustain Talk: clients statements in favor of continuing the problematic behavior
Change Talk: clients statements in favor of making changes. The professional will then reinforce this behavior is it’s something positive
* Supporting Self-efficacy
How Well Does Humanistic Therapy Work?
* Meta-analysis suggest it is just s effective as other ajar therapeutic approaches
* The specific components (empathy, unconditional positive regard and genuineness) are significantly related to the success of the therapeutic relationship and therapeutic outcomes.
* Motivational Interviewing has received consistent empirical support for wide range of problems
* Ex: substance use disorders, gambling addiction, smoking cessation, weight loss efforts, depression and anxiety
* Additionally, MI can be incorporated into other forms of
Behavior Psychotherapy:
Behavior psychotherapy: clinical application of behavioral principles
* Historical Roots
* Pavlov: discovered classical conditioning when studying digestion in dogs
* In the early 1900s Watson made the argument that behavioral principles would apply to people as well
Edward Lee Thorndike and B.F. Skinner discovered operant conditioning
Goals of Behavior Psychotherapy:
* Primary goal is observable behavior
* The behavioral approach stemmed from dissatisfaction with/ the psychodynamic approach
* Emphasis on empiricism
The belief that the study of human behavior should be scientific
Regular connection of empirical data…change in behavior should be measured in every session.
Defining Problem Behaviorally:
Clients aren’t the problem just their behaviors
* Professionals don’t want to make inferences about what’s happening in the client’s mind
* Connection between symptoms and underlying “diseases” are greatly speculated in psych
* Defining problems in behavioral terms (diagnosis) makes it easier to identify targeted behaviors and measure the changes. Ex: depression
Behavioral Techniques: Exposure Therapy:
We want the client to face their fears.
* Treats people with anxiety disorders (ex: agoraphobia, phobias)
* Breaking the pattern and confronting what they are afraid of
* A particular stimulus (ex: spiders, heights, the dark) becomes paired w/ aversive outcome (pain, anxiety)
* Clients work through a fear hierarchy (also referred to as an anxiety hierarchy)
Two different methods of working through a fear hierarchy;
Imaginal Exposure: imagining anxiety provoking situations
In vivo exposure: exposing the client to real-life items or situations that are anxiety-provoking
* When working you check on your client's well-being during exposure therapy.
Behavioral Techniques: Systematic Desensitization
* Systematic Desensitization for phobias and anxiety disorders
* Similar to exposure, but systematic desensitization involves pairing the feared object with a new response that blocks the fear out.
Relaxation training is the first step.
The therapist teaches the client various relaxation techniques
* Before the exposure the client will be in a relaxed state
Behavioral Techniques: Exposure Therapy
* Exposure and Response prevention has a lot of empirical support when treating OCD
* Exposing people to what they’re afraid of and preventing them from performing their typical response. Ex: washing their hand unnecessarily
Prolonged Exposure:
Prolonged Exposure: Behavioral Therapy used to treat disorders of trauma and stress like PTSD; another form of exposure therapy
* Developed by Edna Foa
* It was empirically well supported (manualized) treatment for PTSD
* This approach teaches individuals to gradually approach their trauma-related memories, feelings and situations
* PTSD is characterized by the avoidance of anything that reminds the individual of the trauma
* Prolonged Exposure is usually conducted over 8 to 15 sessions. It often recommended that sessions are longer than typical
* Prolonged exposure tends to be anxiety provoking for most clients
* USe positive therapeutic relationship so that the client feels comfortable
* It can also be difficult for therapists
Imaginal and In Vivo Exposure:
Imaginal Exposure: client describes event in detail
* Client and therapists discuss and process the emotion raised by the imaginal exposure in session
* In Vivo exposure: The client confronts the feared stimuli