Comprehensive Psychotherapy Lecture Notes

Introduction to Psychotherapy

• Multiple working labels

  • “Psychotherapy” (Jerome Frank) → planned, emotionally-charged, confiding interaction between trained, socially-sanctioned healer & sufferer whose aim is relief of distress/disability.

  • “Psychological treatment” (Barlow, 2004) → interventions that:

  • Derive from psychological science.

  • Target causal/maintenance psychological processes of specific disorders.

  • Demonstrate efficacy in controlled outcome studies.

Key Dimensions Along Which Therapies Vary

• Supportive ↔ Change-oriented.

• Directive ↔ Non-directive.

• Problem-focused ↔ Personality-focused.

• Evidence-based ↔ Non evidence-based.

• Manualized ↔ Non-manualized.

• Choice of therapeutic model.

Major Approaches (Table 10.1 Recap)

• Behavioral → learning-based behavior modification.

• Cognitive-Behavioral → change maladaptive thoughts & behaviors.

• Dialectical → emotion regulation, distress tolerance, interpersonal skills.

• Mindfulness/Acceptance → relational-frame metaphors & experiential exercises.

• Psychodynamic → insight into unconscious forces.

• Client-Centered/Humanistic → growth via unconditional positive regard.

Prochaska & DiClemente Stages of Change

• Pre-contemplation → no intent to change.

• Contemplation → aware/problem recognized; no commitment.

• Preparation → intent & initial steps.

• Action → overt behavior change.

• Maintenance → sustain change.

• Termination / Relapse → upward spiral learning from lapses.

Therapy Models Covered in Course

• Psychoanalytic → Psychodynamic.

• Humanistic models.

• Behaviorism (three waves):

  • First wave: Behavioral.

  • Second wave: Cognitive-Behavioral (CBT).

  • Third wave: Acceptance-based (ACT, DBT).

Psychoanalytic & Psychodynamic Approaches

Historical Roots

• Freud → psychoanalysis (method + theory).

• “Psychodynamic” = broadened, derivative approaches.

Core Tenets

• Psychic determinism: all mental events are caused.

• Unconscious motivation.

• Instinctual drives: Eros vs. Thanatos.

• Structural model: Id (pleasure), Ego (reality), Superego (morality) → intrapsychic conflict.

• Psychosexual stages: Oral, Anal, Phallic, Latency, Genital.

• Anxiety types: Reality, Neurotic, Moral.

• Ego-defense mechanisms: repression, projection, reaction formation, displacement, fixation, rationalization, denial, sublimation (defense use linked to psychopathology).

Clinical Techniques (making unconscious conscious)

• Free association.

• Dream analysis (manifest vs. latent content).

• Analysis of resistance.

• Analysis of transference.

• Examination of everyday behavior & early life.

• Interpretation.

Evolution/Brief Psychodynamic Forms

• Neo-Freudians: Jung, Adler, Rank…

• Object-relations theory.

• Interpersonal Psychotherapy (IPT; Klerman & Weissman).

• Strupp’s Interpersonal Dynamic Psychotherapy (focus on relationship disturbances, corrective emotional relationship, cyclical maladaptive patterns).

Seven Features of Psychodynamic Psychotherapy (Shedler, 2010)

1. Facilitate expression of affect.

2. Explore avoidance/defenses.

3. Identify recurring patterns.

4. Link past to present.

5. Emphasize interpersonal relations.

6. Work with transference in therapy relationship.

7. Explore fantasy life (dreams, uncensored thoughts).

Humanistic Psychotherapy

Contrast With Psychoanalysis

• Origins of pathology: incongruence between self-view & external expectations (vs. unconscious conflict).

• Human nature: inherently positive/optimistic.

• Therapist’s role: facilitator; client is expert on self.

Major Forms

• Client-Centered Therapy (Carl Rogers).

• Existential Therapy.

• Gestalt Therapy (Fritz Perls).

Client-Centered Therapy Basics

• Phenomenological tradition: phenomenal field & phenomenal self.

• Goal: self-actualization (Maslow’s hierarchy – physiological → self-actualization).

• Growth promoted when necessary & sufficient conditions present:

  • Empathic understanding.

  • Unconditional positive regard.

  • Genuineness/congruence.

• Therapist “does” vs. “does not” lists:

  • DO: reflections, allow free expression, weekly sessions.

  • DO NOT: advice, reassurance, persuasion, questions, skills teaching, interpretations, criticism.

Gestalt Therapy Highlights

• Whole > sum of parts; emphasis on present-moment awareness.

• Techniques: here-and-now focus, attending to non-verbals, responsibility, role-play (“empty-chair”).

Evaluation of Humanistic Approaches

Strengths

• Emphasize subjective experience, free will, growth, present moment, therapeutic relationship.

Limitations

• Over-focus on feelings; constructs vague/immeasurable; minimal assessment; research base weaker; terminology obscure.

Behavioral Therapies

Philosophical Underpinnings

• Scientific rigor; focus on observable behavior; avoid unmeasured constructs.

Historical Milestones

• John B. Watson (Little Albert).

• Mary Cover Jones (counter-conditioning with Peter).

• Joseph Wolpe (systematic desensitization).

• B.F. Skinner (operant conditioning).

• Bandura & Rotter (social-learning → cognitive elements).

Three Waves Recap

1. First: Strict behaviorism.

2. Second: Cognitive additions (CBT).

3. Third: Acceptance/mindfulness (ACT, DBT).

Core Learning Principles

• Classical Conditioning: UCS, CS, UCR, CR; acquisition, extinction, generalization.

• Operant Conditioning: reinforcement (↑ behavior) vs. punishment (↓ behavior); positive vs. negative contingencies.

Exposure-Based Techniques

• Flooding (prolonged, maximal exposure).

• Graduated exposure via fear/anxiety hierarchy.

• In-vivo vs. imaginal; commonly combined with response-prevention.

• Principles for maximal effect: long sessions, varied settings, hierarchy, full attention, no avoidance, end with fear reduction, can be stand-alone or multicomponent.

• Application example: PTSD exposure (Edna Foa).

Systematic Desensitization (Wolpe)

1. Problem assessment.

2. Technique rationale.

3. Relaxation training (PMR).

4. Construct anxiety hierarchy.

5. Scripted pairing of relaxation with hierarchy items → counter-conditioning.

Contingency Management

• Token economies, time-outs, successive approximation (shaping), Premack (Grandma’s rule).

Aversion Therapy

• Antabuse for alcohol; bitter nail polish for nail-biting, etc.

Behavioral Activation (BA)

• Activity monitoring/scheduling, mastery & pleasure tasks, goal-setting, positive reinforcement, reduce avoidance, skills rehearsal. Effective alone or with CBT.

Social Skills / Assertiveness Training

• Rationale → modeling, role-play, homework, feedback.

• Distinguish passive, assertive, aggressive styles.

Behavioral Treatment Stages

1. Target definition & baseline measurement.

2. Functional analysis (A→B→C) & plan.

3. Implementation (session & natural env.; homework).

4. Outcome assessment (ongoing measurement).

5. Reformulation if insufficient change.

Strengths & Criticisms

• Strengths: efficacy (meta-analyses show behavioral > psychodynamic/humanistic), efficiency (fewer sessions), broad applicability.

• Criticisms: skill-demanding, terminology off-putting, seen as cold/directive, limited focus on “inner growth”.

Cognitive Therapies

Historical Emergence

• Beck & Ellis influenced by social-learning (Bandura, Rotter).

• Response to limitations of behaviorism; integration of cognition + learning.

• 2010s → transdiagnostic focus, mechanisms > DSM categories; CBT = most evidence-based, widely taught; online CBT can equal face-to-face efficacy (Miller et al., 2021).

General Model (A-B-C)

• Activating event → Beliefs → Consequences (emotion/behavior). Thinking causes emotion & behavior.

Rational Emotive Behavior Therapy (REBT; Ellis)

• Identify irrational beliefs (demandingness, awfulizing, low frustration tolerance, conditional acceptance).

• Directive, disputational debates + behavioral homework.

Beck’s Cognitive Therapy (CT)

• Developed for depression.

• Negative Cognitive Triad → automatic thoughts.

• Cognitive restructuring steps: identify thoughts, examine evidence, generate rational responses.

• Tools: Dysfunctional Thought Record, Downward Arrow.

• Common thinking errors: all-or-nothing, overgeneralization, mental filter, catastrophizing, personalization, etc. (lists provided in slides 68–69).

CBT for Specific Disorders (examples)

• Depression: BA + cognitive restructuring; sessions 8–16.

• Social anxiety: rehearsal, exposure, cognitive work; sessions 16–20.

• General anxiety, panic, PTSD, bulimia, substance use – multicomponent CBT programs (see slide 76 for session counts).

Stress Inoculation Training (Meichenbaum)

• Phases: Conceptualization → Skill acquisition/rehearsal → Application; goal = “inoculate” against future stress.

Evaluation

• Strengths: high effectiveness, efficiency, diverse techniques, aligns with health-training, wide disorder coverage.

• Weaknesses: can feel cold, not growth-oriented, less suited for vague problems, debate over primacy of cognition.

Third-Wave Acceptance-Based Therapies

Dialectical Behavior Therapy (DBT; Linehan)

• Designed for Borderline Personality Disorder (BPD) [DSM-5 criteria: 5 of 9 symptoms such as abandonment fear, unstable relationships, identity disturbance, impulsivity, suicidal behavior, affective instability, chronic emptiness, anger, transient paranoia/dissociation].

• Components: weekly individual therapy + group skills training.

  • Core Mindfulness (observe, describe, participate).

  • Distress Tolerance (bear pain skillfully).

  • Emotion Regulation.

  • Interpersonal Effectiveness.

• Dialectics balance acceptance & change, validation & confrontation; wise mind = synthesis of emotion & rational mind.

Acceptance & Commitment Therapy (ACT; Hayes)

• Motto: Accept, Choose, Take action.

• Six “hexaflex” processes fostering Psychological Flexibility:

  1. Acceptance.

  2. Cognitive Defusion.

  3. Present-moment contact.

  4. Self-as-Context (observing self).

  5. Values identification.

  6. Committed action (values-guided goals).

• Techniques rely on metaphors (e.g., “Passengers on the bus”), experiential exercises, Values Bull’s-Eye worksheet.

• Therapist stance: collaborative, vulnerable, non-expert.

Effectiveness & Critiques

• ACT & DBT outperform no-treatment; usable across ages/formats; ACT not superior to other CBTs; DBT resource-intensive.

• Debate over novelty vs. traditional CBT overlap.

Therapy Outcome Research

Common Factors Producing Change

• Expert role, catharsis, therapeutic alliance, anxiety reduction, mastery/competence.

Client Variables Influencing Outcome

• Distress level, intelligence, age, openness, gender, ethnicity/social class.

Therapist Variables

• Age, sex, ethnicity, personality, empathy/warmth/genuineness, own therapy, degree/experience.

Efficacy vs. Effectiveness

• Efficacy → controlled RCTs (high internal validity) | Effectiveness → real-world practice (external validity).

• RCT gold standard; case studies & pre-post single groups weaker evidence.

Classic Findings

• Eysenck 1952 review: 72\% medical care improvement vs. 44\% psychoanalysis vs. 66\% eclectic → spurred research despite methodological flaws.

• Smith, Glass, & Miller 1980 meta-analysis:

  • 475 studies, 25{,}000 patients, avg 16 sessions.

  • Avg client better than 80\% of untreated.

  • Effect sizes: Cognitive-Behavioral 1.13; Systematic Desensitization 1.05; overall mean 0.85.

• Psychodynamic: mixed; short-term slightly inferior to other txs at follow-up (Svartberg & Stiles 1991); others show equivalence (Crits-Christoph 1992).

• NIMH Depression Collaborative Project (efficacy): CBT, IPT, Imipramine+CM, Placebo+CM all improved; medication favored severe depression; psychotherapy sufficient for mild/moderate; differential relapse patterns at 18-month follow-up.

• Consumer Reports 1995 effectiveness survey (~7{,}000 respondents): majority reported improvement; few differences across provider type; longer treatment associated with better outcomes (methodological caveats: self-report, retrospective, sampling bias).

Evidence-Based Treatment (EBT) & Evidence-Based Practice (EBP)

• EBT = intervention with beneficial effects in RCTs.

• EBP = integration of EBT evidence, clinician expertise, & client preferences.

• Resistance: “art vs. science” debate; possible rival explanations for improvement (placebo, spontaneous remission, regression to mean, effort justification, multiple treatment interference, reporting bias).

General Conclusions

• Most formal therapies outperform informal help/placebo.

• No single therapy universally superior, yet certain methods show disorder-specific efficacy (e.g., exposure for anxiety).

• Common factors significantly contribute to outcome.

• Therapist/client characteristics matter but evidence mixed.

Ethical, Philosophical, & Practical Implications

• Choice of model tailored to client needs, stage of change, cultural/contextual factors.

• Manualization & fidelity vs. clinician flexibility.

• Necessity of ongoing assessment (baseline, outcome, reformulation) for accountability.

• Debate over scientific rigor vs. humanistic values (e.g., warmth vs. manual adherence).

Numerical & Statistical References (Select)

• 2004 – Barlow proposes “psychological treatment.”

• 5/9 DSM-5 criteria for BPD diagnosis.

• 7 common psychodynamic features (Shedler).

• 3 waves of behavior therapy.

• Smith et al.: 475 studies, 25\,000 pts, 80\% better off, mean ES 0.85.

• NIMH project: 250 pts, 4 conditions, 3 sites, 18-month follow-up.

• Multicomponent CBT programs: sessions range 8–24.