Psychotherapy Notes

  • Chapters Overview
    • Part III: Psychotherapy (Chapters 11-16)
    • Chapter 11: General Issues in Psychotherapy
    • Chapter 12: Psychodynamic Psychotherapy
    • Chapter 13: Humanistic Psychotherapy
    • Chapter 14: Behavior Therapy
    • Chapter 15: Cognitive Psychotherapy and Mindfulness-Based Therapies
    • Chapter 16: Group and Family Therapy
    • Part IV: Special Topics (Chapters 17-19)
    • Chapter 17: Clinical Child and Adolescent Psychology
    • Chapter 18: Health Psychology
    • Chapter 19: Forensic Psychology

General Issues in Psychotherapy (Chapter 11)

  • Introduction

    • Psychotherapy is the most common professional activity of clinical psychologists.
    • This chapter covers across-the-board issues, such as whether psychotherapy works and how it is practiced.

  • Does Psychotherapy Work?

    • Early Evidence:
    • Mid-1900s: Subjective descriptions of individual clients’ progress, written by therapists.
    • 1950s: Empirical studies began to appear.
    • Eysenck's Study (1952):
    • Claimed clients got better without therapy and psychotherapy offered little benefit.
    • Criticized methods, claims overturned, but inspired subsequent research.
    • Meta-Analyses (1970s-1980s):
    • Statistically combined results of many separate studies.
    • Showed consistently positive results about the effects of psychotherapy.
    • Methodological Issues in Outcome Research:
    • Complex task requiring multiple decisions from researchers.
    • Whom to Ask (Tripartite Model):
    • Client: Their lives are affected, but opinions can be biased due to eagerness to see positive results or negative factors.
    • Therapist: More experience, but views can be biased, reflecting on therapeutic skills.
    • Society: Outsiders (general public, legal system, family, employers, insurance companies); emphasize client’s ability to perform duties. A single perspective does not need to be chosen, researchers can solicit all opinions of each
    • When to Ask:
    • Immediately after therapy, or months/years later for lasting benefits. Improvement should be evident at various points in therapy.
    • Time of asking can influence results, with researchers making multiple answers either within or across studies
    • How to Measure:
    • Questionnaires or interviews with interested parties; content and structure impact data.
    • Behavioral measures (e.g., observing a child with ADHD at school/home).

  • Efficacy Versus Effectiveness of Psychotherapy

    • Efficacy: Psychotherapy works in controlled research studies (“in the lab”). Maximizes internal validity with well-defined patients who only meet criteria for the specific disorder
    • Effectiveness: Psychotherapy works with actual clients in clinics, private practices, hospitals (“in the real world”). Greater external validity, variability between therapists and methods

  • Results of Efficacy Studies

    • Meta-analyses consistently show psychotherapy works (.85 average effect size).
    • Benefits endure over time and exceed placebo effects.
    • Psychotherapy is not a panacea; some clients worsen or drop out.
    • Recent trend: Transdiagnostic approach targeting underlying pathology common to emotional disorders (e.g., unified protocol for anxiety and depression).

  • Bridging the Gap Between Research and Practice

    • Gap exists between science and practice.
    • Researchers may conduct studies that are artificial and irrelevant, while practitioners resist changing their practices.
    • Efforts to recognize and bridge the gap have increased (e.g., practice-oriented research).
    • Reluctance exists due to value placed on intuition, irrelevant research to practice, and the deemphasizing of the therapeutic alliance

  • Results of Effectiveness Studies

    • Effectiveness studies generate similarly positive results in realistic settings.
    • Consumer Reports study (1995): Psychotherapy had positive, lasting effects.
    • Methodological questions about sampling bias and self-reports exist, but these studies complement efficacy studies.

  • Alternate Ways to Measure Psychotherapy Outcome

    • Increased attention to neurobiological effects through fMRI and PET scans.
    • Findings: Therapy produces reliable changes in brain activity and structure.
    • Medical cost offset: Psychotherapy reduces medical costs and hospital days.

  • Which Type of Psychotherapy Is Best?

    • Early infighting among orientations on which had strongest empirical support, with the war mainly led by behaviorists and non-behaviorists
    • Dodo Bird Verdict: Competing therapies are found to work about equally well, with reviews again and again yielding the virtual tie
    • Researchers explain this finding by pointing to common factors in all forms of psychotherapy (e.g., therapeutic relationship).
    • Notion that different therapies benefit from the same underlying mechanisms dates back to the 1930s.
    • Common factors are therapeutic and act as “active ingredients."

  • Therapeutic Relationship/Alliance

    • A strong relationship between the therapist and the client has the most evidence behind it.
    • Coalition and partnership between allies working toward a mutual goal.
    • The therapeutic relationship strongly contributes to the outcomes for adults, children, and families.
    • The quality of the therapeutic relationship is the best predictor of therapy outcome and accounts for more variability in therapy outcome than do the specific techniques.
    • Surveys of clients prefer a warm therapist to treatment with empirical support.
    • Vital regardless of the emphasis the therapist places on it.
    • A good therapeutic alliance can facilitate client improvement, experience with therapist, and improve client ratings.

  • Other Common Factors

    • Hope (or positive expectations): Provides optimism that things will improve.
    • Attention: The Hawthorne effect (performance improves as a result of being observed).
    • Other common factors: Reinforcement of novel behaviors, desensitization to threatening stimuli, confronting a problem, and skill training.

  • Three-Stage Sequential Model of Common Factors:

    • Stage 1: Support factors (therapist–client relationship, warmth, acceptance, trust).
    • Stage 2: Learning factors (expectations about oneself, thought patterns, corrective emotional experiences, insights).
    • Stage 3: Action factors (taking risks, facing fears, practicing new behaviors, working through problems).

  • Reconsidering the Dodo Bird Verdict: Specific Treatments for Specific Disorders

    • Chambless argues against the idea that all psychotherapy approaches are equally efficacious.
    • Empirical studies have not yet examined all specific comparisons in regards to specific therapies and particular disorders

  • What Types of Psychotherapy Do Clinical Psychologists Practice?

    • Seven times since 1960, the Division of Clinical Psychology has been surveyed to assess the type or orientation of psychotherapy that its members practice and their responses
    • Eclectic/integrative therapy was the most commonly endorsed orientation until 2010, when cognitive therapy took it's place
    • Cognitive therapy has seen remarkable popularity since the 1980s.
    • The endorsement of psychodynamic/psychoanalytic therapy has declined significantly.

  • Psychotherapy Formats

    • Individual: 98%
    • Couples/Marital: 48%
    • Family: 34%
    • Group: 20%

  • Stages of Change Model

    • Precontemplation: No intention to change.
    • Contemplation: Considering change.
    • Preparation: Intending to take action soon.
    • Action: Actively changing behavior.
    • Maintenance: Preventing relapse. Customize treatment

  • The Future

    • Experts foresee a rise in mindfulness, cognitive, behavioral, multicultural, eclectic/integrative, Internet-based therapies, and evidence-based practice.

  • Eclectic and Integrative Approaches

    • The Eclectic approach (technical eclecticism) takes the best treatment for the client based on empirical literature of clients. Versatile

  • Integrative Approach

    • The Integrative Approach involves blending techniques in order to create an entirely new, hybrid form of therapy, combining elements from psychoanalytic, cognitive, behavioral, humanistic, or other therapies into a personal style

Psychodynamic Psychotherapy (Chapter 12)

  • It has become less popular than previously in the 19th century
  • There is still the belief among psychoanalysts that if a patient asks you if you are "a Freudian," the correct answer is “no.” (Gabbard, 2009a, p. vii)
    • The primary goal of psychodynamic psychotherapy is to make the unconscious conscious and become aware of their thoughts and feelings
    • Insight helps capture this phenomenon that had previously gone unseen by the patient.
    • In free association, psychodynamic psychotherapists simply ask clients to say whatever comes to mind without censoring themselves at all.
  • Freud believed all behavior is determined and there is no such thing as a random mistake or