361 week 12

-        Common factors in group treatment

o   Imparting information

§  Group members can receive advice and guidance not just from the therapist but also from other group members

o   Instilling hope

§  Observing others who have successfully grappled with problems helps to instill hope

o   Universality

§  Group members discover that they are not alone and that others have similar problems, fears, and concerns

o   Altruism

§  Helping others in the group leads to greater self-worth

o   Interpersonal learning

§  Interacting with others in the group teaches clients about interpersonal relationships, social skills, sensitivity to others, resolution of conflicts, and so on

o   Imitative behavior

§  Watching and listening to others leads to the modeling of more useful behaviors

o   Corrective recapitulation of the primary family

§  The group context can help clients learn more adaptive methods for coping with family-related problems

o   Catharsis

§  Learning how to express feelings about others in the group in an honest, open way builds a capacity for mutual trust and understanding

o   Group cohesiveness

§  Group members develop relationships with one another that enhance self-esteem through acceptance

-        Sensitivity training groups (T-groups)

o   Bethel, Maine, late 1940s, business executives and interpersonal awareness and effects. Not a psychotherapeutic context

o   Focused on the here-and-now, constructive feedback on how one affects others. People give and receive constructive feedback for how they come across to others in the group. Cf emotional intelligence. Main purpose: to be a more effective businessperson (= increase profits)

o   “deep” individual analysis underemphasized

o   Cultural factors to be considered – is it for everyone? Cultural factors important in re-acceptability of openness and frank feedback. Relevant in couples/family therapy too

-        Levels of communication between the sender (P) and the recipient (R)

o   P

§  Feelingsàintentionsàbehavior—verbal and nonverbal—as exhibited

o   R

§  Behavior—verbal and nonverbal—as perceivedàfeelingsàinterpretation of P’s intentionàevaluation of P as a person

-        Couples/family therapy – two core elements

o   Cf. previous graphic of levels of communication. Does a person’s intent always have the intended impact, as portrayed here:

§  Intent à impact

§  Not always…in fact, in distressed relationships, the intent of one’s actions of words often do not have the intended impact. Helping the parties communicate about their intentions and about the impact on others is a common strategy in couples and family therapy as well as in many  forms of group therapy – a continuing contribution of T-groups

o   Second core element is “general systems theory”

§  Think of it as a general viewpoint, a paradigm, which has us view individual behavior operating within a complex set of intricate relationships, and change in one part creates a loss of homeostasis in the whole system such that efforts to change one person necessarily involves considering the complex system within which that person lives.

§  For example, agoraphobia in one parent may (unfortunately) be part of what holds things together – the other parent and perhaps also the children accommodating to the one parent’s fear of leaving the home

-        Acceptance in couples/family therapy

o   Accept your partner/family member and yet encourage change – not an easy balancing act

o   Based on Marsha Linehan’s Dialectical Behavior Therapy

o   Jacobson and Christensen’s Acceptance and change in couples therapy

§  Follow-up of behavioral marital therapy outcomes in an RCT revealed lots of relapses

§  Predictors of poor outcome

·        Lack of compromise and accommodation

·        Reactance

§  Their solution – accept, “letting go of the struggle to change and in some cases embracing those aspects of a partner which have been precipitants of conflict… turn areas of conflict into sources of intimacy and closeness” and then partner may indeed change in direction that the other desires

o   An example of acceptance – “reframing”

§  “what one partner sees as the other partner’s ‘uptightness’ might be reframed as the ‘stability’ that first attracted him/her. Or alternatively, what one partner sees as ‘flakiness’ or ‘irresponsibility’ might be reframed as the ‘free-spiritedness’ or ‘rebelliousness’ that so attracted him/her in the beginning of their relationship. The therapist must help the partners notice the positive aspects of what they have come to see as purely negative behavior. Often this behavior is in some way related to a quality one partner once found attractive about the other”

§  Davison perspective: characteristics that one person found appealing, even sexy, when they were courting may, twenty years later, be very difficult to see in a positive light. The flakiness of the 19-year-old with few family responsibilities may wear a little thin when, years later, there are children and the myriad of other responsibilities that people usually face as they move through the life cycle

o   Acceptance means resignation? Not necessarily:

§  “the purpose of ‘acceptance work’ is not to promote resignation to the relationship as it is….rather it is designed to help couples use their unsolvable problems as vehicles to establish greater closeness and intimacy. For couples who have difficulty changing their behavior, acceptance provides a viable alternative for building a closer relationship. For couples who do benefit from the traditional approach (that directly aims to change problematic behavior), acceptance-based behavioral couples therapy can facilitate further progress by providing an alternative way to establish an even closer relationship, given that there are problems in every relationship that are impervious to change. Paradoxically, acceptance interventions are also predicted to produce change in addition to acceptance…because at times the pressure to change may be the very factor that prevents it from occurring”

-        Davison’s comments on acceptance in family therapy

o   When a couple has been together for many years, there can be an accumulation of anger, hurt, resentment, and betrayal that makes it a challenge even to decide what restaurant to go to on a Friday evening. Good will is gone. Motives are constantly questioned. If a negative interpretation can be placed on positive behavior, it will be. And if a behavior therapist asks the partners to do something nice for each other, the kind of couple Jacobson and Christensen are talking about will either not budge or, if they do make a specific change, will readily attribute it to the therapist’s instruction, for example, “he doesn’t really appreciate me for my good work at the office today; he’s complimenting me only because Dr. Smith told him to”. It is no accident that couples therapy can be extraordinarily taxing for the therapist and unusually boisterous and noisy. Compare with transference as a play

-        Additional comments on family and couples therapy

o   Note how the earliest thinking on family therapy concerned schizophrenia (like the “double blind” of the Palo Alto group), which has turned out to be wrong but which spawned a paradigmatic shift in our thinking about how families operate and how to intervene, “systems theory”

o   Universities are also complex systems are they not? Ditto for any group – a dorm, a fraternity or sorority. Our own course this semester makes us a system too. Consider the scandals USC has been experiencing the past few years. How can they be addressed?

o   Remember: and as with individual and group psychotherapy, there are many many theoretical approaches. “family” or “couples therapy” convey little – except that at least three people are involved including the therapist. Recall the description I provided of a Gestalt therapist wedging himself between a husband and wife to symbolize the intrusiveness of the wife’s mother in their marriage and the wife’s passivity as well as the husband’s reluctance to take action – it was the marital relationship that was being dealt with but through the prism of Gestalt therapy

-        Three basic concepts for understanding community psychology:

o   Primary prevention

o   Seeking mode

o   Institutional level of analysis

-        Basic concepts and approaches in community psychology

o   Three kinds of prevention (really intervention)

§  Tertiary – basically this is treatment as we have examined this semester

§  Secondary – early detection so that nascent problems may not become serious enough to require tertiary “prevention” (e.g., suicide hotlines. Or reducing high blood pressure to avoid heart attacks or strokes)

§  Primary – efforts to reduce or eliminate any kind of problem, thereby removing the need for the first two kinds of prevention. This is the focus of community psychology. In medical circles, called public health. E.g., encouraging safer sex to avoid HIV/AIDs. Or reducing racism/bigotry to prevent psychological problems in discriminate (“protected”) groups like Blacks, Hispanics, Jews

·        Note: none of the above is inconsistent with biological factors

·        Also, community mental health is not the same as community psychology – a common misconception

o   Two components of all mental health care:

§  Mode of delivery

·        Waiting – characteristic of tertiary prevention, treatment. Pt. seeks out professional help

·        Seeking – characteristic of primary prevention, i.e., community psychology. Initiative by professionals

§  Conceptual (theoretical and empirical underpinnings)

·        Virtually countless, e.g., psychodynamic, CBT, etc. this has been the focus in the focus in the first third of this course

·        Psychoanalytic approach

o   Waiting mode

§  Psychodynamic explanations of abnormal behavior. Therapist waits for patient to initiate contact and then  used insight therapy

o   Seeking mode

§  Psychodynamic explanations of abnormal behavior. Professional attempts to prevent illness through public education and extends traditional treatments into community settings

·        Learning approach

o   Waiting mode

§  Learning theory of interpretation of emotional dysfunction. Therapist waits for client to initiate contact and then uses techniques such as systematic desensitization

o   Seeking mode

§  Learning theory interpretation of emotional dysfunction. Professional extends services into the community through public education

o   Levels of analysis

§  Rappaport proposes that we view society as composed of four levels:

·        The individual

·        Small groups

·        Organizations

·        Institutions (main realm for community psychology, includes values. An example is discouraging sexual reorientation/conversion tertiary therapies for gay people)

-        Some special issues in community psychology

o   Blaming the victim

§  His argument: if one works to help people adjust to a toxic social environment a la tertiary prevention, one is basically blaming the victim

o   Community psychology versus community mental health (conflated by most authors)

§  CMH is primarily or exclusively tertiary prevention/treatment

§  CMH is aimed primarily at lower to lower-middle class people. Is less expensive – fewer sessions, fewer doctoral-level helpers, more group therapy

§  CMH – changing locus of services (many different kinds) not same as changing models of treatment. “old wine in new bottles”

§  In contrast to CMH, community psychology, recently called prevention science, aims to:

·        Reduce environmental and recently also address biological factors that put people at risk

·        Strengthen protective factors so as to decrease people’s vulnerability to (1)

-        Some community psychology methods of intervention

o   Some examples of what can be considered community psychology programs:

§  Mass media and other programs for the prevention of cigarette smoking in order to reduce health problems

§  The prevention of HIV infection and AIDS through programs aimed at changing sexual practices among sexually active adults and adolescents

§  Reducing the risk of cardiovascular disease through mass-media education about improving diet and lifestyle

§  The establishment of suicide prevention centers with telephone hot lines, which desperate people can use to weather a suicidal crisis

§  Efforts through Head Start programs to prevent educational deficits and associated social and economic disadvantages

§  Creating more healthful school environments

-        Effectiveness of community efforts

o   Effectiveness: variable and hard to evaluate, but overall positive

§  Some of the problems addressed have major genetic or biological factors, but, as mentioned, not a huge focus thus far in community psych

§  Unlikely that any realistic social change will be able to address these biological variables or reduce stress levels enough such that most diatheses don’t kick in. economic inequality, racism, sexism

o   Evaluation of community psych difficult due to:

§  Confounding variables (and chaos theory)

§  Attrition

§  Based on the assumption that we know how to prevent certain problems, that we know how they develop

-        Politics and values

o   Possible the main problem with community psych efforts

§  Politics more than science

o   1960s and 1970s big societal changes

§  YAVIS patients the focus (young, attractive, verbal, intelligent, successful)

§  But shift to social problems from the intrapsychic

§  Plus Eysenck’s 1952 critique

§  Community psych important in the US, where a large gap had developed between the need for mental health care and the availability of services. Still exists, maybe more so

§  Social upheaval, Kennedy’s new frontier and Johnson’s great society

§  Community psych fit right in, also community mental health centers as less expensive tertiary mode of delivery

§  But what do we know about changing social systems? How do we know what people want, should want? And what do they need?

§  Psychologists as social activists