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The therapeutic process
A final analysis
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Psychotherapy: What is it?
“verbal interaction between a professional
counsellor and one or more persons
suffering from a psychological disorder”
Psychologist vs. therapist vs. psychiatrist
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Differences
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Training
Quality/ Organization/ Ethics
Medication
Legal right to Dx
Training in assessment or therapeutic
orientations
• 8 vs 6
• Research
• Psychological testing
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Who Seeks Treatment with
Mental Health Specialists?
• Olfson & Pincus (1994)
– Americans made 79.5 Million visits for psychotherapy
– More likely to seek and use psychotherapy:
separated or divorced
women
white
ages 35-49 years
more than 15 years of education
– Greater likelihood of seeking treatment if in poor general
health and have health-related functional impairments
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Types of Treatment Available
• Psychotherapy Orientations
– Psychoanalytic / Psychodynamic / Insight-oriented
– Behaviour Therapy
– Cognitive / Cognitive Behavioural Therapy
– Humanistic Therapy
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Orientations –
Psychoanalytic/Psychodynamic
• This is the school of thought that Freud started – recall
from personality lecture. Was the first real model of
psychotherapy early 1900s
• Analogy – therapist is on an archaeological dig –
trying to gently uncover the unconscious material that
is buried by repression/defense mechanisms
• Unconscious material is central, work to develop
client’s insight into unconscious motives, conflicts;
emphasis on early childhood functioning
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Criticisms - Psychoanalytic
• Vague, imprecise and unscientific
• Abstract concepts (id, ego, superego) not related to
reality or day-to-day behaviour
• Difficult to test / evaluate effectiveness (when do we
know the unconscious has been uncovered?)
• More appropriate for high functioning, intelligent
verbal individuals…
• More expensive, time consuming than other equally
effective therapies
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Orientations – Behavioural
• Behavioural approach – historically, the
school formed as a reaction to
psychoanalysis
• Highly structured, focus on here-and-now,
behavior (not feelings, insights)
• Advantages: sometimes it’s not necessary
to explore childhood conflicts. BT is more
appropriate for certain focal, circumscribed
problems (fear of heights, social skills
training, difficulty public speaking, smoking
cessation). Also is much shorter term, less
expensive than psychoanalytic. If applied
appropriately, BT can be very effective.
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Orientations –
Behavioural
• Psychopathology: problem behaviours are
learned through operant conditioning (+ and
– reinforcemt) and classical conditioning
(forming associations)
• Setup: behaviourist is a directive helper /
trainer; therapy is structured; discuss
behaviour and contingencies; no discussion
of thoughts, feelings, unconscious; no
attention to relationship with therapist
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Behaviorism
• Intervention: change problem behaviour
through learning, reinforcement,
modeling
• Goal: unlearn problem behaviours,
replace with more adaptive behaviours;
learn new positive behaviours
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Behaviour Therapy - Techniques
• Operant Cond. – reinforce desired behaviours
– Token Economies (earn stars, points, chips for desirable
behaviour, can exchange for desired object or activity)
– Extinction (stop reinforcing undesirable behaviour)
• Classical Cond.- “Counter-conditioning” (re-condition a
more desirable response to stimulus)
– Systematic desensitization (learn to relax; then describe
anxiety-producing situation; then engage in anxiety
producing situation)
• Modeling – teaching by example, role-play
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Criticisms - Behaviour Therapy
• Too simplistic, reductionistic
• Doesn’t account for where the symptoms came
from in the first place
• If you eliminate the behaviour, the client may still
have an underlying problem that will cause them
difficulty in other areas
• Problems are not always with the person’s
behaviour  sometimes it’s their thinking,
feelings, self-esteem…
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Orientations –
Humanistic / Person-Centred
• Humanistic therapists - believe that
human experience is unique; all
humans are born with an innate
desire to try to fulfill themselves,
reach their full potential; there is no
objective right way/wrong way to live;
people are viewed as basically good,
believe we all naturally move towards
developing into our own ideal self.
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Orientations –
Humanistic / Person-Centred
• Psychopathology : Not pathology, but disrupted
development; problems arise when there is a
mismatch between the real self and desired self,
or when envt prevents person from reaching
potential
• Setup: therapist is nondirective, empathic;
engages in an sharing experience with the client
as an equal
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Humanistic continued…
• Intervention: focus on what / how things
happen for the client (not why);
empathic understanding, reflects;
unconditional positive regard; client
defines own cure
• Goal: promote growth, fulfillment;
evaluate self and world from own
perspective; focus on present, future
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Criticisms – Humanistic Therapy
• Concepts are hard to define (selfactualization), vague (each person is
unique)
• Very nice…but how does the therapy
affect lasting change in
thinking/behaviour?
• Is it wise to let the client guide therapy
and formulate their own treatment
goals?
– What if they have impaired judgment,
impulse control problems?
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Orientations –
Cognitive (& Cognitive Behavioural)
• Psychopathology: problems arise when
people have faulty, irrational thought
patterns; these result in negative feelings,
problems in relationships/behaviour
• Setup: structured; client & therapist are a
team; set agenda, work problems together
in a systematic way; client does homework
& tests out in real life
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Cognitive
• Intervention: focus on here & now; may
involve thought records, discussion &
teaching of new rational ways of
thinking; role-play
• Goal: to change the way clients think
about themselves, the world; behaviour
change will follow
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Techniques –
Cognitive (& Cognitive Behavioural)
• Identifying maladaptive thinking (handout),
e.g:
– Mind reading, catastrophizing,
overgeneralization, all-or-nothing thinking
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Thought Records (handout)
Cognitive reframing / restructuring
Exploring alternatives
Homework / in-vivo experiments
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And…
• In vivo experiments –new way of thinking, go
into world and try it out. Discuss how client feels,
acts; reinforces idea that changing thinking can
change feelings, behavior. Generalize what they
learn in therapy to outside world.
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Criticisms –
Cognitive (& Cognitive Behavioural)
• Too much emphasis on cognition;
suggests that everything is “mind over
matter”; that all problems can be
corrected by changing thinking
• Suggests clients are irrational, not
logical
• Too structured, simplistic, mechanical
• Doesn’t give enough emphasis on where
maladaptive thought patterns came
from, where problems originated
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New on the market:
The Integrative Approach
• Integrate elements from various
approaches
– Primarily CBT, but spend more time exploring
where the core beliefs came from, where the
problem originated
– Humanistic, but use some CBT techniques to
help client achieve goals
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Is Psychotherapy Effective?
Eysenck (1952) sparked a debate
– reviewed 24 studies of psychotherapy with emotionally
disturbed people
Therapy:
No Therapy:
67% improved
72% improved
Spontaneous Remission
– improvement without psychotherapy; often attributed to
positive life events or passage of time/maturity
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Key Words
• Demand characteristics
• Double-blind technique
• Placebo effect
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Eysenck’s Study: The Fallout
• Several important methodological problems
with Eysenck’s study
• Many studies followed; psychotherapy
shown to be more effective than no Tx
• Widely accepted that psychotherapy is
better than than no treatment
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Evaluating Effectiveness:
Psychotherapy Research
• Difficult to define what “effective” means
– Freudian:
Insight into unconscious processes
– Behaviour:
Changes in maladaptive behaviour
– Cognitive:
Changes in irrational thinking
– Humanist:
Acceptance of one’s self
• Who judges whether change has taken place?
– Client, therapist, friends, family, teachers, employers
• There are literally hundreds of types of therapy
today…
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Is Psychotherapy Effective?
Smith (1980)
• Reviewed 475 studies on effectiveness
• Results
– typical client is better off than 80% of those untreated
(compared to waiting list)
– little overall difference across various approaches
– psychotherapy does work, but no one therapy is better
than the rest
MODEST EXCEPTION: Behaviour Therapy
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Factors Predicting
Effective Psychotherapy
• If psychotherapy is effective, and it
depends little on the type of therapy used,
then what does it depend on? (Luborsky,
1971)
– Therapy characteristics
– Client characteristics
– Therapist characteristics
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Therapy Characteristics:
Worst Predictor of
Effectiveness
• Overall, therapy characteristics was the worst of
the three sets of predictors
• Exception: Number of Sessions
– more sessions meant more improvement
– Luborsky reviewed 15 studies with more than 2400
clients
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Client Characteristics:
Best Predictor of
Effectiveness
Improvement was markedly higher if the client:
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had a higher IQ
had a less severe disorder
was better educated
was in a higher socioeconomic class
was highly motivated to get better
The perfect client…
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Therapist Characteristics:
2nd Best Predictor of
Effectiveness
• Improvement was markedly higher if the
therapist:
– had more experience
– was perceived as empathic
• Paraprofessionals are at least as effective as
professionals for specific problems
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The Future of Psychotherapy
Research
• Must still study interaction among
predictors
– Process research is becoming very popular
– Need to evaluate which therapy works for
which clients, under what circumstances
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