Download ch16_Psy_TX

PowerPoint  Lecture Notes Presentation
Chapter 16
Psychological Treatment
Abnormal Psychology, Eleventh Edition
by
Ann M. Kring, Gerald C. Davison, John M. Neale,
& Sheri L. Johnson
Psychodynamic Treatment


Briefer and more active than traditional
psychoanalysis
Both emphasize:
» Importance of early parental relations
» Unconscious symptoms

Therapist listens for core emotional and relationship
themes
» Looks to patient’s reaction to therapist for clues

Use of interpretation to facilitate insight
» Understanding facilitates cathartic release of emotion
» Symptom reduction assumed to follow from increased
insight and understanding of patterns
Copyright 2009 John Wiley & Sons, NY
2
Experiential Therapies

Basic assumption that humans are innately good
» Emphasize our creative and expressive aspects


Aims to promote growth by helping client
understand and value internal emotions and needs
Therapist provides safe environment for this
exploration
» Use of empathy

People’s innate goodness and effectiveness is
thwarted by too many internalized demands and
preferences from others and from society
Copyright 2009 John Wiley & Sons, NY
3
Experiential Therapies

Roger’s Client-Centered Therapy
» People can be understood only from the vantage
point of their own perceptions and feelings
» Humans are innately good, effective, and selfdirected
– Self-actualization
» People’s innate goodness and effectiveness is
thwarted by internalized demands and preferences
from others
» Conditions of worth vs unconditional positive
regard
Copyright 2009 John Wiley & Sons, NY
4
Experiential Therapies

Gestalt therapy (Fritz Perls)
» Help clients realize how they block themselves from
experiencing and expressing their emotions and needs
» Focus on the here-and-now, rather than past
» Emphasis on techniques
– “I” language
– Empty chair
– Attention to nonverbal and paralinguistic cues

Emotion-Focused therapy (Greenburg)
» Combines elements of client-centered and gestalt
therapies
» Adaptive and maladaptive emotions
– Foster awareness of maladaptive emotions and learn to
regulate them
Copyright 2009 John Wiley & Sons, NY
5
Behavioral Therapies

Exposure
» Effective for several anxiety disorders

Operant techniques
» Useful for behavioral problems and substance
abuse
» Behavioral activation therapy for depression
(Jacobson et al., 2001)

Especially effective for childhood problems
» Bed-wetting, thumb-sucking, nail-biting,
aggression, tantrums
» Parent training often integral to treatment success
Copyright 2009 John Wiley & Sons, NY
6
Cognitive Behavioral Therapy

All based on awareness of maladaptive thoughts
» Modifying cognitions alters feelings, behavior, &
symptoms



Beck’s Cognitive Therapy
Ellis Rational Emotive Behavior Therapy
Recent innovations:
» Linehan’s Dialetical Behavior therapy
» Mindfulness based cognitive therapy
» Acceptance and Commitment therapy

All emphasize awareness of emotions without impulsive
reacting
» Acceptance
Copyright 2009 John Wiley & Sons, NY
7
Cognitive Behavioral Therapy

Beck’s CBT

» Several studies have
demonstrated its
effectiveness for
depression
» CBT as effective as
medication for severe
depression (Hollon et
al., 2002)
– Effects maintained
over 1 year follow up
CBT effective for:
»
»
»
»
»
»
Depression
Panic disorder
GAD
Social phobia
Chronic pain
Irritable bowel
syndrome
» Bulimia nervosa
Copyright 2009 John Wiley & Sons, NY
8
Couples Therapy

About 50% of marriages end in divorce within first 7 years.
» Those in distressed marriages, 2 – 3 x more likely to
experience a psychological disorders
– Marital distress may be either a trigger for or a consequence of a
disorder

Predictors of relationship distress
» Signs of conflict and differences are ignored
– Demand-withdraw cycle
» Stone-walling
» Defensiveness
» Expressions of contempt for partner

Treatment focus:
» Improving communication, problem-solving, satisfaction,
trust, and positive feelings
Copyright 2009 John Wiley & Sons, NY
9
Table 16.1 Goals in Different Forms
of Couples Therapy
Copyright 2009 John Wiley & Sons, NY
10
Family Therapy

Based on assumptions
» Problems of the family influence each member
» Problems of each member influence the family

May include:
» Focus on roles within family, e.g., parental
responsibilities
» Identification of family “scapegoat”
» Teaching communication and problem-solving
» Psychoeducation
Copyright 2009 John Wiley & Sons, NY
11
Treatment Outcome Research


Therapy is effective
Analysis of over 300
studies showed
most people (75%)
improved after
therapy (Lambert &
Ogles, 2004)
Copyright 2009 John Wiley & Sons, NY
12
Table 16.2 Examples of Empirically
Supported Treatments for Adult Disorders
Copyright 2009 John Wiley & Sons, NY
13
Figure 16.2 Stepped Care
Copyright 2009 John Wiley & Sons, NY
14
Standards for Treatment Outcome
Research


Clear definition of sample and diagnoses
Clear description of treatment
» Driven by treatment manual


Reliable and valid outcome criteria
Control or comparison treatment conditions
» Randomized controlled trials (RCTs)
– No treatment, placebo, other treatment


Random assignment
Sample of sufficient size for statistical tests
Copyright 2009 John Wiley & Sons, NY
15
Challenges to Evaluating Treatment Outcomes:
Table 16.3 Treatments that May be Harmful
Copyright 2009 John Wiley & Sons, NY
16
Challenges to Evaluating Treatment
Outcomes

Use of treatment manuals
» Detailed set of instructions for implementing treatment
at each stage of therapy
» Minimize therapist differences
» Increase internal validity but may reduce external
validity
– Alternative: manuals that offer freedom to therapists

Defining the sample
» Based on DSM diagnosis
» Samples should be selected by psychological profiles
instead
– Match clients to treatment
Copyright 2009 John Wiley & Sons, NY
17
Challenges to Evaluating Treatment
Outcomes

Concerns about those who are excluded
from treatment studies, including
» Individuals with more than one disorder
» Participants who refuse participation
because they may receive control condition
or placebo

Makes generalization difficult
Copyright 2009 John Wiley & Sons, NY
18
Treating Disorders in the Real World

Efficacy
» Determination of whether a treatment works under
ideal conditions

Effectiveness
» How well a treatment works in the real world

Standards for real world outcome research
»
»
»
»

Broad range of problems in sample
Allow therapists more flexibility
Examine broad range of outcomes
Briefer assessments
Effectiveness research can focus on how to
foster better treatment in the community
Copyright 2009 John Wiley & Sons, NY
19
Evidence of Treatment
Effectiveness

Traditional psychoanalytic therapy
» Clients with severe psychopathology (e.g.,
schizophrenia) do not do as well as those
with anxiety disorders
» People with more education tend to do
better than those with less education
» Poor outcomes are more likely when a
therapist makes frequent interpretations of
transference reactions
Copyright 2009 John Wiley & Sons, NY
20
Evidence from Randomized
Control Trials (RCT)


Psychodynamic therapy
Although psychodynamic treatment has received
support, there are three important caveats:
» Psychodynamic treatment offers advantage compared
to control only when treatment lasts more than 20
sessions
» Psychodynamic treatments have not been found to be
more helpful than general treatment as offered in the
community
» Brief psychodynamic therapies fare best when
therapists use a manual and receive specific training
Copyright 2009 John Wiley & Sons, NY
21
Evidence from Randomized
Control Trials (RCT)

Experiential therapies
» Demonstrated positive effect, mostly for
less severe problems
» Emotion-focused therapy has the strongest
results
» Two studies suggest that Gestalt therapy,
with unrestrained emotional expression, led
to deterioration in some participants
Copyright 2009 John Wiley & Sons, NY
22
Evidence from Randomized
Control Trials (RCT)

Cognitive therapy
» Beck’s therapy achieves greater short-term
improvement than wait-list controls, noncognitive behavioral treatments, and a
heterogeneous group of other psychotherapies
– Also appears to prevent future depressive episodes
» REBT also has demonstrated effectiveness as
does Marlatt’s Relapse Prevention Therapy
Copyright 2009 John Wiley & Sons, NY
23
Evidence from Randomized
Control Trials (RCT)

Couples Therapy
» About 80% of couples report improvement
compared to those who receive no treatment
» More successful than individual therapy in
reducing relationship distress

Family therapy
» Efficacy in reducing symptoms of broad range
of disorders
– Schizophrenia, agoraphobia, substance abuse,
bipolar disorder
Copyright 2009 John Wiley & Sons, NY
24
Choosing Among Therapies



Much debate and controversy about
comparisons among therapies
For depression, CBT may have small
advantage over other therapies
CBT seems to have a distinct advantage over
other therapies in treatment of anxiety disorders
» Except for exposure therapy

Couples vs. individual treatment
» Both relieve depression
» Couples therapy also leads to greater relationship
improvements
Copyright 2009 John Wiley & Sons, NY
25
Importance of Culture and Ethnicity in
Psychological Treatment
Copyright 2009 John Wiley & Sons, NY
26
Importance of Culture and Ethnicity in
Psychological Treatment

Most RCT samples have been white, non-Hispanic
people
» Results may not apply to other groups

Ethnic matching
» Preference for therapist from similar background
– Outcomes are not better with therapist-client match
» Cultural competence may matter more than ethnic
matching

All ethnic groups are highly heterogeneous
» Avoid stereotyping
» Consider the degree to which the person is assimilated
into, and holds the same values, as the majority culture
Copyright 2009 John Wiley & Sons, NY
27
Importance of Culture and Ethnicity in
Psychological Treatment

Several studies have tested whether standard empirically
validated treatments work with culturally diverse
populations
» Group IPT efficacious for people living in Ugandan villages
» Efficacy of CBT for African Americans with anxiety disorders
» Treatments for childhood anxiety and disruptive disorders do
not vary by ethnicity

Standard treatments can be enhanced by adding
culturally sensitive components
» Family values and spirituality in Latino cultures
» Sensitivity to higher rates of trauma experienced by African
American women
Copyright 2009 John Wiley & Sons, NY
28
Therapy Process Research


Draw the best ideas from different
treatments
Two types of process research
» Common factors approach
– Therapeutic alliance that includes empathy, positive
regard, engagement, goal setting with flexibility
» Mechanisms of change
– Changes in cognitions as a result of CBT

Both behavioral activation and medication alone result in
cognitive change
Copyright 2009 John Wiley & Sons, NY
29
COPYRIGHT
Copyright 2009 by John Wiley & Sons, New
York, NY. All rights reserved. No part of the
material protected by this copyright may be
reproduced or utilized in any form or by any
means, electronic or mechanical, including
photocopying, recording or by any information
storage and retrieval system, without written
permission of the copyright owner.
Copyright 2009 John Wiley & Sons, NY
30