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Clinical Interventions: Overview & Methods Dr. Kline FSU-PC What is Psychotherapy? Psychotherapy essentially is treatment conducted within a professional relationship by trained therapists to help/facilitate clients in distress (Neitzel et al., 2003). This definition, allows us to identify: *The participants (i.e., the client and therapist) *The basic framework of the situation (professional relationship) *The basic goal of the therapy (reduction of emotional distress/help with the problem). Who are the therapists? While, therapists are trained professionals at dealing with client’s problems & issues, the type of training, theoretical orientation, years of education, & scope of ability vary. In general the following individuals are considered therapists: Clinical Psychologists (PhD & PsyD) Master’s level psychologists Psychiatrists MSW Marriage and Family therapists (MFT) Characteristics associated with good therapists? Advanced Training Good Interpersonal Skills Good Listening Ability Clients prefer therapists with advanced training. Includes communication, relationship-building, & selfmonitoring skills. Should be able to listen to clients & effectively communicate with them. Genuineness, empathy, & Unconditional positive regard. These promote rapport with the client & build trust. Who are the clients? Clients, like therapists, vary is several characteristics, but with one notable exception: ***Most clients that seek help from a therapist have reached a point where their coping mechanisms no longer function.*** Occasionally, some clients seek therapy because someone else is distressed (e.g., a parent, judge, employer, spouse, or other family member). These clients tend to be less motivated than clients seeking help for themselves. Which clients tend to fare better in their treatment outcomes? 1. Clients who “do their homework” tend to do better. That is, clients who “complete” assignments given to them by their therapists (e.g., keep a diary of emotions, etc.) show better treatment outcomes. Burns & Spangler (2000) reported that depressed patients who were homework compliant, reported decreases in depression. 2. Clients who are cooperative & open tend to have better treatment outcomes than clients who are resistant & defensive. (Orlinksy, Grawe, & Parks, 1994). The Therapeutic Relationship A. Professional Guidelines- therapists have commitments to honor in their relationship with a client. These commitments protect the client & therapeutic relationship. These commitments are: Confidentiality – information about the client isn’t revealed with anyone except for unique circumstances (e.g., client is danger to himself/herself, is a danger to others). Informed consent – therapists must tell clients what the guidelines are for confidentiality. Ethics - Clients have a right to know what is appropriate conduct for therapists within a therapeutic relationship. The ethics code for these issues are published in the American Psychological Association’s “Ethical Principles of Psychologists and Code of Conduct”. B. Therapist Objectivity & Self-Disclosure Although therapists need to be empathetic & understanding, there will be situations in which therapists will have to “push” their clients to overcome resistance in dealing with a problem. This requires objectivity on the therapist’s part, because the therapist will have to determine when to detach themselves from their clients so they can “insist” their clients progress towards a solution to their problems. However, there will also be occasions in which therapists may want to use self-disclosure (divulging something about themselves to their client) as a means of building trust and rapport with their clients. E.g., a family counselor whose been divorced may carefully divulge something about his/her own experience so as to build common ground with a client going through a divorce. The client “identifies” with the therapist, thereby promoting trust in the therapeutic relationship. – Caution: therapists should only divulge a minor bit of information about themselves to their clients. Too much or too little information may impair the relationship between the therapist and client. C. Therapeutic Alliance – determined by two factors Factor 1: The emotional ties that develop between the therapist & client (trust, respect, etc.). Factor 2: The common goal of the therapeutic relationship which is to help the client achieve his/her goals. Outpatient Settings Inpatient Settings Therapist’s office, rented spaces in community centers, etc. Public, private, & VA hospitals, residential rehab & treatment centers, prisons, jails, etc. Therapist office-most common setting for therapy. Privacy is required. Hospital-most common setting for treatment. Psychopathology is usually fairly serious with in-patient care. Goals of Psychotherapy 1. Fostering insight: Therapy should improve a client’s insight into why he or she behaves the way they do. ***The rationale here is that by understanding your behavior problems (mistakes), you are empowered to make behavior changes that are adaptive & healthy.*** According to Nietzel et al., 2003, therapists of all theoretical backgrounds need to encourage their patients to understand “their” actions. One method for facilitating insight in your patients, is for the therapist to interpret the client’s behavior. ****This is done to motivate clients to examine their own behavior and draw inferences about the meaning of their actions. Note: this is not to show client’s the therapist is right!!!!!*** Caution: Therapists will want to avoid divulging information that is too confrontational to client’s who are disturbed or who have a fairly severe diagnosis that may not be able to handle such news at the time. 2. Reducing emotional discomfort: Therapists often are faced with client’s who are in severe emotional pain & anguish. This makes therapy challenging as the patient is greatly distressed. Therapists don’t want to completely reduce the client’s distress as this may eliminate their desire to address their problems, but will want to reduce the client’s distress to some extent to promote a positive treatment outcome. One way to achieve this goal is for therapists to use the therapeutic relationship to improve the client’s emotional strength. For instance, if the client feels they can count on the therapist be understanding and non-judgmental, they are better equipped to deal with the onslaughts from the others. Therapists can convey the message to client’s that although things seem hopeless and insurmountable now, you will be able to make changes in your life that improve your outlook considerably. 3. Encouraging Catharsis: Catharsis, involves releasing pent-up emotions (frustration, anger, helplessness) that have been bothering the client for a long period of time. Therapists should encourage catharsis, by empowering client’s to express their emotions, frustrations, and issues in therapy. Therapist to client: “Tell me how you feel about that?….” “How did that make you feel when he/she did that to you?...” There is some evidence that such emotion-focused techniques may be helpful in easing tension for client’s who are distressed or repressing their problems. 4. Providing New Information: Among other things, therapists help their clients by educating them. That is, therapists provide information to client’s about their: **maladaptive thought patterns (e.g., identifying irrational or inaccurate beliefs) **Problem behaviors (e.g., self-destructive behaviors such as addictions, actions designed to hurt others). Psychodynamic Therapies Psychodynamic therapies assume that an individual’s behavior is determined by the interaction of powerful competing forces within the person. These forces are largely: **unconscious (outside the person’s awareness) **Develop in early childhood. **Result in coping mechanisms designed to deal with anxiety. This is a push-pull theory!!!! Origins of Psychoanalysis Shortly into Freud’s career as a physician, he examined several patients who displayed neurological symptoms with no known organic cause (e.g., some patients complained of paralysis, yet could move their limbs in their sleep). Freud labeled these patients as, “neurotics.” Most of these patients exhibited hysterical paralyses, amnesia, blindness, & speech loss. Treatment for these neuroses consisted of baths or electrically generated heat, which Freud believed resulted in symptom relief due to the power of suggestion (e.g., placebo effect). Freud decided to try hypnosis as a method of suggestion that might alleviate neurotics’ symptoms. Hypnosis: its history with psychoanalysis Joseph Breuer, a colleague of Freud’s, recommended that hypnosis and the cathartic method be used to treat neurotics. Breuer had a patient (Anna O.) come to him complaining of (headaches, cough, neck & arm paralyses) that originated shortly before her father’s death, but became worse afterwards. Breuer, noticed Anna when into “trance-like states” that resembled hypnosis. During one of these “trances” he encouraged his patient to describe the events that occurred during her day. This resulted in a short-term improvement in her symptoms immediately following the trance. On one session, Breuer noticed that one of her “symptoms” that was linked with a distressing event, disappeared following her account of the event in her trance. Breuer made the connection between the distressing event that Anna had either forgotten or was simply unaware of during the day and her neurological symptoms. Using hypnosis, Breuer encouraged Anna to recall everything about her symptoms and the events in her life. This seemed to work as symptoms continued to disappear with these “therapeutic sessions.” Freud’s use of hypnosis & other treatments: Freud took Breuer’s advice & used hypnosis to treat neurotics. However, because not all patients could be easily hypnotized, he started simply requiring patients to close their eyes and recall emotions, thoughts, feelings, and events that came to mine. Later, he simply asked the to mention whatever they were thinking. He also started to ask patients to describe their dreams as he felt dreams may divulge hidden motives/events that were the route of their problems. Goals of Psychoanalysis The goal of psychoanalysis is to make a client’s unconscious motives, drives, and conflicts available to them so they can deal with it. Freud reasoned that if individuals were confronted with the reasons why they behaved in maladaptive ways, they would be forced to change their behaviors. However, the client must figure these things out for himself/herself, with the therapist as a guide. Three main goals of Psychoanalytic treatment: 1. Intellectual & emotional insight into the underlying causes of the client’s issues. 2. Working through the implications of these insights. 3. Strengthening the ego’s control over the id & superego. This takes on average (3-5 sessions per week for 2-15 years) with a psychoanalyst. Psychoanalytic Treatment Methods: 1. Free Association – Evolved from a non-hypnotic way for Freud’s patients to “consciously” recover emotional memories. The client needs to say everything that comes to mind without editing or censorship (Neitzel et al., 2003). This should allow bits & pieces of unconscious material to appear. The therapist will have to look for “patterns of association” that indicate something important. Clients who only talk about trivial issues (small-talk) are seen as constructing barriers that impedes their progress. Thus, there should be something of substance mentioned in the session. 2. Dream Analysis Freud believed dreams represented repressed memories, wishes, and desires. Freud argued dreams contained two kinds of content: **Manifest content- the actual events or images that occur in the dream. **Latent content – the unconscious information in the dream that occurs in the forms of symbols. Freud had client’s recall the manifest content of their dreams, to see if he could detect the unconscious material masked in the dream’s images and actions. Psychoanalysts may examine several dreams produce by a given client to see if any common themes develop and how these may relate to their problems in daily life. 3. Transference The client’s feelings toward the therapist and their relationship is known as transference. Freud argued the unconscious information regarding authority figures from childhood lie at the root of many clients’ current problems. Therapists will try to remain a bit detached & divulge very little about themselves to their clients to encourage clients to project onto them unconscious attributes & motives associated with parents, spouses, & other people in their lives (e.g., client may see therapist as neglectful parent, loving spouse, jealous lover, etc.). When transference occurs it provides the therapist and client with an opportunity for the client to discover the issues that are bothering them with other people in their lives. Therapists need to be careful that they don’t project their own unconscious desires, feelings, & so forth onto their clients, something called countertransference. Behavior Therapies A. Assumptions of behavior therapies: 1. Behavior disorders are assumed to have developed through learning (conditioning, modeling, etc.). 2. Therapies should be based on results of research in learning based methods. 3. The goal of behavior therapies is to modify overt, maladaptive behaviors. 4. Therapies should focus on clients’ current problems in their natural environments. 5. Treatment should be based on carefully controlled empirical studies examining the efficacy of therapies on treatment outcomes. B. Origins of Behavior Therapy The link between behavioral methods & psychopathology actually began in the 1920s and 30s when Pavlov examined experimental neuroses in dogs after exposing them to electric shock. The dogs’ symptoms included: agitation, barking, biting the equipment, & forgetting previously learned events (Nietzel et al. 2003). Watson & Raynor’s work on Little Albert was a follow-up to Pavlov’s work described above. They showed you could condition “fear” responses in an 11-month old infant through classical conditioning. Origins (contd.) By the 1950s & 60s behavior treatment was used to treat a variety of problems (anxiety disorders, sexual disorders, schizophrenia, etc.). Today, behavior therapies rank high among treatments for a variety of psychopathology and is the gold standard for treating certain disorders (phobias, anxiety, autism). Behavior therapy treatment methods: 1. Systematic Desensitization: first developed by Joseph Volpe in 1958, the goal of this treatment is to extinguish fear and/or anxiety in individuals (and organisms). This is accomplished by systematically exposing individuals to fear-eliciting stimuli that are gradually increased in intensity over trials. Therapy consists of three parts: ***Relaxation training*** ***Creating a graduated hierarchy of fear-evoking events*** ***Imagined /virtual reality desensitization*** Formula for Systematic Desensitization: Part I: Clients are trained to employ a relaxation method to reduce anxiety. Progressive relaxation training, a common relaxation method, requires that clients voluntarily tense specific muscle groups (hands, arms, etc.) for a period of time & then focus on the sensations of relaxation that follow muscle release. E.g., require clients to clench the fist for several seconds followed by release. Part II: The therapist creates a graduated hierarchy of events/situations the client finds as increasingly anxiety-provoking. Each event (or stimulus) should be perceived as more anxious than the preceding event. Part III: The client may use either imagined desensitization or more realistic desensitization. On the first trial on imagined desensitization, the client mentally “visualizes” the first event on the graduated hierarchy and tries to remain relaxed until fear/anxiety is extinguished. If they can do this for 10 seconds, the therapist encourages them to visualize the next event on the hierarchy, and so forth. Clients may also use a more real-world approach, by being exposed to carefully monitored levels of the fear-eliciting stimulus. Again, if clients can go 10 seconds with little to no anxiety, they are then exposed to a slightly more intense version of the feareliciting stimulus, and so forth. Desensitization Hierarchy 1. Imagine writing the word, spider. 2. Image while reading a book you notice a small spider on the cover. 3. Imagine a spider the size of your hand across the room from you. 4. Imagine the big spider has crawled closer to you; it’s about 3 feet from you. 5. Imaging the spider is now 1 foot away and crawling towards your hand. 6. Imagine the spider is crawling onto your hand. 2. Exposure techniques: The goal of exposure therapy is to fully expose the client to the fear-eliciting stimuli so that they experience anxiety and wait until it finally extinguishes. One common exposure method is flooding. Flooding—requires that client is exposed to a maximally intense “level” of the fear-eliciting stimulus. This should cause a severe anxiety response that with prolonged exposure (time) should diminish, thus extinguishing the association between anxiety & the fear-eliciting stimulus. E.g., putting a tarantula in the hand of a client with arachnophobia!!!! Important points for exposure methods: Exposure methods will only work if enough time is allowed for the anxiety responses to extinguish. Removing the fear-eliciting stimulus too early will only reinforce avoidance behavior, thus strengthening the association between the anxiety & fear-eliciting stimulus. Therefore, exposure therapies require a strong commitment on the part of both client & therapist. Efficacy of Exposure treatments: Exposure treatments have been shown to be successful in treating obsessive-compulsive disorder (OCD), phobias, & panic disorder. In treating OCD, clients are exposed to the stimulus linked with their obsessive thoughts (e.g., dirt) & not allowed to engage in the ritualistic behaviors that usually reduce their anxiety (e.g., compulsive handwashing). This is called exposure and response prevention (ERP). 3. Modeling Has been used to treat phobias, social withdrawal, OCD, antisocial conduction, aggressiveness, & autism. A client with a clinical problem, can observe live or videotaped models performing behaviors that the client avoids with no negative consequences experienced. Treatment is most effective when are very similar to the client, have high status, & are reinforced for their responses (Neitzel et al., 2003). Contingency management Refers to operant conditioning methods where behaviors are strengthened or reduced based on consequences. **Shaping** - develops new behaviors by strengthening successive approximations of desired responses. **Time out***- reduces frequency of undesirable behaviors by removing client from setting where being has been reinforced. **Contingency contracting**-a formal contract is written out by a therapist & client stating what consequences will be for undesirable behaviors. **Token Economies**- tokens are earned for desired behaviors, lost for unwanted behaviors. Tokens may be used to obtain something else (e.g., like money to buy things). Cognitive-Behavioral Therapy All cognitive therapies attempt to modify individuals’ thoughts (cognitions), thereby resulting in changes in the clients’ responses. Cognitive approaches assume psychopathology results from faulty/inaccurate cognitions (beliefs, schemas, problem-solving strategies) that are linked with our affectivity (emotions). E.g., depression results from negative thoughts & beliefs about the self (“I am worthless,” “No one loves me,” “I’m a failure,” etc.). These negative beliefs result in negative affectivity, thereby leading to depressive symptoms. If you change the faulty perception, the maladaptive actions & underlying affectivity resulting in depressed mood will dissipate. The combination of behavior & cognition in cognitive-behavioral therapy Cognitive-Behavioral therapy represents the blending of cognitive & behavioral techniques to treat psychopathology. Therapists with a behavioral orientation, recognized the importance of perception & thoughts in treating disorders, while cognitive therapists recognized the significance of change maladaptive actions in improving self-esteem. Cognitive-Behavioral treatment methods: 1. Beck’s Cognitive Therapy: Developed by Aaron Beck, this method attempts to improve mental problems by identifying & correcting the distorted beliefs (thoughts) that result in the abnormal behaviors. Beck argues that logical errors & distortions in thinking result in depression & other forms of negative affectivity. E.g., A man concludes that he’s worthless, because a woman he asked on a date turns him down. There may be multiple reasons for her response that has nothing to do with him, but he focuses on his unworthiness. Applying Beck’s therapy Distorted & inaccurate beliefs are identified & corrected by therapists using these strategies (see Neitzel et al., 2003, p255). 1. Recognizing the connections between cognitions, affect, & behavior. 2. Monitoring occurrences of cognitive distortions. 3. Examining the evidence for & against these distortions. 4. Substituting more realistic interpretations for dysfunctional thoughts. 5. Providing assignments that allow clients to practice new thinking strategies & more effective problem-solving. 2. Rational Emotive Behavior Therapy: REBT, developed by Albert Ellis, attempts to treat abnormal behavior that results from irrational thoughts & beliefs. Individuals with irrational, self-defeating thoughts, develop unrealistic expectations of what is needed for them to be happy. When these expectations/beliefs are unmet, depression & anxiety result. The goal of REBT is to replace the client’s irrational & selfdestructive beliefs with rational, logical thinking patterns that do not result in negative affectivity. Therapists need to be strong, direct, and focused when working with clients. Humanistic Therapies These therapies focus on helping clients deal with their anxieties, focus on clients’ positive/healthy thoughts & behaviors, and strive to help client’s recognize their full potential as individuals. Behavior problems result from anxieties, which impair an individual’s ability to grow & develop into health well adjusted adults. Clients are seen as in charge of their own therapeutic intervention & basically good people. Humanistic Therapy Methods: 1. Client-Centered Therapy: Carl Rogers developed this form of treatment which views the client as the one in charge of his or her therapeutic outcome. He argued that therapists need to enable client’s to discover for themselves the cause of their problems as well as the mechanisms by which the client could resolve their problems. If the therapist provides a comfortable, empathetic environment for the client to focus on their problems, then client will improve (if-then statements). Therefore, the goal of client-centered therapy is to provide the client with an opportunity to further his/her personal growth. Therapists need to express unconditional positive regard, empathy, & congruence to help their clients. Unconditional Positive Regard According to Rogers, this conveys three important pieces of information to clients: 1. The therapist cares about the client. 2. The therapist accepts the client (for who they are). 3. The therapist trusts the client’s ability to change. In a nutshell, unconditional positive regard, means not placing conditions of worth on others. Rather, people are cared about and accepted as they are. You don’t need to “earn” someone’s love, but are given it freely, regardless of your behavior. Empathy Therapists can only help their clients if they possess the ability to place themselves in their clients’ positions. That is, the therapist must try to see the world as the client does to understand what the client is feeling. Empathy is conveyed via active listening. In particular, therapists, “reflect” what the client has said to the client. This serves two purposes: **Communicates the therapist’s knowledge of the client’s problems. ***Indicates the therapists desire to understand the client’s problem. Congruence Therapists’ responses to clients should be consistent with their feelings. That is, therapists need to be honest & open with their own feelings so as to be sensitive and genuine with their clients. Clients need to be able to “trust” their therapists. If the therapist makes a comment to the client, they should feel they can “believe” the therapist. Thus, actions should reflect real the therapists’ real feelings and thoughts.