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Psychotherapy & Intervention Review of the Homework Trull: Chapter 11 (Interventions) Yalom: Three Unopened Letters (chapter) Questions? Comments? How does this fit in? 2 of 59 Interventions Overview Defining Intervention Psychological intervention (from text): A method of inducing changes in a person’s behavior, thoughts, or feelings. Alleviation of human suffering Removal of psychopathology Reduction in disordered behavior, cognitions, feelings 3 of 59 Interventions Overview Psychotherapy is one specific way to alleviate suffering Many things can be therapeutic (playing music, reading, etc.) Not all things are psychotherapy Therapy is a specified intervention New suggestion to differentiate therapy from treatment (Barlow, 2004) Consistent with medical profession 4 of 59 Interventions Overview Psychotherapy as an intervention should… be be be be specifiable plausible replicable trainable Example: EMDR (or power therapies) for PTSD 5 of 59 The Different Foci of Interventions Solve a specific problem Improve the individual’s capacity to deal with existing behaviors, feelings, or thoughts Prevention of problems Increasing person’s ability to take pleasure in life or achieve potential 6 of 59 Interventions Overview Overall Effectiveness of Psychotherapy as an Intervention Overall, evidence shows that psychotherapy works The average person receiving therapy is functioning better than 80% of those not receiving treatment Meta-analysis Smith, Glass, & Miller (1980) 7 of 59 8 of 59 Interventions Overview Consumer Reports Survey (Nov, 1995) 4,000 readers responded Therapy resulted in some improvement for the majority (relative) MD, PhD, and MSW all about the same Therapy alone was as good as therapy + meds More treatment was related to more improvement 9 of 59 Interventions Overview Consumer Reports Survey Serious Limitations/Criticisms: Probably unrepresentative sample Retrospective—halo effect Cognitive dissonance effect may be occurring May only say that folks like getting therapy Not external validity, not internal validity, more customer satisfaction which matters!, just differently 10 of 59 Interventions Overview Commonalities of treatments (According to Lambert & Bergin, 1994) Therapist as some kind of expert Release of emotions/catharsis Therapeutic alliance/relationship Anxiety reduction/release of tension Interpretation/Insight Building competency/mastery 11 of 59 Interventions Overview Nonspecific factors Goal of clinical science is to specify The therapeutic relationship “Magical powers” 12 of 59 Interventions Overview What therapy is not for Working on therapists issues Seeking intimate relationships with others Getting therapist needs met (attention, affection) 13 of 59 Interventions Overview Variables thought to be related to psychotherapeutic outcome Client YAVIS client Not research related Some research on these variables, though 14 of 59 Young Age: age = outcome Weak evidence Why any evidence? Is this also “Attractive” variable??? 15 of 59 Verbal Openness: openness = outcome Why? 16 of 59 Intelligent Intelligence: intelligence = outcome not w/behavior change Why? 17 of 59 Other variables of interest Degree of client distress: distress = outcome Motivation Mixed results Does not matter Evidence is inferential Gender Doesn’t matter overall Need to be sensitive to power issues May matter in certain situations 18 of 59 Interventions Overview What about therapist variables? Empathy, warmth, and genuineness? Age? Personality? Freedom from personal problems? Experience and professional identification? What about own values about ethnicities, genders, orientations, etc.? 19 of 59 Interventions Overview Therapist Variables Empathy, warmth, and genuineness Age Not related to outcome Personality these = outcome Too difficult to specify Freedom from personal problems Too hard to specify 20 of 59 Critical Thinking Moment Freedom from personal problems Should psychologists not have a history of psychological problems? Is this feasible? What if they have a history of problems? How could we specify this issue where it might matter? Past or present? Degree? Type? Level? Does this affect thoughts on requiring therapy? 21 of 59 Interventions Overview Therapist Variables Experience Professional identification Does matter More experience, better outcomes This is equivocal Does not matter What about own values about ethnicities, genders, orientations, etc.? 22 of 59 Typical Elements of Therapy Initial contact Lay down the basics Policy of not acknowledging client outside of therapy first Informing of 24-hour vs. not 24-hour care Providing opportunity for informed consent for services 23 of 59 Typical Elements of Therapy Assessment Typically called “intake” Assessment measures (gathering objective data) What are they coming in for? What attempts have they made in the past to deal with problems? 24 of 59 Typical Elements of Therapy Assessment What are their strengths/weaknesses? Harm to self or others? Alcohol, drug, medication, medical conditions, health, nutrition, etc Social support available History/family history 25 of 59 Typical Elements of Therapy Implementation of treatment Working towards targeted goals May be following manualized treatment, may not On-going assessment of progress 26 of 59 Typical Elements of Therapy Termination Final assessment of progress Summarize treatment gains Process termination Anticipate pitfalls 27 of 59 Typical Elements of Therapy Termination Can get feedback about therapist skills Not looking to process therapist’s own issues Schedule “Booster sessions” May schedule follow-up session 3, 6, or 12 months later 28 of 59 Theoretical Perspectives and Assumptions of Psychopathology Different paradigms have different assumptions about what creates human suffering, and what alleviates it Each paradigm is complete Each has pros and cons Each will dramatically affect choices of assessment and intervention Some are more scientific Some are more applicable to psychology 29 of 59 Main paradigms Psychoanalytic/psychodynamic Humanistic/Existential Behavioral/Learning Cognitive Biological 30 of 59 Main paradigms Note: these are culturally rooted and take an individual (not pluralist or cultural) approach to pathology Community psychology Feminist psychology Each will understand psychopathology differently 31 of 59 Review of the Homework Trull: Chapter 12 (Dynamic therapies) Questions? Comments? How does this fit in? 32 of 59 Psychoanalytic/Psychodynamic/ Freudian theories Assumptions of psychopathology Role of the unconscious Limited access to what occurs for us psychologically Unconscious conflict leads to tension anxiety Conflicts are NOT expressed directly 33 of 59 Psychoanalytic… These all take psychic energy Fixed amount of psychic energy = Hydraulic Model If one uses too many defense mechanisms one will run out of psychic energy --- or if you use too much energy in one Result in less well-functioning organism In pathology, look for symptoms of distress, cannot see the actual pathology directly (disease model) 34 of 59 Psychoanalytic Assumptions of curative factors in psychoanalytic theory Curative process is the resolution of the unconscious tension Need to free up the psychic energy being spent on defenses Challenges We cannot directly access unconscious conflict Uses hypothetical constructs for problems 35 of 59 Review of the Homework Trull: Chapter 13 (Humanistic) Questions? Comments? How does this fit in? 36 of 59 Humanistic/Existential Theories Assumptions of psychopathology Blocked in ability to grow, or How we understand ourselves becomes incongruent with what we actually see Anxiety Feel anxious when contact with information that is not consistent with how we view ourselves (our self-concept) Incongruence between the self-concept and society 37 of 59 Humanistic Theories Assumptions of curative factors Want to create a fully functioning person Need to remove conditions of worth Need to allow client to find meaning and do own growth Continue to pursue our greatness, our own full potential Client holds the key to psychological health happiness This is called non-directive therapy Also called person-centered or clientcentered therapy 38 of 59 Humanistic Theories Therapist provides Genuineness Unconditional positive regard Therapist is not “phony,” expresses feelings openly and honestly Therapist does not place conditions of worth on client Accepts and respects client no matter how client behaves, no matter what client says Empathy Therapist tries to see things from the client’s perspective 39 of 59 Review of the Homework Trull: Chapter 14 (Behavioral & CBT) Questions? Comments? How does this fit in? 40 of 59 Behavioral or Learning Models Assumptions of psychopathology People learn their problems Problems occur naturally through a learning process Classical conditioning Operant conditioning e.g., Substance abuse, Personality disorders, depression This learning is NOT direct instruction e.g., phobias Typically natural and can even be passive Problems are sustained largely through escape and avoidance of aversive events 41 of 59 Behavioral or Learning Models Thoughts require a slightly modified analysis but are still understood as both important and as behaviors The avoidance of thoughts can lead to more problems in living It is the avoidance that produces the problems, not the thoughts Interpersonal problems can be fundamental in bringing about and sustaining ineffective behaviors (psychopathology) 42 of 59 Behavioral or Learning Models Assumptions of curative factors If problems are learned, new and more effective behaviors can be learned as well Real key is exposure and extinction Keep in mind both classical and operant conditioning Techniques Graduated exposure treatments Flooding 43 of 59 Graduated Exposure Person gradually taken into the feared situation or exposed to the feared stimulus or traumatic memory until the anxiety subsides Systematic desensitization Use counterconditioning extinction to reduce fear Work through an “anxiety hierarchy” of situations that lead to fearful reactions Imagine fearful situations while remaining relaxed Also used in Cognitive processing therapies (CPT) for sexual assault 44 of 59 Systematic Desensitization 45 of 59 Systematic Desensitization 46 of 59 Flooding Person is taken directly into the feared situation until the anxiety subsides Escape response is prevented completely Pros and cons to this When would you NOT use this? Just as effective as systematic desensitization for phobias 47 of 59 Behavioral or Learning Models Challenge Hard to conceptualize problems contextually that include rich factors Challenge Difficult to identify all key variables in behavioral analysis 48 of 59 Behavioral or Learning Models Contemporary Behavior Therapies All have very active behavioral component Acceptance Commitment Therapy Functional Analytic Psychotherapy Focus on intrapersonal acceptance Having emotional unwanted experiences Focus on interpersonal processes Creating better relationships Dialectical Behavior Therapy Focus on emotional regulation and suicidal behaviors Used with Borderline Personality Disorder 49 of 59 50 of 59 Cognitive Approaches Assumptions of psychopathology Thoughts are the cause of our problems Way we think about the world dictates how we feel about ourselves, others, and the future This is a cognitive triad Depressed people have a negative cognitive triad Combined with logical errors get depressed 51 of 59 52 of 59 Cognitive Approaches Assumptions of curative factors Need to identify dysfunctional core schema and replace with more accurate and effective schema Need to challenge the cognitive distortions or false beliefs with evidence and look for more accurate thoughts Techniques Identify irrational beliefs, maladaptive interpretations of events Challenge beliefs directly Encourage more rational beliefs and interpretations 53 of 59 Cognitive Approaches Challenge Schema are metaphorical What is it that you are changing? How do you measure this? Challenge Evidence that thoughts do not lead behavior, they follow behavior 54 of 59 Biological Approaches Assumptions of psychopathology Psychological problems are caused by events at the biological (cellular) level Disruptions in neurotransmitters cause the expression of emotional or psychological disturbances Behavior at the level of physiology has direct expression at the level of psychology Look for symptoms of distress, cannot see the actual disease entity for most psychopathology (c.f. Alzheimer’s) Disease model of psychopathology 55 of 59 Biological Approaches Assumptions of curative factors Repairing disrupted neurotransmitter levels will produce a corresponding change in behavior Repair should function similarly for all people (given variations in body chemistry) Drug therapies Electroconvulsive Therapy (ECT) Psychosurgery 56 of 59 Biological Approaches Challenge Origins of psychopathology do not have known physiology So what are we doing? Challenge Not all drugs work for all people 57 of 59 58 of 59 Critical Thinking Moment Reviewing eclecticism Why not combine all of the theories? Remember theoretical vs. technical eclecticism OK to take technology Need to explain in broader theory Remember that these theories have Competing assumptions of origins of pathology AND Corresponding curative factors How do you know which to believe at which time? 59 of 59