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PS381 Class 17.docx

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Wilfrid Laurier University
Richard Walsh- Bowers

Class 17 - Psychotherapy: Basic Concepts and Applications Definition of psychotherapy -a developmental, interpersonal situation consisting of a relationship between sufferer and healer with the goal of relieving problems by altering how the sufferer feels, thinks and acts. proceeds with history, a beginning, middle and end professional relationship between someone who is in psychic pain and someone who has the abilities to heel three psychological ways that the suffering is cured – with respect to how we feel, think and act psychotherapy can occur in a dyad, within a group, or with a family or couple. -the healer has specialized training and draws on theoretical concepts to apply certain helping techniques. some psychotherapists are more comfortable with understanding the theoretical backgrounds, others are more pragmatical Major Models of Psychotherapy – 1 stands for primacy, 3 means least important Psychoanalysis – version pioneered by Freud, most important is AFFECT (noun) refers to emotions associated with particular motives, unconscious motivation primarily. Uncovering unconscious motivation and how the person feels towards those motives. Least important is behaviour. Only ever done in a dyad, between two people. Psychodynamic – Affect, Cognition, Behaviour (same as psychoanalysis) BUT can be done individually, group or family. Person Centered – Affect, Cognition, Behaviour – Can be done individually, group or family. Insight-Action – most important aspect is changing Behaviour, then Affect, then Cognition. Two types: PSYCHODRAMA – never done with individual, always in group GESTALT – Can be done individually, and in group. Behaviour Therapy – most important is behaviour, then cognition, then affect Can be done individually, group or family Cognitive – most important is COGNITIONS. Least important is how you feel about those cognitions. Can use cognitive therapy in any modality. Family System - theoretical focus of each of these domains can be quite different Commonalities Among Theories of Therapy -therapy involves three phases: exploring the problem, understanding it, and trying to solve it. when problem is solved, treatment is over -unconscious dynamics of resistance to change, transference, and counter-transference occur Transference: client projects onto the therapist unfinished business we have with family/friends…etc. Some therapies bring out transference out into the open Counter transference: therapist projects onto the client/patient. Unconsciously. Resistance to change: Ambivalent – pulled into two directions. We want therapy because we’re suffering, but it’s scary because we have to change how we feel, think, and act. -moral and political persuasion are at the root of the therapeutic-change process. attempt to persuade client to particular POV origins of the problem and best way to solve the problem Carl Rogers – shaped responses of clients, what normally happens in the therapeutic session -Therapy can result in improvement, no change, deterioration, or ‘iatrogenesis’ (harm caused by the healer) Therapy is a continuum, from no help/harm to heaps of help at the other end -Nonspecific or ‘placebo’ qualities of faith, hope and caring saturate the helping relationship. Nonspecific or “placebo” Influences -success of therapy depends on a warm, trusting climate between suffer and healer -relationship qualities are called nonspecific or ‘placebo’ effects because they lack specific therapeutic activity. -yet placebo effects account for a large portion of treatment effects Common Factors -Therapist-offered conditions -Empathy, warmth, caring, and a nonjudgmental attitude -Expert role -Release of emotions (catharsis) letting fear evaporate through: Systematic Desentisation, Psychotherapy, Gestalt...etc. Every therapy is set up to allow patients to release emotions -Therapeutic Alliance: therapist tries to join with the patient/family/group, form an alliance to take the heat of patient’s shoulders -Distress/Reduction -Rationale/insight -Competence/Mastery Misconceptions about Therapy -There is one best therapy TRUTH: different therapies is better for different problems/situations -Therapy is equally effective for whatever ails you TRUTH: It can’t deal with everything, useful for psychological issues -Therapy can really change your life around -Therapeutic changes are permanent -The longer the therapy, the better the results -One course of therapy is the rule for most clients. Who are the Healers? -Professional groups include psychiatrists, nurses, social workers, psychologists, occupation therapists, and creative art therapists. -Historically, primarily male, now female -Mainly white, middle class, and supporters of the political status quo -Others serve informally as healers: Doctors, massage therapists, teachers, clergy, hairdressers, self-help groups. Psychotherapists’ Characteristics and Treatment Outcomes -Training – unrelated to outcome -Experience – “. -Gender – “. -Age – “. -Well-being – correlated with outcome. -Expectations about client – “. regardless of training/experience, you have to be competent. You have to have good supervision and talent Who are the Sufferers? -In private therapy, usually verbal, intelligent, successful individuals participate -In public clinics, a greater range of characteristics prevails -Whether private or public, women are more likely to go More socially acceptable for women to express their feelings opposed to men Men complain more about being sick/hungover, etc. -For decades, professionals thought that psychotherapy could not benefit people with schizophrenia, bipolar, or character disorders – these individual received ‘supportive psychotherapy’ rather than psychoanalysis. This view now is changing. Essentials of A Psychotherapy Relationship -it occurs in a socially acceptable place of healing -the frequency and length of meetings are planned and limited -The goals of the relationship are specified -A therapeutic alliance (a “facilitative therapeutic relationship”) is crucial. -So is confidentiality [next slide]. Limits of Confidentiality -with written consent of client -Comply with reporting laws: Child abuse Abuse of disabled or elderly -Protect the client and others: -Tarasoff case -Suicide prevention -Mandated by court (subpoena) -Consultation with colleagues when uncertain. Psychotherapy Integration Movement: I -By the 1980s, extensive reviews of outcome studies (“meta-analyses”) showed that all forms of treatment were relatively effective. -Many prominent academic psychologists then acknowledged the impact of relationship & placebo factors on treatment-outcome. They recognized that understanding the meaning clients gave to their “environmental stimuli” was crucial to treatment effectiveness. -In 1985 these clinical psychologists initiated a scholarly movement to end the polarized debates between models of therapy and integrate them. Psychotherapy Integration Movement: II -However, many cognitive behaviour therapy (CBT) devotees continue to assert that their approach is superior to all other models, denying the value of psychotherapy integration. This opinion is common in Psychology textbooks. -In my own clinical work, I developed a “psycho-educational model,” integrating psychodynamic, person-centred, & behavioural perspectives in two clinical areas: [1] community-based treatment for individuals with long-term mental health challenges. [2] group treatment of children & youth. Class 18 – Clinical Research and Programme Evaluation Origins of the Scientific Approach to Clinical Psychology in the US: 1 Clinical psychologists after World War II promoted their sub-discipline as scientifically- based & validated. In their “scientist-practitioner model” they expressed commitment to the tenets of natural science psychology: –Experimental method of statistical control. –Interventions developed on the basis of “laws of behaviour,” which they believed were universal, i.e., applicable to all regardless of social historical context. -any interventions that we develop that have to do with providing treatment, should be done with the laws of universal behaviour, not cognitive psychology -psychologists in NA believed they could develop laws that are generalized to all people, past, present, future … now we know it’s self deceptive Origins of the Scientific Approach to Clinical Psychology in the US: 2 -By the 1960s, however, most non-academic, clinical psychologists rarely engaged in clinical research or even evaluated clinical services. -Meanwhile, academic clinicians typically conduct “analogue research” of treatment outcomes, based on university students. Although the researchers generalize to actual clinical cases, the two types of samples generally are not equivalent. -In effect, not much clinical research has been useful. History of Psychotherapy Research -1940s – Carl Rogers and associates recorded interviews to analyze the process of therapy -1952 – Concerning treatment outcomes, British psychologist Hans Eysenck reviewed the literature and claimed that psychodynamic therapies were no more effective than ‘spontaneous remission’ and that behaviour therapy was superior in outcomes -Moral of the Eysenck story: Practice critical thinking concerning claims for research superiority of one type of therapy -1966 – US psychologist Allen Bergin concluded that Eysenck made major errors in his review and that no single type of therapy is best for every client Two kinds of Psychotherapy Research -Process research – How does the therapy work? What are the “mechanisms” that lead to therapeutic change? Ex. Carl Rogers •Outcome research – Is the therapy effective? Does a particular treatment for a particular clinical problem work? •Historically, most psychotherapy research has been outcome-oriented and analogue, based on non-clinical samples. Analogue Research Analogue research entails testing a treatment with non-clinical samples, usually university students with mild phobias, moderate depression, or excessive body-image concerns but not an eating disorder. Investigators then generalize to clinical populations. The advantages of analogue research are the convenience of university research and heightened experimental control, yielding internal validity. The disadvantage is questionable relevance to actual clinical practice (i.e., dubious external validity), which, of course, should be the point of such research. Between-Group Outcome Research Designs -Investigators randomly assign clients to treatment and control/comparison conditions. They assume that random assignment controls for nuisance variables. -They also assume that any obtained differences between the groups are due to the treatment. -Control or comparison groups can include no treatment, clients on a waiting list for treatment, or a “placebo” condition (i.e., a credible condition but one that should not work according to the theory underlying the tested treatment). Factorial Designs - these designs investigators ask, which treatment works best and is the combination better than each one alone? For example: (Problem, major Depression) No medication, no Medication, no psychotherapy psychotherapy Group A – receive nothing Group B – No U/D and psychotherapy No medication, Medication, psychotherapy psychotherapy Group C - Upper Group D – both medication and psychotherapy Types of Validity in Research: Internal: The treatment caused change in the outcome variables. External: The results can be generalized to actual clinical conditions. Construct: The treatment change occurred for the reasons the researcher thinks it occurred.  theoretical validation, investigative team hopes that positive effects of treatment have occurred because of the theory of behind the treatment worked. They use the result to justify the conclusion. CBT has construct validity •Statistical significance refers to the fact that the difference between the mean score of the treatment group and the mean score of the control group is larger than would be expected to occur by chance. •Clinical significance refers to the practical value of the effect of an intervention. Does it make a “real” difference in the lives of actual clients or patients? We should be focusing on individual differences •Outcome data also can be used individually (i.e., relative to individual clients) to track their progress. The percentage of individuals who show improvements (e.g., 1 standard deviation below or above the mean score of a measure) can be clinically valid and useful data. Single Subject and Small-N Designs -Besides control- or comparison-group experimentation, investigators could employ “single-subject” or “small-N” designs. Operant conditioners (behaviour modifiers) prefer this approach, although theoretically investigators could use it to evaluate any type of psychotherapy. -Investigators assume that changes in dependent variables (treatment-outcome) are unlikely to occur by chance with the introduction (or removal) of the treatment regimen. -Investigators repeatedly assess the behaviour of interest and establish a “baseline” of behaviour. They clearly and precisely specify the treatment and replicate it repeatedly by applying and withdrawing the treatment. Empirically Validated Treatments: 1 -Some settings in the US, intertwined with private health-insurance providers, require that only treatment validated by experimental research can be used. Typically known as “managed care” systems, this system has led US psychologists to rely on empirically validated treatments, which generally has meant CBT, because this type of therapy is easily researched with analogue samples in universities. -In short, insurance corporations’ push for profits drives “empirically-validated treatments.” Empirically Validated Treatments: 2 -In Canada, both public & private practice is not yet heavily influenced by the swing toward empirically-validated treatments. Moreover, in Canada and the US, researchers continue to debate the best methods for conducting research on therapy; different research approaches could show different results about “empirical validation.” -In Europe, where health care is non-profit & public, some psychologists practice various forms of psychoanalysis & existentialism. Empirically-validated treatments are not required, because health & mental health are publicly funded. Some problems with Clinical Research - It is very difficult to subject clinical phenomena, which by definition are complex, to conventional, statistically-controlled experimentation, which by definition demands simplicity. Rich clinical concepts and practice defy precise experimental testing. - Qualitative methods, which seek to understand but not to predict or control human phenomena, are gaining acceptance among some researchers. But, by definition, qualitative methods cannot provide “empirical validation.” Qualitative Methods and Research -Qualitative methods are congruent with the phenomena of interest to clinicians. Clinical & qualitative research- interviewing, although different, are similar. Both types rely on the content of interviews. But in most approaches to clinical interviewing the process of interviews (i.e., the clinical relationship) is just as important as content, whereas in qualitative interviewing, processes support content. -Historically, in Canadian and US graduate programmes in clinical psychology, students receive little or no exposure to qualitative research and to critical thinking about what constitutes “research.” **Pursuing knowledge that is based on words not numbers -Piaget – qualitative It is very difficult to subject clinical phenomena, which by definition are complex to conventional, statistically-controlled experimentation, which by definition demands simplicity. Rich clinical concepts are practice defy precise experimental testing. Qualitative methods, which seek to understand but not to predict or control human phenomena, are gaining acceptance among researchers. But, by definition, qualitative methods cannot provide empirical validation comparison to different approaches to research Conventional Conventional Alternative -Naturally constructed reality & -Socially Constructed Reality Objective Observer &the inter-subjective observer Linear cause and effect Multiple circular causes and effects Relations between variables among variables Microscopic focus on ArtificiallyMolar focus on naturally occurring Abstracted Elements whole systems Different Assumptions About Research Natural Science Human Science Nature constructs “reality.” Social-historical situations construct Objective observers are separate reality. Observers & observed are from what they observe. [Realism] inter-related. [Social constructionism] Linear cause and effect deterministic Multiple, circular, & inseparable causes relations exist between natural & effects exist among natural phenomena. [Determinism] phenomena. They shape each other simultaneously. [Indeterminism] Investigators employ a microscopic Investigators focus on naturally focus on artificially reduced occurring whole systems. [Holism] abstracted elements. [Reductionism] The goal is to establish universal The goal is to describe individual laws & truths that transcend history cases, situated in time & context. This & social location. [Generalizability] knowledge might be transferable to other localized cases. [Transferability] Evaluation of Clinical Services -Psychologists could conduct systematic evaluation (a/k/a “programme evaluation”) of clinical services, but there is little history of doing so. Instead, academics typically concentrate on research conducted in universities, while clinicians typically don’t evaluate the services they provide. -The first step of programme evaluation is to determine whether it is possible. Only when specific program objectives exist can evaluators proceed. -Any evaluation of clinical services should include attention to the organizational structure & social climate of the setting in which the clinical services are provided. -Evaluators should form a partnership with staff & managers of the setting in which the evaluation will occur. A respectful partnership will yield valid data; if staff feel exploited by evaluators, they might produce bogus data. -In a “stakeholder” approach, of partnership, staff & managers understand, support, & participate in the evaluation to make the findings meaningful for the organization. •Formative evaluation seeks to determine whether service delivery is consistent with program design & if it is reaching the intended clientele. •Summative evaluation seeks to determine whether the service is effective. In this type of programme evaluation, evaluators frequently do not have a control or comparison group. Consequently, they ideally would use multiple methods to provide a comprehensive picture of the services evaluated. Class 19 – Two Forms of Psychoanalysis: Classical Psychoanalysis & Psychodynamic Models Classical Freudian Analysis -Founded by Sigmund Freud. -Patient reclines on a couch to facilitate free-association. -Analyst sits behind the patient. -Normally 3-5 sessions / week for many years. -The primary goal is to increase the analysand's awareness of her / his repressed motives in order to bring relief from neurotic conflicts and maximize conscious choices. -Where ID is, let EGO be -from unconscious to conscious Therapists Role: -The analyst is outwardly detached, literally beyond the analysand’s vision, but is inwardly involved. -Transference – the analysand’s emotional reactions and fantasies about the analyst, rooted in her/his primary relationships – is the heart of the psychoanalytic process. The analyst is a “blank screen” onto which the analysand projects wishes, fantasies & needs -don’t talk a lot -paying real close attention to what client is saying -interpret the transference explain to patient/client, why he or she is having positive or negative reactions to therapist Procedures: -The analyst cultivates transference in the form of free association, the latent (symbolic) content of dreams, & reports of internal conflict. -The analyst initially facilitates the development of transference by exploring the developmental history of the analysand. -Using good timing, the analyst interprets transference reactions and the analysand’s resistance to help her or him attain insight. Ensure that we the therapists have material to interpret the transference by directing client to describe his/hers history: -Family origin -Tell me your earliest memory Patient may disclose parts of history -Good timing of interpretations -Interpreting resistance of clients -Analysis cannot be too fast or too slow -We could scare the client/patients -Art of good timing – through extensive supervisored experience The concept of Resistance Patient’s efforts to ward off efforts to dissolve neurotic methods of resolving problems. Examples: –Talks less –Is late for appointments –Discusses trivial matters –Shows intensification of symptoms –Symptoms disappear prematurely (“flight into health”) person is ambivalent, wants to change, but doesn’t want to Evaluation Basis -Empirical support chiefly consists of case studies. -The general conclusion is that highly reflective people with neurotic anxieties, who value the approach, and who are very wealthy can benefit from classical psychoanalysis. Public or Private Practice -Because of the clientele suited for the model, the length of treatment, and the expense, classical psychoanalysis is practiced privately only. -In public and private settings, psychodynamic psychotherapy employs a similar theoretical model, but the relationship is face to face, less intense, and shorter in duration. Psychodynamic Models -The term refers to the range of models that apply psychoanalytic principles to a wider range of people & circumstances than Freud did. -The duration is usually weekly for 1-3 years, although there are short-term adaptations. -These models involve face to face contact, which was Alfred Adler’s innovation. Procedures The therapeutic procedures are similar to psychoanalysis, but the primary purpose is not to elicit transference reactions. •Rather, interpretations are used to strengthen the patient’s ego functioning & help her or him to explore the childhood roots of her or his problems. •Just as in classical analysis, the therapist focuses on process (what they’re saying and how they’re saying it) as well as content. -Freudian slips of the tongue are just as important Evaluation Basis -Both case studies & experimental testing with comparison-group research indicates that psychodynamic models can be effective for some people. -These models are suitable for: –Reflective people with neurotic conflicts. –People with personality disorders. -Sometimes these models are used with people suffering from a psychotic disorder. Public or Private -From the 1940s to the 1980s, psychodynamic models dominated in both public & private settings. -With the shift to “managed care,” although professionals still might conceptualize cases psychodynamically, short-term, solution-focused treatments, such as CBT or interpersonal therapy, are much more common. Psychoanalytic Alternatives •Carl Jung •Alfred Adler •Neo-Freudians •Ego Psychologists •Object Relations Key Points in Jungian Theory •Jung’s theory diverged from Freud’s: –Less emphasis upon sexuality in understanding neuroses and upon psychosexual stages –Greater emphasis upon universal themes (entire development spectrum), adult development, and interested in each person’s spiritual growth •Collective Unconscious –Universal unconscious motives. –Archetypes (inborn dispositions to think, behave, and perceive in certain ways). •Personality: Introversion and extraversion: I = inward looking; E = outward looking Jung’s Analytic Psychotherapy -Some of Jung’s methods and concepts are similar to Freud’s: –Free association –Dreams –Transference -Goal of treatment: Individuation –To fully develop one’s unconscious capacity. –Through insight, freeing oneself to express one’s innate capacity for creativity and expression. Adlerian Assumptions -“The unconscious” refers to phenomena not understood rather than to an unconscious mind. -Social relationships (particularly early family relationships and birth order) shape the developing personality. -With insight clients will chose to give up dysfunctional behaviour and choose healthier alternatives. Characteristics -Cooperative relationship between therapist and client. -Clear goals established and agreed upon by therapist and client. -Therapist is overtly encouraging and might give advice. Adlerian Psychotherapy Stages -Establish a good working relationship between client and therapist. -Understand the client’s lifestyles and goals: –Explore client’s place in family and client’s life-story. –Explore client’s goals. -Achieve insight through interpretation: –The therapist facilitates the emergence of insights that aid the client in taking constructive action. -Achieve reorientation: –The client chooses alternative ways of behaving. Adlerian Summary •Strong influence on social, neo-Freudians such as Karen Horney, Erich Fromm, and Harry Stack Sullivan. •Influenced existential and humanistic therapists as well, who stressed the importance of people creating meanings for their lives. •Influenced cognitive therapists re: the idea that people’s interpretations of significant events in their lives are more important than the events themselves. Neo Freudians •Erich Fromm •Karen Horney •Harry Stack Sullivan •They accepted unconscious motivation. •But they focused on current interpersonal relationships rather than on early development. Ego Psychologists •Anna Freud •Heinz Hartman •They emphasized adaptation to one’s current social environment and the strengthening of one’s ego functions. [The ego is the so-called “executive” of the personality.] -How well can we adapt to our social environment, develop all aspects of our EGO to live in our sociological niche -Some people believe that this a regressive point of view Recent Developments in Psychodynamic Therapies “Interpersonal Psychotherapy” [IPT] (Klerman et al., 1984) –Treatment for depression originally; later, grief reactions and interpersonal problems. –Lasts 12 to 16 weeks. –Three phases: First: Obtain history & formulate the problem. Second: Active treatment focused on 1 or 2 problems. Third: Recap the gains made and terminate. -As effective as CBT for depression. -Helpful for long-term maintenance of therapeutic gains in the treatment of depression. -Helpful for post-partum depression. -As effective as CBT for bulimia nervosa. Class 20 – Insight Therapies (Gestalt Therapy, Psychodrama and Creative Arts) & Person Centered Therapy Gestalt Therapy -Founded by Fritz Perls and popular in the 1970s & 1980s. -Goals: [1] Heighten awareness of: [a] one’s “here-and- now,” projected needs. [Focusing on there-and-then causes anxiety and depression and diverts people from expressing their “true selves.”] [b] the impact of emotional conflicts on one’s body parts. [2] Consciously incorporate projected needs into one’s total personality. Role of Therapist –Active, directive stance, urging clients to take personal responsibility for their problems. –Focuses on inferred unconscious processes underlying the client’s nonverbal actions. –Directs the client to externalize (“act out”) feelings about “unfinished business” in her or his life. Techniques include “the empty chair” [see image in next slide] and role-playing “top dog -- underdog” situations in the client’s life. -Evaluation is scarce and verification of success consisted primarily of case studies. -Gestalt therapy primarily is practiced by private therapists, although some public mental health professionals experimented with its techniques. -It is no longer in fashion. Psychodrama -Created by Jacob Moreno just before WW I. -Goals: –Emotional catharsis. –Greater spontaneity for the patient. -The therapist coaches the client to re-play key interpersonal conflicts in her / his life with the assistance of co-therapists or other patients. -It occurs in a room with other patients as audience and potential “actors.” -Role-switching occurs, because of the facilitation of awareness & insight. -The evaluation base consists of observational and case study research. Psychodrama seems effective for some people in some ways. -Private institutes for psychodrama exist in the US, and some public mental health services In Canada also have used psychodrama. Creative Arts Therapy -Art, music, dance, drama, and literature can be used as therapy. -The goal is personal expression of inhibited emotions. -The therapist guides the client’s artistic production from an outwardly detached stance but encourages the client to fully express herself or himself. The therapist might or might not interpret the client’s artistic product. -Evaluation consists primarily of case studies, although there is some comparison-group literature on drama and music therapy. These therapies are more common in private than in public practice. Person Centered Therapies -This group of psychotherapies is insight-oriented, but with a focus on the “here & now” vs. the “there & then” emphasized in psychodynamic models. -The founders of person-centred therapies regarded them as a “third way” between psychodynamic models & behaviour therapy. -Existentialists emphasize the client’s responsibility to make life-affirming choices, whereas humanistic therapists emphasize self-actualization and personal growth. 1. Client-Centered [Humanistic] 2. Existential 3. Logotherapy Client-Centered [humanistic] -Founded by Carl Rogers -Goal: Increased freedom of choice through heightened self-awareness of blockages in one’s personal development. -The therapist’s role is to understand the client’s world as that person perceives it. -The main technique is “active listening,” which involves 3 core dimensions: –Genuineness (congruent reactions). –Unconditional positive regard (warmth + belief in the client’s capacity to change). –Empathic understanding. Theoretically, the client, not the therapist, makes interpretations about her or his experience. In practice, client-centred therapists do make some interpretations and sometimes are directive. The Revised Model has Two Stages: First, the therapist is “non-directive” and works to establish rapport, trust, and understanding. Then, the therapist is directive: confronting and challenging the client positively and negatively, using self-disclosure & demonstrating conditional positive regard. Evaluation: -It is quite effective with mildly disturbed individuals and with university students. -It is insufficient for seriously disturbed persons or for those who need skill development. -Few clinicians, including clinical psychologists, identify with this school of therapy. However, counselors favour it. Existential Therapies -Models include those developed by Viktor Frankl, Rollo May, & R. D. Laing. -The basic existential theme is: “To live is to suffer, then we die. Meanwhile, seize the moment and live life to the fullest, choosing wisely.” -The premise of existential therapies is: People potentially have the freedom to make choices in a responsible manner, but one’s inner conflicts impede expressing this freedom. -Goals: –Enhance coping with existential anxiety. –Increase freedom of choice through self-awareness of blockages related to internal conflicts. -Therapist’s role: –Employ the core client-centred dimensions. –Serve as a model of “existential authenticity” in living one’s life by making active choices. -The therapist’s only “techniques” are to encourage the client to explore her or his “lived experience” & confront the client concerning existential decisions. -Empirical evaluation consists of case studies & shows positive outcomes for reflective clients. A few current psychologists claim they practice “experimental existential therapy.” -Most mental health professionals in North America ignore existential models, although they remain popular in Europe and Latin America. Logotherapy Founded by Nazi-camp survivor, Viktor Frankl. -The goal is to understand how the agony of life’s meaning, even in the midst of Holocaust conditions, is central to a client’s well-being. -The therapist stresses the necessity for the client to confront the present and future rather than the past, and take responsibility for her or his actions. •One technique is paradoxical intention: The therapist directs the client to consciously perform the behaviour that makes her or him anxious. •Evaluation consists of case studies. Logotherapy is known in North America but few practice it. I Never Promised you a Rose Garden •Based on a true story, this novel is a compelling example of effective existential psychotherapy with a severely disturbed young woman, “Deborah.” -“Dr. Fried,” the therapist [actually, Frieda Fromm-Reichmann, a famous mid-20 century US psychiatrist] exhibits four characteristics of a good therapist beyond faith and caring: –Hope –Involvement –Confrontation –Choice HOPE: Early on, Dr. Fried acknowledges Deborah’s internal core of strength & her potential for recovery. Later, Dr. Fried gives Deborah hope by reminding her of her strength, which Deborah is not recognizing because of the setbacks she is experiencing. INVOLVEMENT: Deborah perceives Dr. Fried as neither frightened of her nor patronizing to her. Dr. Fried shows excitement when she sees Deborah’s apathy beginning to dissolve. Dr. Fried shows understanding & affection for Deborah, for example by touching her on the arm. Dr. Fried shares a childhood memento with Deborah. CONFRONTATION: Dr. Fried challenges Deborah to realize that life is not “a rose garden.” Rather, ordinary life is full of challenges. “Poop” happens. Dr. Fried confronts the way Deborah blames her problems on others. CHOICE: Dr. Fried stresses that Deborah has the power of choice & must take responsibility for her actions. Dr. Fried points out that Deborah can be crazy if she wants to be, as long as she makes a true and conscious choice. She also reminds Deborah that being well is Deborah’s own choice. CURRENT PERSON CENTERED THERAPY – EMOTION FOCUSED THERAPY -Developed by psychologist Leslie Greenberg at York University, Toronto. -Focus on helping clients understand their inner experience and make wise choices. -Includes elements of client-centered, existential, and Gestalt therapies. -Psychological distress results from an inability to find words or images to understand or express one’s experience and results from interpreting one’s experiences as dysfunctional. -Emotional schemes – “implicit, idiosyncratic organizational structures that serve as the basis for human experience and self-organization” – can dominate one’s consciousness & actions. They need to be identified and re-structured. SIX PRINCIPLES IN TWO STAGES •Relationship principles [similar to Client-Centred Therapy]: –Empathic attunement –Therapeutic bond –Task collaboration Task-facilitation principles [ditto]: –Experiential processing –Growth and choice –Task completion Empathic exploration -Two chair work –“Experiencing” chair –Other [passive] chair -Empty-chair dialogue -EFT strategies and assumptions are based upon process psychotherapy studies, and there are some validating outcome studies. -The treatment is clearly described in contrast to other humanistic therapies. -It can serve as a model for training therapists. -But early studies suggested it is most helpful for clients suffering from relatively mild distress and minor psychopathology. BEHAVIOUR THERAPIES Behaviour therapies (BT) emerged in the 50s and 60s. -Although the underlying theory (Pavlovian classical conditioning) can’t explain them, the nonspecific or placebo dimensions of BT are identical to those of all therapy models. -Behaviour therapists give instruction, advice, and ‘homework’ for anxiety disorders. These directive treatments are particularly suitable for clients chiefly interested in practical results. As a result, they work. -Ironically, when prominent behaviour therapists sought therapy they saw psychodynamic therapists, while claiming BT is superior for everybody else. Skinner – Operant Conditioning -theories remove ‘mind’ from consideration -not necessary to deal with mental processes -works for individuals who like the practical methodological Counter Conditioning Premise – Clients achieve relearning by the therapist eliciting relaxation in the client when anxiety-producing stimuli are present. The underlying theory is classical conditioning in which mental processes are absent. classically conditioning patient/client to be relaxed in the face of a fearsome snake/rat/public speaking, etc. Goal – Anxiety reduction. [Exercise in relaxation] Aid the patient to reduce anxiety learning how to relax theory you can’t be relaxed and tense at the same time Therapist’s role – directive, prescriptive, & objectively detached (“scientific”). Procedure – Therapist and client construct a hierarchy of anxiety-producing situations. Then they pair graded-imagining of these situations with relaxation responses. But classical conditioning as a theory excludes mental processes like imagining. Thus, the theory can’t explain how the Rx works.  therapist is implying imagination, which contradicts classical conditioning… Simple stimulus response at a reflex •Effective mainly for specific phobias & anxieties. •Few well-designed studies show counter-conditioning to be more effective than other therapy models. •Never popular among public mental-health practitioners. •Most private behavioural practitioners have shifted to a more broad-spectrum approach, including CBT and non-BT approaches. -No clinical psychologists used any BT technique at internship -Counter-conditioning techniques work, not necessarily better than other techniques Marvin Golfree – originally BT switched to cognitive then switched to psychotherapy movement which made you switch what you would use based on the problem -not much behavioral in CBT B-mod practitioners have a similar goal & role to that of behaviour therapists. However, B- mod actually is not a form of psychotherapy, because it does not presuppose an active mind & feelings. B-mod applies Skinner’s principles of operant conditioning, which focus on overt behaviour. •Procedures include management of reinforcement contingencies & shaping of new behaviours. •B-mod is very limited in clinical applicability. It works well with individuals under conditions of total institutional control such as persons with severe developmental and intellectual challenges. •Re: effectiveness, durable changes only occur under conditions of total institutional control. Functionally Deporticative – limited intellectually because of age/trauma or severe developmental delay Institutionalized patients respond very well to Behaviour Modification (Autistic) PREMAC – coached moms and dads on ensuring that their children emitted behaviour. A contingent on behaviour B as the reward. For the parents, practicing the piano was important. The likelihood of you enjoying the piano practicing will escalate if your parents apply the PREMAC principle. Less desired behaviour emitted first, more desired behaviour serves as the reinforcer. Practice piano, then drawing, and road hockey. More desired behaviour becomes reward. Summaries of Behaviour Therapy and B-Mod •The theories behind these approaches exclude thinking, wishing, and feeling and the fact that treatment occurs in the context of a relationship. •Behaviour therapy works quite well with clients with specific phobias, but not for the theoretical reasons that behaviour theorists believe. A better explanation for their efficacy lies in the nonspecific influences inherent in the treatment relationship The next three slides depict an operant behavioural analysis of the treatment relationship. It’s impossible to describe it without introducing mental processes Class 22 – Cognitive Behavioural Therapies -1960s – Behaviour therapists began to realize that how patients thought about their problems was important to modify to effect durable behaviour change. -At a time when North American psychologists were re-discovering mental processes, some behaviour therapists introduced Cognitive Behavioural Therapy [CBT], which is now the dominant model of therapy in clinical psychology. -The most influential cognitive therapists are Aaron Beck, Albert Ellis, & Donald Meichenbaum. -some behavioural change occurred but it wasn’t durable – limited period of time -behaviourism as general theory of psychology was loosing favour -no cognitive revolution was happening in anywhere in world but NA Revolution changed introduced mental processes back into psychology •Beck - Identify errors in the client's logical thinking & alter her or his negative thoughts. - Psychiatrist, not B just CT -Encourages patients to alter negative thoughts so that their feelings can be lifted up - The therapist uses “collaborative empiricism” to engage the client [1] Focus is on content rather than process [2] Primary techniques: ‘cognitive restructuring’ and ‘behaviour rehearsal.’ - Collaborative Empiricism – focuses on content of what client is saying what the person is actually saying - Encourages client to restructure what he/she is thinking - Illogical nature of thoughts, encourages client to rethink the logic - Practice and rehearse these statements •Ellis – Given that emotions are the consequences of thoughts and beliefs, change the client's irrational beliefs & irrational self-statements. - Rational Emotive Therapy – analyzes feelings that people associate with irrational thoughts…change those crazy making thoughts to more constructive - The therapist confronts and argues with the client to persuade her/him to change - Ellis – challenges, confronts, argues with clients - Persuade vigoursly the crazy way they think about themselves - If you change, your feelings will improve - Ellis represents a classic middle class, aggressive New York City mentality …challenging, aggressive •Meichenbaum – Teach clients to alter their self-speech externally & then internalize these changes to modify their behaviour & feelings. - Self statements, teaches clients to alter what they say to themselves about their issues and problems - Coaching how to change negative statements to positive ones - If we change the way we think/talk to ourselves, our feelings will be uplifted, and behaviour will change accordingly - The therapist examines the client’s self-statements & encourages more adaptive internal speech. Lev Vygotsky – proposed ideas about psychology that were decades ahead of their time Control function of speech – preschoolers, do they keep what they’re thinking inside or out loud…OUTLOUD Look at self statements of patients Encourage client to change maladaptive speech to more adaptive internal speech Beck’s Cognitive Therapy -Originally developed for treatment of depression -Dx concept of the “Depressive Triad”: –Negative view of self –Negative view of world –Negative view of future Internalized what we say to ourselves Concepts of Cognitive Disorders All-or-none Thinking – we say things like, If it isn’t all good
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