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Midterm II Study Notes.docx

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Wilfrid Laurier University
Richard Walsh- Bowers

PS381 MIDTERM II STUDY NOTES 1 Emily Fong WEEK 6.3 NOTES – PSYCHOTHERAPY: CONCEPTS & APPLICATIONS Psychotherapy: a developmental, interpersonal situation that consists of a relationship b/w sufferer & healer - Developmental phenomenon b/c it precedes w/ history of a beginning, middle & an end - Interpersonal b/c involves at least 2 parties (the client & the therapist) - Goal: to relieve problems by altering how the sufferer feels, thinks & acts - Can occur in a dyad, w/n a group, or w/ a family or couple - Healer has specialized training & draws on theoretical concepts to apply certain helping techniques - 3 psychological ways in which relief of suffering occurs o How we feel o How we think o How we act MAJOR MODELS OF PSYCHOTHERAPY (Chart Summary) THEORETICAL FOCUS TYPICAL MODALITY AFFECT COGNITION BEHAVIOUR INDIVIDUAL FAMILY GROUP PSYCHOANALYSIS [Classical Version]1 2 3 Y N N PSYCHODYNAMIC [Adaptations of 1 2 3 Y Y Y Psychoanalysis] INSIGHT-ACTION [Psychodrama PD: N 2 3 1 N Y (PD) or Gestalt GT: Y Therapy (GT)] PERSON-CENTRED [Humanistic or 1 2 3 Y Y Y Existential] BEHAVIOUR 3 2 1 Y Y Y THERAPY COGNITIVE 3 1 2 Y Y Y * Family therapists employ a very different orientation to couples & FAMILY SYSTEMS families than any of the above models, although family therapies have been influenced by these individual-centred models. PS381 MIDTERM II STUDY NOTES 2 Emily Fong - Modality  form the therapy takes - Affect  refers to emotions associated w/ particular motives; unconscious motives - Behaviour  changing behaviour in the way of which those who integrate psychodynamic theory w/ action would do it) - The theoretical focus of each of these domains can be quite different o Ex. Psychoanalysis in its classical version (Freudian way) stresses affect & uncovering emotions. Least important is behaviour o Ex. Insight-action emphasizes behaviour. Psychodrama always done in group; Gestalt therapy done in group or individually COMMONALITITES AMONG THEORIES OF THERAPY - Therapy involves 3 phases: o Exploring the problem o Understanding problem o Trying to solve problem - Unconscious dynamics occur: o Resistance to Change  Ppl are ambivalent to therapy (they want it b/c they are suffering, but don’t want it b/c there’s change involved) o Transference  Client projects onto the therapist unfinished emotions/business that would otherwise be directed at a family member/friend/parent/etc. (unconsciously done)  Unlikely to happen in behaviour therapy o Counter-transference  When the therapist unconsciously projects their thoughts onto the clients - Moral & political persuasion are at the root of the therapeutic-change process o Therapists unconsciously engage in persuading their clients (ie. Persuading/selling their clients to the idea of cognitive behaviour therapy)  not brainwashing o Some therapies are more explicit than others - Therapy can result in improvement, no change, deterioration, or “iatrogenesis” (harm caused by the healer) o Therapy should be understood as a continuum  is not always therapeutic - Nonspecific or “placebo” qualities of faith, hope & caring saturate the helping relationship NONSPECIFIC/”PLACEBO” INFLUENCES - Success of therapy depends on a warm, trusting climate b/w sufferer & healer - Relationship qualities are called nonspecific/”placebo” effects o b/c they lack specific therapeutic activity  they are not associated w/ a particular technique, but any particular technique needs to be embedded in these qualities or else it won’t work - Yet placebo effects account for a large portion of treatment effects - The expectations of the client help make the specific techniques applied in therapy even more effective o The success of the techniques then acts to further increase the client’s expectations - When the client is believing that the technique will work, believes the competence of the healer, and is motivated, they are more likely to show progress PS381 MIDTERM II STUDY NOTES 3 Emily Fong COMMON FACTORS - Therapist-Offered Conditions o Empathy, warmth, caring & a non-judgemental attitude - Expert Role o Therapist is perceived to be the expert & competent in their field - Catharsis o Release of emotions; like a gigantic purge - Therapeutic Alliance o The nature of the relationship b/w client & therapist o It’s like rapport; rapport helps to massage the alliance; working together w/ a technique to get to the same goal o Feedback - Distress Reduction - Rationale/Insight o There is an intellectual level going on above the therapy experience - Competence/Mastery (in the client) o A goal of psychotherapy o Client leaves the therapy feeling more confident & more competent o Helps the client to achieve greater effectiveness & satisfaction o Ppl who experience a sense of mastery (who feel confident, expect to do well, or just feel good about themselves ) are more likely to function in an effective fashion MISCONCEPTIONS ABOUT THERAPY 1) There is one best therapy o There is no best therapy for all situations  there may be a better therapy for a particular situation 2) Therapy is equally effective for whatever ails you o Not everything can be solved by therapy 3) Therapy can really change your life around o May not always have a +ve change 4) Therapeutic changes are permanent 5) The longer the therapy, the better the results o No evidence to prove this o If therapy is focused, then it doesn’t need to be long at all 6) One course of therapy is the rule for most clients o Won’t solve all your problems  more things can come up in your life 7) At worst, therapy is harmless WHO ARE THE HEALERS? - Professional groups incl. psychiatrists, nurses, social workers, psychologists, occupational therapists & creative arts therapists - Historically primarily male, now clinically most are female o But mostly men in psych faculties teaching - Mainly white, middle-class & supporters of the political status quo  not representative of all types of pops. - Others serve informally as healers (doctors, massage therapists, clergy, teachers, hairdressers, self-help groups) PS381 MIDTERM II STUDY NOTES 4 Emily Fong Psychotherapists’ Characteristics & Treatment Outcomes - Unrelated to Outcome o Training o Experience  no consistent relationship w/ +ve outcomes o Age o Gender - Correlated w/ Outcome o Emotional well-being  Therapists much recognize problem-areas in their own lives  Must be able to look at patients w/ objectivity o Expectations about client o Competence o Empathy, Warmth & Genuineness (often times considered just indicators of the quality of therapeutic alliance) *Pygmalion Effect  have +ve expectations for a particular outcome (Rosenthal effect?) WHO ARE THE SUFFERERS? - Private therapy: usually verbal, intelligent, successful individuals participate (b/c they can afford it) - Public Clinics: greater range characteristics amongst participants - Women are more likely to go to therapy (regardless of public or private) o b/c it is more socially acceptable for women to express feelings - For decades, professionals thought that psychotherapy could not benefit ppl w/ schizophrenia, bipolar, or character disorders  these individuals received “supportive psychotherapy” rather than psychoanalysis o View is not changing (it depends on the individual case) ESSENTIALS OF A PSYCHOTHERAPY RELATIONSHIP - It occurs in a socially acceptable place of healing - Frequency & length of meetings are planned & limited - Goals of the relationship are specified - Facilitative therapeutic relationship (therapeutic alliance) is crucial - Confidentiality Limits of Confidentiality (when it can be broken) - Written consent of client - Comply w/ reporting laws o Child abuse o Abuse of disabled/elderly - Protect client & others o “Tarasoff” case  If client wishes to hurt someone, it is therapist’s duty to inform the victim o Suicide Prevention - Mandated by court (subpoena) - Consultation w/ colleagues when uncertain to get a more objective perspective PS381 MIDTERM II STUDY NOTES 5 Emily Fong PSYCHOTHERAPY INTEGRATION MOVEMENT - By 1980s 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 o Recognizes that understanding the meaning clients gave to their “environmental stimuli” was crucial to treatment effectiveness  What meaning does the client attribute to that treatment - 1985 clinical psychologists initiated a scholarly movement to end the polarized debates b/w models of therapy & integrate them o This disagrees w/ notion that there is one best therapy - However, many CBT devotees con’t to assert that their approach is superior to all other models o They deny the value of psychotherapy integration o This opinion is common in psych txtbks - Psycho-educational model o Integrating psychodynamic, person-centred & behavioural perspectives in 2 clinical areas: 1) Community-based treatment for individuals w/ LT health challenges 2) Group treatment of children & youth SEQUENCE OF PSYCHOLOGICAL TREATMENT 1) Initial Contact 2) Assessment 3) Goals of Treatment 4) Implementing Treatment 5) Termination, Evaluation & Follow-up STAGES OF CHANGE (Client) 1) Pre-contemplation  client has no intention of ∆ing his/her behaviour; typically come in for treatment b/c of outside pressure 2) Contemplation client is aware that a problem exists, but not yet committed to ∆ing it 3) Preparation client intends to make a ∆ 4) Action 5) Maintenance  client works on preventing relapses 6) Termination REVIEW: COMMONALITIES AMONG THERAPY MODELS - Developmental Processes/Phases: o Exploration o Understanding o Action - Unconscious Dynamics: o Resistance to change o Transference o Counter-transference - Nonspecific Relational Qualities o Hope PS381 MIDTERM II STUDY NOTES 6 Emily Fong o Faith o Caring - Treatment success depends on: o Therapist’s belief in their particular model o Matching treatment w/ clients’ particular beliefs & expectations o A strong “working alliance” (therapeutic relationship) w/ clients WEEK 7.1 NOTES – CLINICAL RESEARCH & PROGRAMME EVALUATION ORIGINS OF THE SCIENTIFIC APPROACH TO CLINICAL PSYCH IN THE USA - Clinical psychologists after WWII promoted their sub-discipline as scientifically-based & validated - In their “scientist-practitioner model” they expressed commitment to the views of natural science psychology o Experimental method of stats control o Interventions developed on the basis of “laws of behaviour,” which they believed were universal  Ie. Applicable to all regardless of social historical context - By 1960s but, most non-academic, clinical psychologists rarely engaged in research/evaluated clinical services o Meanwhile, academic clinicians typically conduct “analogue research” of treatment outcomes 2 KINDS OF PSYCHOTHERAPY RESEARCH Process Research: Investigates the specific events that occur during therapy b/w therapist & client. How does the therapy work? What are the “mechanisms” that lead to therapeutic ∆? Criticized by outcome researchers as failing to show that processes internal to therapy were correlated w/ outcome. Methodology: filming therapy sessions. Outcome Research. Is the therapy effective? Does a particular treatment for a particular clinical problem work? - Historically, most psychotherapy research has been outcome-oriented & analogue, based on non-clinical samples Analogue Research - Entails testing a treatment w/ non-clinical samples (usually university students w/ mild phobias, moderate depression, or excessive body-image concerns, but not an eating disorder) - Investigators then generalize to clinical pops. - PROS: o Convenience of university research PS381 MIDTERM II STUDY NOTES 7 Emily Fong o Heightened experimental control o :. Internal validity - CONS: o Questionable relevance to actual clinical practice (ie. Dubious external validity) HISTORY OF PSYCHOTHERAPY RESEARCH - 1940s  Carl Rogers & associates recorded interviews to analyze the process of therapy - 1952 Concerning treatment outcomes, British psychologists Hans Eysenck claimed that psychodymanic therapies were no more effective than “spontaneous remission” & that behaviour therapy was superior - 1966 US psychologist Allen Bergin concluded that no single type of therapy is best for every client - Moral of Eysenck Story: Practice critical thinking concerning claims for research superiority of one type of therapy B/W GROUP OUTCOME RESEARCH DESIGNS - Investigators randomly assign clients to treatment & control/comparison conditions o Assume that random assignment controls for nuisance variables o Also assume that any obtained differences b/w the groups are due to the treatment - Control/comparison groups can incl. no treatment, clients on waiting list for treatment, or a “placebo” condition (ie. A credible condition, but one that should not work according to the theory underlying the tested treatment) - Wait list control group  a control group whose members receive treatment only after the study is completed FACTORIAL DESIGNS - Investigators ask which treatment works best & is the combination better than each one alone - Ex: No medication, no Medication, no psychotherapy psychotherapy Group A Group B No medication, psychotherapy Medication, psychotherapy Group C Group D TYPES OF VALIDITY IN THERAPY RESEARCH Internal: The treatment caused ∆ in outcome variables External: The results can be generalized to actual clinical conditions Construct: The treatment ∆ occurred for the reasons the researcher thinks it occurred PS381 MIDTERM II STUDY NOTES 8 Emily Fong STATISTICAL & CLINICAL SIGNIFICANCE Statistical Significance: refers to the fact that the difference b/w the mean score of the treatment group & the mean score of the control group is > 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/patients? - Outcome data can also be used individually (ie. Relative to individual clients) to track their progress - The %age of ppl who show improvements (ex. 1 standard deviation below/above the mean score of a measure) can be clinically valid & useful data SINGLE SUBJECT & SMALL-N DESIGNS - Operant conditioners (behaviour modifiers) prefer this approach o But theoretically, investigators could use it to evaluate any type of psychotherapy - Investigators assume that ∆s in DV (treatment-outcome) are unlikely to occur by change w/ the introduction (or removal) of the treatment regimen - Investigators repeatedly assess the behaviour of interest & est. a “baseline” of behaviour - Clearly & precisely specify the treatment & replicate it repeatedly by applying & w/drawing the treatment SOME PROBLEMS W/ CLINICAL RESEARCH - Difficult to subject clinical phenomena to conventional, statistically-controlled experimentation o Rich clinical concepts & practice defy precise experimental testing - Qualitative methods seek to understand, but not predict/control human phenomena o Gaining acceptance among some researchers o But, by definition, qualitative methods cannot provide “empirical validation” QUALITATIVE METHODS FOR CLINICAL RESEARCH - Are congruent w/ the phenomena of interest to clinicians - Clinical & qualitative research-interviewing are similar o Both types rely on the content of interviews o But are different in that clinical interviewing the process of interviews (ie. The clinical relationship) is just as important as the content, whereas in qualitative interviewing, processes support content - Historically, in graduate programs in clinical psych, students receive little/no exposure to qualitative research & to critical thinking about what constitutes “research” PS381 MIDTERM II STUDY NOTES 9 Emily Fong COMPARISON OF DIFFERENT APPROACHES TO RESEARCH Conventional Alternative Naturally Constructed Reality Socially Constructed Reality & the Objective Observer & the Inter-subjective Observer Linear Cause & Effect Multiple, Circular Causes & Effects Relations between Variables among Variables Microscopic Focus on Molar Focus on Artificially Abstracted Elements Naturally-Occurring Whole Systems DIFFERENT ASSUMPTIONS ABOUT RESEARCH Natural Science Human Science Nature constructs “reality.” Objective Social-historical situations construct observers are separate from what they reality. Observers & observed are observe. [Realism] inter-related. [Social constructionism] Linear, cause & effect deterministic Multiple, circular, & inseparable causes relations exist between natural phenomena. & effects exist among natural phenomena. [Determinism] They shape each other simultaneously. [Indeterminism] Investigators employ a microscopic focus Investigators focus on naturally on artificially reduced abstracted elements. occurring whole systems. [Holism] [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 - Academics typically concentrate on research conducted in universities - Clinicians typically don’t evaluate the services they provide - First step of program evaluation is to determine whether it is possible - Evaluators can only proceed when specific program objectives exist - Any evaluation of clinical services should incl. attention to the org.’l structure & social climate of the setting in which the clinical services are provided - Evaluators should from a partnership w/ staff & managers of the setting in which the evaluation will occur o A respectful partnership = valid data (if staff feels exploited by evaluators, they might produce bogus data) - “stakeholder” approach staff & managers of partnership understand, support & participate in the evaluation to make the findings meaningful for the org. - Formative Evaluation: seeks to determine whether service delivery is consistent w/ program design & if it is reaching the intended clientele PS381 MIDTERM II STUDY NOTES 10 Emily Fong - Summative Evaluation: seeks to determine whether the service is effective o Evaluators often do not have a control/comparison group :. They ideally would use multiple methods to provide a comprehensive picture of the services evaluated WEEK 7.2 NOTES– 2 FORMS OF PSYCHOANALYSIS (CLASSICAL PSYCHOANALYSIS & PSYCHODYNAMIC MODELS) CLASSICAL FREUDIAN ANALYSIS - Patient reclines on a couch to facilitate free-association o Free-association: patient was to say everything & anything that came to mind - Analyst sits behind patient - Normally 3-5 sessions/week for many years - GOAL: to make the unconscious conscious. Make patient aware of his/her repressed motives in order to bring relief from neurotic conflicts and maximize conscious choices - Therapist’s Role: o Analyst is outwardly detached (beyond patient’s vision) & is inwardly involved o Transference: the patient’s emotional rxns & fantasies about the analyst, rooted in his/her primary relationships – is the heart of the psychoanalytic process o Analyst is a “blank screen” onto which the patient projects wishes, fantasies & needs - Procedures: o Analyst cultivates transference in the form of free association, the symbolic content of dreams, & reports of internal conflict o Analyst initially facilitates the development of transference by exploring the developmental history of the patient o The analyst uses good timing to interpret transference rxns & the patient’s resistance to help him/her attain insight - Concept of Resistance: o Patient’s attempt to ward off efforts to dissolve neurotic methods of resolving problems o Ex. Talks less, is late for appts, discusses trivial matters, shows intensification of symptoms, symptoms disappear prematurely (“flight into health”) - Evaluation Base: o Empirical support chiefly consists of case studies o General conclusion  highly reflective ppl w/ neurotic anxieties, who value the approach, & who are very wealthy can benefit from classical psychoanalysis - Public/Private Practice: o Only practiced privately  b/c of the type of clientele suited for the model, length of treatment, & expense PS381 MIDTERM II STUDY NOTES 11 Emily Fong PSYCHODYNAMIC MODELS - Refers to the range of models that apply psychoanalytic principles to a wider range of ppl & circumstances than Freud did - Duration: usually 1-3 yrs (there are also ST adaptations) - These models involve face-to-face contact (which was Alfred Adler’s innovation) - Procedures: o Similar to psychoanalysis (but primary purpose is not to elicit transference rxns) o Interpretations are used to strengthen the patient’s ego functioning & help him/her to explore the childhood roots of her/his problems o Therapist focuses on process as well as content (like in classical analysis) - Evaluation Base: o Case studies & experimental testing w/ comparison-group research indicates that psychodynamic models can be effective for some ppl o Models are suitable for:  Reflective ppl w/ neurotic conflicts  Ppl w/ personality disorders o Sometimes these models are used w/ ppl suffering from a psychotic disorder - Public/Private Practice: o 1940s-1980s dominated in both public & private settings o w/ the shift to “managed care”, although professionls still might conceptualize cases psychodynamically, ST, solution-focused treatments (like CBT or interpersonal therapy) are much more common o In public & private settings, psychodynamic psychotherapy employs a similar theoretical model to classical analysis, but the relationship is face-to-face, less intense, & shorter in duration PSYCHANALYTIC ALTERNATIVES - CARL JUNG o Jung’s theory diverged from Freud’s:  Less emphasis upon sexuality in understanding neuroses & upon psychosexual stages  Greater emphasis upon universal themes, adult development & spiritual growth o Collective Unconscious  Universal unconscious motives  Archetypes  inborn dispositions to think, behave, & perceive in certain ways o Personality: Introversion & Extroversion  I = inward looking; E= outward looking o Some of Jung’s methods & concepts are similar to Freud’s:  Free association  **Dreams  **Transference o Goal of Treatment: Individuation  To fully develop one’s unconscious capacity  Through insight, freeing oneself to express one’s innate capacity for creativity & expression - ALFRED ADLER o Assumptions: PS381 MIDTERM II STUDY NOTES 12 Emily Fong  “The unconscious”  refers to phenomena not understood rather than to an unconscious mind  Social relationships (particularly early family relationships & birth order) shape the developing personality)  W/ insight, clients will choose to give up dysfunctional behaviour & choose healthier alternatives o Characteristics:  Cooperative relationship b/w therapist & client  Clear goals est. & agreed upon by therapist & client  Therapist is overtly encouraging & might give advice o Stages:  Est. a good working relationship b/w client & therapist  Understand the client’s lifestyles & goals **Adler & Neo-  Explore client’s place in family & client’s life-story Freudians stressed  Explore client’s goals importance of culture,  Achieve insight through interpretation learning, & social  Therapist facilitates the emergence of insights that aid the client in relationships instead taking constructive action  Achieve reorientation of instinctual forces  Client chooses alternative ways of behaving  Summary  Strong influence on social, Neo-Freudians such as Karen Horney, Erich Fromm, & Harry Stack Sullivan  Influenced existential & humanistic therapists as well, who stressed the importance of ppl creating meanings for their lives  Influenced cognitive therapists re: the idea that ppl’s interpretations of significant events in their lives are more important than the events themselves - NEO-FREUDIANS o Erich Fromm, Karen Horney, Harry Stack Sullivan o Accepted unconscious motivation o But they focused on current interpersonal relationships rather than on early development - EGO PSYCHOLOGISTS o Anna Freud, Heinz Hartman o Emphasized adaptation to one’s current social environment & the strengthening of one’s ego functions (the egos is the so-called “executive” of the personality)  Accepted the role of the ego in mediating conflict b/w id & realw world, but believed that the ego also performed other extremely important functions  Emphasized the adaptive, “conflict-free” functions of the ego (incl. memory, learning & perception) o Focused more on the current problems in living than on a massive examination of the past o Tends to emphasize the importance of building the patient’s trust through “reparenting” in the therapy relationship o Sometimes viewed transference as an impediment to therapy - OBJECT RELATIONS o See the need to form relationships w/ others as a primary influence on human behaviour o Focus more on the role of love & hate, as well as autonomy & dependency, in the development of the self PS381 MIDTERM II STUDY NOTES 13 Emily Fong RECENT DEVELOPMENTS IN PSYCHODYNAMIC THERAPIES Interpersonal Psychotherapy (IPT) - Treatment originally for depression; later, grief rxns & interpersonal problems o Focuses on the connection b/w onset of clinical problems & current interpersonal problems o Current social problems are addressed, not enduing personality traits/styles - Last 12-16 wks - 3 phases: 1) Obtain history & formulate problem 2) Active treatment focused on 1 or 2 problems 3) Recap the gains made & terminate - Role of the Therapist o Therapist is active, non-neutral & supportive o Use realism & optimism to counter patients’ typically –ve & pessimistic outlook o Emphasize the possibility for ∆ & highlight options that may result in +ve ∆ - Is the most empirically supported of all psychodynamic therapies - As effective as CBT for depression - Helpful for LT maintenance of therapeutic gains in the treatment of depression - Helpful for post-partum depression - As effective as CBT for bulimia nervosa WEEK 7.3 NOTES– INSIGHT: ACTION THERAPIES (GESTALT THERAPY, PSYCHODRAMA & CREATIVE ARTS, & PERSON-CENTRED THERAPIES) GESTALT THERAPY (do not confuse w/ Gestalt Psych  completely diff.) - Fritz Perls - Popular in 1970s & 80s in the US - GOALS: o Heighten awareness of:  One’s “here-and-now” projected needs (how are you currently dealing w/ your emotional conflicts?)  focusing on there-and-then causes anxiety & depression & diverts ppl from expressing their “true selves”  The impact of emotional conflicts on one’s body parts o Consciously incorporate projected needs into one’s total personality - **Mos
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